UNIVERSITY of 
 
 AT 
 
 LOS ANGELES 
 LIBRARY
 
 FHONT VIEW or THE ORGANS IN THEIR NATURAL RELATIONS. 
 The heart Is partly covered by the lungs, but its true outline is indicated 
 by a dotted line. Only ten ribs are shown on each side, the eleventh 
 and twelfth (the floating ribs) being too short to be included in the 
 section.
 
 A TEXT-BOOK OF 
 
 NURSING 
 
 FOR THE USE OF TRAINING SCHOOLS, FAMILIES, 
 /IND PRIVATE STUDENTS 
 
 BY 
 
 CLARA WEEKS-SHAW 
 
 / * 7 S 1 
 
 THIRD EDITION, THOROUGHLY REVISED 
 AND ENLARGED 
 
 NEW YORK 
 
 D. APPLETON AND COMPANY 
 i 906 
 
 IG751 
 NUV ISO/
 
 COPYRIGHT, 1885, 1892, 1902 
 BY D. APPLETON AND COMPANY
 
 S53 t 
 
 THE holiest task by Heaven decreed, 
 
 An errand all divine, 
 The burden of our common need 
 
 To render less, is thine. 
 
 The paths of pain are thine. Go forth 
 With patience, trust, and hope ; 
 
 The sufferings of a sin-sick earth 
 Shall give thee ample scope. 
 
 Beside the unveiled mysteries 
 
 Of life and death go stand, 
 With guarded lips and reverent eyes, 
 
 And pure of heart and hand. 
 
 J. Or. WHITTIER.
 
 PEEFACE TO THE THIKD EDITION 
 
 THIS book, first introduced to the public by my 
 ever-to-be-remembered friend, Prof. Edward L. You- 
 mans, to whose most kind encouragement and assist- 
 ance it owed its existence, is now for the second time 
 revised and brought up to date under the supervision 
 of his niece, Dr. Alice C. Youmans. It follows the 
 same practical lines as the earlier editions, and until 
 something more comprehensive is offered, I trust will 
 continue to be of use to nurses both amateur and pro- 
 fessional. Primarily designed for the latter class, I 
 assume that elementary acquaintance with anatomy and 
 physiology which is now of course a fundamental part 
 of their training. The fragments of these here intro~ 
 duced, serving for them merely the purpose of review, 
 may perhaps render the context more intelligible to the 
 untrained majority whom also I hope to help. To the 
 whole nursing sisterhood, I present it, in memory of the 
 days when I was one of them, adding a reminder that 
 " they never are alone who are accompanied by noble 
 thoughts." 
 
 CLABA W. SHAW. 
 
 1908.
 
 CONTENTS 
 
 CHAPTER PA Oft 
 
 I. INTRODUCTORY NURSING AND NURSES ... 1 
 
 II. THE SICK-ROOM THE HOSPITAL WARD ... 14 
 
 III. BEDS AND BED-MAKING BED-SORES .... 28 
 
 IV. CIRCULATION PULSE TEMPERATURE ... 44 
 V. RESPIRATION VENTILATION WARMTH ... 62 
 
 VI. THE SKIN BATHS MASSAGE 75 
 
 VII. URINE CATHETERIZATION ENEMATA ... 90 
 
 VIII. THE OBSERVATION OF SYMPTOMS .... 110 
 
 IX. MEDICINES AND THEIR ADMINISTRATION . . . 125 
 
 X. LOCAL APPLICATIONS VENESECTION TRANSFUSION . 154 
 
 XL FOOD AND ITS ADMINISTRATION 172 
 
 XII. BONES FRACTURES DISLOCATIONS BANDAGING . 194 
 
 XIII. CONTAGION AND DISINFECTION 223 
 
 XIV. SURGICAL NURSING OPERATION CASES . . . 234 
 XV. GYN^ICOLOGY 260 
 
 XVI. OBSTETRICS 268 
 
 XVII. SICK CHILDREN 289 
 
 XVIII. SPECIAL MEDICAL CASES 306 
 
 XIX. EMERGENCIES, SURGICAL AND MEDICAL . . . 335 
 
 XX. THE TERMINATIONS OF DISEASE .... 371 
 
 VOCABULARY . . 379 
 
 INDEX . , 393
 
 TEXT-BOOK OF NURSING 
 
 It, 7S/ 
 
 CHAPTER I 
 
 "Blessed is he who has found his work; let him ask no other 
 blessedness." T. Carlyle. 
 
 HEALTH has been comprehensively defined as the 
 "perfect circulation of pure blood in a sound organ- 
 ism." Any departure from either of these three condi- 
 tions constitutes disease. There is recognized in nature 
 a certain tendency to reparation, a predisposition to re- 
 turn to the conditions of health, whenever there has 
 been any deviation from them. To assist this is the ob- 
 ject of treatment. To keep the patient in the state 
 i most favorable for the action of this reparative tend- 
 - ency, is especially the vocation of the nurse. There 
 ^ are few who will not be called upon to serve in this 
 ^ capacity at some time in their lives; fewer still who 
 ^ will not at some time have occasion to be grateful for 
 the ministrations of a skill'iu and efficient nurse, or 
 annoyed by the blunders of an awkward and incom- 
 petent one. 
 
 Nursing, therefore, is an art, the importance of 
 which can scarcely be overestimated. It properly in- 
 cludes, as well as the execution of specific orders, the 
 administration of food a ad medicine, the personal care 
 of the patient, attention to the condition of the sick- 
 room, its warmth, cleanliness, and ventilation, the care- 
 
 1
 
 2 A TEXT-BOOK OF NURSING 
 
 f ul observation and reporting of symptoms, and the pre- 
 vention of contagion. It is a work which falls largely, 
 though not exclusively, to the share of women, and it 
 has sometimes been claimed that all women make good 
 nurses simply by virtue of their womanhood. But this 
 is far from true. To fitly fill such a position requires 
 certain physical and mental attributes, which all women 
 even all good women do not possess, as well as some 
 special training. A natural aptitude for nursing is a 
 valuable basis for instruction, but will not take the place 
 of it, nor will good intentions ever compensate for a 
 lack of executive ability. 
 
 Unimpaired health and power of endurance, intelli- 
 gence and common sense, are primary essentials for a 
 nurse. She should be a person of even, cheerful tem- 
 perament, not easily irritated or confused for to lose 
 temper or presence of mind in the sick-room ig fatal to 
 usefulness. She must have acute perceptions, habits of 
 correct observation and accurate statement, and some 
 manual dexterity. She needs to be quiet, neat, and sys- 
 tematic, and capable of eternal vigilance. 
 
 There is in this work, room for the exercise of tal- 
 ents of the highest and virtues of the rarest order; and 
 it ought not to be true, as it is, that many of the 
 applications for admission into our training-schools are 
 from those utterly unfit for the work; either surviving 
 relics of the by-gone times -when a nurse ranked on or 
 below the par of house-ma'd, or sentimentalists with 
 their heads full of romantic visions of themselves flit- 
 ting about like angels of mercy, bathing the brows of 
 suffering heroes, and distributing among them flowers 
 and smiles. The latter class arc sure to be disappointed, 
 generally disgusted, for they fir.d the reality practical, 
 prosaic, and often even revolting. But it is a field of
 
 INTRODUCTORY NURSING AND NURSES 3 
 
 usefulness such as is nowhere else afforded, and a woman 
 with the requisite qualifications, who desires to be really 
 of service to her fellow-creatures, and to adopt an em- 
 ployment of absorbing interest, can not do better than 
 to train herself for a nurse. It is to such as have en- 
 tered upon this course with an earnest aim to well 
 qualify themselves, and to elevate the professional 
 standard, that the following instructions are addressed./' 
 
 When you have once undertaken the care of a sick 
 person, his welfare is of course understood to become 
 your first consideration. With this object always in 
 view, your duties may be classified as threefold: those 
 which you owe to yourself, those due to the physician 
 under whose direction you work, and such as relate im- 
 mediately to the patient. Something is perhaps owing 
 also to the school with which you are or have been con- 
 nected. You are at least afforded an additional motive 
 for guarded conduct by the remembrance that you are 
 its representative to the public, the exponent of its 
 methods, and that, according as you behave yourself 
 well or ill, credit or discredit is reflected upon the en- 
 tire school. It may at first glance seem somewhat 
 strange to assert that your own personal duties should 
 take precedence, but a little reflection will show that 
 whatever theories of self-devotion you may entertain, 
 and however willing you may be to sacrifice your own 
 comfort to the welfare of your patient, disregard of the 
 duties to yourself will sooner or later incapacitate you 
 for the fulfillment of all others. You may give up your 
 convenience, your pleasure indeed will be perpetually 
 called upon to do so as the inevitable claim of the work 
 you have chosen but your health you have no right to 
 risk. Remember that self-sacrifice is not always unsel- 
 fishness, and that the nurse who takes the best care of
 
 4 A TEXT-BOOK OF NURSING 
 
 her own health will be beet able to care for her patient. 
 Ill-regulated zeal only defeats its own object; if you 
 wish to be really and permanently efficient, you will take 
 pains not to lower the standard of your own physical 
 condition. Even a nurse is but human; you can not 
 retain your vigor and consequent usefulness without a 
 due allowance of rest, food, and exercise. It is your 
 duty, as well as your right, to insist upon securing these, 
 and to take proper time for the care of your own person, 
 and for your meals. You owe it to yourself also, and to 
 the whole nursing sisterhood, to enforce a suitable re- 
 gard for your reputation, and for the dignity of your 
 position. The maintenance of strict propriety and de- 
 corum on your own part will rarely fail to command 
 respect. 
 
 To the doctor, the first duty is that of obedience 
 absolute fidelity to his orders, even if the necessity of 
 the prescribed measures is not apparent to you. You 
 have no responsibility beyond that of faithfully carry- 
 ing out the directions received. It is true that nearly 
 all orders are conditional, and that circumstances may 
 occasionally arise which would render literal adherence 
 to the plan of treatment indicated, useless or even in- 
 jurious, whence the necessity for an intelligent under- 
 standing of the case on the part of the nurse. But only 
 the most positive and evident reasons justify any depar- 
 ture from her instructions. In a hospital, where a 
 medical attendant is always within call, there will never 
 be any occasion to assume such responsibility. Here 
 military discipline should prevail, and implicit, unques- 
 tioning obedience be the first law for the nurse, as for 
 the soldier. In private practice there is more room 
 for the exercise of judgment, but a good nurse is very 
 careful to do not always what seems to her best, but
 
 INTRODUCTORY NURSING AND NURSES 5 
 
 what it seems to her that the doctor will best approve. 
 Whatever may be your own private opinion of the course 
 pursued, you will, by conscientiously carrying out your 
 instructions, give it every chance of success, and never 
 permit yourself to express an unfavorable criticism upon 
 it. Loyalty to the doctor includes encouragement of 
 the patient's faith in him, so long as he is in charge of 
 the case. The imagination is so largely active in dis- 
 ease that to infuse doubt and distrust into the patient's 
 mind is often to destroy all hope of doing him good. 
 The nurse is a connecting link between doctor and pa- 
 tient, responsible to the one, and for the other, and can 
 do much to promote good feeling between them. Be- 
 tween doctor and nurse there should be the most per- 
 fect accord; let him find you always ready to second his 
 efforts with an enthusiasm equal to his own. You owe 
 to him, finally, the utmost candor and truthfulness. 
 Nothing should induce you to pervert or conceal from 
 him anything bearing upon the case, and, if you should 
 chance to be so unfortunate as to make a mistake in 
 carrying out his orders, be honest enough to promptly 
 acknowledge, and by that means do what you can to 
 rectify it. 
 
 Etiquette requires that the nurse should rise when 
 the doctor enters the room, and remain standing 
 while talking to him. After making your report, an- 
 swering his questions, and seeing that he is furnished 
 with everything that he is likely to need, leave the room 
 and give the patient a chance to see him alone unless 
 you have had special instructions to the contrary. In 
 this way you will secure for yourself also an opportunity 
 for private speech. 
 
 To your patient you owe attention to whatever can 
 affect his health or his comfort. You must be ever on 
 2
 
 6 A TEXT-BOOK OF NURSING 
 
 the alert to minister to and even to anticipate his many 
 personal wants. These will vary so much in different 
 cases that few directions can be laid down beyond the 
 general ones for constant watchfulness and thoughtful- 
 ness. No two patients are alike, and it is by no means 
 the greatest sufferers who give the most trouble, or 
 make the heaviest demands upon a nurse. 
 
 There is one necessity common to all cases, that of 
 cleanliness. Keep him with a clean skin, clean clothes, 
 clean air, and clean surroundings generally, and much 
 will be done toward satisfying your patient's needs. 
 This, of course, includes the strictest attention to your 
 own person, which should be an example of cleanliness. 
 A neat and attractive appearance goes far toward mak- 
 ing a nurse acceptable. Your dress should be fresh and 
 tidy, of quiet colors, and with immaculate caps and 
 aprons, if such are worn. The hands especially should 
 be well cared for, kept smooth and warm, with the nails 
 short, and well brushed. Cold or heavy hands will make 
 a patient shrink from your touch; long, sharp nails are 
 likely to scratch him. Cultivate a touch at once firm 
 and gentle, light and steady. 
 
 The prejudice against cleanliness and fresh air, 
 which even in this enlightened age will frequently be 
 encountered, must be combated firmly, though always 
 kindly. It is often a matter of no small difficulty to 
 persuade a patient to submit to having his room suit- 
 ably ventilated; and almost equally prevalent among the 
 ignorant, and still more unaccountable, is the dread of 
 clean clothes. 
 
 Such notions must not, for the patient's own sake, 
 be altogether yielded to, neither should they be allowed 
 to give rise to endless dissensions. Cultivate the pa- 
 tient's confidence in your judgment, while making him
 
 INTRODUCTORY -NURSING AND NURSES 7 
 
 feel that you are really his friend, ready and willing to 
 consult his preferences on all minor matters, and he 
 will be less likely to suspect you of arbitrary decisions 
 upon others. Never use force where persuasion will 
 avail, even with a delirious patient, and do not make 
 an unnecessary display of authority. 
 
 The authority must, however, exist, and will occa- 
 sionally have to be exercised. You will often be obliged 
 to insist upon things very much against the inclinations 
 of your patient, and to administer remedies when he 
 only desires to be " let alone," and no sentiments of 
 mistaken tenderness should deter you from the perform- 
 ance of duty, even when it is mutually disagreeable. It 
 is from failure in this direction, as well as from de- 
 fective knowledge, that amateur nursing is often faulty. 
 A calm, steady discipline is needed in the sick-room 
 that patient, cool control which is far more likely to be 
 exerted by a stranger than by a relative; the very in- 
 tensity of interest felt for a dear friend often tending 
 to incapacitate for judicious ministrations. You must 
 not allow the longing to comfort and soothe the sufferer 
 to blind you to his real interest, yet be on guard against 
 growing hard and unsympathetic in this rigid adherence 
 to duty. Undoubtedly much familiarity with suffering 
 does to some extent blunt the sensibilities, but the rela- 
 tion between nurse and patient is one of so much de- 
 pendence on the one side and so much helpfulness on 
 the other, as to tend to develop what may be described 
 as the maternity of nursing. A sick person is, for the 
 time being, as a child, and looks to his nurse for a 
 mother's care. From such a relation a certain tender- 
 ness of feeling almost inevitably springs, and with it 
 patience to bear with the whims and irritability of the 
 sick.
 
 8 A TEXT-BOOK OF NURSING 
 
 And a nurse soon learns to make allowance for the 
 close connection between mental and physical states. 
 Invalids are often utterly unreasonable. It is as much 
 a part of some diseases as the physical symptoms, and 
 perhaps as little under control. You will scarcely mind 
 what a sick person says to you, so long as you are sure 
 that he has no real ground for dissatisfaction. But bear 
 in mind that diseased fancies can not be dissipated by 
 argument; there must be either absolute proof that 
 they are unfounded, or an effort to do away with the 
 cause of complaint. At least, do not set a thing down 
 as unreasonable, and so do nothing about it, without 
 thorough investigation. The senses of the sick are often 
 abnormally acute, and a source of discomfort, as a bad 
 odor or an unpleasant draught, may make itself pain- 
 fully evident to them, while it is quite imperceptible 
 to any one else. There may be many little personal 
 matters about which other people must know better 
 than yourself the tastes and habits of your patient. 
 With regard to such things you will of course be glad 
 to receive suggestions and assistance. You will almost 
 always find somebody willing to help in the care of the 
 sick. You will be fortunate if they do not rather hin- 
 der. Often the greatest trial of a nurse is the well- 
 meant interference of the patient's friends. If there 
 are any among them to whom you can leave your pa- 
 tient, you must bear in mind that many details, matters 
 of course to you, are likely to be unfamiliar to the in- 
 experienced, and leave with your relief the clearest and 
 most explicit directions about everything that is to be 
 done. If in writing, there will be so much less room 
 for mistakes. If you have no such relief, and find that 
 your strength is being overtaxed, state the case to the 
 doctor, and ask for help. If, for any reason, you find it
 
 INTRODUCTORY NURSING AND NURSES 9 
 
 necessary to give up a case the care of which you have 
 once assumed, you must at least not leave it until you 
 have seen your place adequately supplied. To leave, 
 unadvisedly, a patient in a critical condition should be 
 regarded as a breach of contract; no conscientious nurse 
 would feel justified in doing it. With a chronic case, 
 of probable long duration, you are under no obligation 
 to stay on indefinitely, but when you wish to go, you will, 
 of course, give notice of the fact in time for other ar- 
 rangements to be made. Under no circumstances ought 
 you to threaten the patient with leaving him. 
 
 As a rule, whatever tends to keep the invalid quies- 
 cent and contented is good for him, all occasions of 
 excitement bad. A tranquil, peaceful, though cheery 
 atmosphere should prevail. As far as possible, let every- 
 thing appear to the patient to be moving smoothly and 
 easily, no matter what difficulties and annoyances you 
 may encounter. Try to secure for the sufferer repose 
 of mind as well as of body, freedom from anxiety, and 
 absence of all discussions. If he sees that nothing is 
 overlooked or forgotten, he will soon learn to have faith 
 in you, and will gladly leave you to do his thinking for 
 him. Do not call upon him for decisions, even of small 
 matters, but decide for him. When there is doubt in 
 your own mind as to the best plan to be pursued, con- 
 sult, not the patient, but the doctor. Frankly acknowl- 
 edge your ignorance to the person from whom you can 
 get the desired information. There are very few prac- 
 titioners who will not be willing to explain to you what 
 they can, if they are asked at the right time and in the 
 right way. 
 
 Try to find out why things are done, to be familiar 
 with underlying principles as well as details of practice. 
 Learn to nurse by reason rather than by rule, for no
 
 10 A TEXT-BOOK OF NURSING 
 
 rule can be laid down to which exceptions will not arise. 
 Do not fancy that after you have heen through a train- 
 ing-school you will know all there is to know about 
 nursing; in fact, you will only have been taught how 
 to learn, how to appreciate and profit by the experi- 
 ence which you will get. Every new case will teach you 
 something new. 
 
 Says the great English physiologist: "If knowledge 
 is real and genuine, I do not believe it is other than a 
 very valuable possession, however infinitesimal its quan- 
 tity be. Indeed, if a little knowledge be dangerous, 
 where is the man who has enough to be out of dan- 
 ger! " Learn, then, all that you can only take care 
 that your knowledge is real and genuine, and not a mere 
 smattering of technical terms and you may be assured 
 that the more you know, and the more thoroughly you 
 know it, the more will you realize the depth of your 
 own ignorance, and the less will you dare to make any 
 other than the legitimate use of your knowledge. 
 
 You will often find yourself regarded as " next thing 
 to a doctor," and be called upon to furnish information 
 and give advice to an extent quite beyond your prov- 
 ince. Just here should be an essential point of dif- 
 ference between the trained and the untrained nurses. 
 It is only the latter who may be expected to proceed 
 to the practice of therapeutics on their own account, 
 those who have had no formal instruction as to their 
 duty, its extent and its limits; not those who are taught, 
 but those who are untaught, and who have picked up, 
 in a hap-hazard way, certain isolated facts regarding 
 medical treatment, which they generalize and act upon. 
 The trouble with such nurses is not that they know 
 too much, but that they know too little. It is impos- 
 sible that, with sickness and its treatment always under
 
 INTRODUCTORY NURSING AND NURSES 11 
 
 their eyes, they should not assimilate some informa- 
 tion; the only question is whether they shall be taught 
 it systematically, and in its proper relations, or whether 
 they shall be left to appropriate and use it empirically. 
 The question has been sufficiently answered by the suc- 
 cess of the training-schools, and the ever-increasing de- 
 mand for nurses trained to a knowledge befitting their 
 position. 
 
 A few very simple remedies only can you recommend 
 without overstepping the bounds of propriety, but you 
 will find a broad field of missionary labor in promul- 
 gating general principles of hygiene, sanitary science, 
 and physical culture. Do not offer drugs for every ail- 
 ment presented to your notice, but show the growing 
 child how to expand his chest and carry himself erect. 
 Explain to the young girl just developing into woman- 
 hood her need for special care; teach the tired mother 
 how to relax the tension of her muscles; preach the vir- 
 tues of cold water, simple diet, and rational exercise, 
 and you may be an educational influence of inestimable 
 value. 
 
 . In speaking of the relations between nurse and pa- 
 tient, it should not be necessary to more than refer to 
 the fact that a nurse occupies a position of trust, and 
 is perforce admitted to a knowledge of many private 
 affairs. No one with any sense of delicacy can regard 
 as otherwise than inviolably sacred what is thus tacitly 
 left to her honor. It is true that your patients will be 
 largely dependent upon you for society, and that it is 
 often difficult to produce conversation on demand, but 
 it is certainly possible to be bright, cheerful, and enter- 
 taining without resorting to gossip. To further this 
 end, as well as for your own sake, it is advisable to go 
 occasionally to places of amusement, to read recent
 
 12 A TEXT-BOOK OF NURSING 
 
 books, and to keep yourself posted on matters of general 
 interest. 
 
 All these directions will be seen to apply more par- 
 ticularly to the private nurse. In a hospital, the inti- 
 mate intercourse of the home nurse with her patient is 
 impracticable and undesirable. Over-familiarity is to 
 be avoided, and strict impartiality preserved, but at the 
 same time the greatest patience and gentleness may be 
 exhibited, and all possible regard for the comfort of the 
 patients. 
 
 The work and the position of the nurse are in many 
 ways radically different. She is under constant super- 
 vision, and literal obedience to orders will carry her 
 safely through the exigencies of hospital service, but in 
 private nursing a much greater responsibility falls to 
 her share; there is more room for the exercise of her 
 own judgment, and for the development of her own in~ 
 dividuality. The qualities required are so diverse as to 
 be rarely found in combination. An excellent ward 
 manager may succeed but poorly as a private nurse, for 
 the generalship and executive ability which count for 
 so much in the hurry of ward work become valueless in 
 comparison with the tact and adaptability so infinitely 
 more important in the care of a single patient at home. 
 The readiness with which a nurse adapts herself to the 
 habits and idiosyncrasies of a family which she enters 
 for the first time, and the degree of harmony which she 
 is able to maintain with all its members, are more con- 
 vincing evidence of her good sense and fitness for a deli- 
 cate position than the most brilliant examination pa- 
 pers. It is in this point that some of our most intelli- 
 gent nurses and best ward keepers fail when they come 
 to the crucial test of outside practice. 
 
 You should in each new place make it a rule to dis-
 
 INTRODUCTORY NUESING AND NURSES 13 
 
 turb as little as possible the ordinary household arrange- 
 ments, however little you may find them to your taste, 
 and to make no unnecessary work. Any manifest con- 
 sideration for the servants will usually be repaid with 
 interest, and is to be recommended as a matter of policy 
 if from no higher motive. But the ideal nurse, the one 
 worthy of her high calling, is inspired by love, not 
 policy, and her sympathies are broad and universal. 
 Pages might be written 1 upon the ethics and etiquette 
 of nursing, but to little profit. The instincts of pro- 
 priety and the gracious tact which is the culmination 
 of culture can not be taught by books. The basic laws 
 of good morals and good manners fit every situation, and 
 the minor adaptations of the conduct of life to special 
 circumstances are better acquired from example than 
 precept. 
 
 " Ask God to give thee skill 
 
 In comfort's art ; 
 That thou may'st consecrated be, 
 
 And set apart 
 Unto a life of sympathy ; 
 For heavy is the weight of ill 
 
 In every heart ; 
 
 And comforters are needed much, 
 Of Christ-like touch." 
 
 A. E. Hamilton.
 
 CHAPTER II 
 
 "Thank God every morning when you get up that you have 
 something to do which must be done whether you like it or not. 
 Being forced to work, and forced to do your best, will breed in 
 you temperance, self-control, diligence, strength of will, content, 
 and a hundred virtues which the idle will never know." Charles 
 Kingsley. 
 
 THE comfort and well-being of the invalid depend 
 to so great an extent upon his surroundings that, in 
 consideration of the universal liability to illness and ac- 
 cidents, there ought to be in every well-arranged house 
 an apartment chosen and especially fitted for the use of 
 the sick. But the matter, in spite of its importance, is 
 so generally ignored that it is very rarely that a nurse 
 will have the good fortune to find any provision made 
 for such contingency. You will be called upon to nurse 
 in all sorts of places, and often under the worst possible 
 sanitary conditions. It is important to have a clear idea 
 of what a sick-room ought to be, in order to know how 
 to choose the least among unavoidable evils, and how 
 best to utilize such advantages as you may chance to 
 secure. 
 
 A model sick-room is spacious, light, airy, clean, and 
 quiet. The larger the room, the better can it be aired; 
 the more airy it is, the cleaner will it be; and the 
 cleaner it is, the more favorable is it for the recovery of 
 the patient. Space is therefore an important considera- 
 tion from a hygienic point of view. The sick-room 
 14
 
 THE SICK-ROOM 15 
 
 should be located on the sunny side of the house, having 
 a south or west aspect. Only in exceptional cases, such 
 as inflammation of the eye or brain, is it necessary to 
 have the room darkened, and even then a south room, 
 with the light carefully moderated by blinds and shades, 
 is to be preferred to a darker one on the north side. 
 Light is a healthful stimulus, and in the majority of 
 cases not only light but direct sunshine is to be desired, 
 partly for the additional cheerfulness which it imparts, 
 but still more because of its actual physical effects. The 
 Italians have a proverb, " Where the sun does not en- 
 ter, the doctor does," showing their recognition of it 
 as a powerful remedial agent. Have as many windows 
 as possible, certainly no less than two. They should 
 be such as can be opened at both top and bottom, and 
 should reach nearly to the floor, that the patient may 
 easily see out of them., Bars and streaks of light and 
 bright reflections are to be guarded against, as they may 
 occasion a great deal of annoyance. 
 
 The sick-room should be as far as possible remote 
 from the noises and odors of the house and of the street. 
 It should be solidly built, having walls thick enough to 
 deaden external sounds, and floors substantial enough 
 not to vibrate under every tread. Where this is not the 
 case, manage, if possible, to have the room above unoc- 
 cupied. There are numerous advantages to be gained, 
 especially in cities, by having the sick-room at the top 
 of the house. It will be more quiet, in a stratum of 
 purer air, and in case of contagious disease can be more 
 completely isolated. On no account should there be 
 stationary basins in the sick-room. If you find there 
 such modern conveniences, cork up the overflow holes, 
 and fill the basin with water, which must be changed 
 from time to time, or cover it entirely and closely with
 
 16 A TEXT-BOOK OP NURSING 
 
 a board. The increased security will more than com- 
 pensate for the extra trouble. Only with the utmost 
 precautions against leaky and defective traps are drain- 
 age pipes to be allowed even in the adjoining dressing- 
 room. 
 
 The latter is an important adjunct to the sick-room. 
 In it are to be kept the bath and toilet appurtenances. 
 Ample closet room is also desirable, with shelves- and 
 drawers for the reception of linen, and of the various 
 medical and surgical appliances which may be needed, 
 but which should never be visible in the sick-room. It 
 is a common, but very reprehensible, practice to have 
 food, medicine, and all sorts of paraphernalia lying 
 about, in a confusion that would be enough to make a 
 well person sick. They should all be banished, except 
 at the moment of actual use. Growing plants, and 
 freshly cut flowers of not too strong odor, may fill their 
 place, if desired. They are quite unobjectionable. The 
 water in which flowers are kept must be daily changed, 
 and the flowers themselves thrown away as soon as they 
 begin to fade. Do everything possible to make the sick- 
 room the brightest and cheeriest in the house. A cer- 
 tain amount of depression is the inevitable accompani- 
 ment of sickness. It can not be entirely dispelled, but 
 all counteracting influences should be brought to bear. 
 Dark, gloomy, and unpleasantly suggestive surround- 
 ings do much to intensify it. 
 
 The walls and ceilings are best of some soft, uniform, 
 neutral tint, as pale green or French gray. Avoid wall- 
 papers of conspicuous tone or regularly recurrent fig- 
 ures. Better than any paper is paint, or a hard-finished 
 surface which can be scrubbed. The monotony may be 
 broken by pictures, but judgment needs to be exercised 
 in their selection, and no frames should be used which
 
 THE SICK-ROOM 17 
 
 can not be disinfected. The wood-work should be se- 
 verely plain and flat. There should be no cornices or 
 moldings, and no woolen curtains, portieres, or drapery 
 of any kind. All woolen stuffs easily become infected, 
 and are extremely difficult to disinfect. If any curtains 
 are used, they should be of light, washable material, and 
 should be frequently washed. Carpets are much better 
 dispensed with. Hugs may be used only if small enough 
 to be daily removed, shaken, and aired. If there is car- 
 pet, it can only be thoroughly swept and cleaned when 
 the patient can be got out of the room, but the surface 
 dust can be removed quite effectively and noiselessly by 
 means of a damp cloth wrapper around a broom. It is 
 not a bad idea, especially in obstetrical and surgical 
 cases, to cover a carpet with crash, where it is not prac- 
 ticable to take it up. 
 
 The essential furnishings of the sick-room are, a 
 bed, a bedside table, an easy chair, a lounge, and a large 
 movable screen. The latter can be readily improvised 
 by fastening a shawl or a sheet over an ordinary clothes- 
 horse. Convenient tables are made with the point of 
 support very much on one side, so as to reach well over 
 the bed. They may be raised or lowered to any desired 
 height. Bed-trays, with a low rim around three sides, 
 standing on legs high enough to keep the weight entire- 
 ly off the body, may be used by the patient for all the 
 purposes of a table. 
 
 A bed-rest, a commode, and similar small conven- 
 iences may be desirable, but the fewer superfluous things 
 the better. All the furniture should be of the simplest 
 possible style; elaborate carvings only afford lodging- 
 places for dust, and whatever adds to the difficulty 
 of maintaining absolute cleanliness is to be avoided. 
 Everything should be substantial and in good repair.
 
 18 A TEXT-BOOK OF NURSING 
 
 Ill-fitting blinds, rattling windows, and creaking doors 
 are nuisances demanding speedy remedy. 
 
 Many slight and apparently unimportant noises, 
 which are nevertheless peculiarly annoying to the sensi- 
 tive nerves of the sick, may easily, with a little care and 
 forethought, be done away with. Keep rocking-chairs 
 out of the room. Avoid wearing clothes that rustle, or 
 shoes that squeak. If coal must be put on the fire, 
 bring it in wrapped in a paper, and lay it on, paper and 
 all. Use a wooden rather than a metallic poker to rake 
 the fire. Noise which is understood and inevitable is 
 far less trying than a much slighter noise, unexplained 
 or unnecessary. Intermittent is more hurtful than con- 
 tinuous noise. Sudden, sharp, and jarring sounds are 
 especially bad. A good nurse never startles her patient. 
 Even in such a small matter as your way of addressing 
 him, be considerate of his weakness. Do not speak 
 abruptly from behind him, making him first jump, then 
 turn round, then ask what you said, but get his atten- 
 tion before speaking, and use a clear, distinct, though 
 not necessarily loud, voice. Whispering in the sick- 
 room, or just outside the door, is one of the worst of the 
 many distressing forms in which the solicitude of the 
 patient's friends will manifest itself. There are few 
 things more tormenting, though it is usually done with 
 the very best intentions of not disturbing him. A low, 
 distinct tone, when conversation is necessary, will sel- 
 dom annoy. Whispering always will, as will any sound 
 which strains the attention, or creates a sense of expec- 
 tation. It should be laid down as a rule that whatever 
 the patient is not intended to hear should not be said in 
 his presence. 
 
 These seem very small points to dilate upon, but 
 good nursing depends largely upon attention to details
 
 THE SICK-ROOM 19 
 
 so apparently trivial that a careless person would never 
 think of them, but which yet make or mar the comfort 
 of the invalid. Small things assume momentous pro- 
 portions in the limited interests of a sick-room. Noth- 
 ing is insignificant or beneath notice which has any 
 bearing upon the welfare of the patient. To keep the 
 sick-room in a proper condition is as important a part of 
 your care for him as more personal ministrations. A 
 nurse ought not to be expected to do housework, which 
 can be equally well done by some one else, for she has 
 enough other and more fitting demands upon her time 
 and strength, but, in order to direct others, she should 
 know exactly how it ought to be done. The work of a 
 nurse in a private family varies so much with circum- 
 stances that its limits can not be precisely defined. The 
 position is a somewhat anomalous one, and, with all 
 due regard for your professional dignity, surely you will 
 rather perform the most disagreeable and commonplace 
 tasks than let them go undone to the detriment of your 
 patient. With the extra work which sickness always 
 brings, there is often insufficient service, and the nurse 
 will be obliged to share the burden. You must be pre- 
 pared to encounter many inconveniences; your ingenuity 
 as well as your patience will often be taxed; and some- 
 times you will find yourself looked upon as a kind of 
 machine, expected to run night and day without ever 
 needing to be wound up. 
 
 In a hospital there are no difficulties of this sort. 
 Everything is planned with reference to the needs of the 
 sick; the most convenient appliances are at hand as a 
 matter of course; the duties of each person are definitely 
 assigned, and the work as much as possible simplified by 
 systematic arrangement and regular hours. 
 
 In a ward of twenty patients, with the average num-
 
 20 A TEXT-BOOK OF NURSING 
 
 her of bad cases, there will be usually three nurses, with 
 a maid or an orderly to do the scrubbing and heavier 
 work. The head nurse has the oversight of them all, 
 and, present or absent, is responsible for everything 
 done or left undone. Some assistance may be given by 
 the convalescent patients, though it is an uncertain de- 
 pendence. Care must, of course, be taken not to overtax 
 the strength of any one, but they can be made useful in 
 a good many little ways, and are usually glad of some 
 light occupation. Their work is, however, little to be 
 relied upon, for a patient able to do much is likely to be 
 soon discharged. 
 
 Ward work, in spite of its variety, may, if skillfully 
 planned and systematized, be reduced very much to a 
 routine. Minor arrangements vary in different institu- 
 tions, but the fundamental principles of the nursing 
 service are everywhere the same. The nurses appear in 
 the ward, ready for duty, punctually at the appointed 
 hour. The patients should previously have had their 
 morning toilets made, under the direction of the night 
 nurse, that there may be no delay in getting them ready, 
 for breakfast. The head nurse first reads the report of 
 the night, and ascertains any changes that there may 
 be in the condition of the patients or in the orders given. 
 Unless she has very competent assistants, she will then 
 herself attend to the care of the worst cases among the 
 bed-patients, and to the giving out of the medicines. 
 There are also all the beds to be made, the temperatures 
 to be taken, soiled clothes to be collected and sent to 
 the laundry, the ward generally to be cleaned up, and 
 the diet distributed. All these tasks are divided as the 
 head nurse may direct. One assistant must take charge 
 of the breakfast, see that each patient is served with his 
 appropriate allowance, and those fed who are unable to
 
 THE HOSPITAL WARD 21 
 
 feed themselves. Convalescents should not be allowed 
 to begin until all the bed-patients are attended to. 
 After the meal is over, the dishes are to be picked up 
 and carried out, and the ward made ready for the doc- 
 tor's visit. All this takes time, for sick persons can not 
 be hurried. The nurses must all be ready to attend the 
 staff upon their rounds. The head nurse must be in- 
 formed as to the condition of every patient under her 
 care, ready to answer any questions that may be asked. 
 She must be provided with a note-book, in which to 
 take down on the spot whatever orders are given, and 
 she should call attention to everything which it is im- 
 portant for the doctor to know. It is the duty of the 
 assistants to keep her posted in every particular. No 
 other speaks unless spoken to. Absolute quiet must 
 prevail in the ward during rounds. If there are three 
 nurses, the senior goes on in advance of the staff, and 
 expedites their progress by preparing each case for 
 ready examination. She will know from the nature of 
 the case what is to be done; the clothing must be con- 
 veniently arranged without undue exposure; sometimes 
 it will be necessary to put screens about the patient, or 
 to remove the dressings from a wound. The junior 
 nurse, or probationer, following them, restores things 
 to their previous orderly condition, so that, when the 
 rounds are completed, the ward will not be in a state of 
 general confusion. Provision should be made for the 
 doctors to wash their hands before they leave the ward, 
 and also after making any physical examination, or 
 touching any wounds, before proceeding to the next 
 case. After they have gone, the head nurse will ex- 
 plain to her assistants the orders which she has re- 
 ceived, assigning to each such part of the work as she 
 
 wishes her to do. The rest of the morning will be occu- 
 3
 
 22 A TEXT-BOOK OP NURSING 
 
 pied with the execution of these orders. When any 
 hospital officials coine into the ward, the nurse in charge 
 should rise and remain standing until they have left. 
 Other visitors should be received with courtesy, but 
 only such questions answered as you feel sure they have 
 a right to ask. Information should not be furnished 
 freely to strangers. Visitors should be left alone with 
 their friends, and if there is a time limit, should be 
 notified when it is reached. The nurses take turns in 
 going to their own meals, that the ward may never be 
 left without a responsible attendant. The senior and 
 junior nurses will together attend to the distribution 
 of the patients' dinner; it is usually too much for either 
 to manage alone. One must, however, always be held 
 responsible for the state of the dining-room. She must 
 see that it is in order before she leaves it, the dishes 
 washed and put away, the refrigerator clean, sweet, and 
 locked. The dumb-waiter should be kept closed when 
 not in actual use, and no article except food, and dishes 
 for food, ever be allowed on it. 
 
 After dinner the great press of work is likely to be 
 over, and, after the ward is once more in order, the 
 nurses may each in turn be allowed an hour's absence 
 for recreation. This hour ought, more frequently than 
 it is, to be spent in the open air. Later in the day will 
 be evening temperatures to be taken, supper to be given 
 out, and preparations to be made for the night. 
 
 Besides these enumerated, are numerous other 
 things to be done daily. Old patients are going, and 
 new ones continually coming in all stages of dirt and 
 dilapidation. 
 
 When a patient is admitted, he is at once put to 
 bed, unless by special permission to the contrary. If a 
 stretcher-patient, his coming will have been previously
 
 THE HOSPITAL WARD 23 
 
 announced, and a bed prepared to suit the nature of the 
 case. A list of his clothes must be made, and carefully 
 verified. Such as need it are to be sent to the wash, or 
 to the disinfecting tank, others put away in the ap- 
 pointed place. He must have a bath, if able, and, very 
 possibly, also be treated with some parasiticide. His 
 temperature is to be taken, and any marked symptoms 
 reported. In a susceptible person, the change of sur- 
 roundings, and consequent excitement, may have a con- 
 siderable effect upon the pulse, respiration, and even 
 temperature; it is, therefore, advisable to take them not 
 only immediately upon the entrance of the patient, but 
 again a short time say an hour later. Careful rec- 
 ords should be kept. He will have light, usually fluid, 
 diet only, until special directions are received. 
 
 In the same way every event brings its own demands 
 for more or less time and attention. After twelve hours, 
 the day nurses will be relieved by the night nurse. One 
 at least of the former must stay on duty until the lat- 
 ter comes, even if the day's work should happen to 
 be done earlier. Connections between them must be 
 perfect, and the ward never be left without a nurse in 
 it, or within call. The night nurse is subordinate to 
 the head nurse of the ward, and takes the orders from 
 her. The doctor, in making his evening rounds, will 
 give additional directions. The duty of the night nurse 
 is important, for all seriously sick people need great 
 care at night, and for others they are often the most 
 wearisome hours. She needs to be especially patient, 
 kind, and gentle, for great demands are made upon her 
 forbearance. She must try to get the wards quiet, and 
 the lights down early, and to do her work with as little 
 commotion as possible. Before she goes off in the morn- 
 ing, besides making a verbal report to the head nurse,
 
 24 A TEXT-BOOK OF NURSING 
 
 she must prepare for the doctor a written record of 
 everything noteworthy which has occurred during the 
 night. 
 
 For work to go on smoothly, there needs to be the 
 greatest harmony and accord among all the nurses. 
 They have devoted themselves to a common object, with 
 which no petty personal feeling should ever be allowed 
 to interfere. No nurse is fit for her position who will 
 sacrifice to any narrow jealousies or disputes the work- 
 ing order of her department. 
 
 All that has been said of the care of the sick-room 
 applies with even stronger emphasis to the hospital ward, 
 where a greater number of lives are at stake. The first 
 requisite is scrupulous cleanliness. No amount of ven- 
 tilation will keep the air sweet in a ward that is not 
 clean. It has been sagely remarked, that " dust in a 
 ward is not only dirt but danger." It consists largely 
 of organic matter, which must be taken away, not mere- 
 ly stirred up and redistributed. Nothing really removes 
 dust but a damp cloth or sponge, to which it will ad- 
 here. To sweep properly a room full of people requires 
 more care than a maid will, without special oversight, 
 be inclined to give. The ordinary flourish of brooms 
 raises a cloud of dust, and drives it over the beds, and 
 into the eyes and mouths of their unfortunate occu- 
 pants. On a hard floor, a soft-hair broom should be 
 used or a dry " dust-mop." Water for washing floors 
 should be often renewed, and not too freely used. Vig- 
 orous rubbing with a cloth or carriage sponge, wrung 
 out nearly dry, will do more good than a deluge of dirty 
 water. During the sweeping, the rugs should be taken 
 out of doors and shaken. Some dust will of necessity 
 escape into obscure nooks and corners, all of which 
 should, therefore, be under strict supervision. Dusting,
 
 THE HOSPITAL WARD 25 
 
 except of metallic surfaces, must be done with a damp 
 cloth, followed, if need be, with a dry after-polish. The 
 feather-duster in common use is worse than worthless, 
 except to bring down to an accessible height dirt that is 
 out of reach, for it serves only to scatter the dust and 
 make it less conspicuous, a disadvantage rather than a 
 desideratum. 
 
 All vessels must be removed from the ward imme- 
 diately upon use, and thoroughly cleaned; all waste mat- 
 ter, even water used for washing, should be at once 
 carried out. Communicating passages, bath-rooms, and 
 closets, as well as the ward itself, must be under strict 
 supervision, for it is of little use to have an immaculate 
 ward, if every time a door is opened it gives admittance 
 to a gust of unclean air from some dusty or ill-venti- 
 lated lavatory. To keep the lavatories free from odor 
 needs special care. Water-closets should be thoroughly 
 flushed, and have some disinfectant poured down them 
 daily. Any failure of water supply, or discovery of im- 
 perfect drainage, must be at once reported to the proper 
 authorities. There should be not a hole or corner any- 
 where which will not bear the most rigorous inspection. 
 All basins, bath-tubs, and metal fixtures must be kept 
 bright and shining. 
 
 Kemove from the ward promptly all soiled clothes. 
 Before sending them to the laundry see that no pins are 
 left in them, that they are distinctly marked with the 
 name or number of the ward, and, if private 'property, 
 with the name of the patient. Roll very dirty things 
 in a bundle by themselves. A list must be made out, 
 of which a duplicate is retained, for comparison when 
 the clothes are returned. 
 
 Cleanliness, everywhere " next to Godliness," in a 
 hospital ward, takes precedence of all other virtues:
 
 26 A TEXT-BOOK OF NURSING 
 
 " Order, heaven's first law/' has a secondary, but still 
 an important place. A well-kept ward is characterized 
 by neatness and uniformity. A little care to have 
 things straight adds much to its attractiveness of ap- 
 pearance. The beds should be in an exact line, curtains 
 at an equal height, chairs, tables, and rugs at the same 
 angle to each other. Few things give a ward a more 
 disorderly effect than clothes tucked about the beds 
 or tables, or flung over chairs. The bedside tables must 
 be daily inspected, and no rubbish allowed to accumu- 
 late in them. Unless carefully watched, patients are 
 very apt to stow away, in the nearest place, dirty clothes, 
 relics of meals, dead flowers, apple skins, or any refuse 
 that may need to be disposed of. Eefuse-cans should 
 be provided, always of metal, with tightly fitting covers. 
 They should never under any circumstances be allowed 
 to stand uncovered. They will need to be scoured out 
 frequently with some strong disinfecting solution. 
 
 Nothing should be thrown out which can be in any 
 way utilized. If supplies are liberally furnished, do 
 not, therefore, think that little bits are of no account, 
 but make them go as far as possible. Hospital supplies 
 are of an expensive nature, and it is the nurse's duty to 
 see that nothing is wasted. See also that supplies are 
 well kept up; everything expected to be on hand re- 
 newed before it is quite exhausted. In a surgical ward, 
 the dressing-basket should stand in some accessible 
 place, furnished with everything likely to be called for 
 in an ordinary dressing. 
 
 To keep things in order, it is necessary to work 
 neatly, and clear up after each performance before un- 
 dertaking another. Much confusion will be avoided by 
 getting everything ready, even to the smallest detail, 
 before beginning any process. Have a clear idea in
 
 THE HOSPITAL WARD 27 
 
 mind of what is to be done, and never get excited. You 
 will then be able to be prompt without hurrying, quiet 
 and methodical in movement, and will doubtless soon 
 achieve a reputation as a neat and skillful nurse. 
 
 " The trivial round, the common task, 
 Will furnish all we ought to ask. 
 Room to deny ourselves, a road 
 To bring us daily nearer God." 
 
 John Keble.
 
 CHAPTER III 
 
 " In bed we laugh, in bed we cry, 
 And born in bed, in bed we die. 
 The near approach a bed may show 
 , Of human bliss to human woe ! " 
 
 Isaac de Benserade (trans, by Samuel Johnson). 
 
 IT is the common notion that anybody can make a 
 bed, and possibly also that it is of very little account 
 exactly how a bed is made. To a thoroughly healthy 
 person, who will sleep soundly all night and turn out of 
 bed as soon as he wakes, it does not indeed matter 
 much, although he spends a third of his life in it, 
 whether his bed be well or ill made, so long as it is 
 clean and warm. But the invalid, whose confinement 
 to it is more or less permanent and compulsory, and 
 the acuteness of those sensations is aggravated by 
 disease, finds few things more seriously affecting 
 his comfort than the condition of his bed. To know 
 how best to arrange and take care of it is very im- 
 portant for the nurse. When you take charge of a 
 private patient, who has been till then cared for by 
 home talent, in nine cases out of ten the first thing you 
 will find it necessary to do will be to reconstruct the 
 bed, and often the skillful rendering of this simple 
 service will at once call forth the gratitude of your 
 patient, and gain his instant recognition of your 
 efficiency. 
 
 Let us first consider the frame upon which the bed 
 28
 
 BEDS AND BED-MAKING 29 
 
 is supported. Wooden bedsteads should not be used for 
 the sick when anything else can be obtained. The best 
 are those common in our hospitals, made entirely of 
 metal, iron, or brass, with a mattress of woven wire. 
 These can be kept in a clean and wholesome condition 
 more easily than any other, and are for use in the sick- 
 room far superior to those ordinarily found in private 
 houses. They are non-absorbent, and afford no hiding- 
 places for vermin, which, in spite of all precautions, will 
 sometimes appear, even in well-regulated homes, and to 
 which public hospitals, with their miscellaneous class of 
 patients, are especially liable. The first sign of a bug 
 should be the signal for a most careful search and ex- 
 termination, for, once having gained a foothold, they 
 multiply, as every housekeeper knows, with alarming 
 rapidity. Corrosive sublimate is the surest remedy, but, 
 being a violent poison, it must be handled with caution. 
 Another exterminator, recommended for all kinds of 
 vermin, has the following formula: Aqua ammonia, two 
 ounces; saltpetre, one ounce; soap, scraped, one ounce; 
 soft water, one quart. 
 
 Bedsteads should be on castors, so as to be easily 
 moved, and should be no heavier than is necessary for 
 strength. It is better to have castors upon two legs 
 only, at the head of the bed, rather than upon all four. 
 This will secure ease of movement when necessary and 
 at the same time keep it from being moved inadvertent- 
 ly, which may cause annoyance. The best dimensions 
 for a bed in which a sick person is to be cared for, are 
 six and a half feet long, three feet wide, and two, or at 
 most, two and a half, feet high. If it is too wide, the 
 nurse will be unable to reach the patient without get- 
 ting upon the bed herself, which is always an objection- 
 able proceeding; if it is too high, it adds to the difficulty
 
 30 A TEXT-BOOK OF NURSING 
 
 of raising the patient, and makes it harder for convales- 
 cents to get in and out. 
 
 Over the wire springs will be placed a mattress of 
 some kind. For this various materials are used hair, 
 straw, jute, felt, etc. Straw has the advantage of cheap- 
 ness, and the ticks can be frequently emptied, washed, 
 and refilled, while the old straw is burned; but hair of 
 good quality makes the most comfortable bed, being at 
 once firm and elastic. It can be cleaned and subjected 
 to a disinfecting temperature without injury. This is 
 also true of the so-called " felt " mattress, which, con- 
 sisting simply of layers of cotton batting, is much less 
 expensive, while both comfortable and durable. Hos- 
 pital mattresses are frequently made in sections, as they 
 wear more evenly, and a part can be renewed without 
 taking to pieces the whole. When this is done it is 
 well to have the sections tacked strongly together, as 
 they are otherwise apt to slip apart, leaving an uncom- 
 fortable crack under the patient. Still, an expert bed- 
 maker will get the under sheet tight enough to hold 
 them in place. In some surgical cases it is necessary 
 to have a part removable, to allow the application of 
 mechanical apparatus. 
 
 A feather-bed is a thing never to be thought of in 
 connection with the sick-room, being a combination of 
 every objectionable quality. Its use is nearly equivalent 
 to putting the patient into an immense poultice; it is 
 warm, soft, absorbent, and consequently nearly always 
 damp. Unless it is stuffed unusually full the patient 
 sinks at once into a hole; it is impossible to keep it 
 level, and, if it once gets wet, there is no way of reno- 
 vating it. Once in a while, one comes across some old 
 lady, who, from long usage, has become so attached to 
 her feather-bed as to fancy that she can not sleep on
 
 BEDS AND BED-MAKING 31 
 
 anything else. If she is able to leave it daily, to have 
 it shaken up and rearranged, it is scarcely worth while 
 to struggle against the prejudice; but if she is likely to 
 be confined to bed for any length of time, the first thing 
 to be done is to persuade her to give it up, for, offering 
 as it does every condition favorable to the development 
 of bed-sores, it will be a source of danger as well as of 
 discomfort. After a few days' trial, even the most per- 
 sistent lover of the feather-bed will usually be convinced 
 of the superiority in sickness of an unyielding support. 
 If not, and the sufferer still clings to her old habits, then 
 we are sorry for the nurse, for she has a hard task be- 
 fore her. In many surgical cases it is of great impor- 
 tance that the bed be kept flat and level. Where extra 
 firmness is required a thick board, the size of the mat- 
 tress, is placed under it. This is known as a fracture- 
 board. It should have holes in it for ventilation, or a 
 frame of slats may take its place. 
 
 The propensity of hospital patients to stow away 
 their personal property under the mattresses should be 
 provided against. Give them other safe and convenient 
 places in which to put their things, and insist upon hav- 
 ing the beds kept clear. 
 
 For sheets, cotton is a better material than linen. 
 The latter, being a good conductor of heat and a rapid 
 absorber of moisture, has a tendency to chill the surface 
 of the body; cotton does not conduct away the heat so 
 rapidly, and is, therefore, safer for the use of the sick. 
 Sheeting comes in widths adapted for beds of different 
 sizes. Whatever the width of the sheet, the length 
 should exceed that of the bed by three-quarters of a 
 yard. 
 
 In making the bed spread the lower sheet smoothly 
 and tightly over the mattress, tucking it in securely on
 
 32 A TEXT-BOOK OP NURSING 
 
 all sides. It can be made still more firm, if the bed is 
 being prepared for long occupancy, by fastening it with 
 safety-pins to the mattress. Be careful that the sheet 
 is put on straight, for, if not, it will form wrinkles, 
 and, if pinned, be likely to tear. There should not be 
 a blanket between the under sheet and the mattress. It 
 may be necessary to protect these from discharges by a 
 piece of rubber cloth, covered by a second folded sheet, 
 or a narrower " draw-sheet." The latter, as its name 
 implies, may be easily drawn from under the patient 
 with very little disturbance to him, while another is at 
 the same time slipped into its place. The water-proof 
 and draw-sheet must both be stretched as tightly as pos- 
 sible, and well tucked in. The hem should always be 
 at the top. When rubber sheeting can not be obtained, 
 enameled cloth or oiled muslin will answer the purpose, 
 or, in an emergency, heavy brown wrapping-paper is a 
 fairly good substitute. The rubber, being only for the 
 protection of the bed, should not be retained longer 
 than is really necessary, as the patient may be more com- 
 fortable without it. 
 
 The upper clothing should be enough for warmth, 
 but no more; for too much warmth is enervating, and 
 too much weight impedes respiration. There will be 
 first another sheet, tucked in well at the foot, that it 
 may not be pulled out of place, but left long enough to 
 turn down for some little distance over the blankets. 
 A woolly surface coming in contact with the face is 
 usually very disagreeable, though, in some cases, where 
 there is special need for warmth, as in acute rheuma- 
 tism, the patient will be put directly between the blank- 
 ets. Blankets of good quality are the best bed-covering, 
 being warm, and not weighty. Double ones should al- 
 ways be separated. They should come up high enough
 
 BEDS AND BED-MAKING 33 
 
 to tuck in snugly around the throat, if desired; but the 
 patient should not he allowed to sleep with his head 
 iinder the bedclothes, breathing the noxious emanations 
 from his body. Several thin coverings will be warmer 
 than a single one of equal weight, because of the non- 
 conducting air inclosed between them. Heavy quilts 
 and counterpanes will be found burdensome. The old- 
 fashioned cotton comforter is heavy, and not propor- 
 tionately warm. Eider-down quilts are luxuriously light 
 and soft, but can not be well cleaned or disinfected. A 
 patient sleeping under one should be carefully watched, 
 as it is likely to induce excessive perspiration. If one 
 desires to avoid the weight of a counterpane, a clean 
 white sheet will take away the unfinished look of the 
 blankets alone, and at the same time protect them from 
 dust. Counterpanes, being chiefly ornamental additions 
 to the outfit of the bed, may as well be taken off at night, 
 and so kept clean the longer. An extra blanket will be 
 needed toward morning, and should always be at hand. 
 Blankets, as well as sheets, need washing whenever they 
 are stained or dingy, or are taken from infected beds. 
 Fresh blood-stains can be removed from blankets or 
 ticking by spreading over the spot a paste of fine starch 
 or wheat flour, and allowing it to dry. If, upon rubbing 
 it off, it is found that the stain has not entirely dis- 
 appeared, a second application will be pretty sure to 
 be effectual. Blood and other stains can be removed 
 from rubber by Labarraque's solution (of chlorinated 
 soda). 
 
 The beds in a hospital ward should be made to look 
 as nearly alike as possible, the surfaces even, the spreads 
 equally far from the floor on both sides, and with the 
 corners arranged at the same angle. In some hospitals 
 the convalescents make their own beds; but a great lack
 
 34 A TEXT-BOOK OF NURSING 
 
 of uniformity results, detracting much from the neat 
 appearance of the ward. 
 
 The sick-bed should stand far enough from the wall 
 to he accessible on all sides. It should be in such posi- 
 tion that its occupant can look out of the window, but 
 whatever artificial light is employed is best behind 
 him. 
 
 Nothing should be allowed under the bed, nor should 
 there be any drapery to prevent the free circulation of 
 air below it. The bed should stand steadily, so as not 
 to be easily jarred. Sitting on the bed, leaning against 
 it, or in any way shaking it, occasions great discomfort 
 to the patient. Sometimes even the touch of the bed- 
 clothes can not be endured. They may then be sup- 
 ported over the seat of pain by " cradles " frames of 
 iron or wood made for the purpose. The two halves of 
 a barrel-hoop tied together in the middle will make a 
 fairly good one; or, for a limb, a bandbox, split through 
 the center. Or the clothes may be lifted on a strong 
 cord running diagonally from the head to the foot of 
 the bed. 
 
 For changing a sheet or draw-sheet, while the pa- 
 tient is in bed, the method usually recommended is to 
 roll the soiled sheet lengthwise, from the edge of the 
 bed farthest from the patient, till it reaches him. The 
 clean sheet, previously rolled in the same way, is then 
 unrolled over the space from which the first was taken, 
 until the two rolls lie side by side. The patient may 
 then be lifted or turned over on to the clean sheet, the 
 soiled one being removed, and the rest of the clean one 
 unrolled. Instead of rolling the sheets, it is better to 
 fold them alternately backward and forward in the 
 manner illustrated by Fig. B, as the folds lie flatter than 
 the roll, and, when the upper one is pulled, the others
 
 BEDS AND BED-MAKING 35 
 
 readily follow. This is more easily manageable, and is 
 less likely to become tangled than the more compact 
 roll. If it is not advisable to move the patient, even 
 from one side of the bed to the other, the mattress may 
 be pressed down, while the clean and soiled sheets are 
 together gradually worked under his body. The head 
 
 and feet can be slightly raised to allow the folds to 
 pass. It requires two persons to do this easily. 
 
 The upper sheet can be changed with even less 
 trouble and without exposure. Free the clothes at the 
 foot of the bed. Spread the clean sheet outside of them 
 all, over it a blanket, and tuck them in securely before 
 removing the first set. Finally, slip these from under 
 the clean sheet, and carry the blanket out to air. If the 
 extra blanket is not at hand, the clean sheet may be 
 rolled or folded across its width, tucked in at the bot- 
 tom, and unrolled toward the top under everything else, 
 the soiled sheet being afterward pulled down and re- 
 moved at the foot. See that the blankets are made 
 smooth and straight. If they are not wide enough to 
 tuck in well at the side, the upper one may be laid on 
 across the others; otherwise they will all be dragged off 
 on one side when the patient turns over. 
 
 The common custom of taking a crumpled upper 
 sheet and putting it on in place of a soiled lower one is 
 not good economy in sickness. If there can be only one
 
 36 A TEXT-BOOK OF NURSING 
 
 clean sheet given, let it be the one on which the patient 
 has to lie. His comfort, unless he has an unusual re- 
 gard for appearances, depends more upon having a 
 smooth, fresh surface under him than upon having it 
 where it will show the most. The sheets ought to be 
 changed frequently at least one every day, if only to 
 be aired and used again. See that all clean articles like- 
 ly to be needed are at hand before removing the soiled, 
 and that they are well aired and warmed. Dampness in 
 bed or bedding is always dangerous. If the bed feels 
 close and unpleasant, it may be to some extent aired by 
 lifting the clothes at the edge of the bed, and fanning 
 them up and down a few times. This may be done with- 
 out danger of chilling the patient, and will, especially in 
 warm weather, be found refreshing. 
 
 If you can not change the sheets, pull them as tight 
 and as straight as possible, which will give a fresh feel- 
 ing to the bed. The best possible arrangement is to have 
 two of the narrow beds above described, from one to the 
 other of which the patient can be daily moved. Each is 
 to be supplied with its own complement of bedding, 
 one set being aired while the other is in use. Even a 
 very sick person can be easily moved by two attendants, 
 one standing at his head and the other at his feet. The 
 second bed must be placed as closely as possible by the 
 side of the first, then the sheet upon which the patient 
 lies is lifted by the corners and is carried steadily over. 
 He must be lowered slowly, gently, and without jarring. 
 Then slip from under him the sheet on which he has 
 been moved. Be sure, before you begin, that this is a 
 strong one, with no rent in it that may give way. Two 
 poles or long brush-handles, rolled tightly into the sheet 
 to within a few inches of the patient's body, will con- 
 vert it into an impromptu stretcher, upon which he
 
 BEDS AND BED-MAKIKG 37 
 
 may be kept perfectly horizontal during the moving 
 process. 
 
 If the two beds are of exactly equal height, you may 
 be able to accomplish the transfer alone. One way to do 
 it is to pin a stout rubber cloth to the bed from which 
 you wish to move your patient, letting it lap over on to 
 the other so as to cover the intervening crack and give" a 
 level surface, across which he may be drawn by means of 
 the sheet on which he lies. Or, having the two beds 
 side by side, pull the mattress with the patient on it a 
 little way over the other. He may then be slid down on 
 to the fresh bed, and the first taken away. This is easy 
 if the mattress is not too thick and heavy. 
 
 If the patient is light, the easiest way of all may be 
 to carry him, putting one arm under the knees, and 
 with the other supporting the back just below the 
 shoulders, but this is scarcely advisable except in case of 
 a child. 
 
 All this is assuming that the sick person is perfectly 
 helpless. If he can help himself a little, it of course 
 makes the matter still less difficult. To move him into 
 another bed, although it seems like a great undertaking, 
 is really little more trouble than to rearrange his own 
 under him, while it makes him more comfortable, and 
 gives an opportunity to thoroughly air each bed. There 
 are a few surgical cases fracture of the thigh, etc. 
 in which such a change is impracticable, and in a pri- 
 vate house one is not always able to command hospital 
 conveniences. Where one wide bed must be used, some 
 of the advantages of two may be obtained by using alter- 
 nate sides of it. One half may be kept for the daytime 
 and the other for the night. 
 
 Be especially generous with pillow-cases. Have 
 clean ones often. Pillows need to be frequently
 
 38 A TEXT-BOOK OP NURSING 
 
 changed, or shaken up and turned, as they soon become 
 hot and uncomfortable. In doing this, lift the patient's 
 head carefully, and let it rest on one arm, while with 
 the other hand the desired arrangement is effected. 
 Then lay him back gently; do not let his head drop 
 with a jerk. 
 
 ' To prop up a patient with pillows, first see that one 
 is pushed well down against the small of his back, and 
 then put eacH additional pillow behind the last. This 
 will keep them from slipping, and will support the back 
 without interfering with the play of the lungs. A sin- 
 gle long pillow, stuffed hard, thick at one end and grad- 
 ually diminishing toward the other, like a wedge, is 
 better for this purpose than half a dozen of the ordinary 
 kind. One or two softer ones may be placed on top of 
 it. Wooden bed-rests are made, and, for temporary use, 
 a straight-backed chair, turned upside down, is very 
 good. Bed-rests of netting, secured at each end to the 
 bedstead, are said to be very cool and airy. They can 
 be so arranged as to swing the patient quite off the bed. 
 For a weak patient, with an inclination to slip down to 
 the foot of the bed, Cullingsworth's roller-pillow is val- 
 uable. This is a cylindrical cushion, some four inches 
 thick, with a strip of stout webbing at each end fasten- 
 ing it securely to the head of the bed. The patient sits 
 upon this, as it were, and is supported by it. There are 
 an endless number of invalids' beds made to tip up at 
 various angles, and several forms of patent apparatus 
 for lifting and holding up the patient while the bed is 
 being arranged under him. A very simple and useful 
 appliance for enabling the invalid to help himself is 
 a strap with a handle, pendant from a hinged crane over 
 the bed, or from a ring in the ceiling. 
 
 Small pillows of various sizes and shapes are fre-
 
 BED-SORES 39 
 
 quently serviceable. Rubber air-cushions are especially 
 comfortable. They should be smoothly covered, and 
 the cover should be sewed, not pinned, on. In some 
 cases an air- or water-bed will be called for. They are 
 both made of rubber; the former is filled by bellows, the 
 latter is connected with a hose. The air-mattress may 
 be placed on an ordinary bedstead, but the water-bed 
 lies in a wooden trough. An old blanket, or cloths, must 
 be put under it to keep it from sticking. The water 
 with which it is filled should be at a temperature of 
 about 70 Fahr. Cover with a blanket before putting 
 on the usual bedding. Care must be taken to avoid 
 pricking water- or air-cushions, or beds. All rubber 
 goods need careful handling. They dry out and dete- 
 riorate rapidly, especially when not in use. They should 
 not be put away in a cold room, as freezing is sure to 
 crack them. 
 
 Crumbs in a bed constitute one of the minor miseries 
 of sickness, and can not be too carefully looked out for. 
 There should be a regular crumb hunt after each meal. 
 A bed well cared for is evidence of a good nurse. From 
 neglect or ignorance of its proper management very 
 serious consequences may arise in the form of bed-sores. 
 These result from continued pressure upon prominent 
 parts of the body, and may vary in degree from slight 
 abrasions of the skin to deep wounds. They appear 
 most frequently upon the lower part of the back, the 
 hips, shoulders, elbows, or heels, but may develop wher- 
 ever the conditions are favorable. There is liability to 
 them in all cases of long confinement to the recumbent 
 posture, especially where the vitality is much lowered 
 as in paralysis, fevers, and old age. Very heavy and 
 much emaciated patients are alike predisposed to them, 
 and they are among the most trying complications of
 
 40 A TEXT-BOOK OF NURSING 
 
 surgical cases, where motion is restricted. Bed-sores 
 are frequently occasioned by bad nursing, and the cases 
 are rare in which a good nurse can not avert their 
 formation. They are more easily prevented than cured 
 when once established. Preventive measures consist in 
 keeping the parts thoroughly clean, and the surface 
 under them dry and smooth, in hardening the skin, and 
 in relieving so far as possible the local pressure. This 
 precautionary treatment should be commenced at the 
 beginning of any long sickness, without waiting for 
 manifest signs of danger. The parts most subjected to 
 pressure must be frequently washed with soap and water 
 and thoroughly dried. A draw-sheet should be placed 
 under the patient, which must be changed as often as it 
 becomes damp from any cause, and the greatest pains 
 must be taken to keep it free from wrinkles, crumbs, 
 and inequalities of any kind. The patient's clothes 
 must not be permitted to form folds or creases under 
 him. The skin may be hardened by bathing it several 
 times daily with alcohol, brandy, or eau-de-Cologne, or 
 a solution of bichloride of mercury in alcohol, two 
 grains to the ounce. Salt in whisky, two drachms to 
 the pint, and the dilute solution of sub-acetate of lead, 
 are also good. Follow this treatment by rubbing in 
 well a small quantity of some simple ointment, to keep 
 the skin supple. Finally, dust the parts with some fine 
 powder, to absorb the moisture of the skin. Oxide of 
 zinc is perhaps the best. Lycopodium powder is very 
 fine and soft, but has the disadvantage of staining the 
 bedding. It must be borne in mind also that it is 
 highly inflammable, and must not be used in the vicin- 
 ity of a lamp. Fine starch or the ordinary toilet pow- 
 der used for infants will answer, or corn-starch, if there 
 is nothing else at hand. If the skin is intact, but red
 
 BED-SORES 41 
 
 and angry in appearance, paint the spot thoroughly 
 with nitrate of silver, twenty grains to the ounce. 
 
 When the danger is extreme, or the skin is already 
 abraded, it may be protected by covering it with strips 
 of soap-plaster, or by the application with a broad brush 
 of a single coat of flexible collodion. A thin layer of 
 absorbent cotton with collodion poured over it makes 
 a comfortable and lasting covering. The greatest care 
 must be taken to keep the part from being pressed upon. 
 The pressure may be relieved by frequent changes of 
 position, when such are practicable, by circular pads 
 or air-cushions, or, where the tendency is very marked, 
 by the use of a water-bed. The latter equalizes the 
 pressure, and is, in case of paralysis, or prolonged in- 
 continence of urine, the only efficient safeguard. 
 
 The first symptom of a bed-sore evident to the pa- 
 tient is usually a pricking sensation, or a feeling as if 
 he were lying on something rough. Or there may be no 
 subjective indication whatever. A patient may be de- 
 lirious, paralyzed, or too weak to complain, and a bed- 
 sore be far advanced before it is discovered, unless con- 
 stant vigilance has been exerted in this direction. On 
 this account daily and careful examination should be 
 made of such parts as are especially subjected to pres- 
 sure, and the first discovery of reddening or roughen- 
 ing of the skin, or of pain on pressure, should be ac- 
 cepted as a warning of serious import. If these symp- 
 toms pass unnoticed or uncared for, the discoloration 
 will become deeper, and the inflammation progress until 
 sloughing ensues. 
 
 After a bed-sore is actually formed, its treatment 
 belongs properly in the province of the surgeon, but it 
 is often delegated to the nurse. After the skin is 
 broken it is customary to discontinue the use of spirit,
 
 42 A TEXT-BOOK OF NUKSINQ 
 
 as it causes pain, and to dress with oxide-of-zinc oint- 
 ment or iodof orm. A mixture of tannic acid and oxide 
 of zinc, a scruple of each, worked up into an ointment 
 with an ounce of vaseline, is sometimes recommended. 
 Before applying either of these the wound should be 
 well washed with a solution of bichloride of mercury 
 1 to 5,000, either by means of a syringe or a swab. 
 Finally, cover with a good-sized piece of soap-plaster, 
 having the edges deeply cut, so that it will be pliable. 
 When a slough has formed, its separation is hastened 
 by the use of charcoal or chlorinated poultices. As it 
 becomes detached, it almost invariably reveals greater 
 extent of injury than its superficial appearance would 
 have led one to anticipate, often laying bare,the deeper 
 tissues even to the bone. Poulticing should not be con- 
 tinued longer than is necessary to remove the gangre- 
 nous portion, as it tends to soften and break down the 
 neighboring parts. 
 
 Brown-Sequard advised alternate applications of 
 heat and cold, an ice-bag for ten minutes, followed by a 
 warm poultice for an hour. After the separation of the 
 slough, the resulting ulcerated surface is treated with 
 some stimulating and disinfecting remedy, as balsam of 
 Peru, tincture of catechu, or carbolic acid 1 to 40, ap- 
 plied on lint, only within the limits of the sore. An 
 excellent application at this stage is that known as 
 Wood's mixture, consisting of equal parts of powdered 
 catechu, red cinchona and gum camphor, mixed into a 
 thin paste with balsam of Peru. This makes an indeli- 
 ble stain. Tannic acid also stains. Iodof orm, either in 
 powder or in the form of an ointment, may be used. 
 Cover the lint with a piece of oiled muslin or rubber 
 tissue, of a little larger size, and confine the dressing in 
 place by adhesive strips, not by bandages. It must be
 
 BED-SORES 43 
 
 renewed at least once a day, and the surface of the sore 
 washed with some disinfectant solution before it is re- 
 applied. Remove all pressure by circular pads. The 
 patient's strength must be supported, and the circula- 
 tion improved as far as possible, as the immediate cause 
 of bed-sores is defective nutrition. Regular massage of 
 the tissues about the part injured, may help to im- 
 prove their tone. If neglected, the result may be fatal, 
 as the constant discharge may prove too great a drain 
 upon an already debilitated patient, or pyaemia may 
 supervene from the absorption of septic matter into 
 the blood. 
 
 "Politeness is like an air-cushion; there may be nothing sub- 
 stantial in it, but it eases our jolts wonderfully."
 
 CHAPTEK IV 
 
 " Deeds are the pulse of Time, his beating life, 
 And righteous or unrighteous, being done 
 Must throb in after-throbs till Time itself 
 Be laid in stillness, and the universe 
 Quivers and breathes upon no minor more." 
 
 George Eliot. 
 
 IN view of the definition of health which we have 
 quoted the perfect circulation of pure Hood in a sound 
 organism it becomes desirable for us to know some- 
 thing of the nature of pure blood, and of the means by 
 which its circulation is carried on. It is the most abun- 
 dant as well as the most important fluid of the body, 
 pervading nearly every part of the system; upon its 
 presence and its unceasing motion life as well as health 
 depends. It appears to the naked eye as a simple red 
 fluid, but when examined under the microscope it is seen 
 to be made up of a multitude of little solid bodies float- 
 ing in a clear colorless liquid. They are called corpus- 
 cles, literally little bodies, and the liquid in which they 
 float is known as plasma. The plasma is made up of 
 serum and fibrin. The corpuscles are mostly of a yellow- 
 ish-red hue, and it is from their vast numbers that the 
 blood derives its red appearance. There are some white 
 ones; they are larger than the red, and of a different 
 shape, but are comparatively few in number. 
 
 The blood while it circulates through the body is, 
 though somewhat glutinous, perfectly fluid, but upon 
 44
 
 CIRCULATION 
 
 45 
 
 removal from its natural surroundings it exhibits a well- 
 known tendency to coagulate or solidify. The fibrin of 
 the plasma separates itself from the serum and entan- 
 gles the floating corpuscles into a mass. This peculiar- 
 ity affords protection against undue loss of blood, for 
 
 Red and white corpuscles of the blood. Magnified. 
 
 dangerous haemorrhage would follow even a slight cut 
 did not the clots thus formed effectually close the in- 
 jured blood-vessels and prevent further escape of the 
 vital fluid. Occasionally this coagulation of the fibrin 
 takes place while the blood is still in motion through 
 the vessels, obstructing the circulation very seriously. 
 This is called thrombosis. A clot so formed is called a 
 " thrombus," and when detached and carried into a dis- 
 tant artery or capillary stopping the flow of blood 
 through the vessel, it constitutes an " embolus." 
 
 The office of the blood is to convey nutrition to all
 
 46 
 
 A TEXT-BOOK OP NURSING 
 
 parts of the body, and to remove its waste material. 
 The process is carried on by means of the heart and 
 blood-vessels of three distinct kinds arteries, which 
 carry the blood away from the heart, veins, which bring 
 it back to the heart, and capillaries, connecting the 
 two. 
 
 The heart is a pyramidal organ, situated a little to 
 the left of the center of the chest. The apex, pointing 
 
 downward, forward, 
 and to the left, can 
 be felt between the 
 fifth and sixth ribs. 
 The base is on a 
 level with the upper 
 border of the third 
 rib. The base is 
 fixed, but the apex is 
 freely movable. The 
 heart is composed of 
 muscular fiber. It is 
 enveloped in a fibro- 
 serous membrane, 
 called the pericardi- 
 um, which secretes a 
 lubricating fluid en- 
 abling its movements 
 to be accomplished 
 without loss of power 
 by friction. It is hollow, and is partitioned into four 
 cavities or chambers, of nearly equal capacity, two 
 at the base called auricles, and two below termed 
 ventricles. There is no opening between the ven- 
 tricles. A valve between the two auricles closes 
 at birth and gradually disappears, after which there 
 
 Heart and large blood-vessels.
 
 CIRCULATION 4T 
 
 is no longer any connection between the two sides 
 of the heart. The left side always contains pure, 
 the right side impure, blood. If the valve between 
 the two auricles fails to close when independent 
 circulation is established, or soon after, the impure 
 blood mixes with the pure, giving the skin a blue 
 tinge. A child in this condition is called a <( blue baby," 
 
 Cavities of the heart : ra, right auricle ; rv, right ventricle ; la, left auricle; 
 Iv, left ventricle. The arrows indicate the course of the blood. 
 
 and rarely lives long. But between each auricle and its 
 corresponding ventricle there is an orifice, guarded by 
 a valve, which permits the passage of fluid in but one
 
 48 A TEXT-BOOK OF NURSING 
 
 direction downward. The valve between the right 
 auricle and the right ventricle is called the tricuspid 
 valve; that at the left auriculo-ventricular aperture, 
 the bicuspid, or, more commonly, the mitral valve. 
 Each ventricle has also another opening, provided with 
 a set of " semilunar " valves, connecting it with a large 
 artery, the aorta on the left, and the pulmonary on the 
 right. The auricles also have other openings through 
 which the blood flows into them from the great veins, 
 but they are not supplied with valves. As the auricles 
 become filled, they contract, and the blood, following 
 the line of least resistance, is forced into the ventricles. 
 They in turn similarly contract, forcing it on into the 
 arteries, regurgitation being in each case prevented by 
 the intervening valves. The sounds heard upon auscul- 
 tation are produced by the closing of these valves. 
 Then follows a pause, after which the contractions are 
 repeated in the same order, and are followed again by 
 the same period of repose, during which the cavities un- 
 dergo gradual dilatation. The pause occupies about as 
 much time as the two contractions, the entire action less 
 than one second. The state of contraction of the ven- 
 tricle, or auricle, is called its systole, that of relaxa- 
 tion its diastole. Both sides of the heart act simul- 
 taneously. 
 
 Let us follow on its course the blood which is ex- 
 pelled by the left ventricle. The semilunar valves open 
 to allow it to pass into the aorta, the main trunk of the 
 arteries. This ascends from the upper part of the left 
 ventricle for a short distance, then forms an arch back- 
 ward over the root of the left lung, and passes down 
 into the abdomen, where it is divided into two great 
 branches. In every part of it's course it sends out simi- 
 lar branches on each side. These all divide and subdi-
 
 CIRCULATION 
 
 vide into numberless ramifications, extending to all 
 parts of the body, and gradually diminishing in size as 
 they become more and more remote from the heart. 
 The blood receives an impulse from the ventricular 
 systole, which sends it through the entire arterial sys- 
 tem. The minute branches of the arteries empty their 
 contents finally into an even smaller set of vessels 
 known as capillaries. To call them hair-like is, how- 
 ever, an exaggeration, for they are so fine as to be 
 invisible to the naked eye ; still they serve for the trans- 
 mission of the microscopic blood-corpuscles. They in- 
 terlace in every direc- 
 tion, making an elab- 
 orate network, and 
 finally unite to form 
 blood-vessels of the 
 third order, the veins, 
 which carry the blood 
 back to the heart. 
 These are at first ex- 
 tremely small, but, by 
 constantly running to- 
 gether, they increase 
 in size as they ad- 
 vance, until they final- 
 ly all combine into two 
 great trunks, the su- 
 perior and inferior 
 venae cavae, which 
 
 empty into the right auricle of the heart. The 
 veins returning to the heart follow closely in the track 
 of the arteries which lead away from it, but they lie 
 nearer the surface. 
 
 The smallest arteries and veins are quite similar in 
 
 Diagram of the course of the blood.
 
 50 A TEXT-BOOK OF NURSING 
 
 structure, but the larger ones have numerous points of 
 difference. The walls of the arteries are composed of 
 three coats, an outer one of strong connective tissue, 
 a smooth inner lining, a continuation of the endocar- 
 dium, the lining membrane of the heart ; between these 
 is a layer which in the largest arteries consists of elastic 
 tissue, in those of lesser caliber of elastic and muscular 
 fibers, and in the smallest of the muscular fibers alone. 
 It follows that the largest arteries have the most elas- 
 ticity, and the smallest the most highly contractile 
 power. Their walls have sufficient firmness to retain 
 their cylindrical form even when empty. They are 
 always found empty after death. Veins, on the other 
 hand, are less elastic, have thinner walls, and collapse 
 when empty. Many of the veins are supplied with 
 valves, which permit the flow of blood only toward the 
 heart. The capillaries are less complex than the other 
 blood-vessels, consisting of but a single membrane, and 
 that so thin that their fluid contents readily exude. 
 The velocity of the blood decreases as it approaches 
 the capillaries, its progress being delayed by the nar- 
 rowness and intricacy of the path it has to travel. Time 
 is thus allowed for the assimilation of the nutrient 
 portion of the blood by the living tissues with which it 
 is here brought into intimate contact. As it enters the 
 veins its motion is again somewhat accelerated, though 
 it never regains the speed with which it rushes through 
 the arteries. Having once completed the circuit of 
 arteries, capillaries and veins, the blood is restored to 
 the heart and its general or systemic circulation is com- 
 plete. It has, however, undergone a change in char- 
 acter and appearance during its stay in the capillaries ; 
 some of its elements have been appropriated, it has 
 become charged with waste matter, and has lost its
 
 CIRCULATION 51 
 
 bright color. Before it is fit for further use it must be 
 purified and renewed. To accomplish this, and to re- 
 turn to that side of the heart from which it started, it 
 has another journey to take. This, to distinguish it 
 from the former, is spoken of as the lesser, or pulmo- 
 nary circulation. From the right auricle, into which it 
 is poured by the vena cava, the tricuspid valve allows 
 the blood to flow into the right ventricle, the next con- 
 traction of which forces it by the pulmonic semilunar 
 valves into the pulmonary artery, which leads to the 
 lungs. This, like all the other arteries, is subdivided 
 into numerous small branches, and finally establishes 
 connection with a set of capillaries. In the pulmonary 
 capillaries the blood is brought into close relation with 
 the inspired air, and undergoes a process of renovation. 
 The pulmonary veins then carry it back to the left 
 auricle, ready to start again upon its double circulation. 
 It will be seen that in the pulmonary system of circu- 
 lation the general arrangement is so far reversed that 
 the arteries become the bearers of the impure, and the 
 veins of the pure blood. 
 
 The blood-vessels, branching in every direction, 
 communicate in all parts of the body, so that, if the 
 main course of the blood is interrupted, it may still go 
 on its way by making a detour through minor rami- 
 fications. Such communication of vessels is called 
 anastomosis. The collateral circulation which it allows 
 is of great surgical value, permitting a large artery to 
 be tied without obstructing the general circulation. 
 
 When a larger amount of blood than is natural is 
 sent to any part the condition is called congestion. The 
 blood-vessels enlarge somewhat to let the increased sup- 
 ply of blood through, but the tissues can not take up 
 the excess of fibrin, and the capillaries become clogged,
 
 52 A TEXT-BOOK OF NURSING 
 
 causing a stoppage or stasis. In this state of things 
 the fibrin oozes out of the blood-vessels into the tissues 
 and is deposited in a more or less solid mass. This 
 is known as exudation of plastic lymph. The congested 
 condition may gradually disappear, and the blood re- 
 sume its normal flow after merely temporary stasis. 
 This is termed resolution. The excess of fibrin is not, 
 however, always reabsorbed, but remains outside the 
 blood-vessels causing perceptible thickenings. These 
 are adhesions. Exudation of plastic lymph takes place 
 only when arterial blood is obstructed. If there is 
 stasis of venous blood, we have an exudation of serum, 
 which is dropsy. If the determination of blood to the 
 part is not soon relieved inflammation ensues. A large 
 proportion of all diseases, medical or surgical, are in- 
 flammatory at some time in their course. Disease is 
 always the result of impaired nutrition, and inflamma- 
 tion has been described as misdirected nutrition. It is 
 .characterized by heat, swelling, redness, pain, and exu- 
 dation of serum. It may terminate by resolution, or 
 by suppuration. In the latter case the white corpuscles 
 work their way out of the blood-vessels and multiply 
 in the plastic lymph, producing pus. When small por- 
 tions of tissue die from their supply of nutriment being 
 cut off we have ulceration. Death of a large mass of 
 tissue is gangrene. The character of an inflammation 
 and its treatment depend upon its location and its 
 extent. 
 
 Each contraction of the heart sends out a wave 
 which distends the blood-vessels, and which they, by 
 their elasticity, carry on through the entire arterial 
 system. This intermittent distention of the arteries 
 is known as the pulse. It corresponds with the systolic 
 action of the heart, and is characteristic of the arterial
 
 PULSE 53 
 
 flow, being absent from the venous. Wherever an ar- 
 tery approaches the surface, the pulse-beats can be felt 
 and counted. The pulse is a valuable guide in disease, 
 as it varies with the condition of the heart, and affords 
 an accurate index of its action. It is usually taken, 
 for convenience, at the radial artery, just above the 
 wrist ; if it becomes imperceptible there, it may perhaps 
 still be felt at the temporal, femoral, or carotid, as 
 large arteries retain their pulsation longest. In chil- 
 dren, you may feel it best in the temporal artery during 
 sleep. It is often difficult to feel a child's pulse any- 
 where when it is awake. 
 
 To take the pulse accurately, place two or three fin- 
 gers along the course of the artery, making slight pres- 
 sure, and count for a full minute, by tens, with inter- 
 vals of ten seconds between counts. The rate varies 
 with varying circumstances. Age, sex, food, tempera- 
 ture, position, exertion, mental states, and many 
 other conditions modify it even in health. It is usu- 
 ally more rapid in women than in men, in children than 
 in adults. It is slow during sleep, quicker after taking 
 food, more rapid standing than sitting, and sitting than 
 lying down. The average rate in a healthy adult is 72 
 beats per minute; in a child, from 105 to 120 for the 
 first twelve months of life, to from 80 to 90 during the 
 period from seven to ten years. Considerable vari^ 
 ations from this standard may, however, be compat- 
 ible with health. Individuals differ so much that a 
 pulse which would be quite alarming in one subject 
 might mean nothing wrong in another. 
 
 Nearly all abnormal conditions of the body have 
 
 some effect upon the pulse. Increase in the rate is 
 
 more common than diminution. The character, as well 
 
 as the frequency, is subject to variations. In a quick 
 
 5
 
 54 A TEXT-BOOK OP NURSING 
 
 pulse, each beat occupies less than the usual time that 
 is, each wave is of short duration relatively to the pause 
 between. When the volume of the pulse is greater than 
 usual, it is said to be large or full; if less than usual, 
 small. When the pulse can be easily stopped, it is said 
 to be compressible; incompressible when it can only be 
 arrested with difficulty, or not at all. In an irregular 
 pulse, succeeding beats differ in length, force, and char- 
 acter. In an intermittent pulse, a beat is now and then 
 lost, the rhythm being otherwise regular. The inter- 
 mittency may occur at regular intervals, as every tenth 
 or twentieth beat may be lost, or it may be without any 
 regularity. An intermittent pulse is occasionally ob- 
 served in persons otherwise healthy. It is always a less 
 serious symptom than an irregular one. Other depar- 
 tures from the normal standard are variously described 
 as hard or soft, sharp, jerking, bounding, throbbing, 
 spotty, thready, wiry, flickering, undulatory, etc., the 
 names of which sufficiently explain their effect to the 
 touch. In the dicrotic pulse, a secondary wave of oscil- 
 lation becomes exaggerated so as to be felt. An inex- 
 perienced person may mistake this for the primary 
 wave, and so be led to count double the real number of 
 beats. This pulse is often met in typhoid fever. In 
 some cases the pulse in the two wrists will be different, 
 and rarely it can be felt in one wrist only. When the 
 beat occurs a little later in one radial artery than in 
 the other it is said to be retarded; this usually indicates 
 aneurism. 
 
 The blood has still another function, that of keeping 
 the body warm. Animal heat is generated by continual 
 chemical change, in which the blood is an active agent. 
 The bodily temperature in health remains nearly the 
 same, about 98.6 F., in spite of the variations of the
 
 TEMPERATURE 55 
 
 external temperature. The action of the skin keeps 
 the heat from accumulating, and the arteries, under the 
 influence of the nervous system, dilate or contract, and 
 so assist in maintaining the equilibrium by altering the 
 rate of production to correspond with the loss of heat. 
 Life is secure so long as the production and the escape 
 of heat are evenly balanced. 
 
 There is a definite daily cycle of variations, amount- 
 ing to one or two degrees. According to Quain, the 
 temperature of a healthy adult reaches its highest point 
 between 5 and 8 P. M., and is at its lowest from 2 to 6 
 A. M. A deviation of more than one degree from the 
 normal standard, that is, above 99, or below 97, may 
 be regarded as indicative of disease. There is only a 
 range of about twenty degrees within which life can 
 be sustained. A temperature above 108, or below 93, 
 will in most cases prove fatal. The danger is in pro- 
 portion to the distance from the normal, and to the 
 length of time that the condition continues. Tempera- 
 ture below the normal standard is far more dangerous 
 than the same number of degrees above, as the follow- 
 ing table shows : 
 
 Hyperpyrexia 106, and over, extremely dangerous. 
 
 High fever 103$ 106. 
 
 Moderate fever 101 103^. 
 
 Subfebrile 994 101. 
 
 Normal 98 99. 
 
 Subnormal 97 98. 
 
 Collapse 95 97. 
 
 Algid collapse . .below 95 again extremely dangerous. 
 
 Very high temperatures sometimes occur in hysteria 
 without danger. 
 
 Most, though not all, morbid states are accompanied 
 by alterations in temperature, some of which are so
 
 56 A TEXT-BOOK OP NURSING 
 
 typical as to be of great diagnostic value. Rise of 
 temperature above 99 constitutes fever, or pyrexia. 
 It is occasioned either by imperfect loss of heat or by 
 overproduction. The amount of heat produced is pro- 
 portional to the activity of respiration and the amount 
 of oxygen consumed. The pulse is generally accelerated 
 in proportion to the elevation of temperature, though 
 the proportion varies in different diseases. In scarlet 
 fever, for instance, the pulse will be quicker than in 
 typhoid with the same temperature. If the pulse is 
 more rapid than the temperature will explain, it indi- 
 cates cardiac weakness. 
 
 A change of temperature may be the first symptom 
 of disorder, occurring even before indisposition is felt. 
 It is of importance to get this first variation from the 
 normal temperature ; and as medical advice is not likely 
 to be called for until more evident symptoms have 
 manifested themselves, every mother as well as every 
 nurse ought to own a clinical thermometer, and to 
 know how to use and read it. She can do no harm, and 
 she may do a great deal of good, by using it upon the 
 first suspicion of a departure from health. A slight 
 variation from the normal is of less serious import in 
 a child than in an adult, unless it is found to be increas- 
 ing. An increase, beginning each day a little earlier, 
 is a bad indication ; a decrease from a high temperature, 
 beginning each day earlier, is a sign of improvement. 
 The daily fluctuations take place also in disease, and 
 are sometimes much exaggerated. Sometimes fever is 
 continuously high, with only the normal amount of 
 variation; or it may be remittent, that is, with a wide 
 range between its highest and lowest points, though 
 never sinking to normal ; or intermittent, in which type 
 the temperature alternately rises to febrile height and
 
 TEMPERATURE 57 
 
 falls to or below the normal. In some disorders, as 
 pneumonia, and others similarly initiated with a chill, 
 the rise will be rapid and sudden; in others there will 
 be at first but slight elevation, which gradually in- 
 creases. Typhoid is of the latter class, the temperature 
 rising about two degrees daily, but falling again each 
 morning, so that the maximum mark is only reached 
 on the fifth or sixth day. A febrile temperature may 
 be expected to rise toward evening, but in rare cases the 
 ordinary rule will be reversed, and there will be rise 
 in the morning and remission in the evening. In some 
 cases of typhoid and phthisis two exacerbations have 
 been observed in the twenty-four hours, with two dis- 
 tinct remissions. Such deviations can only be recog- 
 nized by testing the temperature frequently. It will be 
 evident that isolated observations have not the value 
 of a regular series. The temperature should be taken 
 at the same hour each day to exhibit accurately the 
 cycle of fluctuations. An irregularity in temperature, 
 in the course of a disease which has usually a regular 
 type, is indicative of some complication. Or it may de- 
 pend upon local causes, and may be improved with 
 them. Thus constipation will often send up the tem- 
 perature, which will fall again after its relief. Bad 
 air may have the same effect. The decline of fever, or 
 defervescence, may, like the rise, be gradual from day 
 to day, or sudden, dropping to a steady normal in from 
 six to thirty-six hours. The former is said to be by 
 lysis, the latter through a crisis. 
 
 Temperature may be artificially reduced by applica- 
 tions of cold, or by antipyretic medicines; it may be 
 brought up by external heat and stimulants. The 
 former act most effectively at the times when the tem- 
 perature has a natural tendency to fall, and the latter
 
 58 A TEXT-BOOK OP NURSING 
 
 when the tendency is to rise, as the effort of nature is 
 then assisted rather than opposed. 
 
 Any great modification of temperature is usually 
 recognizable to the touch, but to measure its extent 
 with mathematical certainty the clinical thermometer 
 is used. This now familiar little instrument is indis- 
 pensable to every nurse. Before use the index must be 
 thrown down to a point two or three degrees below the 
 normal. Hold it with the bulb down, and shake until 
 the mercury falls. Do not shake it so hard as to force 
 all the mercury into the bulb. 
 
 The temperature may be taken under the tongue, 
 in the axilla, groip, rectum, or vagina. The tempera- 
 ture of the interior of the body is more even, and some- 
 what more elevated, than that of the surface, so that, 
 when it is taken in either of the natural cavities, the 
 index will reach a point at least half a degree higher 
 than in an artificial cavity. The mouth will be a little 
 cooler than the cavities constantly closed, and the axil- 
 lae cooler still, and it will take longer time for the mer- 
 cury to rise in these places, unless the precaution has 
 been taken to keep the mouth or axilla previously 
 closed for ten minutes, that they may have assumed a 
 steady temperature. A little time may be saved by 
 slightly warming the bulb in the hand before its intro- 
 duction. Keep the patient well covered for some little 
 time before taking an axillary temperature. The part 
 should not have been exposed for washing or dressing 
 for at least half an hour previously. The axilla must 
 be first dried from perspiration, care be taken that 
 the clothing is not in the way, and the thermometer 
 held firmly in position. This is best done by pressing 
 the arm closely to the side, and flexing it till the hand 
 touches the opposite shoulder. Where great accuracy
 
 TEMPERATURE 59 
 
 is needed, the thermometer should be left in place until 
 the index has remained stationary for five minutes. In 
 a very emaciated subject it may be impossible to get a 
 correct axillary temperature. 
 
 The temperature is frequently taken in the mouth, 
 the bulb of the thermometer being placed under the 
 tongue. This is not always safe, as there is danger that 
 a child, or an irresponsible patient, may bite off the 
 bulb. The lips must be kept closed during the process. 
 Do not take the temperature in the mouth immediately 
 after a patient has been eating ice, nor wash the ther- 
 mometer in warm water before looking at it, or you may 
 get alarming results. 
 
 The rectum gives, perhaps, the most reliable tem- 
 perature, as there are fewer possible sources of error. 
 This method is always employed for infants. The tube 
 should be oiled and inserted for nearly two inches. Re- 
 member that, if the rectum contains faecal matter, the 
 index will not reach so high a point as if the bulb 
 conies directly in contact with the mucous membrane. 
 
 The length of time required to take a temperature 
 depends not only upon the locality selected, but also 
 to some extent upon the thermometer used. Some will 
 do the work in one minute, while others take three or 
 five, other things being equal. Every thermometer in 
 use ought to be annually compared with some standard, 
 as after a time it will cease to register correctly. The 
 bulb gradually contracts a little, and too high indica- 
 tions result. Never leave a thermometer with a patient 
 unwatched, unless you are very sure he is to be trusted 
 to take care of it. 
 
 Inflammation sometimes gives a local rise of tem- 
 perature, without affecting the general heat of the body. 
 To test this, a surface thermometer is used, one with
 
 60 A TEXT-BOOK OF NURSING 
 
 the reservoir flattened, so as to receive impressions from 
 the open surface. The scale is the same as that of the 
 ordinary fever thermometer, divided into degrees and 
 fifths, but it is not self -registering. They usually come 
 in pairs matched to work together; but this arrange- 
 ment has only the advantage of saving time. One will 
 answer every practical purpose. It is to be applied 
 alternately over the seat of inflammation, and over 
 some corresponding part known to be isothermal with 
 it in health. The difference shows the amount of 
 increase in the local heat. This, like the general tem- 
 perature, will be found to fluctuate, exhibiting periods 
 of exacerbation and defervescence. 
 
 Temperatures should not only be accurately taken, 
 but correctly recorded. Note the degree and hour im- 
 mediately upon taking, without leaving time to forget. 
 Clinical charts are made to be filled up with the records 
 of temperature ; lines drawn from point to point, as the 
 rise and fall are noted, often give very characteristic 
 curves. The accompanying illustration is taken from a 
 tpyhoid case. The corresponding variations of the 
 pulse may be shown on the same chart by a second set 
 of lines drawn in red ink. 
 
 The pulse and temperature should always be con- 
 sidered together, not separately. The pulse is a more 
 certain test of the patient's condition than the tempera- 
 ture. In peritonitis a rapid pulse with low temperature 
 is often a grave indication. The pulse is very rapid and 
 feeble in some patients when under ether, or immedi- 
 ately after an operation not necessarily severe. This 
 needs to be distinguished from the rapid fluttering pulse 
 after profuse haemorrhage. 
 
 Some of the recently discovered antipyretics nota- 
 bly antifebrin may bring the temperature down in two
 
 oiscm 
 
 19 
 
 DATES Of OBSERVATIONS. 
 
 JULY. 
 
 25 
 
 '27 
 
 28 
 
 29 
 
 30 
 
 31 
 
 AUGUST. 
 
 1 
 
 10 
 
 11 
 
 Cat 
 
 fljtr. AM ' PIMM '.PX AM ' PM AM '. PM Ul PM M -PM AM PM 
 
 AM.PMAM.PMAM.PM AM -PM AM PMIAM). PM AM . PM 
 
 AM . PM AM . PM AM . PM AM . PM AM 
 
 1 
 
 'Mill 
 
 r 
 
 _': 
 
 :: : 
 
 -t :! 
 
 i7 
 
 _.
 
 DATE'S Or OBSERVATIONS. 
 
 H 
 
 15 
 
 16 
 
 17 
 
 18 
 
 20 
 
 21 
 
 22 
 
 23 
 
 24 
 
 25 
 
 26 
 
 28 
 
 29 
 
 30 
 
 31 
 
 SEPTEMBER. 
 
 1 
 
 M AM . PM AM . PM AM . PM AM . PM AM PM AN - PM 
 
 AM -PMAM'. PM AM'PMAM'.PMAM.'PMAM.'PM AM*. PHAM^PMAMlpM 
 
 AM.,PMAM'PM AM! PM 
 
 AM . PM AM PM AM PM AM . PM 
 
 A 
 
 L& 
 
 V
 
 TEMPERATURE 61 
 
 or three hours from a high, to a subnormal point, 
 especially in children, who are very susceptible to the 
 influence of drugs. This is not alarming, unless the 
 patient becomes cyanotic and the pulse feeble, but stim- 
 ulants and hot bottles are indicated. 
 
 " We can not kindle when we will 
 
 The fire that in the heart resides, 
 The spirit bloweth and is still, 
 In mystery our soul abides ; 
 But tasks in hours of insight willed 
 Can be through hours of gloom fulfill'd. " 
 
 M. Arnold.
 
 CHAPTEK V 
 
 " Like a kind hand on my brow 
 
 Comes this fresh breeze, 
 Cooling its dull and feverish glow, 
 While through my being seems to flow 
 The breath of a new life the healing of the seas ! " 
 
 J. O. Whittier. 
 
 WE have seen that the blood undergoes in the lungs 
 a process of purification, rendering it fit for renewed 
 use. To understand how this is accomplished, one must 
 know something of the construction and working of the 
 respiratory organs, the chief of which are the lungs, 
 trachea, and muscles of the chest. 
 
 The lungs themselves are of a sponge-like substance, 
 composed of air-cells lined by a network of minute 
 blood-vessels. These blood-vessels are the subdivisions 
 of the pulmonary veins and arteries. A series of bron- 
 chial tubes connect the air-cells with the external air, 
 those of each lung uniting into a single bronchus, and 
 the two finally unite with each other, to form the tra- 
 chea or windpipe. Each lung is enveloped in a delicate 
 membrane called the pleura. This is, at the root of the 
 lung, folded back so as to form also a lining to the 
 chest. It secretes a fluid which keeps it constantly 
 moist, and enables the two surfaces to slide easily 
 against each other. 
 
 The chest is separated from the abdominal cavity 
 by a muscular partition the diaphragm which alter-
 
 RESPIRATION 
 
 63 
 
 nately rises and falls, as its fibers contract and relax. 
 The motion is involuntary, but is partially under con- 
 trol. As the capacity of the chest is increased by the 
 descent of the diaphragm, the additional space is filled 
 by air, sucked in through the trachea and bronchi, and 
 expanding the elastic cells. As the diaphragm rises 
 
 The cavity of the chest, showing the positions of the heart and the 
 lungs: A, left lung; B, heart; D, pulmonary artery; E, trachea or 
 windpipe. 
 
 this extra supply of air is forced out again. The size 
 of the thoracic cavity is still further affected by move- 
 ments of the intercostal muscles, which elevate and de- 
 press the ribs. By these muscular actions, and the con- 
 sequent expansion and contraction of the lungs, the 
 alternate inspirations and expirations are produced
 
 64 A TEXT-BOOK OP NURSING 
 
 which we call breathing or respiration. The lungs are 
 not completely filled and emptied by each respiration; 
 a certain amount of air is stationary in them. The 
 additional supply drawn in and out, sometimes called 
 tidal air, is but a small proportion of the entire con- 
 tents of the lungs ; but it is diffused through and alters 
 the character of the whole. At the end of each expira- 
 tion follows a period of repose about equal to the en- 
 tire period of action. 
 
 A healthy adult ordinarily breathes about eighteen 
 times per minute, taking in each time some twenty 
 cubic inches of air. It takes, at this rate, sixteen res- 
 
 Lungs and air-passages : a, larynx ; b, trachea ; c, d, bronchi ; e, bronchial 
 tubes ; /, lobules. 
 
 pirations to completely renovate the air in the lungs. 
 By this gradual introduction of the outer air its tem- 
 perature is rendered more fit for contact with the deli- 
 cate capillaries, and there is a reserve supply in case 
 of any accidental embarrassment of respiration. It is 
 worth noting that the habit of taking deep inspirations 
 increases the strength and capacity of the lungs.
 
 RESPIRATION 65 
 
 The direct object of respiration is the purification 
 of the blood. Let us see just how this is effected. 
 The air is a mechanical mixture of oxygen and nitro- 
 gen, with a small proportion of carbonic-acid gas and 
 watery vapor. Its average composition is a little less 
 than twenty-one volumes of oxygen to seventy-nine of 
 nitrogen. The nitrogen in the atmosphere acts simply 
 as a diluent. The oxygen is the universal supporter of 
 life, the vitalizing force of all animal organisms. Car- 
 bonic acid, on the contrary, is so poisonous a gas that 
 two or three parts of it in a thousand will produce 
 sensibly bad effects as headache, nausea, and drowsi- 
 ness. Five per cent may be fatal. 
 
 The walls of the air-cells consist of a mere film of 
 mucous membrane, thin enough to allow interchange of 
 gases to take place through it, though impervious to 
 liquids. Such transudation of fluid through a moist 
 animal membrane is known as osmosis. 
 
 Oxygen has a stronger affinity for blood than for 
 nitrogen; so, when it is brought near, it leaves the air 
 inspired, to unite with the blood in the lungs. But car- 
 bonic acid and water both of which are to be found in 
 the blood have greater affinity for air, and pass into it. 
 So the air expired retains its nitrogen, and takes car- 
 bonic acid and water, but loses a part of its oxygen. 
 
 The processes of circulation and respiration are thus 
 intimately connected, and whatever modifies the pulse 
 affects also the breathing. There are usually four beats 
 of the pulse to every respiration. The rate of respira- 
 tion accordingly varies as does that of the pulse, being 
 more rapid in woman than in man, in a child than in an 
 adult, and modified by position, exertion, excitement, 
 and other conditions ; but, unlike the pulse, it is partly 
 under control of the will. Eespirations are best count-
 
 66 A TEXT-BOOK OF NURSING 
 
 ed, when possible, without the knowledge of the patient, 
 as, to be natural, they must be unconscious. They are 
 somewhat slower during sleep. One can usually see the 
 accompanying rise and fall of the chest; but to count 
 accurately, the hand should be laid flatly and lightly 
 over that portion of the abdomen, just below the breast- 
 bone, known as the epigastrium, where the motion may 
 be distinctly felt. Eespirations below eight, or above 
 forty, per minute, may be considered as indicative of 
 danger. The character, as well as the frequency, is 
 subject to variations. Breathing in man is abdominal, 
 in woman chiefly thoracic. It may be regular or irregu- 
 lar, easy or labored, quiet or noisy, deep or shallow. 
 Sometimes it presents very marked peculiarities. 
 When each breath is accompanied by a deep snoring 
 sound, it is said to be stertorous. Difficulty of breath- 
 ing arising from any source is called dyspnoea; total 
 absence of breath is apncea. Dyspnoea arises when, 
 from any cause, the quantity of air reaching the lungs 
 is disproportionate to the amount of blood sent by the 
 heart for purification. The blood may be in an un- 
 healthy condition, it may be congested in the pulmonary 
 capillaries, or it may be sent too quickly. The air may 
 be unfit to perform its work, or it may be shut out by 
 disease of the lungs or air-passages or by the presence 
 of a foreign body. If the supply of pure air be in any 
 way entirely cut off, asphyxia results that is, the blood 
 fails to be oxygenated, a condition necessarily fatal if 
 not soon relieved. 
 
 Carbonic-acid gas is heavier than air, so much so 
 that when pure it can be poured from one vessel to 
 another, like water. The air nearest the ground we 
 might then expect to contain the largest proportion of 
 this gas. It does not, however, so accumulate, owing to
 
 RESPIRATION 67 
 
 the diffusive power of gases, stronger even than the 
 force of gravitation, which compels such as are in con- 
 tact thoroughly to intermingle. The winds and the 
 rain hasten this diffusion, and aid in the purification of 
 the air. Still, with the whole animal creation constant- 
 ly engaged in abstracting oxygen and throwing off into 
 the air a poisonous gas, some counteracting influence 
 is necessary to prevent the entire atmosphere from be- 
 coming depleted, and unfit to sustain life. This is 
 found in the vegetable world, which, under the stimulus 
 of light, reversing the plan of the animal, absorbs car- 
 bonic-acid gas, and gives off in its place oxygen, thus se- 
 curing the continual purification of the air. This circle 
 of changes is perpetually going on, each of the great 
 natural kingdoms deriving its own proper food from 
 the atmosphere, and supplying in return the need of the 
 other. 
 
 When we are out of doors the products of respira- 
 tion are continually carried away by atmospheric cur- 
 rents, while the lungs are as constantly supplied with 
 fresh air. But in any confined space this process is in- 
 terrupted; the air is rapidly deprived of its oxygen, 
 while noxious and irrespirable substances accumulate in 
 its place, unless suitable arrangement is made for the 
 constant renovation of the atmosphere. This accounts 
 for the now familiar fact that the sick and wounded so 
 often do better in the open air than in the best con- 
 structed hospitals. 
 
 Dr. Barnes says, in his admirable Notes on Surgical 
 Nursing : " The most perfect form of hospital, in a 
 sanitary view, would consist of a fine, dry table-land 
 or very gently sloping hillside, while the ward and 
 its fittings might consist of a hammock, a large um- 
 brella, and a movable screen." He had in mind surgi-
 
 68 A TEXT-BOOK OP NURSING 
 
 cal cases particularly; but even for medical treatment 
 his ideal outfit would have advantages, so true is it 
 that bad .air depresses the vital powers, predisposes 
 to disease, and aggravates such as are already estab- 
 lished. 
 
 The air during its stay in the pulmonary cavity ac- 
 quires not only a dangerous proportion of carbonic-acid 
 gas, but also organic impurities, waste matter thrown 
 off from the blood and from the lung substance. Thus 
 vitiated, it is unfit to be again breathed. 
 
 The exhalations from the lungs are but one of the 
 many causes conspiring to contaminate the atmosphere. 
 All the other excreta, notably that of the skin, lend 
 their aid, and there are frequent sources of impurity 
 external to the body. All combustion exhausts oxygen 
 and liberates injurious gases. A single ordinary burner 
 of illuminating gas in a room consumes more oxygen 
 than would be required for three people. Add to this 
 the inevitable floating dust from floors and walls, from 
 clothing, bedding and furniture, and it becomes evi- 
 dent that with such impurities arising continually and 
 from numberless sources, the question of the removal 
 of the vitiated air, and the introduction of such as is 
 in a fit condition for use, is one of the greatest impor- 
 tance, even under ordinary circumstances. 
 
 Where there is sickness it becomes a still more vital 
 consideration, owing to the presence of organic matters 
 in increased quantity, and of most deleterious quality, 
 and to the reduced resistive powers of the system. A 
 thousand cubic feet of air-space, constantly renewed, 
 are necessary for a healthy adult. A sick person should 
 have two or three times as much, since, while the air is 
 more quickly contaminated, renewal must be less rapid, 
 owing to the increased susceptibility to draughts. The
 
 VENTILATION 69 
 
 above-named is the minimum supply to be allowed. 
 Too much fresh air it is impossible to get. 
 
 The substitution of pure for impure air constitutes 
 ventilation. There is happily a good deal of accidental 
 ventilation through the impossibility of building a 
 house perfectly air-tight, but it is very little in propor- 
 tion to the need. Exchange of air spontaneously affect- 
 ed, as by doors and windows, is natural ventilation. It 
 is mainly produced by inequalities in temperature, 
 within and without, which set the air in motion. Arti- 
 ficial ventilation may be either by extraction or pro- 
 pulsion. A chimney with an open fire is a common type 
 of the extraction method. The forcible introduction of 
 fresh air by fans exemplifies that by propulsion. The 
 former is at once the simplest and most effective. 
 There is no better apparatus for ventilation than an 
 open fire. The draught which it creates carries the air 
 from the room up the chimney, while a fresh supply 
 is drawn in to take its place. It is most important to 
 know where this supply comes from. If there is no 
 sufficient inlet from out of doors provided, it may be 
 sucked in from some adjoining apartment or passage, 
 itself so imperfectly ventilated as to afford no better 
 air than that the place of which it takes. A strong 
 draught through a room does not prove it well venti- 
 lated, unless one can be sure that the inward flow is 
 from some source whence there is no danger of addi- 
 tional contamination. There must be direct connection 
 with the outside air, and the higher the points of admis- 
 sion, the purer is it likely to be. 
 
 Two constant currents are necessary one outward 
 removing the impure, and one inward supplying pure 
 air. Inlets and outlets should be of equal capacity, on 
 opposite sides of the room, and at different heights, to
 
 70 A TEXT-BOOK OP NURSING 
 
 secure thorough distribution. It is best to have them 
 small and numerous, giving rise to many and moderate 
 currents. They should be as far as possible from the 
 patient, and from each other. It is, of course, much 
 more difficult to thoroughly ventilate a small room than 
 a large one, and the liability to injurious draughts is 
 greater. 
 
 It is impossible to keep the air of a sick-room abso- 
 lutely as pure as that outside. That is, however, the 
 ideal condition, and the one to which the nurse should 
 aspire. In a large hospital the mutually-involved sub- 
 jects of ventilation and warmth come but little under 
 the control of the nurse. You will have only to ob- 
 serve and report any departure in your ward from the 
 proper standard. In private nursing the matter comes 
 more fully under your own management, and to keep 
 pure the air of the sick-room is a most important part 
 of your duty. It is one in the accomplishment of which 
 you are likely to find many difficulties. You will have 
 to contend with a popular prejudice against fresh air, 
 unfortunately not altogether confined to the uneducated 
 classes, and also with the real danger of chilling the 
 patient. There are some cases in which open windows 
 in the sick-room itself are inadvisable in very cold or 
 damp weather. There is still the necessity for keeping 
 the air fresh and wholesome, and it requires even more 
 than usual care and watchfulness to do this. The air 
 must be admitted from outside into some adjoining 
 room, and then be warmed before it is allowed to reach 
 the patient. In all ordinary cases, however, the win- 
 dows may be kept open, more or less, day and night, 
 without danger. Ventilation during the night is not 
 less important than during the day, though the air must 
 be more cautiously admitted, having missed the warm-
 
 VENTILATION 71 
 
 ing and purifying influence of the sunshine. It is still 
 infinitely to be preferred to the poisoned atmosphere of 
 a close, inhabited room, and must not be altogether 
 shut out. Cold is greatest, and the body least able to 
 resist it, in the early morning, just before daylight ; but 
 it is more heat, not less air, that is called for. Instead 
 of closing the windows, and adding the benumbing ef- 
 fect of carbonic-acid poisoning to that of cold, stir up 
 the fire, and give your patient additional clothing and 
 foot-warmers. If there must be a choice of the two 
 evils, air too cold will in most cases do less harm than 
 foul air. In warm weather, when open windows and 
 doors are matters of course, there is but little difficulty 
 in obtaining an abundant supply of fresh air. But it is 
 a too little appreciated fact that the necessity is none 
 the less in the coldest weather. It is a common error 
 to confound cold air with clean air, and to suppose 
 that ventilation can be measured by a thermometer. 
 Changes in the quality of the air are not so sensibly 
 felt as changes in its temperature; the more care is 
 needed to guard against them. No thermometer regis- 
 ters its deterioration; the only test ordinarily practi- 
 cable is by the sense of smell. A " sick-room odor,"' 
 perceptible upon entering from the fresh air, is incon- 
 trovertible evidence of poor ventilation. It is obviously 
 desirable that a nurse should have a good nose; but 
 after a short time spent in a vitiated atmosphere, its 
 sensitiveness will be lost, and not at once regained even 
 out of doors, so that it ceases to be a reliable guide. 
 One can not be too watchful, for there are few more 
 mortifying occurrences for a nurse than to have the 
 doctor come in from outside, and remark, " Your room 
 is close." 
 
 Even in the coldest weather, windows may be fre-
 
 72 A TEXT-BOOK OF NUESING 
 
 quently thrown wide open for a few moments at a time, 
 the patient being meanwhile protected by additional 
 covering. A large umbrella opened, with a shawl or 
 blanket thrown over both it and the patient, affords an 
 effectual screen. If the patient is able to move about, 
 advantage should be taken of every occasion when he 
 leaves the room, to ventilate more thoroughly than can 
 be done in his presence. But do not depend entirely 
 upon such occasional opportunities. The contamina- 
 tion of the air is continuous ; its purification should be 
 equally so. There are numerous simple devices for 
 opening windows and at the same time protecting the 
 patient from direct draughts. The lower sash may be 
 raised, or the upper one lowered, and the entire open- 
 ing closed by a board. The current of air then enters 
 only in the middle, between the two sashes, and is 
 given an upward direction. Or, placing the board on 
 the window-sill, a little inside of and extending some- 
 what higher than the opening, similarly directs the cur- 
 rent, and gives two apertures for the admission of air. 
 Currents of cold air should be always first directed 
 upward. 
 
 As has been suggested, the best method of securing 
 an outward flow of the foul air is by an open fire. In a 
 large room it may be insufficient for heating ; but other 
 appliances ought to be supplementary to, not substitutes 
 for this. If it is too warm for a fire to be desirable, a 
 lamp burning on the hearth is good to create a draught. 
 Extraction flues must in some way be heated, or they 
 will not draw. To allow open windows, there must be 
 a surplus of heat. Economical housekeepers will some- 
 times object to "heating all outdoors," but it is an 
 economy in the wrong direction. Stoves assist ventila- 
 tion in the same way as grate-fires, though not to the
 
 WARMTH 73 
 
 same extent, by drawing off the foul air. A pan of 
 water should be kept on the stove, to dampen the air by 
 its evaporation. Heat without moisture is injurious, a 
 certain amount of watery vapor being essential to the 
 wholesomeness of the air. Gas or oil heaters are espe- 
 cially objectionable, as they have no provision for the 
 removal of the products of combustion. 
 
 Patients with pulmonary disease often find, to their 
 surprise, that they breathe with less difficulty in damp 
 and foggy weather than on a clear, dry day. Such 
 may derive considerable relief from a kettle of water 
 kept boiling vigorously in the room. A large sponge, 
 or towel, hung in front of a hot-air register, and kept 
 wet, will also sensibly dampen the atmosphere. In all 
 disorders of the respiratory system, if no special direc- 
 tions are given by the physician, keep the room at a 
 temperature of from 70 to 75 Fahr. ; in purely febrile 
 disease, 65 is more suitable; for other cases, 68 is a 
 good point. Whatever temperature is decided to be best 
 should be steadily maintained. 
 
 It is to be remembered that there is especial neces- 
 sity for warmth in children, in the very aged, and in 
 cases of diarrhoea. It is of far greater importance to 
 keep the sick-room warm when the patient is out of bed 
 than when he is in it. People rarely take cold under 
 the bedclothes. Convince your patient of this, if pos- 
 sible, and, observing all precautions against the possi- 
 bility, do not allow any prejudice, either on his part or 
 that of his anxious but ill-instructed friends, to prevent 
 you from giving him an ample supply of fresh, pure 
 air. Remember that the lungs can not, in any confined 
 space, fulfill their office of purifying the blood and re- 
 moving its waste particles unless provision is made for 
 the constant renovation of the air. This can hardly be
 
 74 A TEXT-BOOK OF NURSING 
 
 too much emphasized. There are three important rules 
 in regard to ventilation, viz. : sufficient pure air must be 
 introduced; the foul air must be removed; these ends 
 must be achieved without injurious draughts. 
 
 " But if the pilot slumber at the helm, 
 The very wind that wafts us toward the port 
 May dash us on the shelves. The steersman's part 
 Is vigilance, blow it rough or smooth." 
 
 Scott.
 
 CHAPTER VI 
 
 "Cleanliness of body was ever deemed to proceed from a due 
 reverence to God." Francis Bacon. 
 
 THE skin is not only a protective covering for the 
 body, but a complex excretory organ, doing as impor- 
 tant a work in the elimination of waste products as the 
 lungs, kidneys, and gastro-intestinal tract. It consists 
 of two distinct layers, the derma, cutic vera, or true 
 skin, underneath; and the epidermis, cuticle, or scarf- 
 skin, on the outside. The true skin is filled with blood- 
 vessels and nerves; the cuticle contains none of these, 
 but is connected with them by numbers of sudoriferous 
 tubes. The surface of the body is closely covered with 
 the openings of these tubes, known as pores. From 
 these pores, water and excrementitious matters are con- 
 stantly being thrown off in the form of vapor. By this 
 steady evaporation the temperature of the body is regu- 
 lated. If the body be covered with an impermeable 
 coating, so as to entirely obstruct this process, death 
 shortly ensues. The scarf-skin is continually scaling 
 off and being renewed from beneath; at the same time ; 
 solid matters are to some extent deposited, as the water 
 evaporates from the sweat-ducts. Besides these, there 
 is another set of glands in the skin, called the seba- 
 ceous glands, secreting a kind of oily matter, which 
 serves to keep the skin soft and supple. The excess of 
 this sebaceous matter, the cast-off scales of the cuticle, 
 
 75
 
 76 A TEXT-BOOK OF NURSING 
 
 and the solid deposit from the perspiration, remain on 
 the surface, and, unless removed, fill the pores and pre- 
 vent further evaporation. Thus, even in a state of 
 health, frequent and thorough ablution is a matter of 
 the first hygienic import. Dirt of any kind blocks the 
 mouths of the sweat-bearing tubes and impedes their 
 action. This throws more work upon the other excre- 
 tory organs, disturbing the balance of their functions, 
 so that disease may often be traced simply to a failure 
 to keep the pores of the skin open. 
 
 In sickness it is even more serious, for the exhala- 
 tions of disease are morbid and dangerous, yet bathing 
 is often neglected through fear that the patient will 
 take cold. But cleanliness is a positive aid to recovery, 
 and, with proper precautions, there are very few pa- 
 tients who can not be washed without danger. In al- 
 most all cases at least a sponge bath in bed can be given, 
 care being taken neither to chill nor fatigue the patient. 
 The bed should be protected by an extra rubber and 
 draw-sheet. The room should be warm and free from 
 draughts, and everything likely to be needed at hand 
 plenty of hot and cold water, soap, sponges, towels, 
 clean clothing, etc. Take plenty of time, and, exposing 
 only a small part of the body at a time, wash, dry, and 
 cover it before proceeding further. Use a sponge or a 
 flannel wash-cloth. This will retain the heat much bet- 
 ter than cotton. After the bath some light refreshment 
 may be allowed, if the patient seems at all fatigued. A 
 bath should never be given within two hours after a 
 full meal. 
 
 The clothing should always be warmed before it is 
 put on. To change a night-dress, or shirt, slip off the 
 sleeves of the soiled one and pull it up toward the neck. 
 Then put the arms in the clean sleeves, lift the patient's
 
 BATHS 77 
 
 head and shoulders, and the soiled garment can be 
 slipped off over the head with the same motion that puts 
 on the clean one. Pull the latter down smoothly under 
 the back, but not too tight. In this way the patient 
 has only to be raised once. If he ought not to be lifted 
 at all, the shirt or gown must be ripped all the way down 
 the front. In taking it off, slip out one arm and put on 
 the corresponding clean sleeve, work it under the shoul- 
 ders, pushing the soiled one before it, and change the 
 other sleeve. If two garments are worn, fit one inside 
 the other before beginning, and put them on as one. 
 Where there is an injured arm or side, begin with it in 
 putting on a garment, but, in taking one off, begin 
 always with the sound side. 
 
 The mouth should be often washed, and the teeth 
 brushed, or wiped off with a bit of soft cloth. Water 
 containing a few drops of tincture of myrrh, Candy's 
 fluid, or listerine, is good to rinse out the mouth. To 
 remove sordes from the teeth, a mixture of lemon-juice, 
 glycerin and ice-water, in equal parts, will be found effi- 
 cacious. Another good mouth wash is made by adding 
 one minim of crude carbolic acid to two ounces each of 
 alcohol and water. 
 
 In combing the hair begin at the ends, holding the 
 hair firmly near the roots, to avoid pulling and to keep 
 the head steady. It is best arranged in two braids, or 
 twisted on top of the head, so that the patient will not 
 have to lie on a knot. When the hair is much matted, it 
 is better to cut it short, though, with time and patience, 
 very bad tangles can be straightened out. If the pa- 
 tient is in the hands of a good nurse from the commence- 
 ment, it will never be allowed to get into such a condi- 
 tion. To clean the hair there is nothing better than 
 tar soap. A little aromatic spirit of ammonia in water is
 
 78 A TEXT-BOOK OP NURSING 
 
 good, and it contains alcohol enough to make it dry 
 quickly. If the hair is naturally dry, vaseline well 
 rubbed in is a better dressing. Blood-clots in the hair, 
 as after a scalp-wound, can be dissolved out by a solu- 
 tion of washing soda. In disinfecting after exposure to 
 contagious diseases use a saturated solution of boracic 
 acid. As a rule, the hair should be brushed, the teeth 
 cleaned, and the hands and face washed at least twice 
 daily, and the whole body twice every week. The nails 
 should not be neglected. 
 
 Baths are used for remedial purposes as well as sim- 
 ply for cleanliness. They may be general or local, sim- 
 ple or medicated, cold, tepid, or hot; in the form of 
 liquid, vapor, or air. Judiciously employed, baths are 
 valuable therapeutic agents, but their unadvised use, as 
 is true of all powerful remedies, may be hurtful rather 
 than helpful. The exact temperature and duration of 
 any bath ordered must be obtained from the doctor, 
 and the effect upon the patient carefully noted. Tan- 
 ner gives the following temperatures as to be understood 
 when the definite degree of heat is not specified: 
 
 Cold 33- 65 Fahr. 
 
 Cool 65- 75 
 
 Temperate 75- 85 
 
 Tepid 85- 92 
 
 Warm ' 92- 98 
 
 Hot 98-112 
 
 To put a feeble patient in a bath, wrap him in a 
 sheet and lower it gently into the water. Have a warm, 
 dry sheet ready to roll him in when he leaves the bath. 
 Over this fold a blanket, and, putting him in a well- 
 protected bed, leave him wrapped in them for a few 
 minutes. In this way he will be made dry without extra
 
 BATHS 7d 
 
 fatigue. A few long strokes with a soft towel will be 
 all that is needed to complete the process when the 
 wrappings ape removed. If the bath is to be very soon 
 repeated, it is better not to put on the clothes, but to 
 leave the patient folded in a dry sheet, ready for the 
 next plunge. 
 
 Cold baths are employed either to produce reaction, 
 refrigeration, or nervous shock. Cold water abstracts 
 the heat of the body, and affects the internal organs 
 through the nervous system. Upon first entering a 
 cold bath there is experienced a sense of chilliness and 
 depression. The pulse is quickened, but the tempera- 
 ture of the surface is lowered, and the blood accumulates 
 in the internal organs. A condition of reaction soon 
 follows, with invigorated circulation, a feeling of 
 warmth and exhilaration; but if the immersion be too 
 long continued the coldness returns, with weakness of 
 the pulse and general depression. The cold bath is 
 sometimes used as a tonic in cases of debility, but there 
 must be a certain amount of vigor to render it endura- 
 ble. It is best taken in the morning, and followed by 
 vigorous rubbing and gentle exercise. The head must 
 be first submerged, and the bath continued only long 
 enough for the reactionary stage to be reached not 
 more than five minutes. The colder the water, the 
 sooner reaction takes place. A cold sponge-bath can 
 be taken with much less danger of chill if one stand 
 with the feet in warm water. The cold bath is a most 
 speedy and effective way of bringing down a high tem- 
 perature. It may be lowered from one to six degrees. 
 The shock of sudden immersion in cold water may be 
 avoided by beginning with a tepid bath, and gradually 
 reducing it as much as desired by adding cold water or 
 ice. The temperature must be taken by rectum and
 
 80 A TEXT-BOOK OF NURSING 
 
 the patient removed from the bath before it is lowered 
 to the required point, for it will continue to fall for some 
 little time afterward, until the heat of the interior and 
 exterior of the body becomes equalized. 
 
 The " Brand " method is much used for the reduc- 
 tion of temperature in cases of typhoid fever. In prep- 
 aration for this, the patient should first empty the blad- 
 der, and if perspiring, should be thoroughly dried. 
 Cover him then with a sheet, and lift gently into a tub 
 of water at a temperature of 70 F. During the im- 
 mersion, rub him vigorously, and if he be not too weak, 
 encourage him to rub himself. There should be a sup- 
 port for the head. This can be made of a strip of gauze 
 or muslin fastened securely across one end of the tub. 
 On the head should be kept a compress wrung out of 
 ice-water, or ice-water may be poured on the head three 
 or four times during the bath. This is very important 
 when the nervous symptoms are marked. After fifteen 
 minutes, the patient should be lifted upon the bed pre- 
 viously prepared with a rubber sheet and blanket. The 
 wet sheet should be removed, and be replaced by a warm 
 blanket, under which the patient is briskly rubbed dry. 
 This done, take away the rubber and blankets, and cover 
 him comfortably. As soon as shivering ceases, gener- 
 ally in about twenty minutes after removal from the 
 bath, the temperature should be taken to ascertain the 
 result. If put off longer than this, the invalid may be 
 asleep, and should not be disturbed. 
 
 The shivering which comes on ordinarily in five or 
 ten minutes after putting the patient in the water, 
 should not interfere with the continuation of the bath, 
 but if an almost absolute lack of pulse with skin cya- 
 nosed should develop, he should be at once removed to 
 the bed, hot water bottles be applied to the legs and
 
 BATHS 81 
 
 feet, and stimulants be given, if the condition persists. 
 In cases of typhoid fever, these baths will be ordered 
 repeated at intervals of not less than three hours. If 
 at the end of three hours after the bath, the tempera- 
 ture is between 101 and 102 F., it is to be taken again 
 in an hour; if between 100 and 101, in two hours; if 
 below 100, not for three hours. Generally, when the 
 temperature reaches 102, the bath will be given, if 
 three hours have elapsed since the previous one. 
 
 Instead of a bath-tub, a fever cot is sometimes used. 
 This is a frame covered with sacking, below which a 
 rubber cloth is hung, one end lower than the other. The 
 patient, wrapped in a sheet, lies on the sacking, and has 
 buckets of cold water poured over him at stated inter- 
 vals. The water runs through into the rubber trough, 
 which conducts it into a pail at the foot of the cot. 
 
 The wet pack or envelope bath is another method 
 of applying cold or heat. To prepare for this, first put 
 three or four blankets on the bed, and over these a sheet 
 wrung out in cold or hot water, as ordered. Lay the 
 patient on this, and fold the sheet over him, tucking it 
 in well on both sides from the neck to the ankles, the 
 feet not included. The blankets are then to be folded 
 over him, one by one, in the same way, and the patient 
 left in them from thirty minutes to three hours. Give 
 plenty to drink, and keep the feet warm. This treat- 
 ment is usually very comfortable to the patient, and he 
 will often fall asleep while in the pack. It will render 
 the skin moist, subdue restlessness and delirium, and 
 reduce fever. Upon removal, dry off the patient quick- 
 ly and wrap in a warm dry blanket for some hours. If 
 the object is simply to reduce temperature, the sheet 
 wrung out in cold water may be employed, without the 
 superimposed blankets. It should be changed every ten
 
 82 A TEXT-BOOK OP NURSING 
 
 minutes. The same effect may be more easily produced 
 by applying towels wrung out in ice-water, dry enough 
 not to drip, one after another, from the neck downward. 
 When the feet are reached, begin again at the head, and 
 renew each in succession, continuing as long as neces- 
 sary. 
 
 Cold or tepid sponging often gives much relief to 
 a feverish condition. Sponge always downward, and 
 wrap the patient, still wet, in a warm blanket, leaving 
 him undisturbed for an hour. Alcohol in the water 
 mates it more cooling by its rapid evaporation. Alcohol 
 alone may be used. 
 
 If it is desired to produce a shock upon the nervous 
 system, as sometimes when there is disease of the brain 
 or nerves, affusion is employed. This is simply throw- 
 ing cold water upon the body. The shower bath is one 
 form of it, and the douche another. The latter is most 
 used as a local tonic. The stream should be directed 
 from a height not exceeding ten feet, and, if the affected 
 part is very weak or sensitive, should first be brought 
 to bear upon the surrounding portions, and only by 
 degrees immediately upon it. A douche of hot and cold 
 water alternately is often advised. 
 
 A general warm bath is used to induce perspiration, 
 soothe pain, or relax spasm. The effect of warm or hot 
 water is at first agreeable. Transpiration is increased 
 through both lungs and skin, and the circulation accel- 
 erated. A very hot bath excites and stimulates the nerv- 
 ous system, while tepid or warm water rather calms and 
 soothes it. If the water is too hot, or the bath too long 
 continued, languor, giddiness, or faintness may super- 
 vene. The temperature should be tested with a ther- 
 mometer, and the same degree of heat kept up through- 
 out. Care must be taken that no part of the body comes
 
 BATHS 83 
 
 directly under the hot-water tap. Keep the head out, 
 and cool. An invalid should never be left alone in the 
 water, and must be taken out of it at once if any sign of 
 faintness appears. A hot bath will not be given during 
 the menstrual period, or in the last stages of pregnancy. 
 Some surgical cases have been successfully treated by 
 long-continued immerison of the injured part in hot 
 water. For this purpose, especially constructed tubs are 
 provided. Water as hot as can be borne is the best ap- 
 plication for all sprains or bruises. 
 
 A foot-bath is usually given to relieve the head, and 
 should be as hot as possible. If the patient is able to 
 sit in a chair, see that he is warmly wrapped up, and 
 cover both patient and tub with a blanket. Let the 
 water come nearly to the knees. Adding mustard will 
 increase the effect. The bath can be given in bed, if 
 necessary, though less conveniently. Have it well pro- 
 tected, turn up the clothes from the foot of the bed, di- 
 rect the patient to lie on the back and bend the knees, 
 when the feet can be set in a foot-tub or a deep bowl of 
 water. Have it well balanced, cover with a blanket, and 
 let the feet soak from a quarter to half an hour. Then 
 dry them well, and either wrap in flannel or put on 
 woolen stockings. The same treatment will be found 
 useful for cold feet. 
 
 For a sitz or hip bath, the patient is immersed from 
 the knees to the waist and covered with blankets. The 
 temperature of the water must be well kept up, and the 
 bath prolonged about twenty minutes. The object be- 
 ing to excite the menstrual flow, the bath should be 
 given, as nearly as can be calculated, at the time when 
 that would naturally appear. The hot foot-bath is some- 
 times employed for the same purpose. Neither should 
 be given when there is any suspicion of pregnancy.
 
 84 A TEXT-BOOK OF NURSING 
 
 For a hot-air bath, an alcohol lamp and a body- 
 cradle are required. The sheets and the patient's cloth- 
 ing are taken off, blankets enough put over the cradle 
 to render it nearly air-tight, and snugly tucked in. The 
 heated air should enter on a level above the patient, 
 whose body should be sponged with tepid water until 
 there is free perspiration. The lamp may be kept burn- 
 ing for twenty minutes or half an hour, and the patient 
 then sponged off with cool water. A vapor bath may 
 be given with a similar apparatus, or by conducting 
 steam under the cradle from the spout of a boiling tea- 
 kettle. Still another way is by wrapping hot bricks in 
 wet flannel, and setting them on earthen dishes under 
 the cradle. 
 
 Both the hot-air and vapor baths may in less severe 
 cases be given in a cane-bottomed chair, constituting a 
 modified Turkish bath. Let the patient, entirely with- 
 out clothing, sit on a wicker chair, with the feet on a 
 stool. Cover with several blankets, and under the chair 
 burn a spirit-lamp with a large wick. Let the patient 
 drink freely, and, after he has perspired sufficiently, put 
 him in a general bath of 75 or 80, or pour over him 
 a pail of cold water. Dry thoroughly, and keep him 
 warm afterward. 
 
 Both liquid and vapor baths may be medicated. A 
 mercurial vapor-bath is given like the above, but with a 
 special apparatus for the evaporation of calomel. This, 
 after being deposited upon the skin, is not to be rubbed 
 off. An acid vapor may be produced by evaporating 
 vinegar. 
 
 For an alkaline bath, add half a pound of carbonate 
 of soda to fifteen gallons of hot water. 
 
 A sulphur bath is prepared by adding to each gallon 
 of water twenty grains of sulphuret of potassium. This
 
 MASSAGE 85 
 
 must be given in a wooden or porcelain-lined vessel, as 
 the sulphides discolor most metals. This is ordered 
 sometimes for rheumatic affections, and sometimes for 
 disease of the skin in the latter case not usually until 
 the subsidence of the acute stage, as it tends rather to 
 aggravate the rash. With all skin diseases, rain water 
 should be used, or hard water softened by the addition 
 of soda, bran, starch, or gelatin. The skin should not 
 be rubbed, but dabbed dry with soft towels. 
 
 For a bran bath, boil a pound of bran in a bag for a 
 quarter of an hour, drain off the fluid, and add it to the 
 bath. 
 
 For a starch bath, take half a pound of starch, and 
 mix it with two quarts of water before adding it to the 
 bath. 
 
 A salt bath is usually given cold for tonic effect. 
 Either sea-water may be used, or a solution of rock-salt 
 in the proportion of one pound to four gallons of water. 
 
 After any emollient or soothing bath, the patient 
 should be kept quiet; after a stimulating bath, ener- 
 getic friction and exercise are in order. 
 
 MASSAGE 
 
 Massage is, in the hands of a skilled operator, a 
 valuable mode of treatment, and is now much used. 
 It will, to a considerable extent, take the place of ac- 
 tive exercise, keeping the muscles strong and supple. It 
 develops heat at the points of contact, so elevating the 
 general temperature and dilating the vascular system. 
 It furthers absorption, accelerating the motion of the 
 blood currents, removing effete matters, and so promo- 
 ting nutrition. It has usually a powerfully sedative 
 effect upon the nerves, though in some instances it will 
 
 be found to excite rather than to soothe. Insomnia and 
 
 7
 
 86 A TEXT-BOOK OP NURSING 
 
 neuralgia can often be relieved by it, and spinal irrita- 
 tion to some extent controlled. In the treatment of 
 nervous disorders it is often combined with rest, rigid 
 dietetics, and electrical excitation. Perhaps the most 
 conspicuously good results are in cases of chronic joint 
 affections and thickening from inflammatory deposits. 
 
 Massage consists of a peculiar kneading of the un- 
 derlying muscles, and is quite distinct from friction and 
 percussion, which touch only the external tissues, but it 
 is often combined with them, and with the " Swedish 
 movements," active, passive, resistive, or assistive. The 
 word, as commonly used, may be understood to embrace 
 all forms of manipulation. 
 
 A few desultory lessons will not qualify you to give 
 or teach massage. It takes time, patience, and a great 
 deal of strength to acquire the art, and constant practice 
 to retain any facility in it; for, even when once gained, 
 it is soon lost by disuse. Mere rubbing may be agree- 
 able and useful, but it is not massage. 
 
 Theoretical instruction does not amount to much on 
 such a subject, and there are many variations in vogue 
 even among good masseurs, so that the most that can 
 be attempted here is to give a few of the points in 
 which the most rational operators agree, and which 
 experience has shown to be valuable. It is very hard 
 work always too hard to combine with nursing but a 
 skilled manipulator will accomplish more in less time, 
 and with less effort, than an inexperienced one. The 
 whole body can be gone over pretty thoroughly in an 
 hour, after which a general rise of temperature of about 
 one degree may be looked for. 
 
 The hands need to be at once strong and soft, the 
 motions smooth and even, never jerky. The work 
 should be done from the wrists, not from the shoulders,
 
 MASSAGE 87 
 
 and you want equal flexibility and freedom of action in 
 both hands. All movements should be begun slowly 
 and gently, and their force and frequence gradually in- 
 creased. A very tender spot can be barely touched at 
 first, but after a little skillful handling an amount of 
 force can be employed which would have seemed in- 
 credible. The whole hand, not merely the ends of the 
 fingers should be used. In malaxation or massage prop- 
 er manipulation of the deeper tissues the work is 
 chiefly performed by the ball of the thumb and the 
 palm of the hand. Each muscle is kneaded and rolled 
 with carefully graded force. Begin at the extremities 
 and work toward the trunk. If the feet are cold, keep 
 at them until they are quite warm before going on. 
 Take up each group of muscles systematically, com- 
 press, rotate, and relax, advancing by degrees, that each 
 handful may include part of what has been previously 
 treated. Never stretch the tissues in opposite direc- 
 tions at the same time. Muscles should be stretched 
 in the direction from their insertion to their origin, 
 from extremities toward the trunk, on the back from 
 the base of the skull downward, and away from the 
 spinal column. On the chest, follow the pectoral mus- 
 cles in the same way, and on the abdomen knead stead- 
 ily and firmly the ascending, transverse, and descending 
 colon. Massage of the abdomen often relieves dyspep- 
 sia and constipation. 
 
 Friction should act only upon the skin. If counter- 
 irritation is desired, a coarse towel or a brush is better 
 than the hand. Friction may be vertical, transverse, or 
 spiral. Rectilinear friction should be toward the center 
 of circulation, to assist the venous currents. Thus, on 
 a limb, the heaviest strokes should be upward, the re- 
 turning ones much lighter. Friction circularly, or at
 
 88 A TEXT-BOOK OF NURSING 
 
 right angles to the long axis, though sometimes prac- 
 ticed, is awkward and of little use. What may be done 
 by such motions can be accomplished more effectively 
 by vertical and spiral movements. In the latter, both 
 hands are used at once one ascending as the other de- 
 scends. On the limbs, friction may be applied at the 
 rate of one to five hundred strokes per minute; on the 
 body and thighs the pressure must be greater, and the 
 strokes longer, so that they can not be as rapid. Malax- 
 ation and friction may be used in alternation. Take a 
 small portion of the body at a time, as the space between 
 one joint and another, and manipulate it thoroughly be- 
 fore passing to the next. With them may be combined 
 also percussion over masses of muscle and the various 
 passive, assistive, and resistive motions. 
 
 Muscle hacking consists of rapid blows delivered per- 
 pendicularly to the surface; if for slight superficial stim- 
 ulation, by the dorsal surface of the fingers; semiflexed, 
 for deeper effects, by the ulnar border of the palm. 
 Extended vibration is kneading and striking, with a 
 shaking motion added. 
 
 Passive motions are conducted without any effort on 
 the part of the patient. When there is partial control 
 of the muscular action, the operator either helps or tries 
 to hinder the efforts of the patient, being careful not to 
 overtax his little strength, and the exercises are then 
 known as assistive or resistive. Such movements are 
 applied, together with massage, to strengthen weakened 
 muscles and break up adhesions in diseased or anchy- 
 losed joints. It is of importance to know something of 
 their anatomical structure and the limits of natural 
 motion. 
 
 What is known as the Eoman bath is massage with 
 inunction. When there is a dry and insufficiently nour-
 
 MASSAGE 89 
 
 ished skin, inunction may be useful; but it is not an 
 essential part of treatment by massage, though unskilled 
 manipulators often use oil of some kind on their hands 
 to avoid chafing the skin. 
 
 The " rest cure " of Dr. Weir Mitchell is often em- 
 ployed, in connection with massage and electrical stimu- 
 lation, in the treatment of nervous prostration, where, 
 with no apparent organic disease, the patient yet seems 
 generally ill. This condition may arise from various , 
 causes, sometimes from severe mental strain, unusual, 
 cares, or great anxiety. 
 
 The patient is kept in bed, absolutely quiet, yTom 
 three to six weeks, seeing no one except the doctor and 
 the nurse, and allowed to make no effort of ar^y kind, 
 mental or physical. Feeding, and all care of th<3 person 
 are attended to by the nurse. Massage and Electricity 
 take the place of exercise, admii !r >~ > red in jeach case 
 according to definite instructions. ^ /"'the ^'treatment 
 to be successful, the rules laid dov ] ' '\ followed 
 
 to the letter. 
 
 oky hi 
 
 ' ' The best doctors in the world are Dr. Diet, > j. Quiet, and 
 Dr. Merry man." Swift.
 
 CHAPTER VII 
 
 " Mankind, in the main, have little wants, not large, 
 I, being of will and power to help in the main 
 Mankind, must help the least wants first." 
 
 Robert Browning. 
 
 THE principal elimination of waste matter from the 
 body, is through the kidneys. These are two bean- 
 shapeoh bodies, each about four inches long, lying in the 
 lumbar region, one on either side of the spine. The 
 urine, asi it is excreted by the kidneys, passes through 
 two connecting tpfees the ureters into the bladder, 
 whence ifo is j-dorsdically discharged through another 
 tube thttfr effects. The capacity of the bladder, fully 
 distended, vibrati>ut three pints. The urethra in the 
 adult femaotiora an inch and a half or two inches in 
 length, in t fte male eight inches. 
 
 Urine, iit a healthy condition, consists of some 960 
 parts of wate.tr to 40 of solid matter, principally urea 
 the chief was tte product of animal life. The average 
 quantity of urizttie passed in the twenty-four hours is two 
 and a half pints,st or forty fluid ounces. This will contain 
 from 450 to 600 >r grains of urea, besides a small propor- 
 tion of uric acid,^ and various phosphates, urates, and 
 chlorides. It is trb insparent, of pale amber color, hav- 
 ing a characteristic \tflroma, an acid reaction, and a spe- 
 cific gravity of 1020. \ 
 
 There may be considerable deviations from the above 
 
 standard, even strictlyVtwithin the limits of health. 'The 
 
 90
 
 URINE 91 
 
 quantity will vary in proportion to the amount of fluid 
 taken into the system, and to the activity of the skin. 
 When there is free perspiration, less water is left to be 
 carried off by the kidneys, and, consequently, the urine 
 is less abundant, darker in color, and of greater specific 
 gravity, owing to the increased proportion of solid mat- 
 ter. The specific gravity may vary from 1010 to 1035 
 without indicating any departure from health. The re- 
 action may for a time become neutral or even alkaline 
 after a meal, owing to the character of the food taken. 
 Diminished transparency may be due to the presence 
 of the earthy phosphates, or the mixed urates of sodium, 
 potassium, calcium, and magnesium, or to mucus from 
 the genito-urinary tract. 
 
 The same causes of variation may exist to an ex- 
 treme degree in sickness. The quantity may be dimin- 
 ished to two or increased to two hundred ounces. The 
 color may be affected either by diminution of the nor- 
 mal coloring matters or by the addition of abnormal 
 ones. Opacity may be occasioned by the presence of 
 pus. Blood gives a characteristic smoky hue to acid 
 urine; with an alkaline reaction, it is more nearly red. 
 Urine containing blood enough to be readily recogniz- 
 able as such is probably albuminous. Bile imparts a 
 greenish tinge, often seen with jaundice. In some cases 
 the urine becomes viscid or glutinous; in a variety 
 known as chylous urine, there is an increased consist- 
 ency, owing to an addition of molecular fat. In hys- 
 teria, alcoholism, anaemia, and convalescence from 
 acute diseases, the urine may be expected to be pale and 
 abundant. In the early stage of acute fever the specific 
 gravity is likely to be high, as a large amount of solid 
 matter is excreted. Lowered specific gravity is most 
 significant when it attends diminished quantity of urine.
 
 92 A TEXT-BOOK OF NURSING 
 
 In diabetes mellitus, the specific gravity of the urine 
 may be as high as 1050, while at the same time the 
 quantity is largely increased. This is due to the pres- 
 ence of sugar. In the disease known as diabetes insipi- 
 dus, or polyuria, there is an abundant flow of pale urine, 
 but it contains no sugar or albumin, and the specific 
 gravity is proportionately low. 
 
 It has already been noted that the food taken may 
 be of a sort to occasion temporary variations in the 
 character of the urine. Certain drugs also produce 
 specific effects upon it. Turpentine taken internally 
 gives to the urine an odor resembling that of violets. 
 It sometimes increases the flow, and sometimes causes 
 retention. Cantharides may also cause retention, or 
 slow and painful passage of urine, known as strangury. 
 Dark, smoky urine is one of the early symptoms of car- 
 bolic acid or iodoform poisoning. Santonin gives a 
 brilliant yellow color; rhubarb or senna, a reddish yel- 
 low; cubebs, copaiba, and sandal oil, each imparts its 
 peculiar odor. Medicines which increase the quantity 
 of urine are called diuretics. 
 
 It will be seen that many important indications may 
 be derived from careful observation and examination of 
 the urine. The nurse should always be able to report 
 the frequency of micturition, the quantity passed, and 
 any evident peculiarity. A specimen for examination 
 should be taken either from the total accumulation of 
 the twenty-four hours, or from that passed before 
 breakfast. In warm weather even normal urine can not 
 stand for twenty-four hours without becoming decom- 
 posed. It is best kept in a tall, narrow glass, tapering 
 toward the bottom, covered with a loose paper cap to 
 keep out the dust. In getting a specimen for the doc- 
 tor, or for your own thorough examination, care must
 
 URINE 93 
 
 be taken to have it free from all impurities. Six or 
 eight ounces will be wanted. Put it in a clean bottle 
 with a clean cork, and label distinctly with the name of 
 the patient, the date, and the full quantity of which it 
 is a sample. It may be necessary to use the catheter in 
 order to obtain it free from mucus; this is especially 
 true in the case of women with leucorrhcea or vaginal 
 haemorrhage. Whether or not there is any appreciable 
 sediment, a portion should be set aside for twelve hours, 
 in which time sediment sufficient for microscopic ex- 
 amination may be deposited. Note whether the urine 
 is turbid when first passed, or only becomes so after 
 standing, the quantity and character of the sediment, 
 and whether it floats or sinks. 
 
 To determine the reaction, test with litmus paper. 
 If acid, it will turn the blue red; if alkaline, the red to 
 blue; if neutral, it will have no effect upon either. 
 Urine having an acid or neutral reaction may turn al- 
 kaline after standing, but that which is alkaline in the 
 beginning never becomes acid. After standing a short 
 time at a moderate temperature the acidity often in- 
 creases, but after a longer time, and especially in warm 
 weather, the reaction becomes alkaline, with an ammo- 
 niacal odor and a precipitation of sediment. Alkalinity, 
 owing to the presence of ammonia, may be distinguished 
 from that due to the fixed alkalies, potash, or soda, by 
 drying the litmus paper which has been changed by it. 
 If the alkali is volatile, it will disappear, and the paper 
 resume its red hue; otherwise, the blue will be perma- 
 nent. 
 
 The urinometer should have been first tested with 
 distilled water, into which it should sink to 1000. The 
 urine should be well shaken, and, if cloudy, filtered. 
 The glass containing it should not be too small, as the
 
 94 A TEXT-BOOK OF NURSING 
 
 urinometer must not touch its sides. Drop it in the 
 middle, and note carefully the point at which it rests. 
 
 Foreign matters in the urine may be either sedimen- 
 tary or in solution. The most common sediment is com- 
 posed of the urates and phosphates. They subside into 
 a white or pink deposit. They may be distinguished 
 from each other by boiling a little of the urine in a 
 test-tube over the spirit-lamp, the urates being dissi- 
 pated by the heat, while the phosphates are precipitated. 
 The latter may be dissipated by adding a few drops of 
 nitric acid. Mucus is unaffected by heat, acids, or alka- 
 lies. Pus will be deposited as an opaque white sediment, 
 sinking rapidly so long as the reaction is acid and there 
 is no mucus in which it may be suspended. It resem- 
 bles the urates, but is not, like them, dissolved on the 
 application of heat. In Bright's disease albumin is 
 present, and often casts of the tubules of the kidney. 
 The latter are evident only upon microscopic examina- 
 tion. Mucus and pus also can only be positively identi- 
 fied by the microscope. 
 
 Urine to be tested for albumin should first be fil- 
 tered, if not perfectly clear. Fill a test-tube to one third 
 its depth, and, if the urine is not of distinctly acid re- 
 action, add one or two drops of acetic acid to make it so. 
 Boil for a moment and then hold it up to the light. Any 
 opacity appearing will be due either to albumin or earthy 
 phosphates. If the latter, it will disappear upon the addi- 
 tion of a few drops of nitric acid. If the fluid remains 
 quite clear after boiling, set it aside for twelve hours, 
 in which time a sediment may be deposited. Anything 
 except albumin will disappear upon a second boiling. 
 
 If the proportion of albumin is but small, it may be 
 held in solution by a slight excess of acid, on which ac- 
 count the following treatment is perhaps more reliable:
 
 URINE 95 
 
 Fill a test-tube to the depth of half an inch with 
 pure nitric acid. Add to this, by means of a small 
 glass tube, an equal quantity of clear urine, putting it 
 in so gently that it will not mix with, but just overlie, 
 the acid. This can be done by inclining the test-tube 
 and gently rotating the pipette. If there is albumin in 
 the urine, it will appear at the surface of contact as a 
 white zone, of varying thickness in proportion to its 
 quantity. A similar white band may be formed by the 
 mixed urates, if present in excess; but this may be dis- 
 sipated by heat, while the albumin will be still further 
 defined by it. 
 
 Heat precipitates albumin. 
 
 " phosphates. 
 
 " dissolves urates. 
 Nitric acid precipitates albumin. 
 
 " " " urates. 
 
 " " " dissolves phosphates. 
 
 Pale urine produced in large quantity, and at the 
 same time of a high specific gravity, should be tested 
 for sugar. A specific gravity of more than 1030 is 
 sufficient to excite suspicion of its presence. If there 
 is albumin in the urine, it should first be removed by 
 boiling and filtration. 
 
 A pretty and delicate test for sugar is by means of 
 Fehling's solution, of sulphate of copper and tartrate of 
 sodium. This needs to be kept tightly corked, and in 
 the dark, as it is decomposed by the action of light. 
 Dilute with five times its bulk of water, and boil. If a 
 precipitate, or change of color, appears on boiling, the 
 solution is worthless, and a fresh one must be prepared. 
 Add, drop by drop, an equal volume of the suspected 
 urine, when, if sugar is present, a precipitate will ap-
 
 96 A TEXT-BOOK OF NURSING 
 
 pear, varying in color from light-yellow to orange-red, 
 according to the quantity of sugar present. 
 
 An absence of the urinary excretion, owing to a fail- 
 ure of the kidneys to act, is known as suppression. It 
 is less common than retention the failure to expel that 
 which is in the bladder. The latter may be referred to 
 various causes. The bladder may be paralyzed, or the 
 senses dulled, so that there is no desire to pass urine, 
 even when the bladder is full, or there may be a nervous 
 contraction of the urethra, resulting in an inability to 
 do so even when the inclination is felt. When no urine 
 has been passed for some time, if there is pain on pres- 
 sure above the pubes, a dull instead of a clear sound on 
 percussion, and if the outline of the bladder can be dis- 
 tinctly seen, it may be safely assumed to be full, and the 
 use of the catheter is indicated. Cystitis is an inflam- 
 mation of the bladder, marked by peculiarly distressing 
 pain; it is often the result of taking cold, and is a fre- 
 quent complication of uterine diseases. Incontinence of 
 urine arises from weakness of the neck of the bladder, 
 rendering it unable to restrain its contents; it is most 
 frequent in children. Apparent incontinence may be 
 really retention with overflow, caused by the over-dis- 
 tention of the bladder, and consequent muscular strain. 
 Catheterization may be called for even when there is 
 constant slight passage of urine. In all cases of incon- 
 tinence special care is needed to keep the parts clean 
 and to prevent excoriation, by frequent bathing and 
 the application of ointments. Rubber urinals are some- 
 times used. 
 
 Whenever, from any cause, a patient is unable to 
 pass urine voluntarily, the catheter should be used 
 every six or eight hours. If it is properly introduced, 
 and no urine can be drawn, suppression may be inferred.
 
 URINE 97 
 
 This is a very serious symptom, for, if the system can 
 not be relieved of its waste product, the urea is soon 
 absorbed into the blood, and uraemia, a dangerous form 
 of poisoning, results. Hot applications over the kidneys 
 will sometimes excite them to action. So when the 
 difficulty is retention only, hot applications over the 
 bladder may relieve it; they usually will with children. 
 A hot sponge between the thighs may be effective. The 
 sound of running water will sometimes overcome reten- 
 tion due to nervousness. When the use of the catheter 
 in the female is imperative, proceed as follows: Oil the 
 instrument with the finger. Have the patient flat on 
 the back, if possible, with the thighs slightly separated. 
 Find the vagina as a landmark, and just above it will 
 be felt a slight prominence. Immediately above this 
 is the depression which marks the urethral opening. 
 Into this slide very gently the point of the catheter, 
 being careful that it does not slip into the vagina. It 
 should not be pushed far enough to strike the walls of 
 the bladder. As soon as the cavity is reached, the end 
 of the catheter will move freely, and the urine will 
 flow through it into the receptacle provided. If the 
 flow ceases before a reasonable quantity has been passed, 
 withdraw the instrument slightly, turn it, then push it 
 a little farther in than before, when it may begin again. 
 After the bladder is emptied, withdraw the catheter 
 as gently as it was introduced. In no case use force. 
 While removing the catheter, keep a finger over the 
 open end, so that the few drops which it contains will 
 not fall on the bed. If, from over-sensitiveness of the 
 parts, the passage of the catheter causes great irrita- 
 tion, it may be allayed by applying previously a little 
 belladonna or cocaine ointment. 
 
 A distended bladder should not be too rapidly emp-
 
 98 A TEXT-BOOK OF NURSING 
 
 tied by catheter, as there is danger of cystitis from the 
 sudden collapse of its walls. When it is very full, draw 
 only a portion of the contents at first introduction of 
 the catheter, and repeat the process soon. 
 
 To pass the catheter skillfully is an important ac- 
 quisition. It may, in the female subject, be done en- 
 tirely under the bedclothes; no exposure of the pa- 
 tient's person is necessary, but there should be no hesi- 
 tation in using the sense of sight when there is any 
 difficulty in finding the meatus by touch. Do not even 
 then expose the patient unnecessarily, but have the 
 limbs flexed as she lies on her back, and cover each with 
 a blanket, leaving only the vulva visible. In all cases 
 of operation on the perinaeum, vulva, vaginal walls, or 
 urethra, the catheter must be introduced by sight, to 
 avoid any possible damage to the stitches. This is also 
 preferable after labor. Aseptic precautions are also 
 necessary. The catheter should be boiled before use, 
 and kept in a basin containing mercuric bichloride 
 1-3000. It is convenient also to have in this basin a 
 number of cotton swabs. The parts should be washed 
 carefully with the same solution, the labia being sepa- 
 rated, and any wound receiving special attention. If 
 the catheter should happen to slip into the vagina, re- 
 move, and wash it again before inserting in the urethra. 
 When the urine has ceased to flow, the finger placed 
 over the open end of the catheter and held firmly will 
 prevent the urine escaping from the eye of the instru- 
 ment as it is withdrawn. The urethral opening is now 
 again sponged dry with one of the cotton swabs. The 
 catheter is to be washed and replaced in the bichloride 
 solution. 
 
 It is but rarely that the nurse will have need to pass 
 the catheter upon a male, but it will occasionally occur,
 
 URINE 99 
 
 and she should know how to do it. The patient may 
 be standing, but it is better to have him lying on his 
 back, the knees drawn up, slightly separated, and the 
 shoulders raised. The external generative organs must 
 be completely exposed, and the nurse should stand on 
 the patient's left. The penis must be raised to an angle 
 of about 60 with the body, thus effacing the anterior 
 curve of the urethra, using the second and third fingers 
 of the left hand, keeping its palm upward. The thumb 
 and first finger being free are used to draw back the 
 prepuce and " separate the lips of the meatus." The 
 catheter should be warmed, then oiled and held lightly 
 but firmly between the thumb, first and second fingers 
 of the right hand, as a pen is held the shaft of the 
 catheter corresponding to the fold between the abdo- 
 men and the left thigh. The catheter should be intro- 
 duced with slight force, and slowly. If properly started 
 its own weight is nearly enough to effect a passage. 
 Should it meet with resistance, withdraw it a little and 
 then advance, changing slightly the direction of its 
 point. As the catheter passes along the first two inches 
 of the urethra, the point should be directed slightly to 
 the lower surface to avoid the lacuna magna, a large 
 gland in this location. It is wise to continue this in- 
 clination until the angle of the scrotum and penis has 
 been passed. Then it changes and the tendency should 
 be toward the upper surface, thus escaping the sinus of 
 the bulb. When it lies beneath the pubes the shaft is 
 brought around parallel to the surface of the abdomen, 
 and in the median line. Elevate the handle until per- 
 pendicular, and press with the free hand upon the 
 mons veneris, and the root of the penis, thus extending 
 the suspensory ligament. The point will then gen- 
 erally glide into the bladder.
 
 100 A TEXT-BOOK OP NURSING 
 
 The flexible rubber catheter is the most convenient, 
 and least likely to hurt the patient. No. 7 is a good 
 size for ordinary cases. After each use it should be 
 thoroughly cleaned and disinfected. Let a stream of 
 water run through it in both directions, first from the 
 eye downward, lest any sediment be driven down into 
 the point. It may be boiled without injury, and soaked 
 in bichloride. If kept in this solution, it should be 
 rinsed before using. A glass catheter is preferred by 
 many gynaecologists, and has the advantage of being 
 most easily cleaned, and showing most readily the pres- 
 ence of any foreign matter. 
 
 In cases of cystitis, the bladder will often have to 
 be washed out. For this purpose a double catheter or 
 an especially designed syringe is used. Or it may be 
 equally well done by fitting a longer rubber tube over 
 one end of a piece of glass tubing, the other end being 
 inserted into the ordinary catheter, which is then intro- 
 duced in the usual way. The bladder being first emp- 
 tied, pour into the tube, through a glass funnel, the 
 water, or whatever fluid is ordered, a pint at a time, at 
 a temperature of 100 F. Lower the tube and let it 
 run off, and repeat the process until it runs clear. 
 Never try to use a Davidson syringe for this pur- 
 pose, as each impulse will give pain, but a fountain 
 syringe with glass catheter attached makes an excel- 
 lent apparatus, both having first had boiling water, 
 and some disinfecting solution passed through 
 them. If the catheter is not a double one, it 
 must be disconnected each time, to allow the fluid to 
 escape. 
 
 Further elimination of waste matter takes place 
 through the gastro-intestinal tract, beginning with the 
 disintegration of food in the stomach.
 
 ENEMATA 101 
 
 The intestinal canal is formed by the folds of a 
 single long tube, some twenty-five or thirty feet in 
 length. That part of it nearest the stomach is called 
 the small intestine various subdivisions, respectively, 
 the duodenum, jejunum, and ileum; the last five or six 
 feet are of much greater diameter, and are therefore 
 spoken of as the large intestine. This also is subdivided 
 into the caecum, the colon ascending, transverse, and 
 descending and the rectum. It is not directly con- 
 tinuous with the small intestine. The enlargement is 
 abrupt, at right angles to the ileum, and separated from 
 it by a valve. This ileo-caecal valve allows free passage 
 to the contents of the small intestine, but firmly resists 
 pressure from the caecal side. At the end of the caecum 
 is a small closed tube, called the vermiform appendix, 
 the uses of which are unknown. It is frequently the 
 seat of serious inflammation known as appendicitis. A 
 continual motion is kept up in the intestines, by means 
 of which their contents are propelled along. These 
 movements are termed peristaltic. The process of di- 
 gestion is completed in the small intestine; whatever 
 passes beyond this is merely the waste and innutritions 
 residue of the food, and undergoes no further digestive 
 action. The intestines and all the other abdominal vis- 
 cera are bound together and held in place by a strong 
 membrane, the peritonaeum. 
 
 An enema, or clyster, is a fluid preparation for injec- 
 tion into the rectum. Large ones are administered by 
 means of a bulb or fountain syringe. For small ones 
 a syringe of hard rubber is to be preferred. Enemata 
 may be used to secure or control evacuations of the 
 bowels, to obtain remedial effect, local or general, or for 
 the administration of nourishment. According to the 
 purpose for which they are given, they may be classified
 
 102 A TEXT-BOOK OF NURSING 
 
 as purgative, emollient, astringent, sedative, antbelmin- 
 tic, stimulant, nutritive, etc. 
 
 Purgative enemata are in general use for the relief 
 of constipation. They produce the desired result not 
 simply by washing out the accumulated fecal matter, 
 but by distention of the rectum and lower part of the 
 bowel, occasioning a reflex stimulation, and increased 
 peristaltic action of the whole intestinal tract. They 
 are found to act efficiently even when the matter is 
 lodged high up in the intestine, beyond the ileo-caecal 
 valve. A small enema often fails when a large one 
 would be operative. To an adult should be given from 
 one to four pints; a child requires but half as much, 
 and for an infant one or two ounces will be sufficient. 
 Having carefully protected the bed, place the patient 
 on the left side, with the knees flexed. In an obstinate 
 case, an advantage will be gained by adopting the Sims, 
 or the knee-chest position. If the rectum is packed, it 
 may be necessary to remove some of the fecal matter 
 with the fingers before the tube of the syringe can be 
 introduced. Ordinarily the rectum will be found emp- 
 ty, the accumulation being in the lower part of the 
 colon above the sigmoid flexure. 
 
 Pass the fluid several times through the syringe to 
 expel the air from it; oil the nozzle and insert it very 
 gently upward, slightly backward, and toward the left. 
 Under no circumstances use force. See that the end 
 of the tube moves freely in the rectum, neither pressed 
 against the sacrum nor imbedded in a fecal mass. Give 
 the injection very slowly; sudden distention of the rec- 
 tum will produce an immediate and imperative desire 
 for relief. It is a process about which it is impossible 
 to hurry. If the patient complains greatly of pain, rest 
 a little; after a delay of a few moments you can usually
 
 ENEMATA 103 
 
 go on without causing distress. The anus may be sup- 
 ported by a folded towel, or, where there is little con- 
 trol of the sphincter, two or three fingers will have to be 
 passed into the rectum by the side of the tube. After 
 the desired amount has been injected, remove the tube 
 gently, and, continuing to support the anus, keep the 
 patient perfectly quiet for ten or fifteen minutes. If a 
 full enema can be retained for this length of time, 
 there will in ordinary cases be little doubt of a satisfac- 
 tory result. A bulb syringe, as the Davidson, is perhaps 
 the best for giving a purgative enema, as the force of 
 the flow can be regulated by hand and arrested tem- 
 porarily if desired. Nothing requires more care than 
 the proper administration of enemata, and the most 
 frequent reason for failure is that the nurse does not 
 take time enough. A most effective method is to throw 
 the fluid high up into the bowel through a soft rubber 
 tube connected with the syringe. This is known as a 
 high enema. The tube should carry the fluid above the 
 sigmoid flexure, and must of course be introduced with 
 great care. A No. 12 male elastic catheter can be ob- 
 tained of the druggist. It should first be softened by 
 dipping it in warm water. Water alone may be used 
 for the injection, or, where something more stimulating 
 is called for, various medicaments are added, as soap, 
 salt, olive or castor oil, ox-gall, etc. A drachm of glyc- 
 erin will add greatly to the action of an enema, or a 
 saturated solution of Epsom or Rochelle salts may be 
 used. In obstinate constipation and intestinal obstruc- 
 tion nothing is so effective as a high enema containing 
 5 xij-3 XV J of molasses. For ordinary cases soap-suds 
 are excellent and convenient. An enema of this sort 
 may be rendered more certain in its action by the addi- 
 tion of a couple of ounces of oil and half an ounce of
 
 104 A TEXT-BOOK OP NURSING 
 
 turpentine; these, with a small quantity of the soap- 
 suds, should be first injected, and followed by the bulk 
 of the fluid. An injection of olive oil, iv-vj, may be 
 given half an hour before one of water, and allowed 
 to remain, in order to soften the fecal mass. After any 
 operation upon the genital organs or the anus, where 
 there is likely to be a strain upon sutures, such an 
 enema may be given before each movement. Oil should 
 always be warmed, as, when cold, it is too thick to pass 
 through the syringe readily. Another enema exceed- 
 ingly useful for softening scybalous masses in the rec- 
 tum is of a solution of inspissated ox-gall. It should 
 be retained for about an hour, and then be followed by 
 a large enema of soap-suds. This is used especially 
 after operation for laceration of the perinseum through 
 the sphincter. 
 
 The habitual use of large evacuant enemata is to be 
 discouraged, as causing undue distention and a some- 
 what torpid condition of the bowels. 
 
 As to the best temperature for evacuant enemata, 
 authorities differ. Hot or cold water will naturally ex- 
 cite the intestines to more vigorous action than water 
 of the same temperature as the body, but not so much 
 of it can be taken. Either may be used without incon- 
 venience to the patient. The daily injection of a pint of 
 cold water is often advised in case of constipation at- 
 tended by bleeding haemorrhoids. 
 
 Injections of ice-water are sometimes given to check 
 haemorrhage from the bowels. 
 
 When there is an irritable condition of the mucous 
 membrane, enemata of a more soothing nature are indi- 
 cated. Thin gruel is often used, or a decoction of flax- 
 seed, starch, or barley. Emollient enemata should al- 
 ways be warm.
 
 ENEMATA 105 
 
 Hot rectal injections are used to relieve pelvic con- 
 gestion, also in dysentery, for cleansing and relieving 
 inflammation. 
 
 For the rectal douche, a fountain syringe should be 
 used with rectal or stomach-tube attached. The pa- 
 tient should lie on the back, the knees well flexed, with 
 a small pillow under the hips, to insure the passing of 
 the liquid backward and upward. 
 
 Anthelmintic enemata are given to destroy worms. 
 Only a small quantity need be used : for an adult half a 
 pint is sufficient, for a child still less. The remedy 
 to be employed will be prescribed by the physician to 
 suit the case. Salt, quassia, aloes, tincture of iron, and 
 weak carbolic acid are among those used. Avoid mak- 
 ing the solution too concentrated, as it may excite in- 
 flammation. 
 
 To check diarrhoea enemata of starch are frequently 
 given, thin enough to pass readily through the syringe, 
 to which has been added a prescribed quantity of lauda- 
 num, usually about thirty drops to two fluid ounces of 
 starch. These may be ordered after each movement, or 
 regularly every few hours. The action is at once seda- 
 tive and astringent. Other astringents, as sulphate of 
 copper or acetate of lead, are sometimes similarly em- 
 ployed. 
 
 Sedatives are given by rectum for the relief of pain, 
 especially in the region of the pelvis. It takes, as a 
 rule, a third more of any drug than the dose given by 
 mouth to produce the same effect per rectum, and three 
 times as long to produce the effect. Any rectal injec- 
 tion intended to be retained must be given very slowly, 
 in quantity not exceeding three ounces, and of a tem- 
 perature not less than 100 Fahr. Quiet must be en- 
 forced for some time after it is taken. The best instru-
 
 106 A TEXT-BOOK OF NURSING 
 
 ment is a hard-rubber syringe holding the exact quan- 
 tity, to which a long flexible rectal tube is attached. 
 A high enema can be given oftener and retained longer 
 than when the short tube only is used. Care must be 
 taken not to introduce air at the time of the adminis- 
 tration of the enema. An ordinary stomach-tube of 
 medium size is an excellent appliance with which to 
 give the enema, and, in addition, is much more free 
 from danger than the hard rectal tubes. A piece of 
 rubber tubing may be attached to the stomach-tube, and 
 to this a small funnel. The fluid to be administered 
 is poured into the funnel, and allowed to appear at the 
 eye of the stomach-tube; this will exclude the air. The 
 tube is now held firmly, so that the fluid may not es- 
 cape. It should have been previously lubricated, and 
 after being introduced into the rectum for a distance 
 of six or seven inches, the fluid is allowed to flow, the 
 funnel being elevated. Especially do these directions 
 apply to nutrient enemata, which are used when suffi- 
 cient food can not be received or disposed of by the 
 stomach. The possibility of nourishing in this way is 
 often the means of saving life. Any highly concen- 
 trated liquid food may be given. Beef-extracts are 
 most often used. Defibrinated blood has been thought 
 valuable. Brandy, or some other form of alcoholic 
 stimulant, is often given, together with the nourish- 
 ment, but it is so irritating that its use can not be long 
 continued. As food given by rectum has not been 
 through the regular digestive processes, it must, to be 
 easily assimilated, be subjected to artificial digestion; 
 therefore, pepsin or pancreatic extract is commonly 
 added to it. Solutions having a slightly acid reaction 
 are absorbed with the greatest facility. These injec- 
 tions should not be given too frequently, or they may
 
 SUPPOSITORIES . 107 
 
 fail to be retained; absorption is slow, and the rectum 
 not very tolerant of foreign matter. Once in five hours 
 is often enough, and three ounces the maximum quan- 
 tity. If so much can not be borne, try two or one at a 
 time. Before giving a nutrient enema, it is important 
 to ascertain whether or not the rectum contains faeces. 
 If it is not found empty, it will be necessary to give 
 first a purgative enema. It will often be found that 
 after the rectum has been filled several times, the non- 
 absorbed residue will decompose and of itself cause irri- 
 tation. This can be avoided if the rectum is occasion- 
 ally irrigated. 
 
 After using a syringe, clean it by letting plenty of 
 warm water run through it, wipe it on the outside, and 
 hang it up by the extreme end to drain. Never put it 
 away in the box wet. A hard-rubber syringe shrinks 
 in drying, and if left long unused will be apt to leak, 
 but this can be remedied by soaking in hot water. A 
 bed-pan should always be warmed before use by dipping 
 in hot water. Dry it carefully, and, if any difficulty 
 is found in adjusting it, oil the edges. Have a little dis- 
 infecting solution in it. For a very thin patient pad 
 the edges. 
 
 Suppositories are solid bodies for introduction into 
 the rectum, answering, to some extent, the same pur- 
 poses as enemata. They are of various sizes, conical or 
 spherical in form, and, while firm enough to retain 
 their shape under ordinary conditions, are sufficiently 
 soft to melt under the heat of the body. They are 
 usually made of cacao butter, in which some medicinal 
 agent is incorporated. They have the advantage of 
 facility of application, and, being of little bulk, are 
 easily retained. Opium is often given in this form for 
 the relief of local pain or diarrhoea. Suppositories of
 
 108 
 
 A TEXT-BOOK OF NURSING 
 
 soap or boiled molasses are given to children for lax- 
 ative purposes, and are very effective. A suppository, 
 having been first oiled, should be introduced very grad- 
 ually and gently into the rectum, the patient lying on 
 
 CKOPHAGU. 
 
 The alimentary canal. 
 
 the left side as for an enema. It should pass well be- 
 yond the sphincter ani, and it is well to keep the finger 
 applied for a moment, until the rectum becomes accus- 
 tomed to its presence, to lessen the danger of its imme- 
 diate expulsion. Suppositories containing one drachm 
 of glycerin are now often used in place of enemata.
 
 SUPPOSITORIES 109 
 
 They usually produce an effect within fifteen or twenty 
 minutes by setting up uniform peristaltic action and 
 increasing the secretion from the intestinal glands. 
 
 The nurse is often called upon to wash out a pa- 
 tient's stomach, a process much like that of washing 
 the bladder, already described. Either a regular stom- 
 ach-tube or a fountain syringe may be used. In the 
 absence of either, a piece of rubber tubing attached to 
 a funnel will serve the purpose. Clean the apparatus 
 thoroughly, fill the bag of the syringe or a pitcher, from 
 which to pour, with lukewarm water, oil the tube, and 
 instruct the patient, after passing it well back in the 
 mouth, to swallow slowly, breathing as naturally as pos- 
 sible. After this is done, the bag is raised, and the 
 contents allowed to pass slowly into the stomach. When 
 it is full, generally retching will develop; if not, when 
 no more fluid passes into the tube, it should be de- 
 tached from the bag, and the outer end placed over a 
 basin into which the contents of the stomach may drain 
 out. Eepeat until the fluid runs clear; then remove 
 the tube steadily and rapidly. Usually liquid food is 
 given after the washing. 
 
 " Whene'er a noble deed is wrought, 
 Whene'er is spoken a noble thought, 
 Our hearts in glad surprise 
 To higher levels rise. 
 
 " Honor to those whose words and deeds 
 Thus help us in our daily needs, 
 And by their overflow 
 Raise us from what is low." 
 
 Longfellow.
 
 CHAPTER VIII 
 
 "Nothing has such power to broaden the mind as the ability 
 to investigate systematically and truly all that comes under thy 
 observation in life." Marcus Aurelius Antoninus. 
 
 A GREAT point of distinction between the trained 
 and the untrained nurse is, or should be, the ability of 
 the former to observe accurately, and to describe intelli- 
 gibly, what comes under her notice. The nurse who is 
 with her patient constantly, has, if she knows how to 
 make use of it, a much better opportunity of becoming 
 acquainted with his real condition than the physician, 
 who only spends half an hour with him occasionally. 
 The very excitement of his visit will often temporarily 
 change the entire aspect of the patient, and make him 
 appear better or worse than he really is. In order to 
 form correct judgments it is necessary for the physi- 
 cian to know what goes on in his absence, as well as in 
 his presence, and for such information he is forced to 
 rely almost wholly upon the nurse. It is thus of the 
 greatest importance that she cultivate the habit of criti- 
 cal observation and simple, direct, truthful statement. 
 Even where there is no intent to deceive, very few peo- 
 ple are capable of making a report of anything which 
 shall be neither deficient, exaggerated, nor perverted. 
 The doctor wants facts, not opinions ; and a nurse who 
 can tell him exactly what has happened, without ob- 
 scuring it in a cloud of vague generalities, hasty infer- 
 UO
 
 Ill 
 
 ences, or second-hand information, will be recognized 
 as an invaluable assistant. 
 
 The phenomena which accompany disease are 
 termed symptoms. , These may be classified as subjec- 
 tive, those which are evident only to the patient; ob- 
 jective, which may be appreciated by outside observers ; 
 and simulated, feigned for purposes of deceit, either to 
 excite sympathy, or from other motives. It requires 
 both experience and judgment to enable one to distin- 
 guish between real and feigned symptoms. An expert 
 malingerer will now and then deceive an entire hospital 
 staff into the treatment of a malady that has no real 
 existence; while, on the other hand, genuine suffering 
 may chance to be mistaken for fraud, or hysteria, if tfye 
 usual objective manifestations are absent. The diffi- 
 culty of determining the false from the true is often 
 very great, especially where, as is frequently the case, 
 there is an undoubted basis of fact. Entirely subjective 
 symptoms may always be regarded with some degree of 
 suspicion, as disease unaccompanied by any outward 
 sign is comparatively rare. It is better to be duped 
 once in a while than to fail to give aid or sympathy 
 where it is really needed; but, without letting the 
 patient feel that he is being watched, let nothing pass 
 unseen, note the most fleeting signs, and, if you have 
 any quickness of perception, you will soon get an im- 
 pression of his mental attitude as well as his physical . 
 state, and can judge to some extent whether his state- 
 ments are to be relied upon, and whether he has a 
 tendency to exaggerate his ills, or to make light of 
 them. 
 
 To decide as to the existence of disease, of course 
 belongs solely to the doctor, but he will be largely guid- 
 ed by the observations of the attentive nurse, and she
 
 A TEXT-BOOK OF NURSING 
 
 herself will often be called upon to judge as to the 
 urgency of special indications. Shall she send for the 
 doctor in the middle of the night, or apply her own 
 resources? shall she give or withhold the medicine left 
 to be used only in emergency? shall she alter or let 
 alone an arrangement which has proved unexpectedly 
 uncomfortable? are questions constantly arising. The 
 nurse needs to be able to discriminate between the im- 
 portant symptoms and those which are merely inci- 
 dental to recognize those which call for immediate 
 action, and to know what kind of action on her part is 
 called for. 
 
 When you have acquired the habit of observation so 
 nqcessary for you, you will, at the first glance at a new 
 patient, get an idea of his general physiognomy and any 
 prominent peculiarities ; closer investigation will reveal 
 more minute particulars. 
 
 Try to learn all you can of the previous history of 
 the case ; you will sometimes get valuable points which 
 the patient would hesitate, or not think of sufficient 
 consequence, to mention to the doctor in person. 
 
 Note the patient's apparent age, with any indica- 
 tions of premature or disguised age, signs of weakness, 
 size, whether well or ill nourished, emaciated, corpu- 
 lent, or bloated, and any deformities, swellings, or 
 wounds. 
 
 Attitude and expression are sometimes very charac- 
 teristic, giving valuable indications. A sufferer in- 
 stinctively takes the position most calculated for ease. 
 Thus, when one lung is affected, the patient lies on that 
 side, so that the healthy one, which has to do most of 
 the work, may have the greatest freedom of motion. 
 Lying on the back, with the knees drawn up so as to 
 relax the abdominal muscles, suggests peritonitis. With
 
 THE OBSERVATION OF SYMPTOMS 113 
 
 colic, on the contrary, you may find the patient lying 
 on the abdomen, as pressure relieves pain of such char- 
 acter. When a patient who has lain persistently on 
 his back turns over to the side, it may be looked upon 
 as a sign of improvement. There is no surer indication 
 that the distress of dyspnoea is removed than for a pa- 
 tient, who has been forced to sit up, to lie down and 
 compose for sleep. The inability to breathe while lying 
 down is termed orthopncea. It occurs in affections both 
 of the lungs and of the heart. Lying quietly is usually 
 a favorable sign; but in acute rheumatism the patient 
 is quiet because the least motion causes pain. Again, 
 extreme weakness may render it too great an exertion 
 to move. Eestlessness is ominous in most organic dis- 
 eases. Slipping to the foot of the bed is sometimes a 
 very bad sign. ^ 
 
 A pinched and anxious look is often the forerunner 
 of serious mischief, while a tranquil expression is usu- 
 ally of favorable import. Sudden lack of expression, 
 apathy, or immobility of features is a bad symptom, 
 excluding cases of hysteria and mental weakness. In 
 facial paralysis, expression will be totally absent from 
 half the face, or it will be drawn and distorted the 
 healthy side being the one thus affected. 
 
 Some painful abdominal affections are accompanied 
 by a sort of sardonic smile ristis sardonicus from 
 contraction of the muscles of the mouth. Any such 
 contortion of feature is noteworthy, as also extreme 
 thinness or swelling of the lips, and excessive action of 
 the nares. The facial expression in sepsis is very 
 marked and characteristic, although difficult to de- 
 scribe. 
 
 The most important indices of disease are the pulse, 
 respiration, and temperature, sometimes called the
 
 114 A TEXT-BOOK OP NURSING 
 
 three vital signs. They have already been discussed 
 under their several heads. The three are intimately 
 associated, and correspondingly affected. The fre- 
 quency, rhythm, and force of the pulse are to be care- 
 fully observed, and its relations to other symptoms. 
 Note the rate and any peculiarities of respiration, 
 whether it is most abdominal or thoracic, if regular 
 or irregular, easy or labored, and whether or not ac- 
 companied by pain. There is no pain in disease of 
 lung-substance alone; when the pleura is involved, 
 there is sharp pain. In bronchitis or asthma there is 
 difficulty in breathing, an evident muscular effort; in 
 pneumonia it is rapid, and more shallow than in the 
 former. Dyspnoea is common from various causes. 
 There is one very peculiar form of it, known as the 
 Cheyne-Stokes respiration, in which the inspirations, 
 at first short and shallow, become by degrees deep and 
 difficult up to a certain point, and then again more and 
 more superficial until they entirely cease. After a 
 pause of from a quarter to half a minute, the same 
 series of phenomena are repeated in the same order. 
 This is a curious and generally a fatal symptom. 
 
 Cautious respiration indicates lung trouble of some 
 kind. (Edema of the lungs, or the presence of fluid in 
 the air-passages, is evidenced by rattling and shortness 
 of breath. The sounds produced by the passage of air 
 through the fluid in the air-cells, bronchi, or cavities 
 are known as rales. 
 
 Most disorders of the respiratory organs are accom- 
 panied by cough. This is caused by irritation of the 
 air-passages, and is often an effort at the expulsion of a 
 foreign body. Matters coughed up are called sputa. 
 Cough not accompanied by expectoration is said to be 
 dry. The character of the expectoration varies with
 
 THE OBSERVATION OP SYMPTOMS 115 
 
 different diseases. In bronchitis it is at first simply 
 mucous, later it may become purulent ; in chronic cases 
 it is thick and yellow. The sputa of phthisis are at first 
 tenacious and ropy, sometimes frothy, at an advanced 
 stage becoming purulent and streaked with blood; 
 sometimes peculiar cheesy lumps are expectorated. In 
 pneumonia the expectoration is for the most part 
 scanty; after a certain stage it has a characteristic rust 
 color, and a tenacious, tough quality. Gangrene of the 
 lung gives dark, greenish sputa, very copious and offen- 
 sive. Cancer of the lung has a peculiar gelatinous form 
 of expectoration. In children, the sputa are often swal- 
 lowed; if thrown up mixed with food, they may be 
 known to come from the stomach. 
 
 Note whether mucus accumulates during the night, 
 and the time of day when the cough is the worst ; if it 
 is increased by moving, or on first waking; the charac- 
 ter of the cough, whether hard or loose, choking, short, 
 incessant, or paroxysmal. Note frequency, duration, 
 and intensity of paroxysms, and if followed by exhaus- 
 tion or perspiration. The brazen ring of whooping- 
 cough is well known and unmistakable. In laryngismus 
 stridulus, "false croup," a spasmodic affection of the 
 glottis, there is a peculiar crowing sound. Hoarseness, 
 or failure of the voice, known as aphonia, may arise 
 from disorder of the respiratory tract, or may be of 
 purely nervous origin. Singultus or hiccough, a spas- 
 modic contraction of the diaphragm, ordinarily of small 
 account, is an important and unfavorable symptom to- 
 ward the close of an acute disease; a peculiarly obsti- 
 nate form is occasionally seen in hysteria. Yawning, 
 sighing, and sneezing, are sometimes noteworthy as 
 sympathetic phenomena. 
 
 If a patient complains of cold without apparent rea-
 
 116 A TEXT-BOOK OP NURSING 
 
 son, take his temperature. A sense of coldness along 
 the spine is ofter the precursor of a chill, and the tem- 
 perature will be found elevated rather than lowered. 
 Chills, or rigors, are nervous phenomena ; although the 
 patient is shivering, the temperature rises, because the 
 capillaries are so much contracted that the blood can 
 not get to the surface to be cooled. High fever always 
 follows a genuine chill. Chills may usher in acute dis- 
 ease ; if they occur in the course of inflammation, they 
 probably indicate suppuration; in malarial affections 
 they are severe and prolonged, but not dangerous. The 
 temperature should be taken both during and soon after 
 a chill the time of occurrence, duration, number, and 
 degree of severity should all be carefully noted. 
 
 With a fall of febrile temperature there is apt to 
 be profuse perspiration. Extreme weakness, and other 
 causes, often produce the same result. The degree of 
 moisture or dryness of the skin is always an important 
 point. A high temperature with a wet skin is much 
 more alarming than the same temperature with a dry 
 skin. Note in what part of the body moisture appears, 
 at what time, in connection with what other symptoms, 
 whether it is cold or warm, and if there is any peculiar 
 odor about it. 
 
 The skin affords other conspicuous signs as well. 
 Variations from a^ealthy color will at once attract at- 
 tention. The yellow tinge of jaundice is well known, 
 indicating disordered action of the liver. A bronze hue 
 is present in Addison's disease and in some cases of 
 septicaemia. With anaemia there is a peculiar paleness ; 
 in Bright's disease a waxy complexion. Chronic opium- 
 eaters may often be recognized by their sallow skin, 
 taken in connection with other appearances. 
 
 A red color shows excess or suffusion of blood, and
 
 THE OBSERVATION OF SYMPTOMS 117 
 
 a cyanosed or bluish shade, imperfect purification. In 
 pulmonary disease there is often high color of one cheek 
 alone. Sudden change of color may give warning of 
 syncope. Extreme pallor accompanies internal hemor- 
 rhage. Paleness about the mouth, with compressed or 
 slightly parted lips, indicates nausea. Patches of color, 
 flushing, dark circles under the eyes, have each their 
 significance. Any eruption or rash must be especially 
 noticed and promptly reported, its character, location, 
 extent, time of appearance, and associated symptoms. 
 Of less consequence, but still to be taken into account, 
 are deformities, scars, parasites, the cleanliness of the 
 body, any roughness of the skin, etc. Scaling off of the 
 cuticle is called desquamation. This takes place gener- 
 ally in the course of measles, scarlet fever, and some 
 other diseases. Attention will probably be called to any 
 local irritation, or unnatural sensation, as burning, 
 tingling, itching, numbness, or crawling. Early signs 
 of bed-sores can not be too carefully watched for. The 
 condition of wounds must receive attention; blushing 
 or puffiness of the surrounding parts, sudden stoppage 
 or alteration in the quality of the discharge, should be 
 reported at once. 
 
 The eye, besides its own local affections, may give 
 signs of general disorder. It may appear unduly promi- 
 nent or sunken, there may be altered color or inflamma- 
 tion of the conjunctiva, disturbances or loss of vision. 
 Observe the size of the pupils, if one or both are con- 
 tracted or dilated. Squinting, if habitual, is of no im- 
 portance ; but if it comes on in the course of brain dis- 
 ease, it is an unfavorable symptom. Note any swelling 
 of the eyelids, drooping or tremulous movement of 
 them, fear of light, apparent weakness, and over-secre- 
 tion of tears. 
 9
 
 118 A TEXT-BOOK OF NURSING 
 
 The sense of hearing may be preternaturally acute, 
 or, more commonly and less significantly, defective. 
 The former condition sometimes precedes delirium. 
 Subjective disturbances of hearing may arise from con- 
 gestion of the cerebral blood-vessels. Some drugs, 
 notably quinine, produce this effect. Any discharge 
 from the ear should be noted as to its character and 
 amount. 
 
 Taste, like the other special senses, may be impaired 
 or vitiated. With a disordered liver there is often a 
 bitter taste; in phthisis, one of salt; and under some 
 medicinal treatment (mercury, arsenic) a decided me- 
 tallic flavor. The sense may be entirely destroyed for 
 the time; it is rarely over-acute. 
 
 The! tongue offers many valuable indications, for it 
 sympathizes not only with the digestive organs, but to 
 some extent with the whole system. Note if it is dry 
 or moist, clean or coated, swollen, bitten, or indented 
 by the teeth. In fever the tongue is likely to be furred ; 
 but this is not always a sign of disease, for some people 
 in good health have a furred tongue constantly, or it 
 is induced by slight constipation. The fur may be 
 whi{e, yellow, or any shade of brown to nearly black. 
 When the fur begins to grow thin, and clean up from 
 the edges of a fevered tongue, it is a better indication 
 of convalescence than when it clears in patches, or 
 rapidly, leaving a raw or glossy surface. In scarlet 
 fever there is often a characteristic appearance known 
 as the " strawberry-tongue," a bright red with the swol- 
 len papillae showing prominently through the fur. So 
 the swollen and livid tongue of typhus is sometimes de- 
 scribed as a " mulberry-tongue." 
 
 Take the opportunity, in looking at the tongue, to 
 notice also the odor of the breath and the state of the
 
 THE OBSERVATION OF SYMPTOMS 119 
 
 teeth and gums. Looseness of the teeth, and sore 
 gums, are to be watched for while giving mercurials. 
 Salivation, or ptyalism, an over-abundant secretion of 
 saliva, is occasioned by some other drugs as well as 
 mercury, and sometimes occurs spontaneously. At the 
 commencement of acute disease this secretion is more 
 likely to be diminished in- quantity, and thickened. 
 With high fever, the teeth, if not well cared for, may 
 become covered with an accumulation of dark-brown 
 matter known as sordes. A dark line appearing along 
 the edges of the gums is a thing to call attention to; 
 it is an evidence of lead-poisoning. Aphthae (thrush) 
 are to be looked out for in infants, and sometimes occur 
 also in adults in an advanced stage of disease. White 
 patches in the throat are always ominous. Learn to 
 distinguish the discrete white spots of quinsy from the 
 diffuse grayish membrane of diphtheria. Slight sore 
 throat not infrequently accompanies indigestion, or a 
 cold. 
 
 The state of the appetite is an important point. 
 Nearly all acute diseases occasion loss of appetite. An 
 increased appetite, bulimia, is more rare, but may exist 
 even with an inability to retain food. The appetite 
 may be vitiated, the patient desiring improper food; 
 but, as a rule, a longing for particular things shows a 
 need of them which ought to be gratified. Observe 
 with special care how much food the patient takes, what 
 kinds of food are most acceptable, and, as far as you 
 can, the effects of each. 
 
 Thirst may remain when the appetite is completely 
 lost. It almost always exists in acute, seldom in chron- 
 ic disease. A very common symptom is nausea. It is 
 usually relieved by vomiting. Note if it is persistent, 
 if vomiting is accompanied by straining or pain, the in-
 
 120 A TEXT-BOOK OF NURSING 
 
 terval since taking food or medicine, the amount and 
 character of the vomited matter. This will be gener- 
 ally undigested food ; it may contain bile, blood, or even 
 fascal matter. The presence of the latter constitutes 
 stercoraceous vomiting, and is a very important symp- 
 tom, as it indicates intestinal obstruction, which may 
 call for immediate operation. An appearance like that 
 of coffee-grounds is sometimes caused by the admixture 
 of a small quantity of blood. The " black-vomit " of 
 yellow fever has something of this character. When 
 blood is present to any extent in vomited matter, it is 
 usually found also in the stools, giving them a dark 
 color and tarry consistency. Some drugs, as iron and 
 bismuth, also blacken the stools. With jaundice, they 
 will be very light, clay-colored. It is important to note 
 the frequency and quantity of the evacuations, if solid 
 or liquid, any unnatural odor or appearance, the pres- 
 ence of mucus, pus, blood, or worms. If there is any 
 doubt about the character of stools or vomited matter, 
 they should be saved for the doctor's inspection. 
 Tenesmus a constant desire to empty the bowel, with 
 pain and inability to do so is a distinguishing symp- 
 tom of dysentery. Constipation is very common, and 
 is often produced by over-use of cathartics or clysters. 
 Diarrho3a may exist even with impacted faeces, the pa- 
 tient having frequent small movements without unload- 
 ing the bowels. What is passed under such circum- 
 stances will be either fluid, or small, dark, hard masses, 
 known as scybala. This is important to remember, for 
 a nurse is too apt to have the idea that the patient's 
 bowels must be all right if they move daily, without 
 regard to the quantity passed. Where a stricture exists, 
 the evacuations will be very small in caliber. Eructa- 
 tions of gas, rumblings in the intestines, and tympani-
 
 THE OBSERVATION OF SYMPTOMS 121 
 
 tes (distention of the abdomen by gas), are all note- 
 worthy, as also dysuria (painful passage of urine), and 
 suppression, retention, or incontinence. The latter is 
 no evidence that the bladder is empty. There are many 
 important indications to be derived from the urine, as 
 has already been mentioned. In case of dyspnoea with- 
 out apparent cause, examine the urine, and test it for 
 albumin. 
 
 In women the menstrual function calls for special 
 observation; the regularity in the appearance of the 
 catamenia, whether accompanied, preceded, or followed 
 by pain, and any related phenomena. 
 
 Haemorrhage from any organ is always more or less 
 important. Even a nose-bleed may be an initial symp- 
 tom of typhoid. The color, quantity, and general char- 
 acter of any discharge are to be carefully observed. 
 
 Pain is always a subjective symptom, though most 
 often accompanied by others which are objective. Pain> 
 implies life and reaction, and its absence is not always 
 a favorable indication. With an extreme degree of 
 shock there is no pain. Sudden cessation of pain during 
 the progress of severe organic disease generally heralds 
 the approach of death. Pain may be inflammatory or 
 neuralgic ; the former is increased by pressure, the lat- 
 ter relieved by it. Get the patient to describe the kind 
 of pain that he feels, as well as to locate it ; to tell 
 whether it is acute, dull, aching, stinging, burning, 
 steady, spasmodic, etc. Exaggerated sensibility is 
 called hyperaBsthesia ; diminished or lost sensibility, 
 anaesthesia. Either may be general or local. Partial 
 anaesthesia is often conjoined with loss of muscular 
 power paralysis. If the lower half of the body is so 
 affected, it is called paraplegia ; paralysis of the lateral 
 half is hemiplegia. In hemiplegia the temperature
 
 122 A TEXT-BOOK OP NURSING 
 
 may be found a degree, or a degree and a half, higher 
 on the paralyzed side than on the other. Aphasia, loss 
 of the power of speech, occurs most often in connection 
 with right hemiplegia. 
 
 Incoherence of speech, muttering, slowness of com- 
 prehension, loss of interest, unusual irritability of tem- 
 per, difficulty of swallowing, a tendency to spill food or 
 drop things, and picking at the bedclothes, are all 
 symptoms of gravity. Involuntary muscular contrac- 
 tions vary from slight spasms, as cramps, to severe con- 
 vulsions. Subsultus (twitching of the muscles), and 
 many little nervous motions may be so classed. Note the 
 frequency and persistency of movement, whether the 
 convulsions are general, or are confined to one part of 
 the body, whether or not the patient is unconscious, and 
 if the attack is sudden, and the mental state before and 
 after it. 
 
 Under disorders of consciousness are included all 
 sorts of delusions and hallucinations, delirium, and 
 stupor, as well as mental depression or unusual excita- 
 bility. Note the kind of delirium, if quiet, busy, or 
 maniacal ; if persistent, or only occasional, and when it 
 is most violent. Try if the patient can be roused from 
 stupor. Complete insensibility, from which the patient 
 can not be awakened, is known as coma. Profound 
 coma, which does not terminate within twenty-four 
 hours, may be regarded as almost certainly fatal. Con- 
 tinuous sleeplessness, with partial unconsciousness, con- 
 stitutes coma-vigil, also an almost invariably fatal 
 symptom. Insomnia is always ominous in proportion 
 to its duration. It is important to note how much 
 sleep a patient gets, at what time, whether it is quiet 
 or disturbed, the occurrence of dreams, talking in sleep, 
 etc. A patient will often think he has been awake all
 
 THE OBSERVATION OF SYMPTOMS 123 
 
 night, when, in fact, he has had several hours of sleep 
 without realizing it. The nurse should be able to state 
 the facts accurately. 
 
 The degree of intensity of all symptoms, the time 
 and order of appearance, and the combinations, are to 
 be observed. Often a symptom, which by itself would 
 be insignificant, becomes in its relations with others of 
 grave import. If uncertain whether a circumstance is 
 of any value or not, still make note of it, for it is better 
 to report to the physician a dozen superfluous items 
 than to omit one of importance. Do not trust too much 
 to memory, but keep a little memorandum book in 
 which to note facts and take down orders. A sheet of 
 foolscap ruled, after the plan shown on the following 
 page, gives a good form for bedside notes. 
 
 " Look up and not down ; 
 Look out and not in ; 
 Look forward and not back, 
 and lend a hand." 
 
 E. E. Hale.
 
 124 
 
 DATE,- 
 
 A TEXT-BOOK OF NURSING 
 
 BEDSIDE NOTES 
 DAY OF DISEASE, 
 
 NAME. 
 
 
 Time. 
 
 Pulse. 
 
 Res- 
 pira- 
 tion. 
 
 Tem- 
 pera- 
 ture. 
 
 Medicine. Nourishment. 
 
 Sleep. 
 
 Urine. 
 
 Defe- 
 ca- 
 tion. 
 
 Remarks. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Summary : 
 
 
 
 
 
 
 
 
 
 Nurse.
 
 CHAPTEE IX 
 
 " Only grant my soul may carry high through death her cup 
 
 unspilled, . . . 
 I shall boast it mine the balsam, bless each kindly wrench 
 
 that wrung 
 Prom life's tree its inmost virtue, tapped the root whence 
 
 pleasure sprung, 
 Barked the bole and broke the bough and bruised the berry ; 
 
 left all grace 
 Ashes in death's stern alembic, loosed elixir in its place." 
 
 Robert Browning. 
 
 MATERIA MEDICA is a general term including all 
 remedial agents. An official list, with descriptions of 
 these, and instructions for their preparation and use 
 is issued, and every ten years revised, by a national 
 convention, composed of delegates from various medical 
 societies. This publication is called the Pharmacopoeia. 
 Such medicaments as are recognized by it are termed 
 officinal. The composition and preparation of medicines 
 is pharmacy. Drugs have been classified into five 
 groups : 
 
 1. Those promoting constructive changes. 
 
 2. Those promoting destructive changes. 
 
 3. Those preventing septic decomposition. 
 
 4. Those modifying the nervous system. 
 
 5. Those causing some evacuation. 
 
 Some have a purely local effect, while others are 
 more general in their action ; some have a special affini- 
 ty for certain organs, while yet influencing the whole 
 
 125
 
 126 A TEXT-BOOK OF NURSING 
 
 system. Effects may be primary or secondary, direct 
 or remote. The action of any drug must always be 
 preceded by its absorption. To be absorbed, it must 
 be in solution, or of such a nature that it will be 
 changed into a soluble salt within the body. Many 
 medicines are now put up in tablet triturates, a neat, 
 convenient, and compact form. The drug, having been 
 triturated with sugar of milk, is made into a soluble 
 paste with alcohol and water in varying proportions, 
 and then molded into uniform tablets. These provide 
 exact dosage, and can be kept indefinitely. Similar 
 tablets are also made for hypodermic use, and for anti- 
 septic solutions. 
 
 A saturated solution of any substance is one that 
 contains all that can be dissolved in it. 
 
 A mixture is a suspension in some vehicle of an in- 
 soluble substance. 
 
 An emulsion is a mixture of oil and water, made by 
 rubbing up with gum. 
 
 A decoction is a solution of a vegetable substance 
 made by boiling. Decoctions, as a rule, do not keep 
 well, and should be freshly made at least once in forty- 
 eight hours. To an ounce of the crude drug, add fif- 
 teen ounces of water, and boil down to ten ounces. 
 
 An infusion is a similar preparation made with hot 
 or cold water, without boiling. One ounce of the drug 
 to ten of water is now the rule. 
 
 Spirits are alcoholic solutions of volatile substances. 
 
 Tinctures are alcoholic solutions of non-volatile 
 substances. 
 
 Fluid extracts are like tinctures, but stronger. 
 
 These are some of the most common of the numer- 
 ous pharmaceutical preparations. 
 
 Medicines may be introduced into the system
 
 MEDICINES AND THEIR ADMINISTRATION 127 
 
 through the skin, the mucous membrane, or the sub- 
 cutaneous tissue, with the same constitutional results, 
 but differing in degree, and in the time required to 
 produce them. 
 
 There are three ways of introducing medicine 
 through the skin, known respectively as the enepider- 
 mic, the epidermic, and the endermic methods. In the 
 first, the medicinal agent is simply placed in contact 
 with the skin, to be absorbed, so far as may be, by it. 
 If friction is employed to hasten absorption, the method 
 becomes epidermic. In the endermic method the cu- 
 ticle is removed by blistering, and the medicament 
 sprinkled over the raw surface ; absorption is then much 
 more rapid. This is now but rarely practiced, as, 
 although sometimes effective, it is painful and some- 
 what uncertain. 
 
 Endermic medication has been largely superseded 
 by hypodermic or subcutaneous injections. These the 
 nurse will frequently have to give, and she must be 
 thoroughly familiar with the process. There are sev- 
 eral precautions to be observed. A new syringe should 
 be compared with a standard minim-glass, as the meas- 
 urements vary considerably, and accuracy is highly im- 
 portant. See that it is in good working order, does not 
 leak, and that the needle is sharp and unobstructed. 
 Having carefully measured the amount to be adminis- 
 tered, hold the instrument with the needle upward, and 
 force out any bubbles of air that may remain in it. Then 
 pinch up a loose fold of flesh between the thumb and 
 finger, and insert the needle quickly to the extent of an 
 inch deeply down among the muscles. Withdraw it 
 slightly, then inject slowly the contents of the syringe. 
 After removing the needle, keep a finger on the point of 
 insertion for a moment, to prevent the escape of the
 
 128 A TEXT-BOOK OP NURSING 
 
 fluid. Gentle rubbing will hasten its absorption. Tab- 
 lets for use in the hypodermic syringe are put directly 
 into the barrel, water drawn into it until the cylinder 
 is full, and after well shaking to dissolve the tablet, 
 the solution is ready to inject. Clean and wipe both 
 needle and syringe after using, and replace the wire 
 in the needle at once. The best way to clean the inside 
 is to pump a little alcohol through it. This also will 
 prevent the needle from rusting. Hypodermic injec- 
 tions are given to relieve pain, or induce sleep, and 
 when speedy action of a drug is important. Kesults 
 may be expected in about five minutes. Eemedies intro- 
 duced in this way act more powerfully and more rap- 
 idly than in any other, and the operation, if skillfully 
 performed, is but slightly painful. By using a clean, 
 aseptic needle and giving the injection deep in the 
 muscle, the most irritating fluids (ether, brandy, cam- 
 phorated oil, etc.) can be injected with impunity. Such 
 injections are frequently necessary in collapse after 
 operations. The liability to the formation of abscess is 
 said to be least where morphine is used. Abscesses are 
 in most cases due either to carelessness in injecting, to 
 the use of a syringe not thoroughly clean, or to an im- 
 pure solution, but occasionally are unavoidable, result- 
 ing from a lowered condition of the system, which pre- 
 disposes to inflammation upon slight irritation. A 
 dilute is less irritating than a concentrated solution. 
 In some cases painful spots will remain for several days. 
 These may be relieved by bathing with alcohol, or by the 
 application of an ice-bag. Give the hypodermic injec- 
 tion in the arm or leg, never in the neck or stomach, 
 though you may occasionally see a physician do it. In 
 treating a lady, it is better to avoid the arm, on account 
 of the possibility of a resulting abscess, which might
 
 MEDICINES AND THEIR ADMINISTRATION 129 
 
 leave an unsightly scar. The outer side of the thigh is 
 perhaps the best place. The distance from the seat of 
 pain makes no difference, as the effect is systemic, not 
 local. Bony prominences and inflamed parts are to be 
 avoided, and caution observed against puncturing a 
 vein. Death has resulted from the introduction of a 
 solution of morphia directly into a vein. Intravenous 
 injection is occasionally practiced, but only by the phy- 
 sician, and its consideration, except as a thing to be 
 avoided, does not enter into the province of a nurse. 
 Medicines to be given subcutaneously must be perfectly 
 dissolved, and free from the slightest impurity. Solu- 
 tions too long kept develop a fungoid growth, which 
 renders them unfit for hypodermic use. Decomposi- 
 tion may be prevented by adding ac. salicyl., gr. , to 
 an ounce of solution. It is much better to prepare 
 them only as needed. To the solution of morphine, a 
 little atropine should always be added (gr. 1-120 to 
 morph. gr. 1-6), to prevent nausea and lessen the 
 danger of poisoning. In hysterical patients, as well 
 as in those accustomed to the use of morphine in minor 
 ailments, a hypodermic injection of water sometimes 
 has quite as satisfactory an effect. 
 
 Some general effects, as well as those locally upon 
 the throat and lungs, may be obtained by inhalation. 
 In this way anaesthesia is induced by chloroform, ether, 
 or nitrous oxide gas. This is a rapid method owing 
 to the abundant blood supply in the lungs. Volatile 
 substances to be inhaled may be simply evaporated 
 from a piece of cloth or cotton held near the nostrils. 
 Others can be finely subdivided by a hand or steam 
 atomizer throwing the spray into the mouth. The pa- 
 tient should be directed to breathe quietly, without 
 extra effort. A simple and convenient device for the
 
 130 A TEXT-BOOK OP NURSING 
 
 inhalation of steam, or medicinal vapor, is a pitcher of 
 hot water, having closely fitted over it a cone of thick 
 paper, with an aperture at the top through which the 
 patient may breathe. He should inhale by the mouth, 
 and exhale through the nose. The temperature of the 
 vapor should not exceed 150 Fahrenheit. It is made 
 medicinal by the addition to the hot water of prescribed 
 drugs. 
 
 The most common mode of introducing medicines 
 into the system is through the mucous membrane, gen- 
 erally that of the stomach. Applications to other parts 
 of it are more frequently for local effect, and are 
 spoken of elsewhere. 
 
 Medicines are taken into the stomach in various 
 forms of pills, powders, and solutions. With this meth- 
 od about twenty minutes will elapse before the drug 
 begins its action. The process is a little more rapid 
 if given on an empty stomach. Some patients find an 
 almost insuperable difficulty in taking pills. The 
 smaller the pill, the harder it is to swallow, but if its 
 size is increased by enveloping it in bread or jelly, the 
 trouble will often be overcome. Place it as far back 
 in the throat as possible, and follow immediately with a 
 large swallow of water. Pills that have been long kept 
 become very hard, and, if taken in that condition, may 
 pass through the intestinal canal undissolved, and so 
 without effect. If nothing better can be procured, they 
 should be pounded up, and given like powders, in water, 
 milk, or sirup. A small powder may be concealed be- 
 tween two layers of jam or marmalade, and swallowed 
 without difficulty. Powders insoluble in water, as calo- 
 mel or bismuth, may be placed dry on the tongue, and 
 a drink taken to wash them down. Those of objec- 
 tionable flavor are frequently inclosed in wafers of rice-
 
 MEDICINES AND THEIR ADMINISTRATION 131 
 
 paper, or in capsules of gelatin, either of which will 
 dissolve and liberate its contents in the stomach. Pre- 
 sent pills or capsules in a saucer or spoon, not from the 
 hand. 
 
 If there are no special orders given, allow an inter- 
 val of half an hour between medicine and food. Most 
 drugs act more powerfully on an empty stomach, and 
 some are too irritating to be borne. Arsenic, iron, and 
 cod-liver oil are always given after eating. If medi- 
 cines are ordered just before meals, care must be taken 
 that the diet is not such as to be incompatible. Milk 
 taken too near a dose of quinine in solution, or any 
 acid, may be coagulated and rejected. The activity of 
 iodine will be impaired by starchy food. Inquire 
 whether the medicine should be diluted, and if so, to 
 what extent. 
 
 The spoon or glass in which it is given should be 
 washed each time immediately after use. Iron and the 
 mineral acids should be taken through a glass tube, to 
 prevent injury to the teeth, or the teeth should imme- 
 diately after be thoroughly brushed with a soda or 
 borax solution, or with white Castile soap. A separate 
 glass should be kept for oily and strong-smelling medi- 
 cines. Disagreeable tastes may be to some extent les- 
 sened by holding the nose while swallowing. A bit of 
 bread is better than anything else to remove lingering 
 traces of the flavor. Licorice and dried orange-peel, or 
 a piece of preserved ginger, are recommended, but bet- 
 ter than anything to take after medicine is some pun- 
 gent flavor beforehand, as a little brandy, essence of 
 peppermint, or wintergreen, which will blunt the sensi- 
 bility of the nerves of taste. Oil may be given in 
 brandy, strong coffee, lemon-juice, or in the froth of 
 beer. Pour the dose carefully in the center, so that it
 
 132 A TEXT-BOOK OF NURSING 
 
 will nowhere touch the glass, and it can be easily swal- 
 lowed. For a child, shake it in a bottle with hot milk, 
 sweeten, and flavor with cinnamon, or stir it into a 
 cup of hot broth. Nearly tasteless emulsions can be 
 procured of both castor and cod-liver oil. 
 
 It sometimes becomes necessary in the case of a 
 child or a delirious person to administer medicine by 
 force. To do this, compress the nostrils so that the 
 mouth will have to be opened in breathing. The medi- 
 cine can then be carried in a spoon far back in the 
 mouth, and poured slowly down the throat, where if 
 not swallowed, it will be slowly absorbed. Of course 
 only fluids can be given in this way. Powders must 
 never be given to an unconscious patient, as there is 
 danger of suffocation. Force should only be resorted 
 to when all other means fail, as the excitement which 
 it occasions is always injurious. Persuasion accom- 
 plishes much with children, and even an apparently 
 insensible patient may often be induced to swallow if 
 you first attract his attention by gently rubbing the lips 
 with the spoon. 
 
 Children are peculiarly sensitive to the action of 
 drugs, and usually call for but small quantities. A rule 
 given for the administration of medicine to a child 
 under twelve years is: Add 12 to the child's age and 
 divide the age by the sum. For instance, if the child 
 
 2 21 
 
 is two years old, the formula is = or - . Give 
 
 14: 7 
 
 /> n 
 
 $ of the adult dose. If the child is six, = or 
 
 O-J-1.C lo 
 
 -. Give i of the adult dose. There are some excep- 
 
 8 
 
 tions to this rule, as calomel and castor-oil, which need 
 only be reduced about one half for a child.
 
 MEDICINES AND THEIR ADMINISTRATION 133 
 
 The nurse's responsibility in the matter of medi- 
 cines consists in the prompt, accurate, and intelligent 
 administration of such as are prescribed by the physi- 
 cian. Only in cases of unusual emergency, and where 
 medical advice is unattainable, should you ever assume 
 anything beyond this. You will be frequently asked 
 to recommend something for this or that trouble. Do 
 not permit yourself to yield to the temptation to tell 
 what you have seen used in similar cases, for you can 
 not be sure that the cases were exactly similar. Re- 
 member that a well-disciplined nurse never makes a 
 diagnosis, and never prescribes. But you should know 
 the effect that the remedies which you give are intend- 
 ed to produce, and when their continuation is contra- 
 indicated. It is well to familiarize yourself with the 
 ordinary doses of medicines in common use, and with 
 the symptoms of overdosing. 
 
 The susceptibility to the action of drugs varies in 
 different individuals, and is much modified by habit. 
 This is especially true of narcotics. Custom produces 
 tolerance and diminished impressibility, so that after a 
 time increased quantities are required to produce the 
 same effect. There is great danger of becoming de- 
 pendent upon their use. The habit pre-eminently 
 that of opium is so easily acquired, so difficult to 
 overcome, and is followed by such a train of disastrous 
 consequences, that the greatest care should be taken 
 to avoid it. Narcotics ought never to be used except 
 under the direction of a physician. After giving a 
 narcotic, the patient should be kept as quiet as possible 
 until it takes effect. 
 
 If a medicine ordered in gradually increasing doses 
 is for a time discontinued, the acquired tolerance may 
 be lost, and upon recommencing, there must be a re- 
 10
 
 134 A TEXT-BOOK OP NURSING 
 
 turn to the smallest dose, or too powerful effects may 
 follow. 
 
 Some drugs, notably digitalis, have, on the con- 
 trary, a cumulative action, seeming at first inert, but 
 after a few doses acting suddenly and with great energy, 
 having apparently the effect of the several doses com- 
 bined. Such are given in gradually decreasing, rather 
 than increasing, doses. 
 
 The exact results of a given dose can not always be 
 foreseen. It occasionally happens that individual idio- 
 syncrasies interfere with the action of medicinal agents, 
 and even render injurious those usually salutary. Thus 
 opium sometimes excites instead of quieting, and the 
 smallest quantity of mercury will salivate a susceptible 
 constitution. Strong solutions of the bichloride should 
 never be injected into any of the mucous tracts. Every 
 unusual or inordinate action of a drug should be re- 
 ported to the physician, and its use suspended until 
 further directions are received. If a dose given either 
 by stomach or rectum is rejected within five minutes, 
 it may be once repeated after an interval of twenty 
 minutes. 
 
 Peculiar effects sometimes depend upon the imagi- 
 nation, for which reason it is better that the patient 
 should not always know what he is taking. His medi- 
 cine should be brought to him at the proper time, ready 
 to take, without thought on his part, or previous dis- 
 cussion. Regularity and promptness in its adminis- 
 tration are important. Do not fancy that half an hour 
 more or less will make no difference, nor harbor the ab- 
 surd notion that if by an accident the dose should be 
 omitted at one hour the error can be rectified by doub- 
 ling it the next time. 
 
 Medicines should be kept in a dry, cool, and dark
 
 MEDICINES AND THEIR ADMINISTRATION 135 
 
 closet. Dampness impairs the activity of most drugs, 
 and many are decomposed by light or heat. Only a 
 few should be kept on hand, each in small quantity as 
 they do not, as a rule, keep well and of the best qual- 
 ity. It is poor economy to buy drugs where they are 
 the cheapest, as they are almost sure to be adulterated. 
 Get them from a reliable apothecary. What is left of a 
 prescription the use of which is permanently discon- 
 tinued should be thrown away, as it is highly improb- 
 able that the same combination will ever be called for 
 again, and most of them undergo changes in character 
 by age, so that to keep them only increases the contents 
 of the medicine-chest, and increases the liability to 
 error. Liniments, and all preparations for external 
 use, should be kept in a corner by themselves, and 
 labeled Poison. Medicines ought to be kept under lock 
 and key. Especially is it important in a hospital ward 
 not to leave dangerous drugs within reach of the pa- 
 tients. The ward medicine-chest should be systemat- 
 ically arranged, each bottle or box in its own place, so 
 that there need be no delay in finding things called for. 
 All bottles should be distinctly labeled, and one 
 should never omit to carefully read the label before 
 measuring the dose, and again afterward. Attention 
 to this rule would have prevented many serious mis- 
 takes. In pouring, keep the label on the upper side, to 
 avoid defacing it. Remedies for external use are now 
 often put up in fluted bottles of colored glass, recog- 
 nizable to touch as well as sight. For the same pur- 
 pose, it is recommended to tie a bow of ribbon around 
 the necks of the bottles containing them. No medicine 
 should ever be given in the dark. Always shake before 
 opening the bottle; it is often important, and always 
 harmless. Do not leave the bottle uncorked longer
 
 136 A TEXT-BOOK OP NURSING 
 
 than necessary, for volatile substances escape, and oth- 
 ers grow more concentrated by evaporation. 
 
 Medicines should be measured in a graduated glass, 
 or doses of less than a drachm in a minim-tube, both of 
 which can be procured at any drug-store. Spoons are 
 of very variable capacity, and drops differ with the con- 
 sistence of the fluid and the shape of the edge over 
 which they are poured, so that they can be with the 
 greatest care only approximately measured. A minim, 
 the smallest accurate liquid measure, is equivalent to 
 about one drop of an aqueous solution, but it makes 
 three or four of chloroform. The minim of any tinc- 
 ture is usually two drops, of a fluid extract but one. 
 
 APOTHECABIES' MEASURES FLUID MEASURES 
 
 gr. xx = 3j; mix =f3j; 
 
 3iij =3j; f3viij = fj; 
 
 3viij =lj; f |xvj = Oj; 
 
 !xij =B>j. Oviij= Cj. 
 
 APPROXIMATE MEASURES 
 
 1 teaspoon (holding 45 drops 
 
 of pure water) = about 3 j ; 
 
 1 tablespoon " " ss ; 
 
 1 wine-glass " " ij ; 
 
 1 tea-cup " " iv ; 
 
 1 coffee-cup " " viij. 
 
 The gramme (gin.) of the French metric system 
 equals about 15 grains. The cubic centimetre (c. c.) 
 equals about 16 minims. The litre equals about 2 pints. 
 
 The gramme is the unit of weight; the Latin pre- 
 fixes, deci, centi, milli, etc., are used to indicate its sub- 
 divisions, and the Greek, myria, kilo, hecto, deka, etc., 
 its multiples, always on the scale of ten. In place of
 
 MEDICINES AND THEIR ADMINISTRATION 137 
 
 the decimal point, a vertical line is sometimes used, at 
 the right or left of which the numbers are written, as : 
 
 myriagramme, 10,000 
 kilogramme, 1,000 
 hectogramme, 100 
 dekagramme, 10 
 gramme, 1 
 
 decigramme, 1 
 
 centigramme, 01 
 
 milligramme, 001 
 
 The standard weights and measures should be thor- 
 oughly familiar to every nurse, and should be used in 
 place of the ordinary unreliable measurements. It will 
 be found an advantage to have also a ready comprehen- 
 sion of the symbols and abbreviations used in writing 
 prescriptions. The numbers are expressed by Roman 
 figures, and follow always the symbols to which they 
 relate, as: 3j, 3jss., ij, gr. iij, 3 iv, gtt. v, Ib. vj, 
 Til x, etc.
 
 138 
 
 A TEXT-BOOK OF NURSING 
 
 ABBREVIATIONS AND SYMBOLS 
 
 AA, ana, of each. 
 
 Add., adde, add to it. 
 
 Ad lib., ad libitum, as you 
 please. 
 
 Alt. hor., alternis horis, every 
 other hour. 
 
 Alt. noc., alter a node, every 
 other night. 
 
 Applic., applicatur, apply. 
 
 Aq. dest., aqua destillata, dis- 
 tilled water. 
 
 Aq. pur., aqua pur a, pure wa- 
 ter. 
 
 B. i. d., bis in dies, twice a day. 
 
 C., congius, a gallon. 
 
 Cap., capiat, let him take. 
 
 Comp., compositus, compound. 
 
 Conf., confectio, a confection. 
 
 Cort., cortex, bark. 
 
 Decub. , decubitus, lying down. 
 
 Det., detur, let it be given. 
 
 Dil., dilutus, dilute. 
 
 Div. in p. aeq., dividatur in 
 paries cequales, divide into 
 equal parts. 
 
 Drachm., drachma, a drachm. 
 
 Emp. , emplastrum, a plaster. 
 
 PI. or f., fluidus, fluid. 
 
 Ft., fiat, let there be made. 
 
 Garg. , gargarisma, a gargle. 
 
 Gr., granum or grana, a grain, 
 or grains. 
 
 Gtt., gutta or guttce, a drop, or 
 drops. 
 
 Guttat., guttatim, by drops. 
 
 Inf., infuaum, an infusion. 
 
 Inject., injectio, an injection. 
 
 Lb., libra, a pound. 
 
 Liq., liquor. 
 
 Lot., lotio, a lotion. 
 
 M., misce, mix. 
 
 Mist., mistura, a mixture. 
 
 N., node, at night. 
 
 No., numero, in number. 
 
 0., odarius, a pint. 
 
 01., oleum, oil. 
 
 Ov., ovum, an egg. 
 
 Pil., pilula, a pill. 
 
 P. r. n., pro re nata, as occasion 
 
 arises. 
 
 Pulv., pulvis, a powder. 
 Q. S., quantum sufficit, as much 
 
 as is sufficient. 
 5, recipe, take. 
 Rad., radix, root. 
 S. or Sig., signa, write. 
 Sem., semen, seed. 
 SS. or s., semissis, a half. 
 S. V. G., spiritus vini gallici, 
 
 brandy. 
 S. V. R., spiritus vini rectifi- 
 
 catus, alcohol. 
 Syr., syrupus, sirup. 
 T. i. d., ter in dies, three times 
 
 a day. 
 
 Tr., tinctura, tincture. 
 Troch., trochisci, lozenges. 
 Ung., unguenium, ointment. 
 Ul, minimum, a minim. 
 3 , drachma, a dram. 
 , unica, an ounce. 
 3, scrupulum, a scruple.
 
 MEDICINES AND THEIR ADMINISTRATION 139 
 
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 A TEXT-BOOK OP NURSING 
 
 
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 MEDICINES AND THEIR ADMINISTRATION 
 
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 MEDICINES AND THEIR ADMINISTRATION 143 
 
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 MEDICINES AND THEIR ADMINISTRATION 145 
 
 
 
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 MEDICINES AND THEIR ADMINISTRATION 147 
 
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 MEDICINES AND THEIR ADMINISTRATION 149 
 
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 Of all the mineral acids, onlj 
 dilute forms are used medicir 
 They should be taken throu 
 tube, and the mouth after 
 rinsed with a weak alkaline 
 tion, as bicarbonate of soda. 
 
 <jf 
 | 
 
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 o 
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 If 
 
 & VI 
 
 Sometimes has a cumulative ef 
 
 Children are peculiarly sensiti 
 its action, being sometimes 
 ously affected even by its ext 
 use. 
 
 iaM^anwrn. 
 Paregoric. Dose for children TV 
 SqmbVs Cholera Mixture. 
 McMunn's Elixir. 
 Compound Powder of Ipecac. 
 powder of gr. x contains 1 j 
 each of opium and ipecac a 
 of sulphate of potassium. 
 
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 A TEXT-BOOK OP NURSING 
 
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 MEDICINES AND THEIR ADMINISTRATION 151 
 
 Niter, Saltpeter. 
 Candy's Fluid is a solution of the 
 permanganate. 
 
 Contains two per cent of the strong 
 acid. 
 
 Gives a yellow color to all the secre- 
 tions. 
 
 Tartrate of Potash and Soda. 
 
 The blue paper contains Rochelle 
 salt and oicarbonate of soda ; the 
 white, tartaric acid. Dissolve 
 each separately, and pour the 
 larger into the smaller. Brisk 
 effervescence should ensue. Lem- 
 on juice and sugar will improve 
 the taste. The powders need to 
 be kept dry. 
 
 Prompt in action and safe, but apt 
 to occasion griping. 
 
 
 
 b 
 
 
 
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 Diaphoreti 
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 Antispasm 
 dose, a d 
 
 See Cincho 
 
 Laxative. 
 
 Laxative. 
 
 Antipyreti 
 
 J 
 
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 3 
 c 
 
 53 
 
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 Cathartic. 
 
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 152 
 
 A TEXT-BOOK OF NURSING 
 
 Remarks. 
 
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 ' <M .^ 
 
 *3 S JS -^ 
 
 ^3 aj g 
 
 g -U -*J g 
 
 '. Contains antimony, gr. 
 1 is dangerous to use un- 
 
 r. 
 
 ives are sometimes rolled 
 irettes, and smoked for 
 : of asthma. 
 
 lilar to that of digitalis, 
 the disadvantages of that 
 May be given hypoder- 
 
 
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 xpectorant, d 
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 arcotic, simil 
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 .M O 
 
 TRAMONIUM. 
 
 Ext. of leaves 
 Tincture. 
 
 TBOPHANTHUS. 
 
 Tincture. 
 
 
 02 02 02 
 
 02" 
 
 02 
 
 02
 
 MEDICINES AND THEIR ADMINISTRATION 153 
 
 Acts slowly. Give the first dose 
 two hours before bedtime. 3j 
 may be given in all. 
 
 Is burned for purpose of fumigation. 
 
 Used to check haemorrhages and 
 mucous dischare-es. 
 
 i 
 
 C C b" 
 C '^^ *y 
 
 c c 
 
 III 
 
 w 
 
 ^ CO 
 
 <P bb 
 > c be 
 
 "Z "Z fi 
 
 CO -4J 
 
 counter-irritant. 
 
 Discontinue if it nauseates. 
 
 Anti-malarial. . 
 
 Most used externally. 
 White Vitriol. 
 
 
 fe hypnotic. 
 
 "S 
 
 ID 
 
 CO 
 
 <i3 
 
 
 
 e, but slow in its action. 
 
 n and kidneys, arrests 
 of mucous membrane, 
 tympanites of typhoid, 
 trangury. 
 
 not narcotic. 
 
 rial depressant. 
 
 S 
 o 
 
 tonic, 
 nipt emetic. 
 
 | 
 
 * 
 
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 _O 
 
 
 
 3 
 
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 IS OJ 
 
 C3 
 
 
 
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 f 
 
 11. 
 
 X 
 9 
 
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 5 
 
 M 
 
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 !s 
 
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 ID 
 O 
 
 CO 
 
 
 
 S 
 
 9 
 
 Astringent. 
 
 Hypnotic. 
 
 Stimulates 
 hfemorrh 
 relieves 
 
 H "* 
 
 r* 'O 
 
 .S *> 
 j* > 
 1 
 
 eS 
 "eS 
 
 'a, 
 
 CO 
 
 Powerful d: 
 
 Astringent 
 Full dose a 
 
 
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 d 
 
 . 
 
 
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 bcbo 
 
 
 
 
 
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 STRYCHNINI 
 
 SULPHONAL 
 
 SULPHUR. 
 SULPHURIC 
 Dilute. 
 
 ^ tf 
 co 
 
 TANNIC Aci 
 
 TRIONAL. 
 
 TURPENTINI 
 Oil or spi 
 
 VALERIAN. 
 Tincture. 
 
 111 
 
 WARBURG'S 
 
 URE. 
 
 o'^'S
 
 CHAPTER X 
 
 " She doeth little kindnesses 
 
 Which most leave undone or despise 
 For naught that sets one heart at ease, 
 And giveth happiness or peace, 
 Is low esteemed in her eyes." 
 
 J B. Lowell. 
 
 BESIDES general remedies, there are numerous local 
 or topical applications, either soothing, irritant, or 
 protective. Such as protect by arresting fermentation 
 are called antiseptic. These will be spoken of later. 
 
 Poultices, also called cataplasms, are in common 
 use as convenient means to applying warmth and moist- 
 ure. Their effect is to soften the tissues and dilate the 
 capillaries, relaxing the tension of inflamed parts, and 
 so relieving pain. Applied early, they may check the 
 progress of inflammation and prevent the formation of 
 pus; when suppuration has set in, they facilitate the 
 passage of matter to the surface and limit the spread 
 of inflammation. They are useful not only when in im- 
 mediate contact with inflamed tissues, but will also 
 often relieve deep-seated pain. A poultice applied for 
 the relief of the internal organs, or to hasten matura- 
 tion, ought to be large enough to extend over a consid- 
 erable surrounding surface, but over a suppurating 
 wound should be but little larger than the opening. 
 Apply as hot as can be comfortably borne, but do not 
 burn the patient. There is danger of this with the thin 
 154
 
 POULTICES 155 
 
 and sensitive skin of a child, and in cases of paralysis, 
 when the generally lowered condition gives rise to an 
 inability to resist heat and cold, and the skin may be 
 blistered by a poultice that would produce little effect 
 on a healthy subject. Cover with some impervious ma- 
 terial oiled muslin or rubber tissue to keep in the 
 heat, and change frequently, the exact time depending 
 upon the thickness of the poultice. One of ordinary 
 size will keep warm for three or four hours. If allowed 
 to become cold and hard, it will do more harm than 
 good. Poulticing should not be too long continued, or 
 it may retard rather than help the healthy processes, 
 by rendering the flesh sodden and irritable ; it may even 
 develop an eruption. 
 
 Poultices are made of various materials. The sim- 
 plest form consists of several thicknesses of lint or soft 
 cloth, wrung out in hot water. A convenient but ex- 
 pensive substitute is spongio-piline, which is made of 
 two or three layers of sponge and wool, felted together, 
 and coated on the outer surface with caoutchouc. This 
 holds the heat a long time. 
 
 Linseed meal is very generally used, and when of 
 good quality is an excellent material. To make a lin- 
 seed poultice, bring a saucepan of water to the boiling- 
 point, and, without removing it from the fire, stir into 
 it the meal little by little, until it has the proper con- 
 sistency just thick enough to be cut with a knife. It 
 must be smooth and perfectly free from lumps. That 
 eccentric old genius, Dr. Abernethy, says that, if it is 
 perfectly worked together, you might throw your poul- 
 tice up to the ceiling, and it would come down without 
 falling in pieces. The poultice should be spread evenly, 
 about a quarter of an inch thick, upon a piece of muslin 
 previously cut to the desired size, leaving an inch and
 
 156 A TEXT-BOOK OF NURSING 
 
 a half of margin in each direction. Bartholow advises 
 that the muslin be twice the length of the intended 
 poultice, only half of it spread, and the remainder 
 folded back as a cover, but it is rather better to have 
 a separate cover of some thinner material, as mosquito- 
 netting, old tulle, or illusion, if such can be obtained, 
 and to fold over together like a broad hem the edges of 
 both. This makes a strong border. The cover is some- 
 times entirely omitted, and the poultice applied direct- 
 ly to the skin, but portions of it are likely to adhere, so 
 that it becomes difficult to remove it neatly. A little 
 oil on the poultice will help to keep it soft, and make it 
 less likely to stick. A layer of cotton-wool on the out- 
 side will help to retain the heat ; and when the weight 
 of a poultice is painful, and it has in consequence to be 
 made thin, it will be found a valuable addition. Some- 
 times a flannel bag is made to contain the poultice, one 
 end being left long and free to fold over it. The best 
 way to apply a large poultice for the relief of the inter- 
 nal organs is to make one or two turns of a flannel 
 bandage about the part, and then to apply the poultice 
 in such a bag and confine it in place with the rest of 
 the bandage. So arranged, it will keep hot a long 
 time. 
 
 A small board, or a tray, on which to carry the 
 poultice to the patient, will be found very convenient, 
 and is in hospitals always used. Quite as important is 
 it to have a basin in which to carry away the old one, 
 which should always be burned. If it is to be applied 
 to a wound, the old poultice will have been removed, 
 the wound washed, and protected by a "guard" a 
 piece of muslin wet with some disinfecting solution 
 before the fresh one is made. 
 
 A poultice-jacket is sometimes prescribed, to en-
 
 POULTICES 157 
 
 velop the entire chest. This is made in two pieces, 
 front and back, with strings to tie over the shoulders 
 and under the arms. The edges must be firmly sewed, 
 to keep the poultice from escaping. 
 
 Bread poultices are lighter and more bland than 
 linseed, but cool quickly and hold less moisture. Not 
 having the tenacious quality of linseed, they are likely 
 to crumble and become rough as they dry. Milk ought 
 never to be used in their preparation, as it has no ad- 
 vantage over water, and it very soon becomes sour and 
 offensive. Pour boiling water over slices of bread 
 without crust. Let them simmer a few moments until 
 well soaked, then drain off the water, beat up the 
 bread quickly with a fork, and spread. 
 
 As bread is more porous than linseed, it forms a 
 better basis for the charcoal poultice. The formula 
 given is : Fresh wood-charcoal powder, ss.; bread 
 crumbs, ^rjj linseed meal, jss.; boiling water, x. 
 Mix half the charcoal into the poultice, and sprinkle 
 the rest either over its surface or directly upon the 
 wound. This poultice needs very frequent renewal. It 
 is used for putrid sores; it absorbs the fetid odor and 
 promotes a healthy condition, but it is always a dirty 
 application, and other neater and equally effective an- 
 tiseptics have largely taken its place. A linseed poul- 
 tice may be made with some disinfectant solution 
 instead of pure water, as weak carbolic acid, bichloride 
 of mercury, or solution of chlorinated soda. The latter, 
 as well as correcting the odor, affords moderate stimu- 
 lation to the wound. It is made in the proportion of 
 one part Labarraque's solution to four of water. An- 
 other gently stimulant application is the yeast poultice, 
 mainly used to hasten the separation of gangrenous 
 sloughs. Mix six ounces of yeast with the same quan-
 
 158 A TEXT-BOOK OF NURSING 
 
 tity of water at blood heat; stir in fourteen ounces of 
 wheat flour, and let it stand near the fire till it rises. 
 Apply while fermenting. Another recipe given for the 
 yeast poultice is : Mix a quarter of a pound of flour, or 
 linseed meal, with two ounces of yeast or beer grounds. 
 The mixture is then heated, being constantly stirred 
 until it is warm. The former is officinal. Dough, just 
 as mixed for bread, will answer the purpose of a yeast 
 poultice admirably. It is not necessary to wait for it 
 to rise, as the heat of the body will cause it to do so. 
 Put a sufficient quantity in a muslin bag, allowing 
 plenty of room for it to rise. 
 
 Starch makes a very bland poultice, and retains the 
 heat well. It is used for cancers and to allay the irrita- 
 tion of skin diseases. Make as for laundry use: mix 
 first with cold water, and then add boiling water until 
 it thickens. 
 
 Powdered slippery elm, Indian meal, and oatmeal 
 are also used for poultices. A very light and soothing 
 one may be made of one part slippery elm to two parts 
 linseed meal. Scraped carrots, boiled or raw, are 
 thought to have an especially cleansing effect; onions 
 and horse-radish are sometimes used for their stimula- 
 ting properties. A hop poultice is a thin bag loosely 
 filled with hops and wrung out in hot water. This has 
 a sedative effect. Bran is treated in the same way. A 
 bran jacket may be made like that of linseed, above 
 described, and has the advantage that the same one can 
 be rewet and used again and again. It needs to be 
 stitched through and through, as well as round the 
 edges, to keep the bran in place. Bandage close to the 
 body with a wide roller. 
 
 Laudanum is often added to a simple poultice, or 
 sprinkled over its surface, for the relief of pain. An-
 
 FOMENTATIONS 159 
 
 other sedative poultice sometimes ordered consists of 
 one part powdered hemlock-leaf to three parts linseed 
 meal. In either case the constitutional effects of the 
 drug are to be looked out for. 
 
 Camphor, incorporated in a bland poultice, is some- 
 times applied to the perinaeum for the relief of stran- 
 gury. 
 
 A spice poultice is made by mixing ginger, cinna- 
 mon, clove, and Cayenne pepper, a teaspoonful of each, 
 with half an ounce of flour, and brandy enough to make 
 a paste. The same effect, that of mild counter-irrita- 
 tion, may be produced by sewing the spices into a bag, 
 to be dipped into whisky or brandy when required for 
 use. 
 
 A mustard poultice is made by the addition to a 
 simple linseed poultice of a prescribed proportion of 
 mustard, usually from one eighth to one fourth. A 
 good substitute for a mustard poultice may be made by 
 dipping a clean flat sponge into mustard paste prepared 
 in the usual manner. Fold this in a handkerchief or 
 piece of muslin, and apply. The poultice may be re- 
 newed by simply moistening the sponge afresh with 
 warm water, its strength being perfectly preserved. 
 
 Fomentations are poultices in modified form, appli- 
 cations of hot water, pure or medicated, by means of 
 pieces of flannel or flat sponges. They have the advan- 
 tages of being clean, light, and quickly prepared; but 
 they require constant attention, needing to be changed 
 every ten or fifteen minutes. Two pieces of flannel 
 should be at hand, each doubled to the desired size. 
 These are called stupes. They are to be saturated with 
 boiling water, and wrung out as dry as possible. For 
 this purpose a stupe-wringer is needed a piece of 
 stout toweling with a stick run through the hem at each
 
 160 A TEXT-BOOK OF NURSING 
 
 end. Put the stupe in the middle of this, saturate with 
 boiling water, and twist the sticks in opposite directions 
 until no more water can be squeezed out. A towel may 
 be used as a wringer, but there is danger of scalding 
 one's fingers. A stupe cool enough to be wrung out by 
 hand is too cool to be of much use. It should be dry 
 enough not to wet the bed or the clothing. Have 
 another all ready to apply before removing the first. 
 There should be two layers, no more. Shake these 
 slightly apart to let the air in between them, and they 
 will keep hot longer. Cover with oiled muslin, an inch 
 larger in each direction than the stupe, and over that 
 lay a piece of dry flannel, or a layer of cotton- wool. 
 The stupe should never be allowed to get cold. After 
 the fomentations are discontinued, carefully dry the 
 part to which they have been applied, and keep it cov- 
 ered for a time with a warm, dry flannel. Fomenta- 
 tions are not applied to discharging wounds, as the 
 stupes would at once be soiled. Their chief use is to 
 relieve spasm of the internal organs. They may be 
 made more irritant or sedative by the addition of ap- 
 propriate medicaments. Twenty or thirty drops of tur- 
 pentine or laudanum may be sprinkled over each stupe, 
 or it may be steeped, instead of pure water, in some 
 remedial decoction, as of poppy-heads, hops, or chamo- 
 mile flowers. A stupe recommended for a child con- 
 sists of Jamaica ginger, paregoric, and hot water, in 
 equal parts. In using turpentine there is some danger 
 of blistering the skin, and any sore spot must be first 
 covered with some impervious dressing. 
 
 When it is better to avoid relaxation of the tissues, 
 " dry fomentations " are employed. Toasted flannel is 
 often used, but it does not retain heat well. Thin bags 
 of heated sand, ashes, or salt, bran or hops, hot bricks,
 
 FOMENTATIONS, AND OTHER APPLICATIONS 161 
 
 plates, tins, and water-bottles, and all applications of 
 dry heat come under this head. The Japanese hand- 
 warmers are excellent for this use. Keep the ventila- 
 ting holes uppermost, and do not cover them too closely. 
 Rubber bags for hot water should never be more than 
 half full. Expel the air from the remaining space 
 before screwing on the cap. Be sure that hot water- 
 bottles are corked too tightly to allow any possibility 
 of leakage. All such appliances should in every case 
 have a covering of flannel which can not be displaced. 
 An undershirt or large stocking will serve the purpose. 
 With a child, or an unconscious patient especially, you 
 can not be too careful about this. There are several 
 cases on record in which patients after an operation, 
 and before recovering from the ether, have suffered 
 severe burns in consequence of an uncovered heater 
 coming in contact with the skin. An occurrence of this 
 kind results from a degree of carelessness on the part 
 of the nurse which is simply unpardonable. 
 
 Hot applications are usually better than cold, the 
 latter being used chiefly to subdue inflammation. They 
 are good only in its earliest and latest stages, never 
 when matter is forming or during sloughing. To be 
 of any use they must be kept cold, and confined to a 
 limited space. If the treatment is begun and suspended, 
 the reaction will render the inflammation more severe 
 than if it had never been undertaken. 
 
 The simplest method of applying cold is by pieces of 
 muslin laid on ice, and changed for fresh ones before 
 they get warm. This calls for constant attention. The 
 bed must be well protected ; in all applications of water 
 care must be taken that neither it nor the patient's 
 clothing gets wet. 
 
 Ice is best applied in a rubber bag. These come in
 
 162 A TEXT-BOOK OP NURSING 
 
 different shapes to fit the various parts of the body. 
 The bag should be not more than half filled, with bits 
 less than an inch square, and the supply be renewed be- 
 fore the last piece is melted. The ice will keep longer 
 if mixed with one third sawdust. Put a muslin cover 
 on the ice-bag, and confine it with a bandage so that it 
 may not slip about. An ice-bladder for application to 
 the head can be folded in a napkin and pinned in posi- 
 tion upon the pillow, so that its weight will not press 
 upon the head. In the absence of a regular ice-cap a 
 cap-shaped sponge may be used, which will absorb the 
 water as it melts. This must, of course, be wrung out 
 before it is saturated. Ice can be finely broken by 
 wrapping it in a stout cloth and pounding it. Coils of 
 rubber or lead-tubing are now extensively used as a 
 substitute for the ice-bag, ice-water being siphoned 
 through them from a tub placed at an elevation above 
 the bed. 
 
 All evaporating lotions must be left uncovered. A 
 single thickness of lint or muslin is used, and frequent- 
 ly wet. Do not use flannel, or you may get a blister. 
 Such are alcohol, vinegar, muriate of ammonia, etc. 
 
 Other lotions are put on several folds of lint, laid 
 on the affected part, and covered closely with oiled 
 muslin, or rubber tissue. The lint can be rewet with- 
 out taking it off by pouring some of the lotion over it. 
 
 A lotion applied to the eye is known as a collyrium. 
 Collyria should be introduced at the outer angle of the 
 eye, either by a glass dropper, or a camel's-hair brush 
 used for nothing else. Draw down the lower lid, and 
 tell the patient to look up at the instant the drops are 
 slid in. Moist cloths must never be bound tightly upon 
 the eyes, or they will assume the nature of a poultice, 
 always harmful to those delicate organs.
 
 COUNTER-IRRITANTS 163 
 
 Liniments differ from lotions in their mode of appli- 
 cation, being rubbed in until the part is dry. Lini- 
 ments usually contain poisonous ingredients, and must 
 be used with care, the hands afterward being well 
 washed before touching any sensitive spot. 
 
 Ointments are either spread on lint the exact size 
 required or are rubbed in like liniments. The rubbing 
 in of an ointment is termed inunction. 
 
 Croton oil or antimonial ointment is rubbed into the 
 surface with a piece of flannel, a very small quantity at 
 a time, at intervals of four or five hours, until an erup- 
 tion appears. This is for counter-irritant effect. 
 
 Counter-irritants relieve inflammation of the deep- 
 er parts by causing dilatation of the superficial capil- 
 laries and contraction of those in the inflamed tissues, 
 probably through reflex nervous action. There are two 
 distinct varieties rubefacients, producing merely local 
 warmth and redness, and vesicants, epispastics, or blis- 
 tering agents. Still a third class produce a pustular 
 eruption over the surface to which they are applied. 
 Of this kind are the above-mentioned Croton oil and 
 tartrate of antimony. 
 
 Counter-irritants are applied usually over or near 
 the seat of disorder, but sometimes at a remote part, 
 to obtain what is called revulsive action. In this way 
 mustard poultices on the feet, or a mustard foot-bath, 
 may be employed for the relief of the head. 
 
 Mild counter-irritation results from hot fomenta- 
 tions and poultices, and from the various ammoniacal 
 and camphorated liniments. One of the most common- 
 ly used rubefacients is mustard. To make a mustard 
 plaster or sinapism, take one part of powdered mus- 
 tard and from two to five times the quantity of flour, 
 according to the strength desired. Mix into a paste
 
 A TEXT-BOOK OF NURSING 
 
 with tepid water, and spread it evenly between two 
 pieces of muslin. Hot water or vinegar, often recom- 
 mended, will weaken the active principle of the mus- 
 tard; and though, when made with tepid water, the 
 plaster on first application feels cold, it soon gets warm. 
 It should not be left on long enough to vesicate, as the 
 sore produced is painful, and slow to heal. From twen- 
 ty minutes to half an hour is usually long enough. 
 With an insensible or delirious patient, the action must 
 be carefully watched ; if neglected, deep ulceration may 
 ensue. For a child, it is well to mix it with one third 
 glycerin instead of pure water, as the action will be less 
 severe, and it can stay on longer. Confine in place 
 with a bandage. The burning sensation which follows 
 the use of a mustard plaster may be relieved, if ex- 
 treme, by dusting the part with flour or fine starch, 
 or dressing it with vaseline, and covering with cotton 
 to exclude the air. Cayenne-pepper plaster is made 
 by mixing a tablespoonful of Cayenne into a thin paste 
 of flour and water. Spread like a mustard paste. Or 
 a quantity of red pepper may be stitched into a flat 
 flannel bag, wrung out in warm water, and applied over 
 the seat of pain. Mustard leaves, mustard paper, and 
 capsicum plasters are prepared for use by simply dip- 
 ping in tepid water. They are neat, quickly ready for 
 use, and very effective. 
 
 Similar local stimulation may be obtained from bits 
 of cantharidal plaster, kept on for an hour or two, but 
 removed before the point of vesication is reached. 
 These are called " flying blisters." The same effect 
 follows the rapid passage of a hot iron over a piece of 
 brown paper, or thin flannel, laid upon the skin. This 
 will often relieve lumbago or chronic rheumatism. 
 Eeddening only is desired. One use of the actual
 
 COUNTER-IRRITANTS 165 
 
 cautery is as a rubefacient. The burn produced by it 
 is dressed like any other of little depth; usually with 
 lint dipped in a solution of bicarbonate of soda, and 
 covered from the air with rubber tissue. 
 
 To produce vesication, the agent most commonly 
 employed is cantharides. This should not be applied 
 where the skin is broken or tender. If it is very thin, 
 as in case of a child, a piece of oiled tissue paper may 
 be interposed between it and the cantharidal plaster. 
 This is said to lessen the danger of strangury, while it 
 accelerates rather than retards the action of the blister, 
 as the active principle of cantharides dissolves in oil 
 with great rapidity. The part should first be washed 
 and dried, shaved if there is any hair upon it, and 
 the plaster secured in place by a bandage rather than 
 by adhesive strips, as the latter may be drawn upon 
 painfully as the blister rises. This should take place in 
 from four to eight hours. If it does not rise within 
 twelve hours, it should be removed and a poultice ap- 
 plied, which will usually produce the desired effect. In 
 taking off the plaster be careful not to tear the skin, 
 and clean off with a little oil any adhesive particles. 
 When the blister is well raised, make a slight incision 
 at the lowest point for the escape of the serum, and 
 dress with oxide-of-zinc powder; or, the direction may 
 be to leave the blister undisturbed, allowing the fluid to 
 be reabsorbed. So far as the general effect is concerned, 
 it is entirely immaterial which course is pursued. Ill 
 effects, as strangury and congestion of the kidneys, 
 sometimes follow the prolonged use of cantharides. It 
 has been supposed even to have induced premature 
 labor. Camphor corrects the action of cantharides 
 upon the bladder. For this reason, another method 
 
 recommended of preparing cantharidal plaster for use 
 12
 
 166 A TEXT-BOOK OP NURSING 
 
 upon a child is to sprinkle it with a solution of cam- 
 phor in ether. The ether will evaporate in a few sec- 
 onds, and a film of camphor be deposited evenly over 
 the surface. A blister will usually be raised upon a 
 young child in from two to four hours; it should be 
 carefully watched, and not allowed to remain too long. 
 Eemove when the skin is well reddened, and poultice. 
 The cantharidal collodion is a convenient form, well 
 adapted to uneven surfaces, as it can not get out of 
 place. One or two coats are applied by a camel's-hair 
 brush ; if covered by oiled silk or rubber tissue it works 
 rather more quickly. The tincture of iodine is applied 
 in the same way; it is much milder in its action, sev- 
 eral coats and repeated applications being usually re- 
 quired to produce a blister. If it burns too severely, 
 it can be washed off by ammonia or alcohol. 
 
 When it is desirable to vesicate very quickly, strong- 
 er ammonia or chloroform is used. A piece of lint 
 or cotton saturated with it is placed upon the skin, 
 its evaporation being prevented and its irritating ac- 
 tion limited by covering it tightly with a watch-glass, 
 or the cover of a pill-box. A blister will be raised in 
 five or ten minutes. This method is always painful; 
 the ammonia, if left too long, will eat into the flesh. 
 
 Blisters should seldom be used in the case of the 
 aged, of those whose circulation is poor, as they may 
 cause extensive sores which are slow in healing. 
 
 The interior of the throat may be treated by gargles 
 or by insufflation, as well as inhalation, already de- 
 scribed. Gargles are fluids brought in contact with the 
 tonsils and forcibly agitated by the air from the larynx. 
 About a tablespoonful at a time should be used, four or 
 five times successively. After an acid gargle the mouth 
 should be well rinsed with some alkaline solution, as bi-
 
 CUPS 167 
 
 carbonate of soda or lime water, to prevent injury to 
 the teeth. 
 
 For insufflation a rubber air-bag especially designed 
 for the purpose may be used, or a large quill, a piece of 
 glass tubing, or even a hollow roll of stiff paper, filled 
 with the prescribed powder. This is placed as far as 
 possible back in the throat, and its contents either 
 blown in by the operator, or forcibly inspired by the 
 patient. 
 
 The nasal douche, once so common, is now seldom 
 prescribed, as there is danger attending its use. If it is 
 followed by pain in the ears it should not be repeated. 
 The use of the post-nasal syringe and the spray has 
 almost entirely superseded that of the douche. 
 
 Cups are applied to relieve congestion, to abstract 
 blood, or to prevent active absorption. For the relief 
 of pain, dry cupping is the most practiced. It is an 
 operation requiring much nicety in its performance. 
 The articles needed are cupping-glasses in the absence 
 of the regular apparatus, small tumblers or wine-glasses 
 with smooth edges may be used a spirit-lamp, a saucer 
 of alcohol, a stick with a bit of sponge or a wad of lint 
 on the end, and plenty of soft towels. The lamp should 
 stand between the patient and the alcohol. Have the 
 cups perfectly dry. Dip the sponge in the alcohol, ig- 
 nite it from the lamp, and let it burn for an instant in 
 the inverted glass; then withdraw and extinguish it, 
 at the same -time rapidly placing the glass over the 
 affected part. The heat will have rarefied the air in 
 it, and as it condenses, on cooling, a partial vacuum is 
 formed, to fill which the skin will be forcibly sucked up 
 and the blood drawn toward the surface. Or, instead 
 of using the torch, pack the bottom of the glass solidly 
 with absorbent cotton, put a few drops of alcohol in the
 
 168 A TEXT-BOOK OP NURSING 
 
 center, and ignite. Invert and apply while still burn- 
 ing. Each cup may remain on from three to five min- 
 utes, being removed before discoloration takes place. 
 They can not be applied over a bony or irregular sur- 
 face. A second cup must not be put in the ring left 
 by a former one. Above all things, avoid burning the 
 patient, either by using the alcohol too freely, so that 
 it drips, or by getting the edges of the glasses too hot. 
 To remove a cup, make pressure with a finger close 
 to it, so that the air will be admitted. Dry it well be- 
 fore using it again. If instead of allowing a cup to 
 remain stationary, it be slid back and forth along the 
 surface, the formation of effused circles is avoided, and 
 a large tract can be treated with one or two cups. An- 
 other apparatus consists of glasses furnished with rub- 
 ber bulbs for exhausting the air. The nurse will not 
 infrequently be called upon to practice dry cupping. 
 Wet cupping is always attended to by the physician. 
 A scarificator, lint, and adhesive straps will be required, 
 in addition to the articles already mentioned. After 
 cupping in the usual manner, the scarificator will be 
 applied, making a series of slight cuts. The glasses 
 will then be replaced. Or sometimes the scarificator 
 will be applied before using them at all. When suffi- 
 cient blood has been abstracted, the haemorrhage can be 
 easily stopped by pads of lint. A dry dressing, or some 
 simple unguent, is all that is needed. Wet cupping is 
 most frequently used in the lumbar region, to relieve 
 inflammation of the kidneys. 
 
 Leeches are commonly used when it is desired to 
 take a small quantity of blood from any locality. They 
 affect a more limited space, and are preferable to cups 
 if the parts are at all sensitive or inaccessible. There 
 are two varieties, the American and the foreign. The
 
 LEECHES 169 
 
 former has three stripes down the back, the latter five 
 or six. The foreign leech is larger and more voracious, 
 drawing four or five times its own weight of blood. A 
 leech will draw more blood from a young child than 
 from an adult, owing to the thinness and greater vas- 
 cularity of the skin. For this reason domestic leeches 
 are generally chosen for children. They should not be 
 applied over any large vessel, but over a bony surface 
 upon which pressure can be made in case of excessive 
 haemorrhage. 
 
 There is sometimes difficulty in making leeches bite. 
 The part to which they are to be applied must be 
 perfectly clean, washed first with soap and water, and 
 again with pure water. The leech itself should be 
 clean; it may be washed and dried in the folds of a 
 towel, but never handled. Strong odors in the room, 
 as of sulphur, vinegar, or tobacco will affect the leech; 
 it may even refuse to bite when the patient has taken 
 certain drugs internally. Various devices are proposed 
 for inducing a leech to take hold; a slight scratch, just 
 sufficient to give the taste of blood, will usually over- 
 come any hesitation. Near the eye, or wherever the 
 exact spot of attachment is important, a test-tube, 
 leech-glass, or small bottle may be used to contain the 
 leech. If the leeches are to be applied inside the mouth 
 or nostrils, it is well to put threads through their 
 tails. It will not interfere with their working, and will 
 keep them from being swallowed. Should such an ac- 
 cident occur, they can be at once rendered harmless 
 by drinking freely of salt and water. A leech should 
 suck from three quarters of an hour to an hour. If 
 they seem sluggish, they can be excited to action by 
 gentle stroking with a dry towel. When full they will 
 drop off. If you wish to take them off sooner, sprinkle
 
 170 A TEXT-BOOK OF NURSING 
 
 a little salt on their heads. Never remove by force, or 
 the teeth will be left in the wound, where they may 
 occasion abscess or erysipelatous inflammation. The 
 leech-bite leaves a permanent stellate scar. The bleed- 
 ing may be encouraged by hot fomentations or poul- 
 tices, or checked if too profuse, by a compress of lint, 
 an application of ice, or, if it resists these, by touch- 
 ing with nitrate of silver. A patient should never be 
 left for the night till all bleeding has ceased. 
 
 After they have been used, the leeches may as well 
 be thrown away, as it is only after a long time and con- 
 siderable care that they will ever be good for anything 
 again. Leeches not used may be kept in a jar of w#ter, 
 with sand and a little excelsior in the bottom, and hav- 
 ing a perforated cover. The water must be changed 
 every four or five days. A piece of charcoal in the water 
 will help to keep it pure. 
 
 When it is desired to draw blood in greater quantity, 
 venesection is practiced. A bandage is twisted tightly 
 about the arm above the spot decided upon. A vein 
 is laid bare by a half inch incision along its course, and 
 separated from its sheath. It is then opened by a 
 knife edge turned upward, great care being taken not 
 to injure its posterior wall. From three to eight 
 ounces of blood will be drawn, the process requiring 
 half an hour or more. If a clot should form, it must be 
 removed by a bit of aseptic gauze. To check the flow 
 of blood, remove the bandage above, and apply a com- 
 press over the incision. 
 
 In preparation for transfusion, the injection into it 
 of a saline solution, the vein of the arm or leg is simi- 
 larly dissected from its sheath, and a clip applied so 
 that the lower portion will be filled with blood. There 
 is then inserted, and securely ligated to it, a glass
 
 LEECHES 171 
 
 canula dipped in the prescribed solution. This is con- 
 nected by a rubber tube after all the air has been care- 
 fully displaced from them both with a glass irrigating 
 flask containing the solution at a temperature of 101 
 F. The irrigator is then elevated about two feet above 
 the vein and the saline solution allowed to run into it. 
 It will take about half an hour to inject a quart. At 
 first the patient seems improved, then comes a critical 
 period, and it will be some hours before any marked 
 benefit is seen. This treatment is used to relieve vari- 
 ous toxaemic conditions as well as to counteract the 
 effects of haemorrhage, or surgical shock. 
 
 In such cases, and in the collapse of cholera, a nor- 
 mal saline solution is sometimes similarly injected into 
 the subcutaneous tissues, usually of the thigh or the 
 abdomen, whence it is rapidly absorbed by the vessels. 
 This is called hypodermoclysis. The absorption is as- 
 sisted by gentle massage. 
 
 In both these processes, everything used must be 
 thoroughly sterilized, and the greatest care be taken 
 that no air is injected with the fluid. 
 
 " Look up and fear not, do thy work in joy: 
 Train nerve and sinew in the glad employ 
 
 Of simple souls that neither strive nor cry. 
 Drink happy draughts of love that will not cloy. 
 Life shall not fail thee, for thy God is nigh." 
 
 W. L. Courtney.
 
 CHAPTER XI 
 
 "We may live without poetry, music, and art; 
 "We may live without conscience, and live without heart ; 
 We may live without friends ; we may live without books ; 
 But civilized man can not live without cooks." 
 
 Owen Meredith. 
 
 ALL animal bodies are made up of the four elements, 
 oxygen, hydrogen, nitrogen, and carbon, together with 
 a small quantity of mineral matter. Oxygen and hydro- 
 gen, in combination, form water, which enters into all 
 constituent parts of the body, amounting to more than 
 two thirds of its entire weight. Life is maintained by 
 a continual process of oxidation, or combustion, pro- 
 ducing heat and energy. To supply material for such 
 production of vital force, and also to build up and re- 
 pair the waste of the tissues carrying on the work, food 
 is required. Our food, in whatever form we take it, is 
 composed of some or all of the four elements above 
 named, in variously proportioned compounds. 
 
 The hydrocarbonaceous compounds, of which starch, 
 sugar, fat, and gum are the most familiar and most im- 
 portant, furnish the materials for oxidation, whatever 
 surplus may be taken into the system being stored as 
 fat. These may be called the heat-producers. 
 
 Nitrogenous compounds are more especially flesh- 
 formers, and go to repair the waste of the body. The 
 most important of them is albumin, and the entire 
 group of related compounds, including fibrin, casein, 
 173
 
 FOOD AND ITS ADMINISTRATION 173 
 
 glutin, gelatin, etc., are, from their resemblance to it, 
 frequently termed albuminoids. 
 
 Neither group has exclusively the one function, for 
 in the transformation of albuminoids into living tissue 
 some heat is produced; and in all healthy tissue there 
 must be present, also, a certain proportion of the hydro- 
 carbons. But the division is still of value, forming the 
 basis of all scientific dietetics. 
 
 In addition to these two great groups of food-matter 
 certain earthy salts are required phosphorus for the 
 nervous system, iron for the blood, lime for the bones, 
 potash and soda for the muscles, etc. These we take 
 insensibly, they being more or less in nearly everything 
 we eat and drink. Common salt (chloride of sodium) 
 is the only one which we make a practice of adding to 
 our food. 
 
 Hydrogen and carbon very readily unite with oyx- 
 gen; it is a peculiarity of nitrogen, on the contrary, 
 that it interferes with oxidation. Entering into the 
 composition of the bodily tissues, it protects them, so 
 that they are not rapidly consumed by the heat of the 
 oxidizing hydrocarbons. Their destruction is generally 
 slow, and the amount of nitrogenous matter needed for 
 repair is much less than the amount of hydrocarbons 
 called for as fuel. In a healthy diet that is, one in 
 which the supply corresponds to the demand the heat- 
 producers should be more abundant than the albumi- 
 noids. In growing children and in convalescents, where 
 disease has caused undue waste of substance, the de- 
 mand for albuminoids is greater. 
 
 Even in health it is well to know something of the 
 constituents of our food, and what purpose each serves 
 in the economy of nature; and, when sickness and its 
 effects upon digestion and nutrition are to be taken into
 
 174 A TEXT-BOOK OF NURSING 
 
 account, it becomes worthy of the most serious consid- 
 eration. The original meaning of nurse was to nourish, 
 and, in spite of all the secondary meanings that it has 
 acquired, the question of nourishment still remains one 
 of primary importance. What food to give, when and 
 how to give it, are constantly recurring problems of the 
 sick-room. 
 
 What kind of food is to be given in each case will 
 usually be decided by the physician ; how best to prepare 
 and administer it are matters for the nurse to know. 
 Everything should be the best of its kind, well cooked, 
 palatably seasoned, and attractively served. Consult, 
 as far as possible, the known tastes of the patient; but 
 do not each time ask him what he would like. Some- 
 thing unexpected will often be acceptable, when to 
 have thought about it beforehand would have taken 
 away all appetite for it. His food should never be pre- 
 pared in his presence, nor the smell of cooking be 
 allowed to reach him, if it is possible to avoid it. Your 
 own meals should never be served in the sick-room; it 
 is equally bad for nurse and patient. Serve everything 
 as nicely as may be, always with a clean napkin, spot- 
 less china, shining silver and glass. Have the dishes 
 dry on the outside, taking particular care that nothing 
 gets spilled from the cup into the saucer. This point 
 needs special emphasis. 
 
 Have hot things very hot, and cold ones really cold. 
 More salt and less sugar will generally be wanted than 
 in health. Highly seasoned food is not good or often 
 wished for, but everything should be agreeably flavored 
 and of good quality : eggs above suspicion, milk always 
 sweet, and butter fresh. The two articles last named 
 ought always to be kept cool and closely covered, for 
 they absorb the odors of whatever is near them. The
 
 FOOD AND ITS ADMINISTRATION 175 
 
 least taint in any kind of food should lead to its rejec- 
 tion, and the substitution of something else. Before 
 taking food to the sick, you should always taste it to be 
 sure that it is just right, but on no account taste it in 
 his presence, or with his spoon. Whatever is not eaten 
 should be at once taken away, as to leave it in sight, in 
 the hope that he will want it a little later, is worse than 
 useless. It is always better to bring too little rather 
 than too much. 
 
 A weak digestion can not manage a load, but must 
 take little and correspondingly often. It is not wise to 
 overburden the patient's stomach in your anxiety to 
 make him take plenty of nourishment, for it is not what 
 is swallowed, but what is digested, that does him good. 
 When only a very small quantity can be retained, it 
 should be in a highly concentrated form. Where there 
 is nausea and diarrhoea, give but little at a time, and 
 always cold. 
 
 Ascertain from the doctor how much he wishes the 
 patient to take within the twenty-four hours, and, divid- 
 ing it up into suitable quantities, give it at regular in- 
 tervals. The importance of regularity can hardly be 
 too much emphasized. If given punctually at fixed 
 hours, a habit not only of taking, but of digesting it, 
 will soon be acquired, for our most automatic functions 
 are influenced by custom. Each time a patient is fed, a 
 note should be made of the kind and approximate quan- 
 tity of nourishment taken. Only in exceptional cases 
 should he be roused from sleep for food, but a supply 
 should be provided for use during the night, as it may 
 be most important to have it at hand. Put it in the 
 coolest place, and cover to keep out the dust. Some 
 light nourishment the last thing at night will often help 
 to send the patient to sleep.
 
 176 A TEXT-BOOK OF NURSING 
 
 In feeding a helpless patient, give the food slowly 
 and in manageable quantities, letting each morsel be 
 fairly swallowed before another is given. If there is 
 difficulty in making him swallow, it will be lessened by 
 taking advantage of his inspirations. See that the head 
 is not turned to either side even a slight inclination 
 may cause the liquid to run out at the corner of the 
 mouth instead of down the throat have the clothes 
 well protected, and take pains not to make an external 
 application of it. A feeding-cup with a spout may be 
 used, but, unless the patient is able to control it him- 
 self, it has the disadvantage that the nurse can not see 
 how fast she is pouring its contents. Fluid food can 
 in most cases be taken more conveniently by suction 
 through a bent glass tube, and patients will often take 
 a larger quantity in this way than they can be induced 
 to in any other. After feeding, always dry the mouth, 
 especially at the corners, if the patient can not well do 
 it for himself. The lips not infrequently become sore 
 from want of this little care. In rare cases it may be 
 necessary to give food by force to a delirious patient. 
 The best way of doing this is through the nose, the 
 patient either lying down or sitting up with the head 
 thrown back. A soft, well-oiled catheter is introduced 
 through the nostril into the oesophagus, and connected 
 with a small funnel into which the food of course fluid 
 only is poured. It should be introduced at least fifteen 
 inches to make sure that it has passed the entrance to the 
 windpipe. After once entering the oesophagus, it will 
 be helped down by the action of the constrictor muscles. 
 There is less danger of getting food into the trachea by 
 this method than by the use of a stomach-tube passed 
 through the mouth. Holding the nostrils to try to make 
 a patient swallow is always attended by some danger.
 
 FOOD AND ITS ADMINISTRATION 177 
 
 With fever, there is often great thirst. Usually it 
 will be quite safe to allow the patient all the water he 
 wants. If not, it is worthy of note that a small glass 
 full will be much more satisfactory, especially to chil- 
 dren, than the same quantity in a larger vessel. Slight- 
 ly bitter or acidulated drinks slake thirst more effectu- 
 ally than water alone. Hot water quenches thirst better 
 than cold, though bits of ice are often very refreshing. 
 They may be easily split off with a pin, in the direction 
 of the grain. Small bits swallowed whole are excellent 
 to control nausea. Sips of very hot water are some- 
 times good for the same purpose. Ice, to keep well, 
 must be so placed that the water will drain off as fast 
 as it melts. Small pieces may be kept in a glass for 
 some time by suspending them in flannel, in which one 
 or two holes are snipped for the water to run through. 
 Confine it by an elastic band about the edge of the 
 glass. A metal spoon in the glass helps to melt the 
 ice by conducting away the heat rapidly. A newspaper 
 wrapped around the ice-pitcher, being, on the contrary, 
 a very bad conductor, will help to preserve it. Ice, to 
 be taken internally, must be clean, and that not only 
 on the outside. It is a great mistake, to think that all 
 deleterious substances are disengaged from it in freez- 
 ing. It is as necessary to have good ice as pure water, 
 which is of recognized importance. Pure water should 
 be transparent, sparkling, colorless, and odorless, 
 though these characteristics do not prove it such. 
 Water of suspicious quality, can be rendered safe to 
 use by boiling it for half an hour, and letting it cool 
 in closely covered vessels. It is always desirable to 
 have it filtered. 
 
 Water should be offered to every patient several 
 times a day, even if not asked for, and its use encour-
 
 178 A TEXT-BOOK OP NURSING 
 
 aged. Few people drink as much as would be good for 
 them. 
 
 To provide food for the sick which will be at once 
 suitable and acceptable is a matter which requires care, 
 judgment, and ingenuity, but it is well worth the ex- 
 penditure of them all. The aim should be to give what 
 will be at once easy of digestion and of value after it is 
 digested. 
 
 Digestion is an elaborate and complex process, in- 
 cluding both mechanical and chemical action. The 
 saliva contains a peculiar ferment called ptyalin, which 
 has the property of converting starch into sugar. The 
 gastric secretion acts in a similar way upon the albumi- 
 noids, changing them into soluble peptones. The bile, 
 the secretion of the liver, has the power of emulsion- 
 izing fats, and the pancreatic and intestinal juices sup- 
 plement to a certain extend the action of all the three. 
 Whatever portion of the food resists the action of all 
 these solvents is rejected from the system as waste mat- 
 ter, while such as is reduced to a fit state of solution is 
 absorbed into the circulation. When the gastric secre- 
 tion is defective, pepsin may be given, with an acid, to 
 aid in the solution of albuminoids ; pancreatin, prefer- 
 ably with an alkali, assists in the intestinal indigestion. 
 
 Liquid food is the most easily digested, and in se- 
 vere illness may be entirely relied upon. Meat con- 
 tains much nutriment in small bulk, but is a good deal 
 of a tax upon the digestive organs. Vegetables con- 
 tain all the food elements, for, as is well known, life 
 can be sustained on a purely vegetable diet, but they in- 
 clude a large proportion of waste in the shape of indi- 
 gestible fibrous tissue. The leguminous plants are rich 
 in albuminoids, the cereals and tubers in starch, 
 although wheat contains a large amount of glutin.
 
 FOOD AND ITS ADMINISTRATION 1T9 
 
 Fruits consist chiefly of water and sugar, with some 
 vegetable acid, and have but little nutritive value. 
 Milk is the only article of diet which contains in itself 
 all the necessary elements of nutrition in their proper 
 proportions. Tea and coffee are rather stimulant than 
 nutrient, but if not too strong are valuable on account 
 of the extra boiled water which they furnish to the 
 system. 
 
 Hot water is almost a panacea, internally and exter- 
 nally. Cocoa and chocolate are nutritious, but unfor- 
 tunately somewhat difficult of digestion. Eggs are of 
 high nutritive value, but in them, and in most other 
 animal foods, the albuminoids predominate. In cook- 
 ing eggs in any way it should be remembered that 
 albumin coagulates perfectly at a temperature much 
 below that of boiling water, and that boiling renders 
 it hard, tough, and indigestible. The same is true of 
 oysters. Beef ranks high among the animal foods, but 
 the usefulness of beef-tea is very generally overesti- 
 mated, as the albuminous and most nutritive portion 
 of the meat is left behind in its preparation. It has 
 value, but it is as a stimulant rather than as a food. 
 Preparations of beef which has been peptonized, or 
 partially digested outside of the body, are far superior 
 to it. Beef-juice may be given either hot or ice cold. 
 Frozen beef- juice will sometimes be acceptable when it 
 is not relished in the fluid form, or it may be stiffened 
 into a solid with gelatin. 
 
 Broths may be made also of any other good meat 
 or poultry. Meat from which the juice is to be extract- 
 ed must always be put into cold water, and gradually 
 heated. It may be allowed to simmer until the meat 
 has quite lost its color, but should never reach the 
 boiling-point. On the other hand, if the meat itself
 
 180 A TEXT-BOOK OF NURSING 
 
 is to be eaten, it should be in the beginning exposed 
 to a high temperature, which will coagulate the fibrin 
 near the surface and so prevent the escape of the juices. 
 Long, slow cooking should follow. 
 
 All soups should be allowed to stand until cold, as 
 the fat can not be perfectly removed while hot. Heat, 
 when required for use, only to the palatable point, with- 
 out further boiling. 
 
 A variety of gruels, porridges, and panadas are 
 made of oatmeal, Indian-meal, arrow-root, rice-flour, 
 corn-starch, etc. Different crushed cereals may be 
 obtained already steam-cooked, which will be found 
 excellent and very convenient. Directions for use are 
 supplied with them, but in most cases they should be 
 allowed more time than specified for cooking. It is 
 important that cereals be thoroughly cooked. They 
 may be mixed with meat broths, or with milk always 
 being well cooked first. 
 
 Both oatmeal and Indian-meal have a loosening 
 effect upon the bowels, and are consequently objection- 
 able when there is any tendency to diarrhosa. In such 
 cases boiled milk is preferable to raw. When there is 
 nausea arising from overacidity of the stomach, lime- 
 water may be added to the milk, in any proportion up 
 to one half. If there is also constipation, carbonic-acid 
 water or Vichy is to be preferred. Mineral waters, 
 both natural and artificial, are much used, chiefly as 
 diuretics and purgatives. They are of many varieties, 
 saline, alkaline, sulphureted, or chalybeate, and, like 
 wines, are to be classed rather as medicine than food. 
 Water charged with carbonic-acid gas, commonly known 
 as plain soda, is the only one which a nurse should 
 give freely on her own responsibility. This is always 
 harmless and often valuable, where there is feverish-
 
 POOD AND ITS ADMINISTRATION 181 
 
 ness, or an irritable stomach. The C0 2 can now be 
 obtained put up in steel capsules, with a siphoned bottle 
 to force it into any desired fluid. It often makes milk 
 acceptable when it can not be taken clear. Skimmed 
 milk can often be taken when the cream can not, and 
 it should be remembered that this contains all the ele- 
 ments of nutrition. Buttermilk is also good. 
 
 Koumyss is a very nutritious and somewhat stimu- 
 lant form of food. The original is prepared in Tartary 
 from mare's or camel's milk ; but an excellent imitation 
 may be made by fermenting cow's milk. This is very 
 valuable, and will sometimes be assimilated when noth- 
 ing else can be retained. Matzoon is somewhat similar. 
 
 Although milk is a most healthful and valuable 
 article of diet when fresh and pure it absorbs noxious 
 germs from the atmosphere so rapidly that it is practi- 
 cally impossible to keep it so, even under the most 
 favorable conditions, and it has often proved a source 
 of danger and a vehicle for the transmission of 
 disease. 
 
 Boiling it, or subjecting it to a high temperature 
 in a steam sterilizer, will destroy the germs of fermen- 
 tation and insure against these elements of danger, but 
 it affects injuriously both the flavor and the quality of 
 the milk. Practically the same result with less altera- 
 tion of its character is achieved by the process known 
 as Pasteurization, which consists in keeping the milk 
 for a longer time at a lower temperature. A tempera- 
 ture of 170 F. steadily maintained for twenty minutes 
 will destroy all the bacteria that may be contained in it, 
 though not their spores. Eepeating this for three suc- 
 cessive days, allowing the intervals for the spores to 
 develop, will effectively finish them all. This is some- 
 times called fractional sterilization. In all cases where 
 13
 
 182 A TEXT-BOOK OP NURSING 
 
 an invalid or an infant is to be fed largely upon milk, 
 it should be so treated. 
 
 Every nurse should be a good cook. It is a most 
 important part of her work. A few recipes for fluid 
 foods are subjoined. Any good cook-book will furnish 
 more substantial ones. A book especially to be recom- 
 mended for the use of nurses is Boland's Hand-book 
 of Invalid Cooking, published by the Century Com- 
 pany. 
 
 EECIPES 
 
 1. Beef -tea. Take a pound of juicy beef cut from 
 the round, remove all the fat, and cut into very small 
 pieces. Put in an earthen pot or an enameled sauce- 
 pan, and add a quart of cold water. Cover it closely, 
 let it soak for an hour, and then simmer gently for two 
 hours more, or until the strength is quite extracted 
 from the beef. Never let it boil hard. Season with 
 salt and pepper. Do not strain it. 
 
 2. Beef-essence. Mince finely a pound of lean, juicy 
 beef, from which all the fat has been removed ; put into 
 a wide-mouthed bottle or fruit-jar, and cork tightly. 
 Set the jar into a kettle of cold water over a slow fire, 
 and let it boil for three hours. Season with salt and 
 red pepper. 
 
 3. Peptonized Beef-tea. To half a pound of raw 
 beef, free from fat and finely minced, add ten grains of 
 pepsin, and three drops of dilute hydrochloric acid. 
 Put in a large tumbler, and cover with cold water. Let 
 it stand for two hours at a temperature of 90, being 
 frequently stirred. Serve in a red glass, ice-cold. Pep- 
 tonized food does not keep well, and should never be 
 used more than twelve hours old. The acid may be 
 used without the pepsin and will partially digest the 
 beef.
 
 FOOD AND ITS ADMINISTRATION 183 
 
 4. Beef-juice. Place half a pound of lean, juicy 
 beef on a broiler over a clear hot fire, and heat it 
 through. Press out the juice with a lemon-squeezer 
 into a hot cup, add salt, and serve hot with toast or 
 crackers. 
 
 5. Beef-tea with Oatmeal. Mix a tablespoonful of 
 well-cooked oatmeal with two of boiling water. Add 
 a cupful of strong beef-tea, and bring to the boiling- 
 point. Salt and pepper to taste, and serve with toast 
 or crackers. Other cereals may be used in place of the 
 oatmeal. 
 
 6. White Celery Soup. To half a pint of strong 
 beef-tea add an equal quantity of boiled milk, slightly 
 and evenly thickened with flour. Flavor with celery 
 seeds or pieces of celery, which are to be strained out 
 before serving. Salt to taste. 
 
 7. Chicken Broth. An old fowl will make a more 
 nutritious broth than a young chicken. Skin, cut it up, 
 and break the bones. Cover well with cold water, and 
 cook slowly for several hours. Salt to taste. A little 
 rice may be boiled with it, if desired. 
 
 8. Mutton Broth. Cut up fine two pounds of lean 
 mutton, without fat or skin. Add a tablespoonful of 
 barley well washed, a quart of cold water, and a tea- 
 spoonful of salt. Let it simmer for two hours. 
 
 9. Oyster Tea. Cut into small pieces a pint of 
 oysters; put them into half a pint of cold water, and 
 let them simmer gently for ten minutes over a slow fire. 
 Skim, strain, add salt and pepper. 
 
 10. Clam Broth. Take three large clams, and let 
 them stand in boiling water until the shells begin to 
 open. Drain out the liquor, add an equal quantity 
 of boiling water, a teaspoonful of finely pulverized 
 cracker crumbs, a little butter, and salt to taste.
 
 184 A TEXT-BOOK OF NURSING 
 
 This and the above are valuable when there is 
 nausea. 
 
 11. Rice Soup. Take half a pint of chicken stock 
 and two tablespoonfuls of rice. Let them simmer to- 
 gether for two hours, then strain and add half a pint 
 of boiling cream and salt to taste. Boil up once, and 
 serve hot. 
 
 12. Sterilized Milk. In the absence of special ap- 
 paratus, put the milk in ordinary nursing bottles, and 
 plug them with absorbent cotton. Stand them in a ket- 
 tle of cold water either on a wire frame or a folded 
 towel so arranged as to keep them from touching the 
 bottom of the kettle or each other. The water should 
 be deep enough to cover the bottles to their necks. 
 Bring it nearly to the boiling-point, and let it stand 
 where it will keep hot without boiling for half an hour. 
 The temperature should be 170 F. Then remove the 
 cotton plugs, cork tightly, and put the bottles away 
 where they will cool. They must remain sealed until 
 required for use. Each should contain only so much 
 as is needed at one time, and any surplus should not 
 be offered again. As soon as emptied, bottles and corks 
 must be most carefully and thoroughly washed, first 
 with a solution of soda and then with clean hot water. 
 Antiseptic cleanliness in every particular is essential 
 to success. The corks should be new, and of good qual- 
 ity. It is said that they may be rendered air and water 
 tight by keeping them for five minutes under melted 
 paraffin. Eubber stoppers are better than corks. 
 
 13. Peptonized Milk. Stir up five grains of pancre- 
 atic extract and fifteen of bicarbonate of soda in a gill 
 of water ; mix thoroughly and add a pint of fresh milk. 
 Put in a bottle or a covered jug, and let it stand where 
 it will keep warm for an hour. Then put on ice until
 
 FOOD AND ITS ADMINISTRATION 185 
 
 required for use. Milk so prepared will have a faintly 
 bitter flavor; it may be sweetened to taste, or used in 
 punch, gruels, etc., like ordinary milk. 
 
 14. Flour Gruel. Mix a tablespoonful of flour with 
 milk enough to make a smooth paste, and stir it into a 
 quart of boiling milk. Boil for half an hour, being 
 careful not to let it burn. Salt and strain. This is 
 good in case of diarrhoea. 
 
 15. Oatmeal Gruel. Boil a tablespoonful of oat- 
 meal in a pint of water for three quarters of an hour, 
 then put it through a strainer. If too thick, reduce 
 with boiling water to the desired consistency. Season 
 with salt. 
 
 16. Oatmeal Gruel with Milk. Soak half a pint of 
 oatmeal in a quart of water overnight. In the morn- 
 ing add more water, if necessary, and boil for an hour. 
 Squeeze through a fine strainer as much as you can, and 
 blend it thoroughly with a pint of boiling milk. Boil 
 the mixture for five minutes, and salt to taste. 
 
 17. Cracker Gruel. Pour a pint of boiling milk 
 over three tablespoonfuls of fine cracker-crumbs. But- 
 ter-crackers are the best to use. Add half a teaspoon- 
 ful of salt, boil up once all together, and serve imme- 
 diately. Do not sweeten. 
 
 18. Indian-meal Gruel. Mix a scant tablespoonful 
 of Indian-meal with a little cold water, and stir into a 
 pint of boiling water. Boil for two hours. Strain 
 and season with salt. Sugar and cream may be added, 
 if desired. 
 
 19. Arrow-root. Mix a teetpoonful of Bermuda ar- 
 row-root with four of cold milk. Stir it slowly into half 
 a pint of boiling milk, and let it simmer for five min- 
 utes. It must be stirred all the time, to prevent lumps 
 and keep it from burning. Add half a teaspoonful of
 
 186 A TEXT-BOOK OF NURSING 
 
 sugar, a pinch of salt, and one of cinnamon, if desired. 
 In place of the cinnamon, half a teaspoonful of brandy 
 may be used, or a dozen large raisins may be boiled in 
 the milk. If the raisins are preferred, they should be 
 stoned, and the sugar may be omitted. 
 
 Corn-starch or rice-flour gruel is made in the same 
 way. 
 
 20. Sago Milk. Wash a tablespoonful of pearl sago, 
 and soak it overnight in four of cold water. Put it in 
 a double kettle with a quart of milk, and boil till the 
 sago is nearly dissolved. Sweeten to taste, and serve 
 either hot or cold. 
 
 21. Treacle Possett. Bring a cupful of milk to the 
 boiling-point, and stir into it a tablespoonful of mo- 
 lasses. Let it boil up well, strain, and serve. 
 
 22. Milk and Albumin. Put into a clean quart 
 bottle a pint of milk, the whites of two eggs, and a 
 small pinch of salt. Cork, and shake hard for five 
 minutes. 
 
 23. Koumyss. Dissolve a third of a cake of com- 
 pressed yeast (Fleischmann's), or its equivalent of fluid 
 yeast, in a little warm not hot water. Take a quart 
 of milk fresh from the cow, or warmed to about blood- 
 heat, and add to it a tablespoonful of sugar and the 
 dissolved yeast. Put the mixture in beer bottles with 
 patent stoppers, fill to the neck, and let them stand for 
 twelve hours where you would put bread to rise that is, 
 at a temperature of 68 or 70. Then put the bottles on 
 ice, upside down, until wanted. Open cautiously over 
 a bowl. 
 
 24. Wine Whey. Heat half a pint of milk to the 
 boiling-point, and pour into it a wine-glass of sherry. 
 Stir once round the edge, and as soon as the curd sepa- 
 rates, remove from the fire and strain. Sweeten if de-
 
 FOOD AND ITS ADMINISTRATION 187 
 
 sired. The whey can be similarly separated by lemon 
 juice, vinegar, or rennet. With rennet whey, use salt 
 instead of sugar. 
 
 25. Mulled Wine. Into half a cup of boiling water 
 put two teaspoonfuls of broken stick cinnamon and 
 half a dozen whole cloves. Let them steep for ten min- 
 utes, and then strain. Beat together until very light 
 two eggs and two tablespoonfuls of sugar, and stir into 
 the spiced water. Pour into this, from a height, a cup- 
 ful of sweet wine, boiling hot. Pouring it several 
 times from one pitcher to another will make it light 
 and foamy. Serve hot. The wine should not be boiled 
 in tin. 
 
 26. Milk Punch. To half a pint of fresh milk add 
 two teaspoonfuls of sugar and an ounce of brandy or 
 sherry. Stir till the sugar is dissolved. 
 
 27. Eggnog. Beat up one egg with a tablespoon- 
 ful of sugar. Stir into this a cup of fresh milk, an 
 ounce of sherry, or half an ounce of brandy, and a little 
 nutmeg. 
 
 28. Hot Eggnog. Beat together the yolk of an egg 
 and a tablespoonful of sugar, and stir into a pint of 
 milk at the boiling-point. Add a tablespoonful of 
 brandy or whisky, and grate a little nutmeg over 
 the top. 
 
 29. Egg Water. Stir the whites of two eggs into 
 half a pint of ice-water, without beating, add enough 
 salt or sugar to make it palatable. Good for teething 
 children with diarrhoea. 
 
 30. Hot Milk and Water. Boiling water and fresh 
 milk, in equal parts, compose a drink highly recom- 
 mended in cases of exhaustion, as it is quickly absorbed 
 into the system with very little digestive effort. This 
 is also true of the egg broth above described.
 
 188 A TEXT-BOOK OP NURSING 
 
 31. Lemonade is best mixed with boiling water, 
 even if to be taken cold. Strain, sweeten to taste, and 
 garnish with a thin slice of the lemon cut from the 
 center before it is squeezed. 
 
 32. Tamarind Water is prepared by pouring boiling 
 water over preserved tamarinds, and setting aside to 
 cool. 
 
 33. Lime-juice may be mixed with cold water and 
 sweetened. All these make very refreshing drinks. 
 
 34. Honey-tea. Strained honey in hot water is 
 sometimes an acceptable beverage. 
 
 35. Lemonade with Egg. Beat one egg with two 
 tablespoonfuls of sugar until very light, then stir in 
 three tablespoonfuls of cold water, and the juice of a 
 small lemon. Fill the glass with pounded ice, and 
 drink through a straw. 
 
 36. Barley Water. Wash thoroughly two ounces of 
 pearl barley in cold water. Add two quarts of boil- 
 ing water and boil till reduced to one quart or 
 about two hours stirring frequently. Strain, add the 
 juice of a lemon and sweeten. For infants omit the 
 lemon. 
 
 37. Toast Water. Toast three slices of stale bread 
 to a very dark brown, but do not burn. Put into a 
 pitcher and pour over them a quart of boiling water. 
 Cover closely, and let it stand on ice until cold. Strain. 
 Good for nausea from diarrhoea. A little wine and 
 sugar may be added if desired. 
 
 38. Apple Water. Slice into a pitcher half a dozen 
 juicy sour apples. Add a tablespoonful of sugar, and 
 pour over them a quart of boiling water. Cover closely 
 until cold, then strain. Slightly laxative. 
 
 39. Gum-arabic Drink. Dissolve an ounce of gum- 
 arabic in a pint of boiling water, add two tablespoonfuls
 
 FOOD AND ITS ADMINISTRATION 189 
 
 of sugar, a wine-glass of sherry, and the juice of a large 
 lemon. Cool and add ice. 
 
 40. Flax-seed Lemonade. Into a pint of hot water 
 put two tablespoonfuls of sugar and three of whole 
 flax-seed. Steep for an hour, then strain, add the juice 
 of a lemon, and set on ice until required. 
 
 41. Potus Imperialis. To a quart of boiling water 
 add half an ounce of cream of tartar, the juice of one 
 lemon, and two tablespoonfuls of honey or sugar. Let 
 it stand on ice until cold. 
 
 42. Irish Moss. Wash thoroughly a handful of 
 Carrageen moss, pour over it two cups of boiling water, 
 and let it stand where it will keep hot, but not boil, for 
 two hours. Strain, add the juice of one lemon, and 
 sugar to taste. 
 
 Slippery elm may be used in the same way, a tea- 
 spoonful of the powder to each cup of boiling water. 
 
 43. Bran Tea. To a pint of wheat bran add a 
 quart of boiling water. Let it stand where it will 
 keep hot, but not boil, for an hour. Strain, and serve 
 with sugar and cream. This is palatable and nutri- 
 tious. 
 
 44. Corn Tea. Parch brown a cupful of dry sweet 
 corn, grind or pound it in a mortar. Pour over it two 
 cups of boiling water, and steep for a quarter of an 
 hour. This is light and nutritious. 
 
 45. Rice Coffee. Parch and grind like coffee half a 
 cupful of rice. Pour over it a quart of boiling water, 
 and let it stand where it will keep hot for a quarter of 
 an hour. Then strain, and add boiled milk and sugar. 
 This is nice for children. 
 
 46. Crust Coffee. Take a pint of crusts those of 
 Indian-bread are the best brown them well in a quick 
 oven, but do not let them burn; pour over them three
 
 190 A TEXT-BOOK OF NURSING 
 
 pints of boiling water, and steep for ten minutes. Serve 
 with cream. 
 
 47. Tea. Tea should be made in an earthen pot, 
 first rinsed with boiling water. Allow a teaspoonful 
 of tea to each half pint of water. Put in the tea, and 
 after letting it stand for a few moments in the steaming 
 pot, add the water, freshly boiling, and let it stand 
 where it will keep hot, but not boil, for from three to 
 five minutes. Long steeping extracts the injurious 
 tannin. 
 
 48. Coffee. Stir together two tablespoonfuls of 
 freshly ground coffee, four of cold water, and half an 
 egg. Pour upon them a pint of freshly boiling water, 
 and let them boil for five minutes. Stir down the 
 grounds, and let it stand where it will keep hot, but 
 not boil, for five minutes longer. In serving, put sugar 
 and cream in the cup first, and pour the coffee upon 
 them. 
 
 49. French Coffee. Some people prefer filtered 
 coffee to boiled. This is made in a French biggin, or 
 a Eussian coffee pot, in either of which the boiling 
 water percolates through the pulverized coffee. The 
 pot is to be set where is will keep hot, but not boil. 
 Black coffee is always made in this way. 
 
 50. Coffee and Egg. Boil together for five minutes 
 a tablespoonful of ground coffee, a quarter of an egg, 
 a quarter of a pint of milk, and a quarter of a pint of 
 boiling water. Beat an egg and four teaspoonfuls of 
 sugar together until stiff and light, and strain the boil- 
 ing coffee into it, stirring all the time. Add two table- 
 spoonfuls of hot cream. This is only to be given in 
 small quantities. 
 
 51. Chocolate. Scrape fine an ounce of Baker's 
 chocolate, add two tablespoonfuls of sugar and one
 
 FOOD AND ITS ADMINISTRATION 191 
 
 tablespoonful of hot water; stir over a hot fire for a 
 minute or two until it is smooth and perfectly dissolved, 
 then pour into it a pint of boiling milk, mix thoroughly 
 and serve at once. If allowed to boil after the chocolate 
 is added to the milk, it becomes oily, and loses flavor. 
 A teaspoonful of corn-starch, mixed with a little cold 
 water, and cooked in the milk before the chocolate is 
 added, will improve the texture and make it less liable 
 to curdle. 
 
 52. Cocoa is chocolate less some of the fats, and is 
 improved by a little boiling. 
 
 53. Eacahout is a mixture of chocolate with arrow- 
 root, rice-flour, etc. Directions for use come with both. 
 
 " They are as sick that surfeit with too much 
 As they that starve with nothing." 
 
 Shakespean.
 
 RECIPES
 
 RECIPES
 
 CHAPTER XII 
 
 " Talk health; the dreary, never-ending tale 
 Of mortal maladies is worn and stale. 
 You can not charm, or interest, or please 
 By harping on that minor chord, disease. 
 
 " Talk happiness ; the world is sad enough 
 Without your woes. No path is wholly rough ; 
 Look for the places that are smooth and clear, 
 And speak of those to rest the weary ear." 
 
 Ella Wheeler Wilcox. 
 
 THE human skeleton is composed of more than two 
 hundred different bones. These bones constitute the 
 framework of the body, and serve to protect the delicate 
 vital organs. There are three important cavities in the 
 body the skull, the chest, and the pelvis each wholly 
 or partly inclosed by bone, and held in position by the 
 spinal column. This itself forms a canal containing the 
 spinal cord, a continuation of the substance of the 
 brain. 
 
 The skull is divided into two parts: the cranium, 
 composed of eight, and the face, of fourteen bones, be- 
 sides those of the ears. The seams or lines of union of 
 these bones are called sutures. That between the two 
 parietal bones is the sagittal suture; that connecting 
 the parietals with the frontal is the coronal suture; 
 that between the occipital and the parietals, the lamb- 
 doidal. These are the most important ones. 
 
 The head rests upon the first of the spinal vertebrae, 
 194
 
 BONES 
 
 195 
 
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 TH TH IN <M TH TH O4 C W O TH <J O TH TH TH TH 
 
 aor.j
 
 196 A TEXT-BOOK OF NURSING 
 
 which is called the atlas; the one next to this is the 
 axis; these two allow the movements of the head in 
 every direction. The spine consists of thirty-three 
 bones, called cervical, dorsal, and lumbar vertebrae, ac- 
 cording to the position which they occupy. Those of 
 the different groups have differences also in shape, by 
 which they are recognizable. 
 
 From either side of the dorsal vertebras spring 
 twelve ribs, forming the framework of the thorax or 
 chest. The first seven are connected in front with the 
 sternum or breast-bone, and are called true ribs; the 
 lower five are distinguished as false ribs, three of them 
 being connected only with the costal cartilages in front, 
 and the last two having no attachment except to the 
 vertebrae. These are termed floating ribs. At the lower 
 extremity of the sternum is the ensiform cartilage. 
 Joined to the upper end of the sternum in front, and to 
 the scapula, or shoulder-blade, in the back, is the clavi- 
 cle or collar-bone ; also fitting into a cavity of the scap- 
 ula is the humerus, the largest bone of the arm. The 
 upper arm has but this one bone ; the forearm has two, 
 the ulna and the radius. The ulna is the larger. It 
 makes a perfect hinge-joint with the humerus. The 
 two prominences at the elbow are called respectively 
 the olecranon and the coronoid processes. The lower 
 end of the ulna articulates with the radius but does 
 not enter into the wrist-joint. This is formed by the 
 lower and larger extremity of the radius, articulating 
 with the eight small bones which make the carpus or 
 wrist. Besides these there are in the hand five meta- 
 carpal bones, forming the palm, and fourteen phalanges, 
 three in each finger and two in the thumb. 
 
 The back of the pelvic wall is formed by the sacrum. 
 This consists in early life of five distinct bones, which
 
 The skeleton. 
 
 14
 
 198 A TEXT-BOOK OP NURSING 
 
 later become fused into one. The coccyx, the extreme 
 end of the spinal column, is also formed by the union of 
 four small bones. The remaining walls of the pelvic 
 cavity are composed, on each side, of three bones, the 
 ilium, ischium, and pubis, uniting in adult life into one, 
 the os innominatum. 
 
 The lower extremity of the body has its bones ar- 
 ranged very much like those of the arm. The thigh- 
 bone or femur is the largest bone in the body. It has 
 a round head, which fits into a cup-like cavity of the os 
 innominatum, called the acetabulum; below this is a 
 narrow neck and two bony projections, the greater and 
 less trochanters. The lower end of the femur articu- 
 lates with the tibia, the larger bone of the leg. In front 
 of the knee-joint is a thick triangular bone, the patella 
 or knee-pan. Parallel with the tibia is a much smaller 
 bone, the fibula. The foot has three divisions : the 
 tarsus, having seven bones, the metatarsus, of five, and 
 fourteen phalanges, arranged like those of the hand. 
 
 The skull contains the brain and organs of special 
 sense; the thorax, the organs of circulation and respi- 
 ration ; while the lower part of the trunk sustains those 
 of digestion and reproduction. 
 
 The bones are composed of about two parts of min- 
 eral to one of animal matter. Lime is the main mineral 
 and gelatin the prodominant animal constituent. Each 
 bone is enveloped in a white fibrous membrane known 
 as the periosteum. This supplies nutrition to the bone. 
 At the joints, or articulations, the bones are covered 
 with a layer of smooth, somewhat elastic cartilage, and 
 furnished with a serous membrane which secretes a 
 lubricating fluid, the synovia. Bones increase in length 
 by the ossification of these layers of cartilage a new 
 layer being deposited as the older one hardens into
 
 FRACTURES 199 
 
 bone; this growth is more rapid at the lower ends of 
 the bones. Similarly they increase in thickness by the 
 continual conversion of the periosteum into osseus 
 structure. In youth the proportion of animal matter is 
 greater than in advanced life; in old age the bones, 
 lacking the gelatinous element, break more readily and 
 take longer to unite. Like the other organs of the body, 
 they are liable to various diseases and injuries. Soften- 
 ing of the bones mollities ossium results from an ab- 
 sence of the normal amount of mineral deposit. Peri- 
 ostitis inflammation of the periosteum occurs usu- 
 ally associated with an inflammatory condition of the 
 bone to which it belongs. Inflammation of the sub- 
 stance of the bone itself is known as osteitis. Caries 
 is ulceration of bone ; necrosis, death of the bone tissue 
 in mass. This is most common in the shafts of the long 
 bones. It is usually of traumatic origin, and always 
 due to defective nutrition of the bone. Inflammation 
 of the synovial membrane is called synovitis.* 
 
 Fractures are the most common injuries of bones. 
 A simple fracture is one in which the bone only is 
 divided. When there is also a wound of the soft parts, 
 by which the broken bone communicates with the outer 
 air, the fracture becomes compound. A flesh wound 
 existing together with a fracture does not render it 
 compound unless it leads down to the seat of fracture. 
 A multiple fracture is one in which the bone is broken 
 in two or more places. A comminuted fracture is one 
 in which the bone is broken into several small frag- 
 ments at the same point. A comminuted fracture may 
 be either simple or compound. A complicated fracture 
 is one in which some joint or cavity is involved in the 
 
 * Note that the termination itis always means inflammation.
 
 200 A TEXT-BOOK OP NURSING 
 
 injury. An impacted fracture is where one end of the 
 broken bone is driven forcibly into the other. In young 
 children, whose bones are soft enough to bend, we get 
 occasionally a partial fracture, of the convex side only, 
 not extending through the bone. This is also called an 
 incomplete or green-stick fracture. Fractures may be 
 transverse, longitudinal, or oblique in direction; the 
 majority are more or less oblique. A fracture is most 
 serious when there is great injury of the soft tissues, or 
 when a joint is involved. The nearer a large joint it 
 occurs the graver the prognosis. The signs of fracture 
 are pain, distortion, loss of function, or unnatural mo- 
 bility, and crepitus. Crepitus is the grating made by 
 rubbing together the ends of the broken bone. It can 
 not always be obtained, as the fracture may be impacted, 
 or some portion of muscle intervene. 
 
 Some special fractures give special symptoms. A 
 fractured spine is indicated by loss of sensation and 
 power of motion below the point of injury, paralysis 
 following in consequence of pressure upon or lacera- 
 tion of the spinal cord. Fracture of the spine above 
 the fourth cervical vertebra, as a rule, causes instant 
 death. With fractured ribs, the patient will complain 
 of sharp pain when he takes a deep breath or coughs, 
 and will often spit blood. The danger from fracture 
 of the ribs or sternum is of injury to the heart, lungs, 
 or large blood-vessels by the broken ends. Fracture of 
 the sternum is rare. Ecchymosis of the eye or behind 
 the ear, or the escape of fluid through the ear, may be 
 a symptom of fracture of the base of the skull. The 
 patient may or may not be insensible. Fracture of the 
 clavicle is one of the most common. Those known as 
 Pott's and Colles's are also frequently met. Pott's 
 fracture is of the lower end of the fibula, usually com-
 
 FRACTURES 201 
 
 plicated with dislocation of the ankle-joint, and frac- 
 ture of the inner jnalleolus. Colles's fracture is of the 
 lower end of the radius, and results from falling upon 
 the hand. Barton's fracture extends obliquely into the 
 wrist-joint, occasioning more inflammation and greater 
 impairment of motion than does the Colles's. 
 
 The process of repair of broken bones is, although 
 slower, essentially the same as that of the soft tissues. 
 For the first two or three days after the injury blood is 
 effused around the broken ends. This is gradually re- 
 absorbed; and during the second week a quantity of 
 lymph is thrown out between and around the fragments, 
 which by degrees hardens, gluing them together. This 
 new bone material is called callus; that between the 
 broken ends, intermediate callus; that surrounding 
 them, provisional callus. When the fragments can be 
 maintained in complete apposition there will be no pro- 
 visional callus; it occurs only where there is mobility 
 of the broken ends. You will always find it in the ribs, 
 which can not be kept perfectly at rest; seldom in the 
 patella, the olecranon, or the cranium. After a frac- 
 ture rs solidly mended the provisional callus is to a 
 large extent reabsorbed. In four or five weeks the cal- 
 lus will usually be hard enough to keep the bones in 
 place, though it is not firm enough to leave unsupported 
 tinder six or eight weeks, and only becomes converted 
 into solid bone after the lapse of months. Small bones 
 unite more quickly than large ones. Cartilage, once 
 destroyed, is not repaired. 
 
 The treatment of fractures consists in putting the 
 fragments in proper position, and keeping them there 
 till the callus has had time to form and harden. For 
 this purpose splints are used, made of wood, tin, paste- 
 board, gutta-percha, leather, felt, or anything that will
 
 202 A TEXT-BOOK OP NURSING 
 
 hold the bone accurately and firmly in place. A splint 
 must be long enough to include both the joints between 
 which the fracture is situated. It needs to be well 
 padded, so that all prominences shall be protected from 
 pressure. A gutta-percha splint is cut an inch larger 
 in every direction than the size required, as it shrinks 
 upon soaking in boiling water, in which it has to be im- 
 mersed to soften it. It is then molded to fit the part, 
 and left on until cold, when it will have hardened into 
 the desired shape. It should afterward be lined with 
 chamois-skin, and perforated all over for ventilation. 
 Sole-leather may be similarly softened and fitted. It 
 does not interfere with the action of the skin so much 
 as the gutta-percha. 
 
 In place of such splints are frequently used bandages 
 saturated with starch, glue, or plaster of Paris, which 
 harden in drying, and hold immovable the part to 
 which they are applied. These, when thoroughly stiff- 
 ened, may be split into two sections, and reapplied as 
 a molded splint, held in place by additional bandages. 
 This makes the limb accessible for inspection and obvi- 
 ates the danger of too much shrinkage. 
 
 Plaster-of-Paris bandages are prepared by rubbing 
 into the ordinary coarse brown gauze and muslin rollers 
 as much of the dry plaster as they will carry. They are 
 then rerolled, and, if not to be at once used, kept in an 
 air-tight tin box. Soft flannel bandages are first put on 
 the broken limb, and over these those containing the 
 plaster, having been wrung out in water. The addition 
 of salt to the water will cause the plaster to set more 
 rapidly. It usually takes about twelve hours. Another 
 way is to mix plaster of Paris with water to the con- 
 sistence of thick cream, and dip in the mixture folds 
 of sheet lint or old soft cloths. Apply with a roller
 
 FRACTURES 203' 
 
 bandage. Starch bandages are put on in the same way, 
 strips of wet pasteboard being included for greater 
 firmness. Starch takes two or three days to dry thor- 
 oughly. A " water-glass " splint is made by saturating 
 white-gauze bandages with a solution of silicate of soda, 
 and applying several layers of them. Those on the 
 outside should be cut with a selvage. 
 
 With either of these, the broken limb must be kept 
 perfectly still until the bandages are firm. Sand-bags 
 are used to keep them in position ; if they are heated it 
 will hasten the drying. The bags should not be more 
 than three quarters full, the sand fine and well dried, 
 and the covering of texture close enough to keep it 
 from sifting through. Chamois-skin is an excellent 
 material for this purpose. If a plaster splint is where 
 it is likely to be soiled, it is well to brush over the sur- 
 face, after it is dry, with Damar varnish, as it can 
 then be washed. When a plaster splint is to be cut off, 
 it will facilitate the process to moisten it with dilute 
 hydrochloric acid along the proposed line of incision. 
 It may be necessary also to cut openings for the escape 
 of secretions from a wound, in which case the position 
 should be accurately noted before the plaster is applied. 
 But for a compound fracture a fracture-box is usually 
 preferred, as the wound will be more accessible. It 
 must be well padded with bran or jute. The sides of 
 the box to which the limb is bandaged answer the pur- 
 poses of a splint. 
 
 Before applying any apparatus the part must be 
 carefully washed and dried, and it is well to dust it over 
 with fine starch or toilet-powder to absorb perspiration. 
 A fractured limb is extended until its length, measured 
 from fixed points, matches the corresponding one. If 
 this extension can be kept up otherwise, splints will not
 
 204 A TEXT-BOOK OP NURSING 
 
 be required. With Buck's extension, for thigh fracture, 
 the leg is bandaged securely to a sliding frame, and kept 
 in position by a heavy weight attached to the foot and 
 leg by adhesive straps. The foot of the bed is ele- 
 vated, so that the weight of the body affords counter- 
 extension. 
 
 In lifting a broken limb, support the parts both 
 above and below the point of fracture, being careful 
 neither to shorten nor twist it. By unskillful handling 
 a simple fracture may easily be converted into a com- 
 pound and much more serious one. 
 
 A dislocation is displacement of one of the bony 
 structures of a joint from the other. It may be, like a 
 fracture, either simple or compound, or complicated 
 with some other injury. The principal signs of dis- 
 location are pain, impairment of motion, alteration in 
 the length of the limb and in the direction of its axis. 
 It is often difficult to distinguish it from a fracture. 
 With a fracture only, crepitus may usually be obtained, 
 the deformity is easily reduced, but returns as soon as 
 the extension is discontinued, the pain continues after 
 reduction, and the limb is never abnormally long. 
 Where a dislocation exists alone, crepitus is rare, the 
 deformity is not easily reducible, but when reduced is 
 not likely to return at once, the pain is always relieved 
 by reduction, and lengthening may exist. A dislocation 
 is always accompanied by more or less laceration of the 
 ligaments and contusion of the adjacent soft tissues. 
 Chloroform or ether is usually given to secure muscular 
 relaxation, and reduction is then effected either by 
 gradual manipulation or forcible extension. 
 
 Laceration or stretching of the ligaments, with 
 twisting of the joint, short of displacement, consti- 
 tutes a sprain. Such an injury is very painful, and it
 
 BANDAGING 205 
 
 often takes longer to recover from it than from a frac- 
 ture. The tendency to inflammation is discouraged by 
 entire rest, with elevation of the sprained joint. Hot 
 applications afford much relief. After the first forty- 
 eight hours, it is customary to support it by bandaging 
 or strapping, and to recommend that it be used as much 
 as possible, to prevent stiffening. 
 
 Abnormal rigidity of a joint, resulting from injury, 
 disease, or disuse, is known as anchylosis. Massage is 
 a helpful treatment. 
 
 Bandages are used to fix dressings in place, to give 
 support, apply pressure, or prevent motion. Those in 
 general use are the roller, single or double, the many- 
 tailed, and the triangular bandages. Roller bandages are 
 strips of muslin, flannel, or gauze, from half an inch to 
 eight inches wide, and from three to twelve yards long, 
 evenly and tightly rolled upon themselves. If made 
 of any material that will not tear evenly, they must 
 be cut by a thread, to insure regularity of width and 
 avoid fraying of the edges. The selvage and all loose 
 threads must be trimmed off. If a bandage is to be 
 wet, it is best made of something that has been washed, 
 or inconvenience may arise from its shrinkage. An 
 old cotton sheet is good material. To piece the strips, 
 lay the two ends flat on each other, overlapping for an 
 inch, and baste together all four sides, leaving raw 
 edges. They must be rolled as tightly as possible, 
 either on a regular bandage roller, or by hand. To roll 
 a bandage by hand, fold the end of the strip over upon 
 itself until you have a little roll stiff enough to keep 
 its shape. Hold this perpendicularly between the thumb 
 and fingers of the right hand, letting the free end of 
 the bandage pass over the back of the left hand between 
 the forefinger and thumb. The right hand should now
 
 206 A TEXT-BOOK OF NURSING 
 
 be kept perfectly still, while the fingers of the left grasp 
 the side of the roll; a movement of the left wrist 
 rotates it, and the left thumb and forefinger regulate 
 the tension. A double-headed roller is made by rolling 
 a bandage from both ends toward the center, or by 
 basting together two single rollers. 
 
 To put on bandages neatly and well is a good deal 
 of an art, and one for which no exact directions can 
 be given. There are a few general principles to be 
 borne in mind, and then adaptations are to be made 
 
 in each case to the shape 
 of the part over which the 
 bandage is to be applied, 
 and to the object in view. 
 A well-fitting bandage must 
 lie smoothly, without wrin- 
 kles, making an even and 
 not too severe pressure. It 
 must not be loose enough to 
 
 To roll a bandage." sli P> nor ti g ht enou g h to 
 
 be painful or to impede the 
 
 circulation. A tight bandage can be loosened a little 
 without removing it, by cutting half through each turn ; 
 but if this does not give sufficient relief it must be 
 taken entirely off. Inexperienced bandagers are very 
 apt to make them too tight in the effort to avoid 
 wrinkles. 
 
 In putting on a roller bandage, unwind no faster 
 than is necessary, keeping the roll close to the body. 
 In taking one off, roll or gather it up in the hand as 
 fast as you unwind, keeping it in a compact form. For 
 bandaging fingers and toes, a roller half or three quar- 
 ters of an inch wide is used, for the hand an inch, for 
 the head or arm two or two and a half inches, for the
 
 BANDAGING 
 
 207 
 
 legs two and a half and three inches, and for the body 
 six or eight. 
 
 Nearly all kinds of bandaging are variations and 
 combinations of two simple forms, the spiral and the 
 figure-of-eight. A 
 simple spiral band- 
 age goes round and 
 round, each turn over- 
 lapping the one be- 
 fore it by one third 
 its breadth. This can 
 be used over a nearly 
 straight part, as a 
 finger. To accommo- 
 date it to the shape 
 of a limb, reverses 
 have to be made. This 
 is done by placing a 
 finger on the lower 
 edge to hold it firmly, 
 and turning the band- 
 age downward over itself at an oblique angle. This 
 brings it the other side out, and changes its direction. 
 These turns can be made as often as needed, whenever 
 the bandage will not otherwise fit smoothly. They 
 should not be made over a prominence of bone, but are 
 best at the back, or on the outer side of the limb. The 
 figure-of-eight bandage is more generally used than the 
 spiral, as it fits better, and is, when familiar, more easy 
 of application. It is wound alternately above and be- 
 low some central point, over which the roll is carried 
 obliquely. As in the spiral, each turn covers two thirds 
 of the preceding. The angles where the folds cross 
 should be equidistant, and should succeed each other 
 
 To reverse a bandage.
 
 208 
 
 A TEXT-BOOK OF NURSING 
 
 in a straight line. The figure-of-eight needs fewer re- 
 verses than the spiral bandage, but they are to be em- 
 ployed as occasion requires. The spiral and the figure- 
 of-eight may be used singly or in combination. 
 
 In bandaging any limb, begin always at the extrem- 
 ity, and work toward the center of the body from left to 
 right. Hold the roller with the outer side next the 
 limb, until reverses are called for. 
 
 To cover a foot, start the free end of the bandage at 
 the instep, and make a turn around the base of the toes. 
 Then carry the bandage diagonally over the foot, across 
 the point of the heel, and back from the other side till 
 it coincides with the first turn. Cover this, and carry 
 
 a second turn around the^ 
 heel, half an inch higher 
 than the first; continue to 
 make alternate turns un- 
 der the sole and behind 
 the heel, crossing over the 
 instep, until the entire 
 foot is covered. Finish 
 with a couple of circular 
 turns around the ankle, or 
 continue up the leg. For 
 covering the leg, the spiral 
 bandage may be used with 
 a succession of anterior 
 reverses, or a continuous 
 figure-of-eight. When the 
 bandage is completed, the 
 
 effect to the eye will be the same whichever method is 
 
 adopted, but the latter will be far more secure, and will 
 
 make more even pressure. It is always to be preferred. 
 
 In finishing off a bandage, make one or two straight
 
 BANDAGING 209 
 
 turns, fold under the end and pin it, or split the last 
 quarter of a yard through the middle, wind the ends in 
 opposite directions around the limb, and tie them in a 
 bow. To apply a bandage over a movable joint, as a 
 knee, make first a circular turn directly over the center 
 of the joint, then apply the figure-of-eight alternately 
 
 Mode of application of a hinge-joint bandage. 
 
 above and below it, close enough to have the edges meet 
 and entirely cover the first turn. This will allow some 
 freedom of motion without displacing the bandage. 
 
 A bandage to cover the groin is commenced with 
 two turns about the thigh; the roller is then carried 
 diagonally to the opposite hip, round the waist, and 
 downward, crossing the first oblique fold in front of the 
 thigh. Another turn about the thigh follows in the 
 same direction as the first, and the same course is re- 
 peated, leaving proper spaces and making a series of fig- 
 ures-of-eight, till the bandage is carried sufficiently far.
 
 210 A TEXT-BOOK OF NURSING 
 
 A bandage of this form, a figure-of-eight which includes 
 two distinct parts of the body, is called a spica. This 
 
 may be used either by itself 
 or as a continuation of the 
 leg bandage. 
 
 In bandaging over a 
 splint, where great firmness 
 is required, the best result 
 is obtained by alternating 
 figures-of-eight with circular 
 turns, which keep them from 
 slipping. This makes a very 
 secure bandage, but not a 
 good one to use directly upon 
 the flesh, as the pressure is unequal. 
 
 To bandage a hand, begin at the tip 
 of the first finger, and cover it by a 
 succession of close spirals or figures-of- 
 eight to its base. Then make a turn 
 around the wrist to keep these from 
 slipping, and return to the root of the 
 second finger. Lead the bandage by one 
 or two spirals to the tip of this, and 
 then proceed down it, as upon the first 
 finger, concluding with another turn 
 about the wrist. Cover each finger suc- 
 cessively in the same way. Then take 
 Spica on the thigh, a slightly wider bandage, start it at the 
 
 with foot and b k f th ^ d d wind it armmd 
 leg bandage. 
 
 the base of the fingers. Carry it ob- 
 liquely across the back of the hand, around the wrist, 
 back to the further side, and again around the palm. 
 Continue these turns alternately till you have a line of 
 crosses straight down the back of the hand, and the palm
 
 BANDAGING 211 
 
 is completely covered. The thumb is finally to be dressed 
 by making alternate turns over it and around the wrist. 
 
 To bandage fingers. To cover the palm. 
 
 This is sometimes called the spica for the thumb. Before 
 covering the palm of the hand, put a little absorbent cot- 
 ton in it. Do the same at the flexures of any large joint 
 that is to be covered by a bandage, 
 to make it fit better, to absorb per- 
 spiration, and prevent chafing. This 
 is especially important at the axilla. 
 A spica for the shoulder may be 
 put on in much the same way as 
 that for the thigh, beginning with 
 one or two turns around the arm, 
 carrying the bandage over the point 
 of the shoulder, across the back, un- 
 der the other arm, and over the 
 chest to the shoulder again. Make 
 another turn about the arm, and re- 
 peat three or four times as required. Spica for the thumb.
 
 212 
 
 A TEXT-BOOK OP NURSING 
 
 Single shoulder spica. 
 
 A double spica for the shoulders, which includes 
 the entire chest, is commenced like the single spica, but 
 
 the second turn across the 
 back, instead of following 
 in the line of the first, is 
 carried down at a sharper 
 angle, and brought around 
 the waist. It is then car- 
 ried again diagonally up 
 the back to the opposite 
 shoulder. Make two or 
 three turns about this arm, 
 as previously around the 
 other, then carry the band- 
 age down across the chest, 
 around the waist, and up 
 across the chest again to the shoulder from which 
 it started. Wind it again about the arm, carry it 
 obliquely down the 
 back, around the 
 waist, etc., leaving the 
 usual spaces, and fol- 
 lowing the direction 
 of the previous turns, 
 till the entire chest is 
 covered. There should 
 then be a line of 
 crosses in the center 
 of the front, in the 
 back, and down each 
 shoulder. 
 
 An admirable band- 
 age for the arm and shoulder, in case of clavicle frac- 
 ture, devised by the late Dr. C. H. Wilkin, of New 
 
 Double shoulder spica.
 
 BANDAGING 
 
 213 
 
 York, is applied as follows: Place the arm of the in- 
 jured side on the opposite breast. Start the bandage 
 in the middle of the back, between the shoulder-blades, 
 and bring it over the well shoulder near the neck down 
 to the outside of the injured arm just above the elbow. 
 Then bring it under the elbow, leaving the tip exposed, 
 and up over the injured shoulder to the starting-point, 
 where it is pinned to the first end of the roller. Con- 
 tinue downward across the back, and round the body 
 in a straight line, over 
 the injured arm, just 
 above the elbow - tip. 
 Carry it round twice in 
 the same place, and the 
 second time cross the 
 back upward to the well 
 shoulder, and down again 
 to the outside of the in- 
 jured arm, and around 
 the elbow as before, leav- 
 ing the proper spaces. 
 This is the best of the 
 
 Wilkin's clavicle bandage. 
 
 numerous bandages in use for fractures of the clavicle. 
 Before applying any of them, a thick wedge which 
 may be made of a folded towel is placed close under 
 the arm so as to throw it slightly outward, and bring 
 the fractured ends into proper position. 
 
 The roller bandage may be so applied as to fur- 
 nish support to one or both breasts, being put on either 
 as a figure-of-eight passing around the neck or as 
 a spica including the shoulders. Firm and even pres- 
 sure can be made upon the breasts by a single broad 
 band passing around them, the spaces between and 
 
 at either side being first filled to a level with cot- 
 15
 
 214 
 
 A TEXT-BOOK OF NURSING 
 
 Breast bandage. 
 
 ton. Straps over the shoulders will help to keep this 
 
 in place. 
 
 The figure-of-eight for the head is one of the most 
 
 useful bandages for re- 
 taining dressings upon 
 the scalp. This is put 
 on as follows: Start the 
 bandage over the ear, 
 holding the roll toward 
 the face. Carry it across 
 the eyebrows, then 
 around the back of the 
 head as high as possi- 
 ble. Continue to wind 
 it round, making each 
 turn a little higher in 
 
 front and a little lower in the back until you have cov- 
 ered as much surface as is required. Another is the 
 
 Capelline. This is put on by a 
 
 double roller, one end of which 
 
 needs to be a third larger than 
 
 the other. Stand behind the 
 
 patient, and, taking the smaller 
 
 roll in the right and the other 
 
 in the left hand, begin low on 
 
 the forehead and carry them 
 
 round the head as far down on 
 
 the occiput as possible. Then 
 
 transfer the bandage in the left 
 
 hand to the right, and continue 
 
 it round, while the other is 
 
 folded over at right angles with 
 
 it, and brought across the top of the head to the front 
 
 in the left hand. Here it meets the other and crosses 
 
 Figure-of-eight on head.
 
 BANDAGING 
 
 215 
 
 it, again running backward, and overlapping the former 
 folds. These turns are continued until the whole head 
 is covered, one bandage going 
 round and round it and the 
 other back and forth across it. 
 All the folds leading from the 
 front of the head to the back 
 should be on the left of the 
 middle, while those leading to- 
 ward the front should be on 
 the right. Finish with one or 
 two extra circular turns. The 
 head may be partially or en- 
 tirely covered by a single 
 roller, making alternately cir- 
 
 Capelline. 
 
 cular and oblique turns, and pinned at the angles. 
 
 To bandage a stump after amputation, either a 
 single or a double roller may be used in much the 
 same way as in bandaging the 
 head, beginning at some dis- 
 tance from the end, making 
 turns back and forth over it, 
 and holding them firmly by 
 circular ones. 
 
 The figure-of-eight may be 
 so applied as to cover the eye, 
 and is often so used. Bandages 
 for the eye should always be 
 light. After the operation for 
 cataract, a single straight strip 
 of muslin is used, furnished 
 'with tapes to tie behind. 
 
 When it is important to avoid motion of the part to 
 be covered, a "many-tailed" bandage may be used. 
 
 Cataract bandage.
 
 216 
 
 A TEXT-BOOK OF NURSING 
 
 This consists of a piece of muslin torn into strips from 
 each side to within an inch or two of the center, which 
 . is left entire. Apply this to the back of the limb, an<J, 
 beginning at the bottom, fold the strips from either 
 side alternately around it, giving them an upward 
 
 direction, and mak- 
 ing them cross each 
 other in front. The 
 bandage of Sculte- 
 tus is an improve- 
 ment upon this. To 
 _______ prepare it, take a 
 
 Many-tailed bandage. gtr jp fa e l en gth O f 
 
 the part to be bandaged, and sew across it at right an- 
 gles other strips overlapping each other by two thirds 
 their width. Without turning this round, lay it on a 
 board, to keep it smooth, and slide it under the limb; 
 begin at the bottom, and fold the strips one after an- 
 other in a slanting direction over it. The strips from 
 opposite sides 
 should cross in 
 front and go half- 
 way round again. 
 This bandage can 
 be applied with 
 
 Bandage of Scultetus. 
 
 very little disturb- 
 ance to the patient, 
 the limb having 
 only to be slightly 
 lifted to slip the board under and again to remove it. 
 The following form may be used after ovariotomy and 
 other abdominal operations. Take nine strips of flan- 
 nel, each four inches wide and one yard and a half long. 
 Place two of these lengthwise on a table at a distance
 
 BANDAGING 
 
 217 
 
 of six inches apart. Sew the other seven across them, 
 beginning at the top and allowing each to overlap the 
 one above it by a little more than half. Pass the band- 
 age under the body, fold the cross strips over the ab- 
 domen from below upward, then bring the free ends of 
 the vertical strips be- 
 tween the thighs, and 
 pin them, one on each 
 side to the front. These 
 will keep the bandage 
 from slipping up or 
 wrinkling under the 
 back. This arrange- 
 ment has the advantage 
 of allowing the wound 
 
 T bandage. 
 
 to be dressed without 
 
 moving the patient. It 
 
 is sometimes used as a substitute for the ordinary 
 
 binder after confinement. Other modifications of the 
 
 many-tailed bandage are made to fit different parts of 
 
 the body. 
 
 The T bandage is constructed on the same plan, 
 but consists of two pieces only, at right angles to each 
 
 other. Its chief 
 use is to retain 
 dressings upon 
 the perinaeum. 
 
 A four-tailed 
 
 bandage is made by splitting a strip of muslin at each 
 end to within a few inches of the center. Such a one 
 may be used to keep dressings on or gives light sup- 
 port to the knee. Place the center over the patella, 
 carry the tails under the knee, cross them so that the 
 lower ones will come above the joint, and the others 
 
 Four-tailed bandage.
 
 218 
 
 A TEXT-BOOK OP NURSING 
 
 below, bring them round, and tie in front, two above 
 
 and two below the knee. The same bandage may be so 
 adjusted as to support one breast, the 
 center being placed under it, the two 
 lower tails meeting over the opposite 
 shoulder, while the upper ones, cross- 
 ing them, join under the arm. 
 
 For the jaw, take a strip a yard 
 long and three inches wide, make a slit 
 of three inches in the center, and split 
 the ends to within two inches of it. 
 Let the chin rest in this slit, carry the 
 two lower halves up in front of the ears, 
 and tie them together on top of the 
 head, while the upper ends are carried 
 back below the ears and tied together 
 behind. Finally, bring these ends ver- 
 Four-tailed band- tically upward, and knot them again 
 age on knee. j n ^ o the corresponding ones from above. 
 Eetractors are wide bandages having two or three 
 
 tails, slit at one end only, used during amputations to 
 
 keep the soft parts out 
 
 of the way while the 
 
 bone is being sawed. 
 These are only a 
 
 few of the many ways 
 
 in which the roller and 
 
 the many-tailed band- 
 
 ages may be used. The 
 
 triangular bandage can 
 
 also be applied in many 
 
 different forms, and 
 
 can anywhere be pro- 
 
 vided by folding or Cut- 
 
 Four-tailed breast bandage.
 
 BANDAGING 
 
 219 
 
 o 
 
 ting a large handkerchief diagonally. On the head, it 
 forms the covering known as a shawl cap. Place the 
 center in the middle of the forehead, let the ends cross 
 low down at the back of the head, catching in the apex 
 of the triangle, and 
 bring them round 
 again to be tied in 
 front. In an exact- 
 ly similar way it 
 may be used to re- 
 tain the dressing 
 on a stump. To 
 keep dressings in Ketractors. 
 
 the axilla, fold over the rectangular corner of the tri- 
 angle, place the center under the arm, cross the ends 
 over the shoulder above, and bring them down, one 
 across the chest and one across the back, to be tied 
 together under the opposite arm. 
 
 It may be applied as a sling to the upper extremity 
 in three ways. If the fore- 
 arm is injured, its whole 
 extent should be supported 
 equally, including the el- 
 bow. Carry the outer end 
 of the sling around the neck, 
 on the side to which the in- 
 jured arm belongs, and the 
 end between the hand and 
 the chest around the other 
 side, tying them at the back. 
 If the injury is of the up- 
 per arm, the sling should 
 
 support the wrist only, making no pressure on the 
 elbow. Turn the hand with the palm toward the chest, 
 
 Shawl cap.
 
 220 
 
 A TEXT-BOOK OF NURSING 
 
 and support it higher than the elbow. Cross the ends 
 in the opposite direction from that above described. 
 
 Sling for forearm. 
 
 With a fractured clavicle or scapula, the front of the 
 sling should bind the elbow well forward, and cover the 
 hand, crossing upon the opposite shoulder the other 
 
 Sling to support upper arm.
 
 BANDAGING 
 
 221 
 
 end, brought up obliquely across the back, and tied with 
 it under the sound arm. A foot may be slung by a wide 
 bandage passing around the neck. 
 
 Rubber bandages are most used to reduce or prevent 
 swelling. They should be put on without reverses, and 
 special care is needed to avoid getting them too tight. 
 Elastic stockings are used for the same purpose, usually 
 in case of varicose veins. 
 
 Another means of affording support, or protection, 
 to a limb, or other part, is by strapping with adhesive 
 plaster. Cut the strips in the direction of the selvage, 
 
 Sling for fractured clavicle. 
 
 which must be taken off. Warm by holding the plain 
 side over the flame of a spirit lamp, or on a bottle of 
 hot water. If it is to be applied over a very uneven 
 surface, immerse it in hot water and press it gently on 
 with a cloth. For strapping a leg, cut the strips an inch 
 and a half wide, and long enough to lap over six inches 
 after passing around the limb. The hair should first be 
 shaved off. Stand in front of the patient, and apply
 
 222 A TEXT-BOOK OF NURSING 
 
 the middle of the strap to the back of the leg; bring 
 the ends around and cross them in front, giving them 
 an upward direction, like the sections of a many-tailed 
 bandage. The next strip is put on a little higher, over- 
 lapping the first by a third, and so on, as far as required. 
 For joints, the strapping should extend for some dis- 
 tance above and below, and the plaster is best spread 
 on leather. 
 
 In case of fractured ribs, or whenever it is desired 
 to limit the movements of the chest, strapping is some- 
 times employed in place of bandaging. It has an ad- 
 vantage in that it can be applied to one side alone. 
 
 Adhesive plaster can now be procured already pre- 
 pared for use, wound upon metal spools, a much more 
 convenient form. 
 
 "Habit is a cable; we weave a thread of it each day, and it 
 becomes so strong we can not break it." Horace Mann.
 
 CHAPTER XIII 
 
 " Learning anew the use of soldiership, 
 Self-abnegation, freedom from all fear, 
 Loyalty to the life's end." 
 
 Robert Browning. 
 
 AMONG the responsibilities which have been men- 
 tioned as pertaining to the nurse, there is none of 
 greater gravity than the prevention of contagion. The 
 atmosphere is everywhere more or less laden with the 
 minute organisms known as bacteria or microbes. 
 These are the lowest forms of vegetable life. 
 
 An individual bacterium is a single cell of colorless 
 protoplasm without a nucleus, either spherical, cocco, 
 or in the form of straight rods, bacilli. They multiply 
 very rapidly, either by fission or by the formation of 
 spores. Moisture is essential to their growth; dryness 
 holds them quiescent. Freezing does not injure them, 
 but heat and light are destructive to them. The spores 
 have more persistent vitality than their parent organ- 
 isms. Microbes are not all of an infectious nature, but 
 among them are the germs of various diseases. Their 
 chief function is to disintegrate and destroy dead ani- 
 mal and vegetable matter. In the course of their work 
 certain highly poisonous chemical products are evolved, 
 known as ptomaines, or toxins. 
 
 One class of pathogenic bacteria produces inflam- 
 mation and suppuration in a wound. These will be 
 further considered when we take up the subject of sur- 
 gical nursing.
 
 224: A TEXT-BOOK OF NURSING 
 
 Infectious diseases are propagated by the agency of 
 such living particles, given off from the body of the 
 sick, and conveying the specific poison. They may lie 
 dormant for a time, but under suitable conditions de- 
 velop and multiply, reproducing the original disease. 
 In some cases the conditions of development are found 
 within the body, and the disease can be directly trans- 
 mitted from one person to another, while in others the 
 germ only originates in the body, and requires to be 
 developed outside before it becomes infectious. Of the 
 latter class are typhoid, yellow fever, cholera, dysen- 
 tery, and the plague, while all the other diseases com- 
 monly recognized as infectious are contagious as well 
 that is, capable of direct transmission. They are all 
 caused by the presence of specific bacteria in the tis- 
 sues. All contagious diseases are infectious, but all 
 infectious diseases are not contagious. The latter 
 term is applied only to those which may be transmitted 
 from a sick to a well person by direct contact, while 
 those which spread indirectly through food, water, soil, 
 etc., are called infectious. Miasmatic diseases, of which 
 malaria is a typical example, result from the entrance 
 of infectious agents from without, and can not always 
 be traced directly or indirectly to another case of the 
 same kind. f 
 
 After exposure to contagion, some time is required 
 for the development of the infectious germs before they 
 actively manifest themselves. This interval, during 
 which the poison remains latent, is known as the period 
 of incubation. It varies in different diseases, and even 
 in different cases of the same disease, though each has 
 its own characteristic type and mode of development. 
 The germs of small-pox or scarlet fever may be carried 
 about indefinitely, or lie hidden in a room or in clothes
 
 CONTAGION AND DISINFECTION 225 
 
 for months, and then under suitable conditions mani- 
 fest the greatest virulence. 
 
 Diseases which attack many people at the same time 
 are termed epidemic; those confined to particular local- 
 ities are endemic. Sporadic cases are such as occur 
 singly, and independently of any recognized infectious 
 influence. 
 
 Disinfectants are such substances as act upon the 
 specific contagia of communicable disease, and destroy 
 them, or render them inert. They are to be carefully 
 distinguished from antiseptics, preventives of decompo- 
 sition, and from deodorants, which merely subdue dis- 
 agreeable smells. Some of the latter may be useful in 
 absorbing deleterious gases, but they have no effect 
 upon the solid particles which convey infection. 
 
 Abundant oxygen is the best disinfectant; it decom- 
 poses the septic germs, as it does all other organisms. 
 Boiling for half an hour will destroy the activity of all 
 known disease germs, though in some cases their spores 
 have a greater resisting power. It is believed, how- 
 ever, that exposure to steam at a temperature of 230 
 F. will be fatal to these also. Dry heat is less effec- 
 tive than moist, therefore steaming is surer than bak- 
 ing. For this purpose especially made steam sterilizers 
 are used, or for small articles the ordinary steamer 
 used for cooking, tightly closed, will answer equally 
 well. Fifteen minutes over vigorously boiling water 
 will destroy whatever pathogenic germs may be shut 
 up in it. In large establishments, steam under pres- 
 sure is used in a closed chamber, giving a still higher 
 temperature. 
 
 Whenever any directly communicable disease is 
 found to exist, the first thing to be done is to isolate, as 
 completely as possible, the patient and his attendants.
 
 226 A TEXT-BOOK OP NURSING 
 
 There should be two nurses for every such case, that 
 each may get the daily open-air exercise which is more 
 than ever important, and neither be obliged to sleep in 
 the infected room. They should avoid contact with all 
 outsiders as much as possible, and always change their 
 clothes upon going out. The hair, which can not be 
 changed, should be covered with a close cap. Nothing 
 should be worn in the room which may not afterward 
 be washed or destroyed. 
 
 The directions given for the arrangement of a sick- 
 room apply with the greatest force in these cases. All 
 superfluous things, particularly such as can not be 
 washed, must be taken out of the room before the pa- 
 tient is put in it. After he is once quarantined, every 
 article carried out of the room must be disinfected. A 
 set of dishes should be kept for his exclusive use, and 
 washed by the nurse. The bedding, clothing, etc., must 
 not be sent to the general laundry, but washed by them- 
 selves after being well soaked in some disinfecting solu- 
 tion. For any minor dressings, and in the place of 
 handkerchiefs when there is a discharge from the 
 throat or nose, use old soft cloths that can be imme- 
 diately burned. All excrementitious and vomited mat- 
 ter must be disinfected with the greatest care. 
 
 There is nothing small enough to be careless about. 
 Even the broom which sweeps the floor should not be 
 used again elsewhere. Do not let the air blow from the 
 sick-room into the rest of the house any more than can 
 not be avoided. It helps to keep the air pure to hang 
 about the room cloths kept wet with some disinfectant. 
 Over the doorway may be hung a sheet similarly damp- 
 ened. This has at least an excellent moral effect, and 
 moral influences are not without value in dealing with 
 contagion. While neglecting no possible precaution,
 
 CONTAGION AND DISINFECTION 227 
 
 try not to create unnecessary alarm. People afraid of 
 infection are predisposed to it by acquiring a nervous 
 condition which renders them doubly susceptible. Yet 
 the danger is not to be underrated, and insufficient pre- 
 cautions may actually be worse than none, giving an 
 unfounded sense of security. 
 
 Take good care of yourself as well as your patient, 
 for the confinement and the isolation make these cases 
 doubly wearing. Try to secure rest and nourishing 
 food at regular hours, and do not let the trouble of 
 having to change your clothes hinder you from getting 
 out of doors every day, even if you are tired. A brisk 
 walk in the fresh air is the best possible disinfectant 
 for yourself. 
 
 So, also, the best way of disinfecting the air of the 
 sick-room is by exchanging it for pure air. Air can not 
 be renewed by disinfecting it, any more than it can be 
 disinfected by deodorizing. Neither process renders it 
 fit to breathe again. In all cases of infectious disease 
 free ventilation is of the first importance. In those dis- 
 eases in which, as in scarlet-fever and small-pox the 
 infectious particles are largely thrown off by the skin, 
 a good deal can be done toward keeping the air pure 
 by inunction of the skin with carbolized ointment, and 
 by frequent bathing and changing of the clothes. 
 
 The burning of pastilles, cascarilla bark, etc., serves 
 rather to add to than to remove the impurities of the 
 air. Charcoal or peat, placed about the room in shal- 
 low pans, does absorb a certain amount of poisonous 
 matter. Carbolic crystals exposed in an open dish, or a 
 carbolic solution sprinkled about the room and on the 
 screens and outer covers of the bed, will quickly cor- 
 rect any offensive odor; but neither of these is to be 
 regarded as a disinfectant. Solutions of sulphate of
 
 228 A TEXT-BOOK OF NURSING 
 
 iron, nitrate of lead, and permanganate of potash, and 
 the various chlorides of lime, soda, and zinc, similarly 
 used, do act as true disinfectants, the former gradually 
 giving off oxygen and the latter absorbing carbonic- 
 acid gas and liberating chlorine; but as they affect only 
 the air coming in contact with them their influence 
 is not far-reaching. The vapors of iodine and bromine 
 and the fumes of nitrous acid have vigorous disinfect- 
 ing qualities, but, as commonly employed, they are only 
 deodorants, as they can not be used in the sick-room 
 in quantity enough to be useful without exciting dan- 
 gerous bronchitis. Indeed, any gaseous disinfectant, to 
 be effective, must be used in quantity incompatible 
 with human presence. Chlorine, sulphurous-acid gas, 
 and formaldehyde are the three commonly employed. 
 
 The most powerful and rapid of the liquid disinfect- 
 ants in general use is the solution of bichloride of mer- 
 cury (corrosive sublimate). It is also a valuable anti- 
 septic. The solution ordinarily used is of the strength 
 of 1 to 1,000, about fifteen grains to the quart. This 
 may be used for disinfecting vessels, sinks, and drains; 
 but not for clothing, as it makes an indelible stain. For 
 the latter purpose may be used a solution of sulphate of 
 zinc and common salt, four ounces of the sulphate and 
 two of the salt to a gallon of hot water. Soak the 
 clothes in this for two hours, and then boil them with 
 soda or borax. Dry in fresh air. Common washing 
 soda, a 2-per-cent solution at 212 F., is an excellent 
 disinfectant for instruments and utensils, and good for 
 general scrubbing, being a germicide, as well as an 
 effective cleansing agent, but it is likely to have a 
 deleterious effect on clothing. 
 
 Cond/s fluid (solution of permanganate of potash) 
 is often recommended, but it can hardly be used strong
 
 CONTAGION AND DISINFECTION 229 
 
 enough to do any good without staining. The sulphate 
 of iron (copperas) should remove such stains, but itself 
 discolors. Stains from copperas can be taken out by 
 oxalic acid or lemon juice. Carbolic also decomposes 
 Condy's fluid, and is incompatible with chlorine, so that 
 it must not be used in combination with either of them. 
 Chlorine and sulphurous acid mutually destroy each 
 other. Chlorine is soluble in water to the extent of two 
 and a half volumes; the solution can be used as a disin- 
 fectant for clothing, etc. It is decomposed by the ac- 
 tion of light. 
 
 Copperas or chloride of lime may be thrown dry 
 into water-closets and drains with good effect. They 
 should afterward be thoroughly flushed. For privy 
 vaults and cesspools, use four pounds of copperas dis- 
 solved in one and a half gallons of water to every cubic 
 yard of contained space. A little disinfectant should 
 be kept standing in all sputa-cups, urinals, and bed- 
 pans, ready for use. For this purpose the tincture of 
 iodine, or Condy's fluid, is excellent. The latter may 
 be known to have lost its efficiency when it has lost its 
 color. 
 
 A good disinfectant is made by dissolving half a 
 drachm of nitrate of lead in a pint of boiling water, 
 then dissolve two drachms of common salt in eight or 
 ten quarts of water. "When both are thoroughly dis- 
 solved, pour the two mixtures together, and when the 
 sediment has settled you have a pail of clear fluid, which 
 is the saturated solution of the chloride of lead. A 
 cloth saturated with the liquid and hung up in a room 
 will at once sweeten a fetid atmosphere; poured down a 
 sink, water-closet, or drain, or on any decaying or offen- 
 sive object, it will produce the same result. The nitrate 
 
 of lead is very cheap, and a pound of it would make 
 16
 
 230 A TEXT-BOOK OP NURSING 
 
 several barrels of the disinfectant. Creolin, a thick 
 fluid, resembling crude carbolic acid, possesses high dis- 
 infecting properties. As it does not mix readily with 
 water it is commonly used in the form of an emulsion 
 of two- to five-per-cent strength. This should always 
 be well shaken before using, and thoroughly mixed with 
 the substance to be disinfected. Any albuminous mate- 
 rial in the mass will interfere with its action. 
 
 With disease which is only indirectly infectious as 
 typhoid and cholera isolation of the patient is not 
 necessary; but the greatest care is essential in disinfect- 
 ing those discharges from the body which contain the 
 germs of contagion. All excrementitious matter must 
 be disinfected and disposed of thoroughly and promptly. 
 For stools, cover the bottom of the receiving vessel with 
 a layer of copperas or chloride of lime before use. After 
 use, add crude hydrochloric or sulphuric acid, in quan- 
 tity equal to half the bulk of the discharge, cover close- 
 ly, and carry at once from the room. These stools must 
 not be emptied into the common closet. The best way 
 to dispose of them is to mix with sawdust and burn 
 them. All clothing and bedding soiled even in the 
 slightest degree with the discharges must be disinfected 
 with equal care and boiled. These, measures, rigidly 
 taken, will prevent the spread of such disease, unless 
 there is some local cause for it. 
 
 When a patient has died from any infectious dis- 
 ease the body should be washed with some disinfectant. 
 Labarraque's solution is commonly used. The burial 
 should be as soon as possible, and strictly private. 
 
 After a case is ended, whether by death or recovery, 
 the room must be subjected to a thorough process of 
 cleaning and fumigation. Everything that can be so 
 treated should be boiled, or baked in a disinfecting
 
 CONTAGION AND DISINFECTION 231 
 
 oven, at a temperature of not less than 220 F. The 
 floor, woodwork, and, if possible, the walls should be 
 scrubbed with some disinfectant, the mattresses taken 
 to pieces for fumigation, and the bedding washed. Rub- 
 ber sheets and aprons are best cleaned with Labar- 
 raque's solution; they, of course, can not be baked. 
 Everything that can not be otherwise thoroughly dis- 
 infected should be hung up in the room while it is 
 being fumigated. All drawers and closets should be 
 left wide open, that the gas may penetrate to every 
 corner. Sulphurous-acid gas, chlorine, or formalde- 
 hyde, may be used for fumigation; the latter is now 
 usually preferred. The first two are powerful bleach- 
 ing agents, and will discolor metals, so that all metallic 
 surfaces should be first covered with a coating of grease 
 to protect them when either of these is used. Chlorine 
 is very destructful to fabrics. 
 
 To fumigate a room or ward with sulphur, close the 
 doors, windows, and fireplace, and paste paper closely 
 over all the cracks. Put the sulphur in iron pans, al- 
 lowing two pounds for every thousand cubic feet of 
 space. Set the pans in larger pans of water, and these 
 on bricks so as not to burn the floor; pour a little alco- 
 hol over the sulphur and ignite, beginning with the 
 pan farthest from the door by which you are to make 
 your exit. Leave the room quickly, and paste up this 
 door like the others. Keep it closed for twenty-four 
 hours; then open all the windows, and let the room air 
 for as much longer. 
 
 When chlorine is used, the same precautions must 
 be taken against its escape. The materials for its pro- 
 duction are better placed in the higher parts of the 
 room than on the floor, as the gas is heavier than air. 
 The following is the best way to procure it in quantity:
 
 232 A TEXT-BOOK OP NURSING 
 
 Mix a pound each of common salt and the black oxide 
 of manganese in a shallow earthen dish, add two pints 
 of sulphuric acid, previously diluted with two pints of 
 water, and stir with a stick. Chlorine is irrespirable. 
 If it becomes necessary to enter a room full of it, hold 
 near the nostrils a handkerchief wet with dilute am- 
 monia, but, when possible, the windows should be left 
 so that they can be opened from the outside. 
 
 The efficiency of both sulphur and chlorine is in- 
 creased by the presence of steam; the latter especially 
 requires a certain amount of moisture in the air. For- 
 maldehyde is now more used than either. This is a 
 gas obtained when a current of air, charged with the 
 vapor of methyl alcohol, is directed on an incandescent 
 spiral of platinum wire. A saturated solution of it in 
 water, which will contain about forty per cent, is called 
 formalin. It may also be had in the form of solid com- 
 pressed tablets. 
 
 Formaldehyde rapidly destroys bacteria in an in- 
 closed space, but it is not to be relied upon to penetrate 
 substances, so that when it is used for fumigation, all 
 clothing, mattresses, pillows, etc., should also be dis- 
 infected by steam. 
 
 The gas is obtained either by the slow combustion 
 of methyl alcohol in specially prepared lamps, or by 
 liberating it by the action of heat from the liquid or 
 solid forms. The latter is the preferred method. For- 
 malin or formochloral is placed in autoclaves, tightly 
 closed receptacles, and brought to a high temperature 
 under pressure. When sufficiently heated, the gas is 
 liberated by opening a valve, and conveyed through a 
 tube into the apartment to be disinfected. In another 
 form of apparatus, a sufficiently high temperature to 
 dissociate the gas is obtained by passing its watery solu-
 
 CONTAGION AND DISINFECTION 233 
 
 tion through a highly heated metal coil, similarly con- 
 nected with a delivery tube. 
 
 The solid tablets are decomposed, setting free the 
 gas by simply heating them in an open vessel over a 
 free flame. Sixty of these should be used for every 
 thousand cubic feet to be disinfected. For the same 
 space, a quart of methyl alcohol should be burned, or 
 a pound of formalin evaporated. 
 
 The room should be prepared as in other modes of 
 fumigation by tightly closing every aperture for the 
 escape of gas, and taking precautions against fire by 
 placing a piece of sheet iron, or a large tin pan, under 
 the apparatus in the middle of the room. Ignite, and 
 make your escape. Generators of thr gas from the 
 aqueous solution must be set at work in an adjoining 
 room, to be under control, and connected by a tube 
 through the keyhole with the one to be fumigated. Ten 
 per cent of glycerin added to the formalin will make 
 it more effective. Keep the room closed for twelve 
 hours, then air thoroughly, and sprinkle with ammo- 
 nia water to remove the odor. 
 
 " Early and provident fear is the mother of safety." Burke.
 
 CHAPTER XIV 
 
 " In-seeing sympathy is hers, which chasteneth 
 
 No less than loveth, scorning to be bound 
 With fear of blame, and yet which ever hasteneth 
 To pour the balm of kind looks on the wound." 
 
 J. R. Lowell. 
 
 WOUNDS of all kinds, with the diseases resulting 
 from them, and such others as are treated by operative 
 or mechanical means, come under the head of surgical 
 cases. A wound is defined as a solution of continuity 
 of the soft parts. It may be of any degree of severity, 
 from a. slight contusion to an extensive laceration. 
 
 An incised wound is a simple smooth cut, like that 
 of a knife, and is dangerous in proportion to its depth. 
 If the edges are torn, the wound is described as lacer- 
 ated. A lacerated cut will be more painful than a 
 sharp incision of the same extent, but the haemorrhage 
 will be more easily controlled. A contusion or bruise 
 is a subcutaneous laceration. It will occasion more or 
 less extravasation of blood, known as ecchymosis. If 
 the contusion is accompanied by a rupture of the in- 
 tegument, the discoloration will be less, as the effused 
 blood and serum find an outlet. This constitutes a 
 contused wound. It is usually made by some blunt in- 
 strument. The tissues may be crushed beyond recov- 
 ery, in which case ulceration sets up around the dead 
 parts, and they become gradually separated. Such 
 separation is known as sloughing. All lacerations par- 
 234
 
 SURGICAL NURSING 235 
 
 take of the character of contused wounds, as there is 
 more or less bruising about the sides and edges. Gun- 
 shot wounds, being made by blunt bodies, are prac- 
 tically tubular contused wounds. They are very pain- 
 ful, and likely to be accompanied by a deep-seated 
 inflammation, as they usually contain foreign matter. 
 Punctured wounds are those made by sharp-pointed in- 
 struments. If of any depth, they are dangerous, from 
 the variety of tissues involved, and from the want of 
 a free vent for any discharge that may be set up. Slight 
 wounds may be rendered more serious by the introduc- 
 tion into them, either at or after the time of injury, 
 of some poison or virus. 
 
 Burns are dangerous in proportion not so much to 
 their depth as to the extent of surface involved. A 
 burn covering half the surface of the body will result 
 in death from shock; recovery is very rare if so much 
 as one third of it is burned. Burns are sometimes 
 classified as of three degrees: The first is a mere red- 
 dening, with slight swelling, owing to distention of the 
 capillary blood-vessels. It is sometimes followed by 
 desquamation of the cuticle. If the heat applied has 
 been a little greater there will be a rapid flow of fluid 
 out of the distended capillaries, and blisters will be 
 formed containing serum, or serum mixed with blood. 
 These may be raised immediately, or after a few hours. 
 With a burn of the third degree the injury is still more 
 severe, so as to destroy the vitality of the part. The 
 gangrenous portion then gradually sloughs off, with 
 free formation of pus, and the wound heals slowly by 
 granulation. The cicatrix of a burn has a strong dis- 
 position to contract, and often produces great deform- 
 ity. Severe burns are not infrequently complicated by 
 inflammatory affections of the internal organs, The
 
 236 A TEXT -BOOK OF NURSING 
 
 lungs and kidneys often become deranged in their ac- 
 tion, and gastric disorders are common. Perforating 
 ulcer of the duodenum occurs seldom earlier than the 
 tenth day after injury. 
 
 Scalds are, in effect, similar to burns, and frost-bites 
 are analogous. Of the latter there are two degrees: one 
 in which vitality is merely suspended, the parts being 
 white, stiff, and numb, and developing an inflammatory 
 tendency upon return of the circulation; and a second 
 degree, in which the vitality is completely destroyed, 
 and gangrene supervenes upon thawing. 
 
 There are five modes described, by either of which a 
 wound of the soft tissues may heal. 1. By primary 
 union, where two cleanly cut surfaces, brought into 
 close contact, simply grow together, without suppura- 
 tion. This is also called healing by first intention. 
 Wounds of the perinaeum and of the face and throat 
 are most likely to heal in this manner. 2. When union 
 by first intention does not take place, there may still 
 be primary adhesion. A layer of lymph exudes, gluing 
 together the surfaces of the wound, which then unite 
 promptly. 3. In the process of granulation, the wound 
 is gradually filled up to the surrounding level by new 
 tissues, appearing in the form of small, red, close-set 
 granules bathed in pus. 4. In secondary adhesion, two 
 granulating surfaces, brought together, unite. 5. Under 
 a scab, where the effusion of lymph forms a thick film, 
 under which the healing process goes on, the surface 
 of the sore contracting and acquiring a new skin. It 
 takes a cicatrix a long time to acquire the vitality of 
 the original structure, if, indeed, it ever does. 
 
 For ordinary purposes it is, perhaps, sufficient to 
 classify wounds as healing by first intention or by gran- 
 ulation, without going further into detail. Destruction
 
 SURGICAL NURSING 237 
 
 of the external tissues, attended by secretion of pus, is 
 ulceration. 
 
 Granulations, if deficient, can be encouraged by 
 stimulating applications, or be checked, if excessive, by 
 astringents. Nitrate of silver is most often used for 
 the latter purpose. 
 
 The healing of a granulated surface may be has- 
 tened by skin-grafting, which consists in placing upon 
 it small portions of skin freshly cut from some part of 
 the patient's or some other individual's body. If the 
 operation is successful, each graft becomes a center 
 around which cicatrization takes place, thus rapidly 
 diminishing the size of the ulcer. The resulting cica- 
 trix possesses more vitality, and is less liable to contract, 
 than that which results from the ordinary healing proc- 
 ess. In deep ulcers, prepared sponge is sometimes used 
 for grafting. This is invaded by the granulations, 
 and is subsequently absorbed. Antiseptic precautions 
 must be taken in grafting. 
 
 The healing process is often hindered by inflamma- 
 tion, a series of changes in the blood and the tissues 
 resulting from irritation or specific poison, and mani- 
 fested by heat, redness, swelling, pain, and suppuration. 
 The swelling will be greatest and the pain least where 
 there is the most loose tissue; in a bony or fibrous tis- 
 sue inflammatory pain is very severe. Inflammation 
 attacking a mucous membrane is of less importance 
 than when a serous membrane or solid part is affected, 
 as the matter can find its way to the surface by one of 
 the natural outlets; otherwise it is pent up in a cavity, 
 or in the substance of some organ. An accumulation 
 of pus in any of the tissues or organs of the body is an 
 abscess. In opening an abscess a free incision should 
 always be made at the lowest point. The common but
 
 238 A TEXT-BOOK OF NURSING 
 
 reprehensible plan of making a small opening and forci- 
 bly squeezing out the contents of an abscess has been 
 aptly termed " surgical barbarism " (Gerster). If it is 
 left to break spontaneously, the resulting scar will be 
 larger than if it is cut. When the pus manifests a 
 tendency to work toward the surface, it is said to be 
 " pointing." No wound should ever be allowed to heal 
 at the surface first, as there will then be no outlet for 
 the imprisoned matter, and it will " burrow " inwardly, 
 doing further injury. Drainage tubes are sometimes 
 used to keep wounds open until they heal from the bot- 
 tom, and to carry off the pus. They are most often of 
 rubber or glass, with holes in the sides, so that the pus 
 may flow in from every direction. Strips of iodoform 
 gauze are used for the same purpose. 
 
 Pus is a thick, cream-colored, opaque discharge, 
 smooth, slightly glutinous, and insoluble in water. The 
 formation of pus is accompanied by pain and throbbing, 
 and, if extensive, with fever, and sometimes chills or 
 rigors. It is a steady drain upon the system, and a 
 patient suffering from a suppurating wound needs to 
 have his strength kept up by the most nourishing food. 
 
 Foreign matters in a wound, or retained and re-ab- 
 sorbed secretions, may give rise to general inflamma- 
 tory fever. To prevent the retention and consequent 
 decomposition of discharges, and to protect from ex- 
 ternal contamination, are the main points of the local 
 hygiene of surgery. 
 
 The treatment of wounds consists in checking the 
 haemorrhage, removing foreign matters, bringing sepa- 
 rated surfaces into apposition, and excluding the air by 
 some aseptic dressing. Decomposed animal matter is 
 one of the most virulent of poisons, and the smallest 
 particle of it carried from one case to another may suf-
 
 SURGICAL NURSING 239 
 
 fice to set up inflammatory action. Great care is needed 
 to guard against this in a surgical ward. Two bad 
 cases should not be put in adjoining beds, when it can 
 by any possibility be avoided, and the proportion of 
 suppurating wounds in the ward ought not to exceed 
 one third. All instruments scissors, forceps, etc. 
 used about the dressing, even of a healthy wound, must 
 be thoroughly cleaned before they are put away or used 
 again. If oil or vaseline is required, do not allow fin- 
 gers to be put into the common bottle, but take out a 
 little, and throw away all that is left of it. The dress- 
 ings taken from a wound must never be carried around 
 from one bed to another, but removed from the room 
 at once. Those which have been next the wound should 
 be burned, not washed, and such as are to be washed 
 must be first disinfected. Avoid soiling your own hands 
 with dressings. Always have a basin in which to carry 
 away the old ones, and do not use fingers where forceps 
 will do as well. Do not go from one case to another 
 without washing the hands in a disinfecting solution. 
 Protect with a bit of plaster any place where the skin 
 is broken, for you may get badly poisoned yourself 
 through a slight scratch. If you find such a slight 
 wound in washing your hands, pour a few drops of 
 glacial acetic acid on the spot. It will bite, but it is a 
 good preventive. Too much emphasis can not be laid 
 upon the necessity for absolute cleanliness in every 
 way. Cleanliness, in its broadest sense, is the best anti- 
 septic; certainly, none can take the place of it. Clean 
 hands, and especially finger-nails, are of literally vital 
 importance. The organic matter which finds lodgment 
 under the nails is in the highest degree dangerous, and 
 has undoubtedly been the source of many cases of 
 blood-poisoning. With sufficient care, however, an al-
 
 A TEXT-BOOK OF NURSING 
 
 most absolute immunity from sepsis can be secured. It 
 is now comparatively rare, and its occurrence always 
 reflects severely upon either surgeon or nurse. 
 
 Before beginning a surgical dressing it is important 
 to have at hand everything likely to be needed: it is 
 awkward for yourself and fatiguing to the patient when 
 you have to leave in the midst of the process to find 
 something that has been forgotten. Of course, when 
 the doctor is to do the dressing you can not always tell 
 just what he will call for, but the things that you know 
 will be wanting should always be ready; and after you 
 have seen a dressing once you should certainly know 
 how to prepare for it again. A protector for the bed is 
 wanted in every case, as also are towels, scissors, pins, 
 and basins. Of these last mentioned there should be 
 three one to receive the discarded dressings, one con- 
 taining fluid to wash the wound, and one to hold under 
 it to catch the discharges. For the latter purpose the 
 crescent-shaped basins are most convenient, as they fit 
 closely to any part of the body. 
 
 Old dressings should never be pulled off forcibly. 
 If they stick to the wound, they should be irrigated un- 
 til wet enough to come off easily. In removing adhesive 
 plaster, take hold of both ends and make traction to- 
 ward the wound from both directions evenly. It may 
 be well to apply new strips of plaster between the old 
 ones before taking them off, so that the wound can not 
 be pulled open. Alcohol, ether, or turpentine will re- 
 move the traces of paster. If obliged to leave a wound 
 undressed, cover it with a guard a piece of gauze or 
 muslin saturated with the antiseptic used. Drain off 
 the fluid from the soiled dressings before throwing 
 them into the waste-pail, and take care that no instru- 
 ments go in with them. Before fresh dressings are
 
 SURGICAL NURSING 241 
 
 applied the wound must be washed with some antiseptic 
 solution. Do not rub, but irrigate very gently until it 
 is quite clean. It will seldom be necessary even to 
 touch it. Dry around the edges with the softest lint. 
 Very extensive wounds, as severe burns, are best 
 dressed only a part at a time. Dry or absorbent dress- 
 ings are now largely used, as moisture is found to pro- 
 mote the development of germs. The practice of sur- 
 gery has been revolutionized since the development of 
 the germ theory. The destruction of infectious germs 
 or the prevention of their multiplication is the one end 
 and aim of the antiseptic treatment of to-day. The ex- 
 clusion of these micro-organisms constitutes asepsis. 
 Antiseptics hinder their development and arrest decom- 
 position, but do not necessarily destroy their vitality. 
 True disinfection is only secured by germicides. Fresh- 
 ly boiled water cooled in covered vessels is used for 
 washing or irrigating wounds, and all dressings are 
 sterilized by heat. If this can be thoroughly done no 
 chemical disinfectants are necessary, but a considerable 
 variety of these are still in use as precautionary meas- 
 ures. By far the most reliable is the bichloride of 
 mercury, or corrosive sublimate. Carbolic acid is large- 
 ly employed, and next in value is peroxide of hydro- 
 gen. Among numerous others of more or less efficiency 
 are salicylic and boric acids, the biniodide of mercury, 
 creolin, iodine, iodoform, thymol, listerine, and the 
 various chlorides of lime, soda, zinc, etc. 
 
 It is useless to ,give full directions for different 
 dressings, as each operator has his own methods, and 
 new ones are continually coming in vogue; but every 
 nurse needs to be familiar at least with the three first- 
 named and most commonly used germicides, to under- 
 stand how to manipulate and prepare them for use.
 
 242 A TEXT-BOOK OF NURSING 
 
 Bichloride of mercury comes in the form of a coarse 
 white powder, or in compressed tablets, and is soluble 
 in boiling water or alcohol. It is commonly used in 
 aqueous solution, of strength varying from 1 part in 
 1,000 to 1 in 5,000. To prepare the 1-1,000 solution, 
 dissolve thirty grains of the powder, accurately 
 weighed, in three and a half pints of boiling water; un- 
 less it is to be used immediately add also thirty grains 
 of common salt. Otherwise it is likely to decompose 
 and degenerate into calomel (the mild chloride of mer- 
 cury), which has no value as a disinfectant. In the 
 ordinary tablet, it is combined with chloride of ammo- 
 nium, 7.5 grains of each. One of these dissolved in a 
 pint of water makes a solution of 1-1,000. This is the 
 strongest used in surgery, and can be diluted to any 
 required degree. The bichloride solutions have a cor- 
 rosive effect upon metals, so that they can not be used 
 for the disinfection of instruments, nor must they be 
 poured into any metallic vessel. Gauze, bandages, and 
 other materials for dressings are rendered aseptic by 
 impregnation with corrosive sublimate after prescribed 
 methods. 
 
 Carbolic acid, when pure, comes in transparent 
 crystals. In this form it is a powerful caustic. The 
 strongest aqueous solution ordinarily used is one part 
 in twenty. To prepare this, set the bottle containing 
 the crystals in hot water until they liquefy. Pour out 
 carefully one fluid ounce and add nineteen of boiling 
 water. Shake vigorously until the acid is in perfect 
 solution. If any floating particles are left undissolved 
 they will retain all the caustic quality of the crystals. 
 A solution of carbolic acid in olive oil or glycerin (1-10 
 to 1-20) is sometimes used. Carbolic solutions and all 
 carbolized dressings should be kept in air-tight recep-
 
 SURGICAL NURSING 243 
 
 tacles, as it volatilizes readily and so loses strength. 
 Carbolic acid can also be procured in compressed tablets 
 a very convenient form, and one which insures accu- 
 racy of measurement. They are both powerful poisons, 
 and must be handled with great care. Enough may be 
 absorbed from the dressing of a wound to produce toxic 
 symptoms, and the nurse should always be on the look- 
 out for constitutional effects when any powerful drug 
 is used as an antiseptic. Where carbolic acid is em- 
 ployed the urine should be carefully observed, as one 
 of the earliest symptoms of poisoning by it is a dark- 
 green color of that excretion. Headache, giddiness, 
 and nausea not otherwise accounted for are suspicious 
 indications; great depression of the vital powers, with 
 low temperature and collapse, may follow. 
 
 Poisoning from the external use of corrosive sub- 
 limate is marked by the same symptoms as when a mer- 
 curial is taken internally salivation, vomiting, and 
 purging, with abdominal and muscular pains, rapid fail- 
 ure of strength, collapse and death, if the cause is not 
 removed. 
 
 Dangerous constitutional effects have been known 
 to result from the absorption of iodoform through a 
 wound. Such cases are marked by great depression, 
 with headache, loss of appetite, a continual taste of 
 iodoform in the mouth, cerebral disturbances, and 
 symptoms otherwise like those of carbolic-acid poison- 
 ing. 
 
 With the peroxide of hydrogen, there is no danger 
 of poisoning, and it does not injure the normal tissues, 
 but it is liable to undergo changes which render it 
 worthless. The official three-per-cent solution is the 
 most stable that it has been found possible to prepare. 
 It will decompose if brought in contact with metal, and
 
 244 A TEXT-BOOK OP NURSING 
 
 effervesces actively in uniting with pus. It is used to 
 determine the presence or absence of pus, as a cleanser 
 of ulcers, and in washing out abscess cavities, septic or 
 tubercular, also to destroy and remove the false mem- 
 brane in diphtheria. For the latter purpose a swab 
 is employed or a glass atomizer. 
 
 To test its strength, mix a little in a test-tube with 
 permanganate of potassium. The resulting efferves- 
 cence will be in proportion to its efficiency. 
 
 Among the materials most frequently used for sur- 
 gical dressing are the bichloride gcfuze, already men- 
 tioned; carbolized gauze, a similar preparation of un- 
 bleached tarlatan or cheese cloth saturated with a mix- 
 ture of carbolic acid, alcohol, resin, and paraffin; ab- 
 sorbent cotton, cotton wool from which all the oil has 
 been extracted, often charged with some antiseptic; lint, 
 a very soft, loosely woven linen with a nap on one side, 
 like Canton flannel. This should always be cut never 
 torn and placed with the smooth side next the wound. 
 Oiled silk or rubber tissue is used to put over other 
 dressings to keep them moist. Surgeon's gauze comes 
 all ready prepared for use in rolls of from one to fifty 
 yards in length. Also adhesive plaster of various kinds, 
 rubber, the heavier " moleskin," and that of zinc oxide. 
 These come w.ound on spools in strips of different 
 widths. 
 
 Sutures of silk, silver wire, catgut, or silkworm gut 
 are used for bringing the edges of the wound together 
 and holding them in place. 
 
 Ligatures of heavier silk or catgut are used for tying 
 arteries, etc. Both sutures and ligatures should have 
 their strength well tested before they are laid out for 
 use. The silk is rendered aseptic by boiling for an hour 
 in a five-per-cent carbolic solution, and is kept in a
 
 SURGICAL NURSING 245 
 
 similar solution, or in alcohol, until wanted. Catgut is 
 first immersed in ether, then boiled in absolute alcohol, 
 in which it is kept. Sterilized sutures and ligatures 
 now come in sealed glass tubes ready for use. 
 
 Sponges of fine quality are much used in operation 
 cases, and they need to be treated with the greatest care. 
 It is so difficult to be sure of getting them perfectly 
 aseptic that they are always a source of anxiety to the 
 surgeon, and some operators will not use them at all, 
 substituting pieces of aseptic gauze. New sponges are 
 first to be thoroughly washed in warm water until all 
 particles of sand and lime are removed. They are then 
 to be placed in a solution of permanganate of potash, 
 o ij to the gallon of water, and allowed to remain in 
 this solution two hours. A solution of hyposulphite of 
 soda, iij to the gallon, is now made up, and to it is 
 added ij of hydrochloric acid. The sponges must be 
 immediately transferred to this second solution, and are 
 kneaded rapidly several times. If allowed to remain in 
 this second solution too long they will become macer- 
 ated. Finally they are washed again in pure water 
 until perfectly clean and free from odor, and are then 
 placed in a five-per-cent (1-20) carbolic-acid solution 
 until required for use, or are preserved dry in tightly 
 closed glass jars. They must not be put in a bichloride 
 solution. Sponges which have been used may be freed 
 from blood and coagula by washing first in a saturated 
 solution of washing soda, and afterward in pure water. 
 They must then be kept in the strong carbolic solution 
 for at least fourteen days before they are used again, 
 renewing the solution once during that time. Sponges 
 which have been in contact with pus are, however, most 
 safely burned. Sponges for surgical use are of two 
 shapes, flat thin ones for abdominal work, when an 
 17
 
 246 A TEXT-BOOK OP NURSING 
 
 absorbent is needed in the cavity, and smaller round 
 ones for general purposes. 
 
 The care of the sponges, dressing materials, and in- 
 struments used in operations forms an important part 
 of the work of a surgical nurse. She must acquire 
 familiarity with the names of instruments in order to 
 be able to pass them without hesitation when called for, 
 and after an operation she will usually be expected to 
 clean and return them to their cases. This must be 
 done so thoroughly that they will be surgically that 
 is to say, aseptically clean, all ready for the next use; 
 they must be washed carefully, for they are expensive, 
 and many of them so delicate as to be easily ruined by 
 careless handling. Instruments with cutting edges, as 
 knives and scissors, should be taken by themselves and 
 washed carefully one by one. Never throw them in a 
 heap together, but lay them down so that they will 
 touch nothing to blunt their fine edges. All instruments 
 should be as far as practicable disjointed, catches un- 
 locked, and tubes syringed through. Before putting in- 
 struments in any disinfectant solution wash all the 
 blood off with soap and water. Tar soap is good for 
 this purpose. Every stain must be removed. Rough 
 surfaces need to be scrubbed with a brush. Silver and 
 steel may be polished with a little whiting moistened 
 with alcohol. Instruments entirely of metal may then 
 be boiled for half an hour, but those having handles 
 of ivory or bone must not be put into hot water, as it is 
 likely to crack them. After most thorough washing, 
 these may be laid to soak in 1-20 carbolic. Finally, 
 dry each perfectly, especially about the joints, and put 
 away each in its own place, so that they will not touch 
 one another. 
 
 It is in operative cases particularly that it is most
 
 OPERATIONS 247 
 
 important for a nurse to be conversant with the prin- 
 ciples of asepsis and antisepsis, and to understand their 
 practical application. The antiseptic methods of treat- 
 ment enable the surgeon to bring to successful results 
 to-day operations which but a few years ago would have 
 been regarded as utterly impossible; and they necessi- 
 tate at every step the intelligent, attentive co-operation 
 of the nurse, for no amount of care or precaution on the 
 part of the surgeon can counteract the bad effects of 
 carelessness on her part. In every detail of preparation 
 of her own person, of the patient, and all surroundings, 
 it must be continually borne in mind that nothing 
 should be brought near the scene of operation which 
 has not been rendered aseptically pure. Cleanliness and 
 surgical cleanliness are two different conditions. It 
 is not enough that all appliances should be free from 
 foreign matter perceptible to the eye, not enough that 
 they are spotless and shining, but they must also be 
 absolutely free from any infectious particles, and must 
 be kept so from the beginning to end of the opera- 
 tion. 
 
 The nurse who is to attend a critical operation 
 should not have been with any infectious case for at 
 least two weeks previously. Should a sudden emer- 
 gency make it necessary for her to be present in spite 
 of such exposure, she must prepare herself by an espe- 
 cially thorough carbolic or sublimate bath from head to 
 feet. The hair should in all cases have been recently 
 washed, and should be closely confined under a well- 
 fitting muslin cap that has been sterilized. Of course 
 only the most immaculate clothing, caps, and aprons 
 are to be worn in the operating-room. Before touch- 
 ing sponges, instruments, or dressings, the nails, hands, 
 and arms as high as the elbow are to be first thoroughly
 
 248 A TEXT-BOOK OF NURSING 
 
 scrubbed with soap and water, as hot as can be borne, 
 by means of a stiff nail-brush; green soap is the best; 
 this is then rinsed off with clean hot water, and finally 
 they are soaked for at least two minutes in some disin- 
 fectant solution, preferably bichloride of mercury, 
 1-2,000. Simply dipping the hands in the solution does 
 not accomplish the desired object the destruction of 
 every latent germ. Another method much in vogue is 
 as follows: Thoroughly clean the hands and arms as 
 above described, then, after rinsing off the soap with 
 clean water, wash them with alcohol. Finally with 
 another brush, scrub for a full minute with a 1-3,000 
 solution of bichloride of mercury. The nails should 
 always be cut short. 
 
 The patient to be operated on should have a bath 
 the night before, when sufficient notice is given, and on 
 the morning before the operation a thorough enema. 
 Only light food should be taken, and, unless very feeble, 
 the patient should fast entirely for three hours before 
 etherization. It is good routine practice to administer 
 a dose of brandy or whisky half an hour previously. 
 See that the patient passes urine the last thing before 
 going to the operating-room. Have the hair well 
 combed and tightly braided, so that it can not get loose 
 and tangled. Artificial teeth must be taken out, and 
 all tight bands loosened. Arrange the clothing so that 
 it will be out of the way, well protected, and easy to 
 change afterward if it should be necessary. If the 
 operation is to be a lengthy one, it will be a wise pre- 
 caution for the patient to wear a flannel jacket, as cases 
 of pneumonia have been known to result from pro- 
 longed exposure under ether. Remove all dressings 
 from the part to be operated upon, and scrub' it well 
 with soap and water; if there is hair about the part,
 
 OPERATIONS 249 
 
 shave it, and cover closely with a towel wet with anti- 
 septic solution. 
 
 In a private house you will have to get the room 
 ready as well as the patient. Have it thoroughly 
 cleansed, well aired, and at a temperature of about 70 
 F. for ordinary cases. If you are preparing for an ab- 
 dominal section, the order will probably be 80, as it is 
 necessary to have great warmth where the intestines 
 are to be exposed. There should be a long, firm table, 
 on which the patient can lie, so placed that a strong 
 light falls upon it, plenty of basins, pails, clean towels, 
 hot and cold water, soap and a new nail-brush, pins, 
 needles, and scissors. The doctor will tell "you what 
 else will be needed, and what dressings he wishes you 
 to prepare. But these he will usually provide himself. 
 All basins and receptacles for instruments or dressings 
 must be carefully attended to, thorough cleanliness of 
 both outer and inner surfaces being essential, inasmuch 
 as the operating surgeon may touch the basin and imme- 
 diately after may be called upon to introduce his hand 
 into the wound. Do not for an instant forget that there 
 must not be the smallest chance that anything may be 
 brought near the wound which has been in contact with 
 any even doubtful surface. 
 
 There is often a delay after everything is ready, for 
 doctors are not always prompt, though the nurse must 
 be. The time which must be spent in waiting for them 
 is most trying for both patient and nurse. The mental 
 condition of the patient is a matter of very grave impor- 
 tance, sometimes seriously affecting the result. The 
 nurse who is possessed of tact and judgment can do a 
 great deal toward inspiring a serene and hopeful frame 
 of mind. 
 
 The instruments, and as far as possible everything
 
 250 A TEXT-BOOK OF NURSING 
 
 that is disagreeably suggestive, should be covered. In 
 the hospital, the anaesthetic is given before the patient 
 enters the operating theater; when practicable, the 
 same plan will be followed in private practice. 
 
 At an operation in a private house the nurse will 
 be called upon to do many things which in a hospital 
 fall to the lot of the junior interne; she may even be 
 called upon to administer the anaesthetic. This will be 
 ether or chloroform, or a mixture of alcohol, ether, and 
 chloroform, occasionally nitrous oxide gas. Ether is 
 poured, two or three drachms at a time, on an inhaler, 
 made large enough to fit over the mouth and nose, the 
 air being entirely excluded. This may be made of a 
 towel closely folded over a paper cone. In operations 
 performed by artificial light, the ether must be kept at 
 a safe distance from the gas or lamp, as it is inflam- 
 mable. The part of the face to be covered by the cone 
 may be anointed with vaseline, to prevent irritation of 
 the skin. Chloroform is not given in the same way, but 
 is sprinkled a few drops at a time on a folded hand- 
 kerchief, or a cone made for the purpose, and held at 
 a distance of two or three inches from the patient's face, 
 which it must never be allowed to touch; a mixture of 
 atmospheric air is needed. Vaseline should be used 
 as with ether. The proportion of chloroform inhaled 
 should not exceed four per cent. Chloroform as an 
 anesthetic is more agreeable and more rapid than ether, 
 and is less likely to nauseate, but it is more dangerous, 
 as it has a powerfully depressant effect upon the heart. 
 The head must be kept low, arid the patient should on 
 no account be raised to a sitting posture while under 
 its influence. The signs of danger are a feeble pulse, 
 a livid face or extreme pallor, stertorous or irregular 
 and gasping respiration. Nitrous oxide or " laughing
 
 OPEEATIONS 251 
 
 gas " is inhaled through a mouth-piece connected with 
 a rubber bag containing the vapor. The resulting 
 anaesthesia is of comparatively brief duration. If you 
 are charged with giving any anaesthetic, do not try to 
 do or see anything else at the same time; the patient 
 requires your undivided attention. Keep your finger 
 on the pulse and your eyes on the face, and at the first 
 warning indication stop giving the vapor. No anaes- 
 thetic should ever be given except under the direction 
 and in the presence of a medical man. 
 
 A properly made and protected bed should be all 
 ready, to which the patient may be transferred as soon 
 as the operation is over. He must be kept warm, and 
 as quiet as possible, free from all excitement, and should 
 not be allowed to sit up for any purpose. After any 
 operation the strength needs to be kept up by nourish- 
 ing food, but only in fluid form, until the doctor's per- 
 mission is given to vary it. The wound must be so 
 arranged that the dressings can be observed without 
 waking the patient, and, particularly, during the first 
 twenty-four hours, it must be carefully watched for sec- 
 ondary haemorrhage. If an operation has been properly 
 conducted, the after-care of a wound will be simple. 
 Dressings are now renewed much less frequently than 
 formerly. An amputation stump or breast may not be 
 disturbed for a week; a joint possibly not for two weeks. 
 To keep the patient quiet and to support his general 
 strength while Nature does her reparative work, is all 
 that is required. 
 
 After a severe operation or injury a complete pros- 
 tration of the nervous system not infrequently occurs, 
 known as a state of shock. Loss of blood and debility 
 favor shock. It may even be caused, in a feeble subject, 
 by sudden strong emotion, The patient becomes pale,
 
 252 A TEXT-BOOK OF NURSING 
 
 and faint or trembling, the mind confused or apathetic, 
 the surface is covered with cold perspiration, there is 
 often nausea, and sometimes relaxation of the sphinc- 
 ters, causing involuntary passages. It may result fatal- 
 ly, the patient sinking into collapse. Brandy and strong 
 beef-tea should be given (by enema, if the patient can 
 not swallow), and heat applied to the extremities. It 
 is in such cases that hypodermatic medication is espe- 
 cially valuable. A hot-water bag over the heart is a 
 powerful stimulant. The efforts to revive the patient 
 must not be continued until they excite him, and he 
 should not be allowed to make any effort himself. 
 
 If a patient after a surgical operation escapes death 
 from shock or hemorrhage, there is still a third great 
 danger to which he is liable that of blood-poisoning. 
 This is now happily rare, but it is well to be acquainted 
 with the symptoms of such forms of it as may be en- 
 countered if aseptic precautions are not thoroughly 
 taken. 
 
 Erysipelas is most contagious, and any patient devel- 
 oping symptoms of it must be promptly isolated. It is 
 most frequent in lacerated wounds, and in those of the 
 head and hands is rarely of other than traumatic or'gin. 
 The secretions of the wound are diminished, and its 
 edges become red and swollen. In a day or two a blush 
 appears about it, of a uniform red color, disappearing 
 on pressure. There will be a high temperature, a quick 
 pulse, headache, nausea, and a coated tongue. The dis- 
 ease may terminate favorably in from ten to fourteen 
 days, but is often fatal. 
 
 Pyaemia is usually initiated with a chill, accompa- 
 nied by a high temperature, and followed by profuse 
 perspiration. The secretions from the wound are ar- 
 rested, the pulse is fast and feeble, and the expression
 
 OPERATIONS 253 
 
 of the face is anxious. Abscesses are liable to form 
 in parts of the body distant from the wound, especially 
 in the joints. The chills may recur at intervals of from 
 eight to twenty-four hours, but there is the greatest ir- 
 regularity in their manifestations. The disease is 
 usually fatal in from four to twelve days. Curative 
 measures amount to little. Try to maintain the pa- 
 tient's strength, and to keep the fever down. Free ven- 
 tilation and perfect cleanliness are of the utmost im- 
 portance, the disease being most often occasioned by 
 fault in this direction. 
 
 Septicasmia is a rather less dangerous form of blood- 
 poisoning than the preceding. It occurs without the 
 repeated chills, is characterized by a high but more 
 regular fever, and a general typhoid condition. There 
 is more probability of a favorable termination. In gen- 
 eral the difference between pyaemia and septicaemia may 
 be thus defined: The latter is a local, the former a gen- 
 eral, expression of blood-poisoning from an infected 
 wound. 
 
 Tetanus is a usually fatal complication, more often 
 following slight wounds than severe ones. It may fol- 
 low exposure of the wound to cold. It is marked by a 
 certain muscular rigidity, which sets in abruptly, be- 
 ginning with the muscles of the throat and jaw, and 
 gradually extending until the whole body is in continu- 
 ous convulsions. It is important that the symptoms be 
 recognized early. 
 
 In addition to these general remarks, it may be well 
 to follow in detail the conduct of the nurse before, dur- 
 ing, and after a capital operation. We will take as an 
 example a case of laparotomy or abdominal section, as 
 here, perhaps more than anywhere else, antiseptic pre- 
 cautions down to the veriest minutiae are vital in their
 
 254 A TEXT-BOOK OF NURSING 
 
 importance. The room must first be prepared for the 
 scene of operation, and this is often, especially when it 
 must take place in a private house, left entirely to the 
 nurse. The room should be cleaned the day before, that 
 it may have time to be well aired. The carpet and cur- 
 tains, all drapery and superfluous furnishings, should 
 be removed, the floor scrubbed, the wood-work, and, if 
 practicable, the walls also, washed with a solution of 
 bichloride, 1-2,000. It is indispensable that a room be 
 selected which can be well lighted and ventilated. The 
 first requisite is a firm, strong, narrow table, upon which 
 the patient will lie during the operation. This must 
 stand where the light is best, and so as to be accessible 
 from every side. Cover it with a thick blanket or quilt, 
 a rubber cloth, and over both a clean sheet, all so tucked 
 in that no portion will be left hanging over the edge. 
 A thin pillow with a rubber case under the muslin one 
 will also be needed, and a couple of light blankets with 
 a second rubber sheet to cover the patient. On a smaller 
 table place dishes of glass, china, or new agate-ware to 
 receive the instruments. A third table may be needed 
 for dressings, ether, towels, etc., and a wash-stand with 
 hot and cold water, soap, nail-brush, and towels for the 
 use of the surgeon. Not less than three dozen sterilized 
 towels will be required, and three pails or bowls for 
 washing the sponges one to contain clear water, one 
 for the warm antiseptic solution, and one for the clean 
 hot solution in which sponges and towels are to be 
 wrung out when called for. A basin to receive these 
 after use will be wanted, and all these things must be 
 aseptically clean inside and out. The antiseptic solu- 
 tion may be distinguished from the others, if desired, 
 by adding a few drops of eosin, which will give it a 
 pinkish color. The sponges, and usually the dressings,
 
 OPERATIONS 255 
 
 will be provided by the surgeon at least he will give 
 explicit directions about them. A broad flannel or mus- 
 lin binder, or a Scultetus bandage, which is preferred 
 by some operators, should be in readiness. The bed to 
 which the patient is to be transferred after the opera- 
 tion is to be made and protected in the same way as for 
 a confinement case, tightly pinned, so that it can not 
 work into wrinkles, as it will be some time before it can 
 be renewed. 
 
 On the evening preceding the day of operation the 
 patient is given a special bath and the hair about the 
 pubic region is shaved, care being taken not to cut the 
 skin. A towel soaked in a soap solution (soft soap forty 
 per cent to water sixty per cent) is placed upon the 
 abdomen, coming well down over the pubes and held in 
 place by a few turns of a roller bandage. Some prefer 
 a moist bichloride dressing. This remains on all night. 
 In the morning a thorough enema is given, and a speci- 
 men of the urine is saved for examination. The soap 
 towel is then removed, and the abdomen is washed with 
 alcohol to take off all the soap. Another towel, which 
 has been soaked in 1-1,000 bichloride solution, and 
 wrung fairly dry, is now placed upon the abdomen, and 
 secured like the other by a bandage. The patient is car- 
 ried to the operating-table with this in place; it is not 
 removed until the last moment. Just before etheriza- 
 tion the patient must be catheterized, no matter how 
 recently urine has been passed. 
 
 The nurse enters the operating-room with surgically 
 clean hands and apron, a gown with short sleeves en- 
 tirely covering the clothing. Some surgeons wish the 
 nurse also to wear rubber gloves. Once there, her busi- 
 ness is to wait on the doctor, to keep out of the way, 
 and to watch every instant to see that nothing is handed
 
 256 A TEXT-BOOK OP NURSING 
 
 to him which has touched any doubtful surface. Should 
 you rest your own hand on the table, wash it again 
 not merely dip it in the antiseptic solution. Should 
 a sponge or a towel chance to fall on the floor, lay it 
 aside, and on no account use it again. And remember 
 that, whatever your interest in the proceedings, you are 
 present not as spectator but as assistant, and keep on 
 the lookout, not so much to see what the surgeon is 
 doing, as what he is likely to want next. A second 
 nurse will wash the sponges, if these are used, first in 
 plain water to rinse out the blood, then in the warm 
 antiseptic solution. Finally they are dipped in hot an- 
 tiseptic, and squeezed as dry as possible before they are 
 handed to the surgeon. No one detail is more impor- 
 tant in these cases than the counting of the sponges. 
 Count them carefully before the operation begins, and 
 make a written memorandum of their number. Do not 
 trust your memory. Neglect of this precaution has 
 caused more than one death. You will be expected to 
 account for every one, and if any are missing you must 
 notify the surgeon before the abdominal wound is 
 closed. The operation having been completed, and the 
 dressings, which must be aseptic beyond suspicion, hav- 
 ing been applied, the patient is put to bed and the room 
 cleared as speedily as possible of all traces of the opera- 
 tion. Hot-water bottles, well protected, must be in readi- 
 ness, and stimulants at hand. The shock is great in 
 laparotomy from the number of nerve centers involved. 
 It is better not to place the pillow under the pa- 
 tient's head until the effects of the ether have worn off. 
 If there is vomiting, the' abdomen should be gently 
 supported by a hand on each side of the wound, to avoid 
 any strain upon the sutures. If the vomiting is per- 
 sistent, the application of ice-cold cloths to the throat
 
 OPERATIONS 257 
 
 will frequently control it. It is important to distin- 
 guish the ether vomiting after laparotomy from the 
 vomiting of early developing peritonitis. In the for- 
 mer, which occurs soon after the operation, everything 
 is rejected as soon as swallowed, and it stops if the 
 stomach is empty, while with acute peritonitis, the pa- 
 tient may take nourishment for hours, and then sud- 
 denly throw up a large quantity of greenish or yellowish 
 fluid having a sour smell. Peritonitis usually develops 
 from twelve to forty-eight hours after the operation. 
 
 Sometimes medicine will be ordered which it is very 
 important to have retained. The simple procedure of 
 cold applications to the throat above mentioned will 
 often prevent its rejection, and it will add to their good 
 effect if immediately after the administration of the 
 dose a few drops of ice-water are forcibly sprinkled on 
 the patient's face. The patient must not be allowed to 
 overload her stomach with ice-water, however much she 
 may desire it. This is one of the few cases in which 
 water is withheld as much as possible. Very hot water 
 will allay the thirst better than ice-water, and does not 
 leave the mouth in such a parched condition, nor is 
 there the same danger that the patient will desire to 
 drink too much of it. 
 
 During the first twenty-four hours it is necessary to 
 watch carefully for any symptoms of hasmorrhage. The 
 same symptoms present here as in cases of haemorrhage 
 elsewhere. Should the nurse suspect it, she should re- 
 move the pillow, slightly elevate the foot of the bed, 
 apply hot water bottles to the extremities, having noti- 
 fied the surgeon as soon as the condition is recognized. 
 
 The urine should be drawn, unless otherwise in- 
 structed, every six hours for the first forty-eight hours; 
 after this the patient may pass her own urine, care
 
 258 A TEXT-BOOK OP NURSING 
 
 being taken to disturb her as little as possible with the 
 bed-pan. The urine must be measured, carefully ob- 
 served, and a specimen saved for examination. It is 
 also important to note whether or not the bowels move, 
 and the character of the defecations, paralysis of the 
 intestines being one of the possible complications to 
 be looked out for. 
 
 The most full and accurate bedside notes should be 
 kept, recording every change in the patient's condition. 
 The temperature, pulse, and respiration are usually 
 taken every four hours for the first few days; however, 
 the nurse should be able by touching the patient to 
 note any marked variation from the temperature last 
 taken, and, if necessary, take it again at once. The 
 nourishment, of course, must be such as ordered by the 
 surgeon. 
 
 Eectal nourishment and medication may be neces- 
 sary, and must be administered with the greatest care. 
 Sometimes the patient will be nourished entirely by rec- 
 tum for several days following the operation, with a 
 view to giving the stomach a complete rest. Tympa- 
 nites, if it develops, may be relieved by the introduction 
 into the rectum of a tube through which the gas may 
 escape. 
 
 When permission is given for the patient to be 
 turned on her side, the nurse must see that the whole 
 body is turned at once, and very gently, so that no twist 
 or strain will come upon the wound. She must never 
 be turned until the surgeon has given distinct permis- 
 sion. When the time comes for the stitches to be re- 
 moved, the same antiseptic precautions must be ob- 
 served as when they were put in hands, instruments, 
 and fresh dressings all sterilized with the same care 
 as in the first place. The patient will probably not be
 
 OPERATIONS 259 
 
 taken out of bed, but may be protected by means of rub- 
 ber sheets above and below the bandage. Over these 
 must be spread towels wrung out in bichloride of mer- 
 cury, 1-1,000. The instruments must be perfectly 
 aseptic, and handed to the surgeon in a dish containing 
 carbolic acid, 1-30. 
 
 The nurse who watches a laparotomy case shares a 
 great responsibility, and the recovery of the patient de- 
 pends to a very great extent upon her ability and faith- 
 fulness. She can in many ways make the patient more 
 comfortable, but she must often seem cruel to be truly 
 kind, and in no case is scrupulous fidelity to orders more 
 obligatory. 
 
 "The hardest duty bravely performed soon becomes a habit 
 and tends in due time to transform itself into a pleasure." 0. W. 
 Holmes.
 
 CHAPTEK XV 
 
 " A traveler between life and death, 
 The reason firm, the temperate will, 
 Endurance, foresight, strength, and skill, 
 A perfect woman, nobly planned 
 To warn, to comfort, and command." 
 
 Wordsworth. 
 
 A LARGE proportion of the cases coining under the 
 care of a nurse are those of disorders of the female re- 
 productive organism, classed as gynaecological. These 
 are sadly common, various, and often complicated. 
 Many of them might be prevented by greater general 
 knowledge and attention to the hygiene of these or- 
 gans. Happily ignorance of her own anatomy is no 
 longer regarded as essential to a woman's refinement, 
 and it becomes every nurse at least to understand some- 
 thing of the anatomy of the genital organs, external 
 and internal, their physiology and function, and the 
 normal processes of menstruation, ovulation, and 
 fecundation. 
 
 In pathological conditions, the first important thing 
 for the nurse to understand is the method of physical 
 examination of the pelvic organs, and what assistance 
 the physician may require. For a merely digital exami- 
 nation, little will be needed beyond your presence and 
 attention to wait upon the doctor as he may desire, and 
 the necessary provision for scrubbing and disinfecting 
 the hands. Never leave a doctor alone with a gyna?co- 
 260
 
 GYN^COLOGY 261 
 
 logical patient except at his own request. If you have 
 opportunity to prepare the patient for examination, 
 the important thing is to see that the rectum and 
 bladder are empty and the external genitals clean. 
 
 An instrumental examination may be made with the 
 patient in the dorsal, knee-chest, or lateral position. 
 Getting the patient properly posed is the duty of the 
 nurse, and requires some practice. 
 
 In the dorsal position, the patient lies flat on her 
 back, with her knees elevated. The knee-chest position 
 is the exact reverse, hips elevated, weight resting on the 
 knees, the chest flat against the table, not supported by 
 the elbows. The third and most common is known as 
 the Sims position. The patient lies on the left side, 
 with the left buttock on the extreme left corner of the 
 table, the left arm behind her, and the knees drawn up, 
 the right above the left. The hand and right arm come 
 well to the right side of the table, the right shoulder as 
 much depressed as possible. This attitude, with the aid 
 of the Sims speculum, gives the most complete view of 
 the vagina and uterus, and is the best suited for opera- 
 tions on the cervix and anterior vaginal wall. The 
 cylindrical and the bivalve specula are more commonly 
 used with the patient in the dorsal decubitus. What- 
 ever position is taken, the patient should be protected 
 from any unnecessary exposure. A sheet placed across 
 the patient with a corner tucked under each foot, the 
 opposite corners under both shoulders, the clothing 
 well up above the waist, will leave the patient entirely 
 protected while waiting. When the physician is ready, 
 the curtain formed by the sheet covering the vulva may 
 be raised, and that covering the abdomen may be pushed 
 down. Under no circumstances will a nurse leave a 
 patient uncovered until the moment for examination 
 18
 
 202 A TEXT-BOOK OF NURSING 
 
 arrives. In placing a subject in the dorsal position, the 
 nurse should herself raise the knees to avoid any strain 
 on the part of the patient, and for the same reason 
 should not let her rise from it without first turning 
 on the side. 
 
 The speculum is prepared for use by boiling, in 
 order to sterilize it. It is then lubricated either by a 
 little oil on the outer surface, or by dipping it in a one- 
 per-cent solution of lysol, a combination of carbolic 
 acid and green soap. This is excellent for the doctor's 
 hands also, as it disinfects as well as lubricates. The 
 Sims speculum must be held in position by the nurse. 
 The usual way of doing this is to stand behind the pa- 
 tient, facing the operator. Stand firm on both feet in 
 an attitude that you can maintain steadily for a long 
 time if necessary. Pass the left arm over the patient's 
 hips, and with the left hand raise the right buttock, 
 and, if desired, separate the labia. The right arm may 
 rest on your own hip to steady it, while the right hand 
 retains the speculum in the exact position, and with the 
 same degree of tension, in which it is handed to you. 
 Other instruments in use for these cases are the de- 
 pressor, sound, probe, tenaculum, curette, volsella for- 
 ceps, uterine dressing forceps, applicator, cotton hold- 
 ers, dilators, and pessaries, with all of which you want 
 to be familiar. Dilators are used for stretching the cer- 
 vical canal, pessaries to hold in position a displaced 
 uterus. If you should be directed to remove a pessary, 
 remember that it must first be turned round so that its 
 long axis will be coincident with that of the vagina. 
 Various tampons and other local dressings are com- 
 monly employed in the treatment of uterine cases, for 
 the preparation of which each doctor will give his own 
 directions. The ordinary tampon is made by cutting
 
 GYNAECOLOGY 263 
 
 a strip of absorbent cotton about three inches wide, 
 and rolling it up, not too tightly, until it has a diameter 
 of about an inch and a half. Tie a piece of twine or 
 stout thread firmly about the middle of this, leaving 
 an end of at least six inches hanging, for convenience 
 in removal. These are used to keep the parts in proper 
 position, and to apply medication. The "butterfly" 
 tampon is a thin, flat piece of cotton with a string 
 similarly tied about the middle. The " kite-tail " tam- 
 pon is a series of bunches of cotton tied at intervals 
 of two or three inches along one string. This form is 
 much used in case of uterine haemorrhage, and should 
 be at hand when there is danger of such, or strips of 
 sterilized gauze for packing, nine inches wide by about 
 seven yards long. 
 
 When a uterine examination is to be made, the 
 tampons should be prepared and sterilized beforehand. 
 Applicators have bits of cotton twisted tightly on their 
 tips, and little balls or squares of sterilized cotton will 
 also be wanted to swab out the vagina. 
 
 Vaginal medication is also applied by means of sup- 
 positories and douches. The latter is a mode of treat- 
 ment which the nurse will most frequently have to give. 
 The douche may be either medicated or of pure water, 
 as directed. The latter, when tepid, is simply for clean- 
 liness, but the hot douche has a distinct therapeutic 
 effect on congested or inflamed pelvic tissues. At first 
 the congestion is increased, but a continued application 
 of the hot water causes a secondary and more or less 
 lasting contraction of the blood-vessels. Thus it is an 
 excellent haemostatic in all forms of capillary haemor- 
 rhage. It also induces uterine contractions, and acts 
 to a certain extent as a local anodyne. Hot douches 
 should be of 112 to 118 F., and are usually ordered
 
 264 A TEXT-BOOK OF NURSING 
 
 as prolonged douches, from two to four quarts being 
 given. The patient should lie on the back, with the 
 hips elevated until they are several inches higher than 
 the shoulders. A douche taken sitting or standing is 
 of very limited utility. A bed-pan with an overflow pipe 
 is needed. The fountain syringe is now chiefly used, 
 as most doctors consider the steady flow under low pres- 
 sure as preferable to the intermittent action of the 
 Davidson. It should be suspended from a considerable 
 height, to give good force to the flow. The air must 
 be expelled by starting the flow of the fluid, and then 
 pinching the tube until after the nozzle is inserted. A 
 thoroughly boiled glass nozzle of the syringe is used, 
 and should be well introduced, that the hot water 
 may come in direct contact with the highest portions 
 of the vagina. It should be carefully slid along the 
 posterior vaginal wall until it has reached a point be- 
 hind the cervix, before the water is injected. Any 
 medication ordered should be included in the last 
 quart. The tube should not be perforated at the im- 
 mediate extremity, as there is danger of injecting the 
 fluid into the cavity of the uterus, and doing serious 
 harm, especially after confinement or miscarriage, 
 when the mouth of the uterus remains open. In no 
 case leave the patient alone with a fountain syringe in 
 operation. 
 
 Cases of miscarriage often require careful nursing 
 to prevent permanent ill effects. The first indication 
 of an approaching abortion is haemorrhage from the 
 uterus, generally accompanied by pain. The patient 
 should at once be put to bed, as the threatened mis- 
 carriage may in some cases be averted by rest and quiet. 
 If this can not be done, care must be taken that the 
 placenta and its membranes, the secundines, are all
 
 GYNAECOLOGY 265 
 
 expelled as well as the foetus, as their retention may oc- 
 casion dangerous haemorrhage or blood-poisoning. The 
 patient should have as much care after a miscarriage 
 as after labor at full term, being allowed in no way to 
 exert herself. It is a great mistake to regard it as of 
 slight importance; the loss of blood is often excessive, 
 and the shock to the nervous system is greater than 
 that produced by regular labor. The one is a natural, 
 the other a pathological, process. A season of perfect 
 rest is necessary to allow the uterus to return to its 
 natural state. Miscarriage is more common among mul- 
 tiparae, women who have borne children, than among 
 primiparae, those who bear for the first time. After 
 it has occurred a few times a predisposition to it 
 exists, and it becomes difficult to carry a child to full 
 term. 
 
 The most common gynaecological operations are 
 those for lacerations of the cervix or the perinaeum, 
 both injuries consequent upon childbirth, and for 
 curettement, scraping. The same general rules apply 
 in all minor operations. In the preparation of the 
 patient the previous condition of the bowels and the 
 character of any vaginal discharge must be carefully 
 noted and reported. At least six hours previous to 
 operation series of enemata should be administered 
 until the water returns clean, that the rectum may be 
 emptied and become quiet. The patient should be given 
 a thorough bath and an antiseptic vaginal douche, 
 1-5,000 bichloride of mercury being commonly ordered. 
 For perineal operations, shave the parts and apply to 
 the vulva a bichloride compress 1-5,000, frequently 
 changed. Have a T bandage ready for use if required. 
 After a cervix or perineal operation, obtain from the 
 surgeon definite directions about emptying the bladder.
 
 266 A TEXT-BOOK OF NURSING 
 
 Of course all orders in regard to diet, medication, and 
 position must be scrupulously carried out. After an 
 operation on the perinaeum it has been customary for 
 the patient's knees to be tied together, that no uncon- 
 scious movement on her part may bring a strain upon 
 the stitches. The perineal wound ought to heal by 
 first intention, and if the stitches are pulled upon so 
 as to cut, even if they are not torn out, this desirable 
 result will be hindered. The treatment consists of 
 rest and the maintenance of absolute cleanliness. The 
 success or failure of the operation depends here large- 
 ly upon the nurse, as a little careless manipulation 
 on her part may render useless the best skill of the 
 surgeon. 
 
 If the patient is allowed to pass urine voluntarily, 
 the sutured parts must be gently irrigated and dried 
 after each micturition. If the patient is catheterized, 
 watch that no inadvertent drop falls upon the wound. 
 A piece of absorbent cotton between it and the catheter 
 will be found a great protection. During defecation, 
 also, the nurse must see that no undue strain is allowed 
 upon the stitches. It may be necessary, especially if the 
 laceration has been through the sphincter, to support 
 the perinaeuin with the hand during the passage of 
 fasces. In these cases, also, the rectum must be washed 
 out after each movement. In all manipulations the 
 utmost gentleness and care must be exercised, and the 
 most scrupulous cleanliness preserved until the stitches 
 are removed, which will be in about nine days. 
 
 In cases of laceration through the sphincter, and 
 also of abdominal section, it is desirable to have the pa- 
 tient under observation and treatment for several days 
 preceding the operation, and the diet restricted to such 
 articles as leave but little solid residue in the intestinal
 
 GYNAECOLOGY 26Y 
 
 canal. By far the greatest number of laparotomies are 
 performed upon female subjects, and for the relief of 
 conditions peculiar to their sex. The care of these 
 cases has been already described. 
 
 " The reaction of matter on spirit is something for which we 
 do not always make due allowance." J. Eoehme.
 
 CHAPTER XVI 
 
 "May we reach 
 
 That purest heaven, be to other souls 
 The cup of strength in some great agony 
 Enkindle generous ardor, feed pure love, 
 Beget the smiles that have no cruelty, 
 Be the sweet presence of a good diffused, 
 And in diffusion ever more intense. 
 So shall we join the choir invisible 
 Whose music is the gladness of the world." 
 
 George Eliot. 
 
 IT is perhaps more often in obstetric cases than in 
 any others that the nurse will be called upon to assume, 
 in his absence, the responsibilities properly belonging to 
 the physician. It may happen that she will be obliged 
 to deliver the child before medical aid can arrive, and a 
 nurse who undertakes this branch of the work should 
 at least know how to conduct a normal case without 
 direction, for the lives of both mother and child may 
 depend upon her skill and promptness. In order to be 
 prepared for such an occasion should it arise, it is neces- 
 sary for .her to possess a much fuller knowledge of mid- 
 wifery than she will ordinarily be called upon to put 
 into practice. The following instructions need to be 
 preceded by a more thorough acquaintance with pelvic 
 anatomy and physiology than can be given here. 
 
 The development of an embryo in the uterus is 
 known as pregnancy, or utero-gestation. During this 
 condition the uterus becomes enlarged, rises out of the 
 268
 
 OBSTETRICS 269 
 
 pelvis, and occupies the abdominal cavity. Other phys- 
 ical signs are suppression of the menses, enlargement of 
 the breasts and the presence of milk in them, and move- 
 ments of the foetus. Milk is sometimes found in the 
 breasts as early as the second month. This is pretty 
 reliable evidence of pregnancy, especially if it occurs in 
 a woman who has not borne children. The mammary 
 glands are so intimately connected with the reproduc- 
 tive organs as to be usually classed among them. Dur- 
 ing pregnancy they become swollen and tender, the 
 veins enlarge, and the circles or areolae about the nip- 
 ples become discolored. The papilla around the nipple 
 become prominent. Swelling of the feet is not uncom- 
 mon, with enlargement of the veins of the legs. When 
 there is much oedema of the legs the urine should be 
 tested for albumin, and if it is found to be present in 
 any quantity the physician should be informed. Dur- 
 ing the last months of pregnancy, the urine should be 
 tested as often as once a week. Bladder disturbances 
 as retention or incontinence of urine are not un- 
 common. A leucorrhceal discharge, may be present. 
 Constipation, diarrhoea, and other disturbances of diges- 
 tion may be looked for. Nausea, particularly distress- 
 ing in the morning when the patient first assumes the 
 erect posture, and thence called " the morning sickness," 
 is common in the early stage of pregnancy. There may 
 be at the same time an abnormal appetite. Salivation 
 sometimes occurs. During the fifth month the move- 
 ments of the foetus usually begin to be felt by the 
 mother. By this time the uterus has risen above the 
 brim of the pelvis, and the nausea may be expected 
 to subside. Many nervous manifestations may accom- 
 pany pregnancy as insomnia, irritability, neuralgia, 
 headaches, toothaches, etc. A cough is common, and
 
 270 A TEXT-BOOK OP NURSING 
 
 in the later stages dyspnoea, arising from pressure upon 
 the lungs. None of all these symptoms occurring singly 
 has any diagnostic value, nor is the absence of them to 
 be counted as negative proof; but when they are found 
 together they afford strong presumptive evidence of 
 pregnancy. Still, a spurious pregnancy will sometimes 
 manifest all of the subjective and even some of the ob- 
 jective symptoms. Perhaps the only positive tests are 
 ballottement and auscultation of the fcetal heart. Bal- 
 lottement consists in displacing the foetus by a push of 
 the examining finger, against which it rebounds with 
 some force, and is recognizable to the practiced touch. 
 It may be performed either externally or internally. 
 The beating of the fcetal heart will usually be audible 
 by the fifth month through the stethoscope. It is very 
 rapid one hundred and thirty or one hundred and 
 forty beats per minute and so readily distinguished 
 from the maternal pulse. When these sounds can be 
 clearly heard, there can be no doubt of the presence of 
 a living child. 
 
 During its intra-uterine existence the embryo, or 
 foetus, is contained in a sac the amnion which se- 
 cretes the watery amniotic fluid in which the foetus 
 floats. The foetus is connected with the uterine wall by 
 the placenta and the funis, or umbilical cord. Through 
 these it receives its nutriment from the mother. 
 
 At the end of nine months the embryo is fully de- 
 veloped, and is expelled from the uterine cavity, the 
 process being known as labor, or parturition. If such 
 expulsion occurs before the embryo is capable of main- 
 taining an independent existence that is, earlier than 
 the seventh month it is known as abortion or miscar- 
 riage; if later than this period, but before the end of 
 the ninth month, it is called premature labor.
 
 OBSTETRICS 2T1 
 
 The full duration of pregnancy is 280 days, although 
 it may be prolonged to 300. The usual rule for calcu- 
 lating the date of its probable termination is to add 
 nine months and seven days to the date when menstrua- 
 tion last began. This is not always reliable, but is based 
 on the theory that conception is most likely to have 
 taken place just after the close of the menstrual period. 
 The approach of labor is heralded by certain prelimi- 
 nary symptoms. During the last two weeks the abdo- 
 men diminishes in size, the uterus sinking down into 
 the pelvis. The pressure upon the lungs gradually be- 
 comes less, so that the difficulty of breathing is removed, 
 but there is increased pressure upon the bladder and 
 rectum, occasioning frequent evacuations. Uterine 
 contractions begin to be felt, and are finally attended 
 by pains. True labor pains come on at regular inter- 
 vals, increasing in intensity, and are usually first felt 
 in the back. False pains are chiefly in front, and are 
 short and irregular. They do not aid at all in the 
 labor, but usually result from indigestion or an over- 
 loaded state of the bowels. A dose of castor oil will 
 clear the intestines and probably relieve false pains, but 
 violent purgation may precipitate the real labor. With 
 the coming on of true pains there is often a discharge 
 of blood and mucus, sometimes called the " show." 
 
 There are three distinct stages of labor. The first 
 stage begins with the first true labor pains, and ends 
 when the cervix is fully dilated. In a normal case, the 
 rupture of the bag of waters occurs at the same time 
 with the full dilation of the cervix. This bag is formed 
 by the pressure of the contracting uterus upon the mem- 
 branes containing the amniotic fluid, and by the same 
 means is forced through the cervical canal, thus dilating 
 it. This is what takes place during a pain. In the
 
 272 A TEXT-BOOK OF NURSING 
 
 intervals between the pains, the uterulT relaxes, the am- 
 niotic bag becomes less tense, and the position of the 
 child may be made out through its walls. Unfortu- 
 nately, however, often the membranes rupture before 
 the os is fully dilated, and then we have what is called 
 a dry labor. The elastic bag to help dilate the cervix 
 is gone, and in its place the hard bones of the fcetal 
 head make pressure. The labor then is apt to be longer 
 and harder for the mother, and is attended with some 
 danger to the child. 
 
 The second stage includes the passage of the child 
 along the pelvic canal, and is concluded by its delivery. 
 After the membranes have ruptured and the cervix is 
 fully dilated, the uterus contracts directly upon the 
 child more and more strongly, forcing it toward the pel- 
 vic outlet, the point of least resistance. Each pain is 
 now accompanied by a strong impulse to bear down, 
 which aids in the expulsion of the foetus. These bear- 
 ing down pains are typical of the second stage. 
 
 After this is accomplished there still remains the 
 third stage, during which the uterus contracts upon the 
 placenta, detaching it from the uterine surface and 
 pushing it out also. The expulsion of the placenta 
 ends the third and final stage of labor, and the woman 
 now enters upon the puerperal state. The empty ute- 
 rus contracts into a firm, hard ball, felt just above the 
 symphysis pubis. It continues for some little time to 
 maintain more or less painful contractions known as 
 " after-pains." These gradually cease. A discharge 
 called the lochia is set up, which lasts for three or four 
 weeks. It takes about six weeks for the organs to regain 
 their normal size and condition. The process is known 
 as involution. The puerperal state is one of peculiar 
 liability to contagion. The interior of the uterus is
 
 OBSTETRICS 273 
 
 after delivery in the condition of an open wound, emi- 
 nently fit for the reception and development of septic 
 germs. For this reason a nurse must never go to an 
 obstetric case from one of contagious disease of any 
 kind, or from a septic surgical case ; and the same anti- 
 septic precautions should be taken as in a surgical 
 operation. 
 
 The average duration of a natural labor is sixteen 
 hours, but in women who have previously borne chil- 
 dren, and often even in primiparae, it is frequently 
 much less. 
 
 It is during the first stage of labor that the nurse is 
 likely to be summoned, and she should answer the call 
 as promptly as possible, so as to have time to make all 
 necessary preparations for the birth of the child with- 
 out hurry. 
 
 Should you have opportunity for previous consulta- 
 tion with the expectant mother, you will frequently be 
 asked to state just what provision it is desirable to 
 make. The following list contains all the essentials, 
 though it may be enlarged and elaborated to any extent 
 to suit the individual taste : For the baby, there will be 
 needed first a small old blanket, a pair of round-pointed 
 scissors, not too sharp, to cut the umbilical cord, 
 and narrow linen tape with which to tie it. Next a 
 bottle of olive oil, a piece of old white Castile soap, 
 some clean soft bits of old linen, sterilized gauze and 
 absorbent cotton, a small soft sponge, a box of talcum 
 powder, not less than four dozen cotton diapers in three 
 sizes, four strips of flannel for bands eighteen inches 
 long by six inches wide, four long-sleeved flannel shirts, 
 six flannel petticoats, eight plain slips, three or four 
 soft woolly blankets (preferably knitted), and two 
 dozen each of large and small nickel-plated safety-pins.
 
 274 A TEXT-BOOK OP NURSING 
 
 For the mother will be wanted six plain night-gowns, 
 one or two flannel wrappers (light and loose), two 
 flannel sacks, a rubber sheet, a roll of antiseptic gauze, 
 ten yards of stout unbleached muslin for bandages, and 
 several dozen sterilized vulva pads. This last may be 
 made of absorbent cotton covered with antiseptic gauze, 
 aud burned after use. Two or three similar pads, a 
 yard square, thick and soft, may be added for the pro- 
 tection of the bed. These also should be sterilized. 
 
 In addition to the above-named articles for the 
 mother and child, } 7 ou should have at hand, when the 
 critical time arrives, plenty of clean towels, a new nail- 
 brush, soap, hot and cold water, ice, three basins, a bed- 
 pan, a fountain syringe, a clean glass catheter, carbol- 
 ized vaseline or lysol, and brandy. Ergot and chloro- 
 form, carbolic acid, and bichloride solution are likely 
 also to be needed. It may be well to ask the doctor 
 whether he wishes you to provide these. 
 
 When it is determined that labor is actually in prog- 
 ress, the patient and the room -should be got in readi- 
 ness. Unless there is a previous history of precipitate 
 delivery, the patient need not at once be put to bed; 
 indeed, it is rather better that she should stand or walk 
 about, resting occasionally on a chair, but maintaining 
 an upright position, as this renders the axis of the 
 uterus coincident with that of the pelvis, and so favors 
 the descent of the head. The bed should be prepared 
 for her, and well protected. The under sheet must be 
 put on tightly, as it may not be changed again for some 
 days, and covered by a rubber and drawn sheet. Over 
 these a second rubber and drawn sheet should be placed, 
 which, after the labor is over, can be removed, leaving 
 the first clean and dry for the patient to lie on. Add 
 to this the above-described absorbent pad. Sometimes
 
 OBSTETRICS 275 
 
 a cot is used during labor, and the patient is afterward 
 transferred to the permanent bed. This is the best way 
 when practicable. 
 
 The patient should have on a clean night-dress, and 
 over it a warm wrapper, which can easily be slipped off 
 when she is ready to go to bed. Brush the hair and 
 braid it tightly. Give a thorough enema, and see that 
 the bladder is emptied. It may be necessary to use the 
 catheter, owing to closure of the urethra by the pressure 
 of the foetal head, but usually there will be frequent and 
 voluntary passage of urine. If the catheter is used, be 
 sure that it is surgically clean. Wash the external parts 
 before using, and do not let it slip into the vagina. 
 If this should happen, take it out, wash, and again 
 boil it before introducing it into the urethra, as other- 
 wise it may carry in enough vaginal mucus to set up 
 cystitis, and so produce a painful complication. You 
 will sometimes be directed to give at this time an anti- 
 septic douche. You may at least wash the external 
 parts, first with soap and water and then with a bichlo- 
 ride solution 1-4,000 or 5,000, using for this purpose 
 absorbent cotton, which can be thrown away not a 
 sponge or a wash cloth. This should be done before 
 each examination and after each micturition. 
 
 The patient should be allowed plenty of digestible 
 food, but no stimulants, as they increase the danger of 
 post-partum hemorrhage. Fluid diet is to be preferred, 
 on account of the possibility that chloroform may be 
 given later. 
 
 The first stage of labor occupies from three to six 
 hours. An examination must be made early to discover 
 the presentation of the child, but when this is once 
 clearly made out, too frequent examinations are to be 
 avoided, as during this stage they only irritate without
 
 276 A TEXT-BOOK OP NURSING 
 
 being of much use. Before making any examination 
 scrub the hands, especially about the finger-nails, most 
 thoroughly with soap and water, rinse off the soap, and 
 soak them in bichloride, 1-2,000. The hand taken di- 
 rectly from this solution will need no further lubrica- 
 tion for an ordinary examination. Introduce the finger 
 into the vagina during an interval between pains until 
 it reaches the open mouth of the uterus. The mem- 
 branes are then lax, and the presenting part of the 
 fcetus can be most easily felt, but the degree of dilata- 
 tion of the os can only be accurately ascertained during 
 a pain, when the membranes are pressed against it. Be 
 very careful not to rupture the membranes before the 
 os is fully dilated. The examination should occupy 
 the time taken up by a pain, and part of the interval 
 preceding or following. In the first stage these inter- 
 vals are long. Efforts at bearing down should not be 
 encouraged, as their only effect is to exhaust the pa- 
 tient's strength. There is often nausea, and even vom- 
 iting. Cramps in the limbs are sometimes distressing, 
 but can generally be relieved by straightening and rub- 
 bing them. Chills are not of rare occurrence. Neither 
 of these is an alarming indication. The patient should 
 be put to bed when the pains change from the back to 
 the front, before the membranes are ruptured, if that 
 event can be anticipated, as, if the body is upright when 
 this occurs, there is more danger that the umbilical cord 
 will be washed down in the gush of waters. The cloth- 
 ing should be pinned up well out of the way, and an 
 extra sheet spread over the lower part of the person, 
 or an unstarched white muslin skirt may be worn. No 
 one should now be allowed in the room but the neces- 
 sary assistants. 
 
 The position taken may be on the back or the left
 
 OBSTETRICS 277 
 
 side, as preferred, in either case near the edge of the 
 bed. The latter is the English mode of delivery. In 
 this country the dorsal decubitus is quite as usual, and 
 generally seems easier for the patient. It is thought 
 that in primiparse the danger of tearing the perinaeum 
 may be less in the lateral position. In general it may 
 be stated that the erect posture should be maintained 
 during the first stage, the dorsal until the head is on 
 the perinseum, the lateral during the birth of the child, 
 and the dorsal again during delivery of the placenta. 
 Very little exposure is necessary; the clothing can be 
 so arranged as to cover the patient and yet be protected 
 from discharges. 
 
 If you have not been able to decide with certainty 
 the presentation of the child before the membranes are 
 ruptured, it is important that you do so immediately 
 after, as there is a possibility of correcting a mal-pres- 
 entation by external manipulation if it is discovered 
 early a possibility which is lost after the child once 
 sinks into the basin of the pelvis. 
 
 In a natural labor the head presents. This is the 
 largest part of the child's body, and where it passes the 
 rest easily follows. The bones of the cranium are soft 
 and yielding, and are united only by membranes, so 
 that when pressed together they can overlap. There 
 are two spaces between them, known as the anterior and 
 posterior fontanelles. By these, and by the cranial 
 sutures, the head is recognized, as well as by its being 
 harder and firmer than any other part. After the rup- 
 ture of the membranes, the scalp will afford a rough, 
 hairy sensation, and the fontanelles can be distin- 
 guished from each other. The anterior is the larger, 
 and has four corners; the posterior is triangular. 
 
 Pass a finger around the edge of the os to discover 
 19
 
 278 A TEXT-BOOK OF NURSING 
 
 if any part beside the head has descended. If the cord 
 has prolapsed, try if possible to replace it above the 
 head, as it is likely to be crushed during the progress of 
 labor, cutting off the child's circulation with fatal 
 result. The operation of returning it will be facili- 
 tated by having the patient rest on her knees and elbows. 
 Remember never to make any examination, or even to 
 touch the patient in the region of the genitals, without 
 first thoroughly washing and disinfecting the hands. 
 
 During the second stage, examinations must be more 
 frequent, to test the degree of advancement of the head. 
 The pains will now be more severe, the intervals be- 
 tween them shorter, and there will be an impulse to aid 
 them by bearing down. This need not be suggested, 
 as it will come of itself at the proper time. The patient 
 not infrequently drops asleep for a few minutes between 
 the pains. The only assistance that can now be ren- 
 dered is to support the back, and to give the patient 
 something to pull upon if she feels inclined. A sheet 
 knotted to the foot of the bed may be useful for this 
 purpose. As the head approaches the perineum, this 
 support should be taken away, and the bearing-down 
 efforts discouraged, lest it be too suddenly stretched, 
 and so torn. The progress of the head through the 
 vulva must be rather restrained than hastened, as the 
 more gradual it is the less is the danger of such a 
 perineal rupture. This is most likely to occur in a 
 primipara, and is usually in consequence of the head 
 being driven too far backward, and too forcibly against 
 the perinseum. It may sometimes be averted by sup- 
 porting the perineum with the palm of the hand, and 
 guiding the head forward. This support should not 
 be continuous, but applied during the last two or three 
 pains, when the anterior margin of the perineum grows
 
 OBSTETRICS 279 
 
 evidently thin. Careful watch should be kept, and, as 
 the head emerges, it should be pressed forward and 
 slightly upward, so as to relieve the strain upon the 
 perinasum as much as possible. The hand should not 
 follow the head, but be kept upon the perineum as it 
 retracts. If a tear seems imminent, do not allow the 
 head to emerge during a pain, but work it out gradually 
 in an interval between pains. This manoeuvre is aided 
 by making traction with two fingers in the rectum. It 
 is well to do the same while the shoulders are passing, 
 though the greatest danger is over when the head is 
 safely born. Look to see if the cord is about the child's 
 neck, and, if so, draw it gently down and slip it over 
 the head. If it can not be loosened enough for this, or 
 if it is wound two or three times around the neck, put 
 a finger under one loop and cut it, tying both ends. 
 There will usually be plenty of time for this, as there 
 is apt to be an interval of several minutes before the 
 shoulders follow the head. After that the perinaeum 
 need no longer be supported, and the hands may be free 
 to receive the child. 
 
 As soon as it is born, lay it down at right angles to 
 the mother, close enough to make no traction on the 
 cord. The shock of exposure to the air will generally 
 excite inspiration. If it does not, wipe out the mouth, 
 to remove any mucus that may obstruct it, slap the 
 child on the back, blow on it, or sprinkle with cold 
 water. Do not cut the cord until the child has cried 
 or until no pulsation can be felt in it; squeeze out the 
 contents to reduce the bulk as much as possible, and tie 
 it in two places, one about two and the other three or 
 four inches from the child's abdomen, and cut between 
 the two with blunt scissors, which will crush the vessels. 
 The end of the cord should be examined after an hour
 
 280 A TEXT-BOOK OP NURSING 
 
 or so, and, if there is any bleeding, another ligature 
 should be applied. The ligature on the placental end is 
 to keep the placenta from being drained of blood, in 
 which case the shrinkage would make its expulsion less 
 easy, and, in case of twins, might be fatal to the second 
 child. The child, once separated from the mother and 
 breathing properly, may be wrapped in a blanket and 
 laid aside in a safe place while the mother receives 
 attention. Immediately upon the birth of the child the 
 assistant should have placed one hand over the abdo- 
 men, to secure contraction of the uterus and to ascer- 
 tain if there is a second child in it. It should be firmly 
 held until after it is entirely empty. 
 
 The expulsion of the placenta may follow immedi- 
 ately upon that of the child, or after an interval of half 
 an hour or more. If after its separation from the 
 uterus it is detained in the vagina beyond a reasonable 
 time, slight traction upon the cord will usually serve to 
 remove it, but no such traction should be made while 
 there is any attachment to the uterine surface. The 
 uterus may be recognized as empty when it is felt as a 
 firm, hard ball just above the symphysis pubis. If it 
 fails to contract after the birth of the child, press it 
 down into the pelvis, with the hand over the fundus, 
 the thumb resting on its anterior surface, while the 
 fingers are pressed down behind the organ. This will 
 generally stir up a pain. If the placenta is not then 
 expelled, repeat the movement with the next pain. As 
 the placenta slips from the vulva, it should be caught 
 and twisted round and round, so that none of the mem- 
 branes will be left behind. A vessel should be at hand 
 to receive it. Later it must be carefully examined to 
 see if it is entire. If any portion is missing, it must be 
 looked out for until it is passed, as it is a possible
 
 OBSTETRICS 281 
 
 source of danger so long as it is retained. After exami- 
 nation, burn or bury it. 
 
 The vulva may now be bathed with warm disinfect- 
 ant solution, the soiled articles removed, and a binder 
 pinned firmly about the abdomen. A straight band 
 eighteen inches wide is the best .shape for this. It can 
 be closely fitted with pins, and should come well below 
 the hips, so as not to ride up. Sometimes a folded 
 towel is put under it, just over the fundus uteri, to 
 make additional pressure at this point. Over the vulva 
 place a pad of absorbent cotton, folded in antiseptic 
 gauze. Some such dressing as this, which can be 
 burned as soon as soiled, has now almost entirely and 
 very advantageously superseded the old-fashioned nap- 
 kin. It should be renewed every three or four hours at 
 first; every time it is changed, and when the patient 
 urinates or defecates, the parts are to be carefully irri- 
 gated with the disinfectant solution, or with water 
 which has been boiled. Before changing the dressing, 
 the nurse should disinfect her hands as in dressing a 
 wound, and take the same care to see that everything 
 brought in contact with the patient is antiseptically 
 clean. 
 
 After the first dressing the mother must be kept 
 entirely quiet, and the nurse may give her attention to 
 the child. No talking should now be allowed in the 
 room, no visitors, no excitement of any kind. Before 
 leaving the mother, note the condition of the pulse, 
 which should be rather slower than usual, from sixty to 
 seventy. If it is above one hundred, look out for some 
 complication, especially hemorrhage. 
 
 After the mother has rested a few hours, and the 
 child has been washed and dressed, it is well to put it 
 to the breast. The first milk, the colostrum, is of quite
 
 282 A TEXT-BOOK OP NURSING 
 
 different quality from the later secretion, and has a pur- 
 gative effect upon the child, clearing the intestines of 
 the meconium, a dark viscid matter with which they are 
 loaded at birth. The suckling of the child helps to 
 secure contraction of the uterus, often occasioning quite 
 severe after-pains; it excites more abundant secretion 
 and draws out the nipple. Indeed, it is quite as much 
 for the mother's sake as for the child's that it is put to 
 the breast thus promptly. The baby will not suffer if 
 it has no food at all for the first twenty-four hours. Dp 
 not accept any suggestions with regard to the necessity 
 of feeding it. The colostrum is scanty, but quite suffi- 
 cient for the need. When the breasts are engorged, 
 very gentle rubbing with warm oil, always in a direction 
 from circumference to center, will accelerate the flow 
 of milk. The milk does not appear in abundance until 
 about the third day. Its secretion may be delayed till 
 the fifth or sixth day. There is almost always some 
 pain and constitutional disturbance accompanying it, 
 and, if the breasts are not properly relieved, milk fever 
 and mammary abscess may ensue. If the child can not 
 empty the breast sufficiently, the milk should be drawn 
 off by a breast-pump. A good substitute for a breast- 
 pump is a champagne bottle with a smooth edge; fill it 
 with hot water, let it stand a moment, then pour it out 
 quickly, oil the edge, and apply the mouth of the bottle 
 over the nipple. As the heated air condenses, the milk 
 will be sucked out into the bottle. The condensation 
 may be increased by wrapping around the bottle a towel 
 wet in cold water. The same method is useful to draw 
 out a retracted nipple, which the child has difficulty in 
 grasping. Sunken or retracted nipples may be some- 
 what helped by gently drawing them out with the fingers 
 several times daily. It is a good plan to manipulate
 
 OBSTETRICS 283 
 
 them in this way during the last two or three months 
 previous to confinement, and at the same time to rub 
 them with vaseline or cacao butter, to render the skin 
 soft and flexible. This treatment will go far to prevent 
 them from becoming excoriated or fissured. Should this 
 happen, it may be necessary to use nipple shields at the 
 time of suckling. The nipples must be kept free from 
 pressure, and the breasts protected by an extra cover- 
 ing, as they are very sensitive to cold. They need to 
 be kept clean, but it is not well to bathe the nipples 
 too much, as it makes them tender. After each nurs- 
 ing, sprinkle them liberally with talcum powder with- 
 out washing or otherwise drying them, and they will 
 in the majority of cases need no other treatment. Of 
 course this must be washed off before the child is again 
 put to the breast, preferably with a solution of boracic 
 acid. 
 
 If the child, for any reason, is not to nurse, the 
 secretion of milk must be checked. This is usually done 
 by bandaging the breasts closely, supporting them by 
 pads of cotton at each side, so that the pressure will be 
 made evenly. The bowels must be kept open, and the 
 amount of fluid taken into the system limited as far as 
 possible. Belladonna is sometimes employed to help 
 dry up the secretion, usually in the form of an unguent 
 rubbed in gently. Kubbing of the breasts must always 
 be toward the nipple. 
 
 The mother during the puerperal state requires the 
 most careful nursing. She should be kept in bed for 
 ten days or two weeks, not being allowed to sit up for 
 any purpose, or in any way to exert herself. It is of 
 the greatest importance that she and everything about 
 her be kept clean. She should have a thorough sponge- 
 bath all over every day, and the vulva should be washed
 
 284 A TEXT-BOOK OF NURSING 
 
 two or three times daily. On the question of douches, 
 doctors differ. If you have no especial directions, it is 
 safe to give one of 1-5,000 bichloride or of boiled water 
 immediately after labor and then no more unless the 
 lochia become offensive, as may occur after five or six 
 days. There should be no odor perceptible on entering 
 the room. Have plenty of fresh air, but at the same 
 time be careful to avoid chilling the patient, especially 
 when she first gets up. The catheter must be used every 
 six or eight hours if the bladder can not be otherwise 
 emptied. There is often temporary paralysis of the 
 vesical neck following labor. A laxative or an emollient 
 enema should be given on the third day, and every 
 second day thereafter until the bowels move naturally. 
 The diet should be light and unstimulating for the first 
 week; after that, if the patient is progressing favorably, 
 she may return to her usual diet. 
 
 One of the greatest dangers attending childbirth is 
 that of ha?morrhage. This may take place either be- 
 fore, during, or soon after labor. 
 
 Haemorrhage immediately after delivery is known as 
 post-partum haemorrhage; occurring two or three days 
 later, it is called secondary. It may follow even a per- 
 fectly natural labor so profusely as to endanger life. 
 There is little fear of it while the uterus is firmly con- 
 tracted. If it is felt to be enlarging and relaxing, it is 
 a sign of danger, and every effort must be made to in- 
 duce contractions, which prevent the escape of blood by 
 lessening the caliber of the blood-vessels. This symp- 
 tom, and other indications of haemorrhage as pallor, 
 coldness of the extremities, feeble pulse and respiration 
 must be watched for, especially when the patient is 
 asleep. 
 
 "Watch particularly the lips, as the mucous mem-
 
 OBSTETRICS 285 
 
 brane, being thinner, shows loss of blood more quickly 
 than the skin. The blood may come in a sudden gush, 
 or in a slow but steady flow, from the placental site, and 
 is in consequence of failure of the uterine muscles to 
 contract and close the blood-vessels left open by the 
 separation of the placenta. The direct object of treat- 
 ment is to induce contractions of the uterus. Open the 
 windows to give abundant fresh air, elevate the foot 
 of the bed, and make vigorous pressure upon the uterus. 
 You may give ergot if the uterus is empty, but never 
 while the fcetus or placenta remain in it. The impor- 
 tant thing is to empty the uterus, and you should not 
 hesitate to introduce the whole hand in order to clean 
 it out. If the placenta has not been expelled, it must 
 now be removed without delay, but never try to extract 
 it by pulling upon the cord. The hand, first made asep- 
 tic, should be inserted well above the placenta, sp as 
 to make sure of getting the whole of it. In the same 
 way, you should sweep out any clots which may prevent 
 the uterus from contracting, and knead the organ vig- 
 orously, with one hand inside and one on the abdominal 
 surface. You may carry into the uterus with the hand 
 a lump of ice, or a sponge soaking in vinegar, or inject 
 hot water (116 F.), but with all this allow the patient 
 herself to make absolutely no effort. The most efficient 
 way of controlling the bleeding is to stuff the uterus 
 full of sterilized gauze. This the nurse can do at once 
 if she is alone and can not leave the patient to prepare 
 a hot douche. 
 
 Internal haemorrhage during labor is a formidable 
 complication, since there may be no escape of blood ex- 
 ternally. The patient suddenly collapses, and has a 
 severe bursting pain in the abdomen. Labor pains cease 
 and the uterus becomes greatly distended. Give stimu-
 
 286 A TEXT-BOOK OF NURSING 
 
 lants hypodermically, and summon the nearest physi- 
 cian. 
 
 Another peculiar danger to which this state is liable 
 is that of puerperal fever, a form of blood-poisoning 
 most commonly established within three or four days 
 after labor, resulting either from absorption of the de- 
 composing matter produced by the woman herself, or 
 from infection brought to her from some external 
 source. After the raw surfaces are healed over and 
 the os uteri closed, the danger is less, but antiseptic 
 precautions ought still to be kept up. The disease is 
 commonly initiated by chills, followed by high fever, 
 the temperature rising to 102, 103, or even, in severe 
 cases, to 106. The pulse is rapid; the countenance 
 sunken and anxious; there is a sickly odor to the breath; 
 usually diarrhoea and vomiting; the lochial discharge is 
 suppressed, or becomes altered in character; the secre- 
 tion of milk ceases. It is often complicated with peri- 
 tonitis or metritis inflammation of the uterus. The 
 symptoms and severity are variable, but it is always dan- 
 gerous and highly infectious. The treatment is prac- 
 tically the same as that of wound infection in general 
 the application of antiseptics to the affected surface and 
 supporting the general strength. Fresh air, surgical 
 cleanliness, and faithful antisepsis will prevent its de* 
 velopment. 
 
 Another disease of the puerperal state, though not 
 entirely confined to it, is phlegmasia dolens, commonly 
 known as milk-leg, from a popular but entirely un- 
 founded notion that the milk settles in the leg. It is 
 caused by obstruction of the femoral vein by a blood- 
 clot, and results most commonly from exposure or over- 
 exertion; it is a local expression of septic infection. 
 The leg swells and becomes intensely painful, the skin
 
 OBSTETRICS 287 
 
 white and tense. There is often fever accompanying it, 
 and sometimes chills. It is treated by absolute res! 
 Support the limb comfortably, keep it warm by envel 
 oping it in cotton wool, and the condition may be ex- 
 pected to gradually disappear, though it does not always 
 terminate so happily. 
 
 Puerperal convulsions sometimes occur, technically 
 termed eclampsia. These are usually of a uramic type, 
 resulting from deficient action of the kidneys, and are 
 very dangerous. On account of the premonitory symp- 
 toms, often overlooked, a pregnant woman should be 
 under the care of a physician for some time previous to 
 labor, and during the later months the urine should be 
 tested for albumin every ten days. Preventive treat- 
 ment is most important. 
 
 Headache, with ringing in the ears and bright 
 flashes before the eyes, dyspnrea, nausea, puffiness of 
 the face, hands, and labia, and diminished excretion of 
 urine, are among the alarming symptoms. Give large 
 doses of cream-of -tartar water (3ij-0j), keep the 
 bowels open with saline laxatives, and try in every way 
 to induce free perspiration. Should the convulsions 
 occur, they may be quieted by chloroform. If no chloro- 
 form is at hand, little can be done except to keep the 
 patient from hurting herself. Eight or ten minims of 
 Magendie may be injected, or chloral, gr. xx-xxx, may 
 be given per rectum. Give plenty of fresh air, see that 
 the clothing is entirely loose, and put something be- 
 tween the teeth to keep the tongue from being bitten. 
 The patient will be entirely unconscious during the at- 
 tack, and may rouse at first as if from sleep, but, unless 
 speedy relief is obtained, soon sinks into fatal stupor. 
 If oedema of the lungs suddenly develops, apply dry 
 cups and mustard poultices.
 
 288 A TEXT-BOOK OP NURSING 
 
 A form of insanity may follow labor, known as puer- 
 peral mania. It usually takes the form of melancholia, 
 often with a disposition to injure the child. It is acute 
 while it lasts, but rarely permanent. It is a possibility 
 against which the nurse should always be on her guard, 
 as it may come on very abruptly, sometimes even before 
 the labor is ended. Look out for a patient who has been 
 low-spirited during pregnancy. 
 
 " Heaven lies about us in our infancy. 
 
 Our birth is but a sleep and a forgetting. 
 The soul that rises with us, our life's star, 
 
 Hath had elsewhere its setting, 
 And cometh from afar." 
 
 Wordsworth.
 
 CHAPTER XVII 
 
 "Dispose not thyself for much rest, but for great patience." 
 Thomas a Kempis. 
 
 THE care of an infant begins with its separation 
 from the mother and the tying of the umbilical cord. 
 Independent circulation and respiration should now be 
 established, and its existence as a separate entity com- 
 mences. The first thing is to see if the heart is beating 
 and the child is breathing properly. The shock of con- 
 tact with the air will generally excite respiration, but if 
 it fails to do so it must be artificially stimulated. To 
 do this, first wipe out the mouth and throat with the 
 finger to remove any accumulation of mucus which 
 might obstruct the air passages, then fan or blow upon 
 the child sharply, sprinkle cold water in its face, slap its 
 back, or, if these measures produce no effect, dip it 
 alternately into cold and hot water. The cold water is 
 merely to produce shock, and the child should remain 
 in it but an instant, and then be immersed for a minute 
 or two in hot water not over 110 F. Then dry and 
 rub with flannel. If natural respirations are still not 
 established, they should be artificially produced after 
 Sylvester's method and kept up as long as the heart 
 beats ever so faintly. If the child seems strong and the 
 heart-beats are vigorous, Schultze's method of estab- 
 lishing respiration may be adopted. His procedure is as 
 follows: Stand and grasp the child so that your thumbs 
 
 289
 
 290 A TEXT-BOOK OF NURSING 
 
 rest on its chest, the index-fingers are in the axillae, 
 and the other fingers cross the back diagonally. Sus- 
 pend the child, held in this manner, between the knees, 
 its face to the front; swing the child upward until your 
 arms are horizontal, then stop suddenly. As the child's 
 head falls backward, support it with the fingers which 
 rest on its back. The legs will curl forward, as if the 
 child were going to turn a somersault backward, and 
 the weight of the body will be thrown upon your 
 thumbs, compressing the thorax and abdomen, and 
 causing a forced expiration. Swing the child back to 
 its former pendent position, and a deep inspiration will 
 be produced. Repeat eight or ten times at intervals of 
 ten or fifteen seconds, then drop the child into a warm 
 bath. If it does not yet breathe, repeat the swinging 
 process as before. This mode of treatment, though in 
 some cases excellent, should not be tried on a feeble 
 infant with weak action of the heart. Do not swing the 
 child too often, and stop if it begins to breathe. 
 Through all these processes, be careful not to let the 
 child become chilled. After every shock of cold water 
 or cold air, a plunge into warm water should be given 
 to restore the vital heat. In delicate and especially in 
 premature infants, although breathing, there may be 
 very low vitality, and warmth may be more essential to 
 their preservation than anything else. It is often a 
 matter of difficulty to keep them warm enough. A 
 couveuse or incubating apparatus, in which a perfectly 
 even temperature can be maintained, is sometimes used, 
 and the child is kept in it until it has acquired suffi- 
 cient vigor to endure the variations of an ordinary at- 
 mosphere. 
 
 All babies need at first a great deal of warmth. 
 Through fear of chilling them, some physicians prefer
 
 SICK CHILDREN 291 
 
 not to have a child washed for several hours after birth. 
 To remove the vernix caseosa, or cheesy varnish with 
 which it will be more or less covered, it may be rubbed 
 with sweet oil, and then wiped off with a soft cloth. 
 For a feeble child, this is all the cleansing of the body 
 necessary at first, except that in all cases the eyes must 
 be thoroughly washed. For this purpose' use a warm 
 saturated solution of boric acid. 
 
 Ordinarily, however, the baby may be washed at the 
 nurse's convenience, while the mother is resting. The 
 bath should be given in a warm place, and its tempera- 
 ture be not much above that of the air. An old-fash- 
 ioned way of testing the heat of the water is by the 
 elbow, to which it should feel neither cold nor warm. 
 
 Take the feet of the child in the right hand, the 
 shouders in the left, letting the head rest upon the arm, 
 and lower it very gradually into the water. Still sup- 
 porting the head with the left hand, wash it all over 
 with a clean soft sponge, then lift it out into the folds 
 of a warm towel. Dry thoroughly, especially about the 
 joints, but without much rubbing. Dust with talcum 
 powder under the arms and between the legs, and look 
 to see if the anus and urethra are open and the child in 
 a normal condition all over. Wrap the cord in dry 
 salicylated cotton and lay it on the left side of the body. 
 Keep it in place by a flannel band about the abdomen, 
 tight enough not to slip, but not so tight as to impede 
 the child's respiration. All the garments should be 
 warm and not too tight. Put one inside another, and 
 the whole on over the feet rather than the head, turn- 
 ing the child no more than is necessary. 
 
 From this time on the baby should have a bath all 
 over daily. The best time for it is in the morning, and 
 half-way between two meals. The temperature of the
 
 292 A TEXT-BOOK OP NURSING 
 
 room in which it is given should be not less than 75, 
 and the temperature of the water 100. The child 
 should not remain in the tub more than five minutes. 
 Little soap is needed and little rubbing, for the skin is 
 very tender. Use talcum powder where there is any 
 suggestion of chafing. Fresh, dry cotton should be 
 put on the cord each day until it falls off, which it will 
 do in about a week; boric acid is a good dressing. It is 
 well then to keep a compress over the umbilicus until 
 it is depressed and of the same color as the surrounding 
 skin. The shirt should be long enough to meet the 
 diapers, to which it may be pinned. It also should be 
 of flannel, with long sleeves, and open all the way down 
 the front. Over this a flannel petticoat or sleeveless slip 
 should come down well over the feet. Socks are unim- 
 portant while long dresses are worn, but the feet must 
 be kept thoroughly warm. The outer garments vary to 
 suit the taste, but everything should be soft, warm, and 
 loose. Cotton diapers are better than linen. These 
 should be changed as soon as wet, and never used again 
 without having been washed. The bowels may be ex- 
 pected to move two or three times daily. The meco- 
 nium ought to be cleared out and water passed during 
 the first twenty-four hours. If the latter fails to occur, 
 apply a hot stupe over the kidneys. The child's breasts 
 will sometimes be swollen and full of milk for a few 
 days after birth. Do not rub or let the clothing make 
 any pressure upon them, and the condition usually will 
 gradually disappear without treatment. 
 
 As a rule, the most suitable food for a baby is its 
 mother's milk, or, that failing, the nearest approach to 
 it that can be made, though there are exceptional cases 
 in which the mother's milk fails to agree with the 
 child. The child should be fed during the first three
 
 SICK CHILDREN 293 
 
 months at intervals of two or three hours regularly. 
 The intervals may be longer at night. In putting the 
 child to the breast, see that the nostrils are not ob- 
 structed; otherwise it can neither breathe nor suck. 
 It should not be allowed to go on sucking indefinitely 
 after it has had food enough, or to suck an empty feed- 
 ing-bottle, its own fingers, or anything else. This may 
 keep it quiet for a time, but ultimately makes matters 
 worse by getting its stomach overloaded or full of wind. 
 A baby need not be assumed to be hungry because it 
 cries, but something is the matter with it, and it is the 
 business of the nurse to find out what. It does not cry 
 unless it is in some way uncomfortable. A child a month 
 old should sleep twenty hours out of the twenty-four 
 without being rocked or carried about. Habits will be 
 easily acquired at this age. The child should sleep in 
 a crib, and be taught to go to sleep by itself. Let it lie 
 on either side, not directly on the back, as there is dan- 
 ger in this position that the milk may regurgitate and 
 get into the trachea. Do not have a strong light in the 
 room, as the eyes of both mother and child are weak. 
 If the child is not to nurse its mother, it may be given 
 half a teaspoonful of the -sirup of rhubarb soon after 
 birth to remove the meconium, as it will miss the pur- 
 gative action of the colostrum. 
 
 In the absence of the mother's milk, that of a suit- 
 able wet-nurse is considered the best food for the child, 
 but desirable ones are very difficult to find. She must 
 be a perfectly healthy and not nervous woman, whose 
 own child is nearly the age of the one she is to nurse. 
 If cow's milk is used, it must be at first diluted with 
 twice as much water, and slightly sweetened. Unless 
 it comes from thorough-bred Jerseys, cream should be 
 added to it and a little salt. Sugar of milk is the best 
 20
 
 294 A TEXT-BOOK OF NURSING 
 
 for sweetening, and boiled water should always be used 
 for diluting the milk. The proportion of water may 
 be gradually lessened, until after six months the milk 
 may be given pure. Milk from a single cow is no longer 
 recommended, as the average from a well-cared-f or herd 
 is more uniform in quality. Condensed milk is, per- 
 haps, of more even quality than the ordinary dairy prod- 
 uct, but it is apt to be constipating. Unless the milk 
 is exceptionally pure and directly obtained, it should be 
 Pasteurized before use. This process consists in rais- 
 ing the temperature of the milk to 167 F., and so keep- 
 ing it for twenty minutes. This practically sterilizes 
 it without boiling, and does not so much alter its char- 
 acter. Milk treated in this way can be kept on ice for 
 several days. Modified milk can now be obtained in 
 some places, especially adapted for children of different 
 ages. An excellent formula is that known as Meigs's 
 mixture, consisting of 
 
 1 part milk, 
 
 2 parts cream, 
 
 2 " limewater, 
 
 3 " sugar water. 
 
 The sugar water is made by adding two heaping 
 tablespoonfuls of pure sugar of milk to a pint of water. 
 Sterilize the entire mixture. Let the infant nurse di- 
 rectly from the sterilizing bottles, substituting a clean 
 rubber nipple for the cork, and warming to the tem- 
 perature of new milk by standing the bottle in hot water 
 for a few minutes. The best appliances are those that 
 can be most easily cleaned. Graduated bottles save 
 labor in the measuring of food. Use a plain black rub- 
 ber nipple fitting over the neck of the bottle, with an 
 opening large enough to allow the milk to drop rapidly 
 when inverted, but not to flow out in a stream. When
 
 SICK CHILDREN 295 
 
 not in use, let them lie in a borax solution, and keep 
 the bottles full of clean water. Just before using, 
 sterilize them both. After use, rinse first with cold 
 water, then wash with hot soapsuds. 
 
 If the food is rejected, either the child is overfed 
 a common source of trouble or the food is in some way 
 unsuitable. Vomiting by an infant is rarely attended 
 with much constitutional disturbance. A child is often 
 rendered restless by thirst, and will be quieted and re- 
 lieved by a little clear cold water. This should always 
 be given at least twice a day. After eight or ten months 
 the daily meals should not exceed six in number. An 
 allowance of bread and milk, or beef -tea, may be given, 
 but it should not come to depend upon solid food until 
 all the teeth are cut. Contrary to the common impres- 
 sion, thick food is less nutritious than thin. The first 
 teeth may be looked for at about the sixth or eighth 
 month, and the others at intervals, until the first set of 
 twenty is complete, at about the age of two years. The 
 process of dentition may be accompanied by various 
 functional disorders. It unsettles the healthy balance 
 of the system, and predisposes to, if it does not exactly 
 cause, disease. The child may be restless and feverish; 
 diarrhoea is common; sometimes even croup and con- 
 vulsions occur. These need medical advice, as at other 
 times, and great attention must be paid to general nurs- 
 ing and dieting. Keep the little one in the open air as 
 much as possible, suitably clothed. If the gums are 
 very painful and swollen, it may be necessary to have 
 them lanced. 
 
 A high degree of development of those qualities de- 
 sirable in any nurse is requisite in the care of sick chil- 
 dren. This calls for infinite tact, patience, and judg- 
 ment, and especially is the habit of critical observation
 
 296 A TEXT-BOOK OF NURSING 
 
 essential, for, with children too young to speak, the in- 
 voluntary revelations of signs and gestures give often 
 the only clew to the seat and kind of distress. The ob- 
 jective symptoms are, fortunately, very marked in chil- 
 dren, and they respond to treatment with a readiness 
 which makes them very interesting subjects. A good 
 deal may be learned from the character of a baby's cry. 
 With abdominal pain the cry will be long, loud, and 
 tearful, subsiding, as the pain is relieved, into long- 
 drawn sobs. The legs will be drawn up to relax the 
 strain on the abdominal muscles. If there is inflamma- 
 tion of the chest, there will be less tears and less noise, 
 the cry begun after each deeper breath or cough will be 
 sharp and suppressed, evidently augmenting the pain. 
 Sharp screams, alternating with low moans or stupor, 
 suggest some affection of the brain. Waking suddenly 
 with a cry, grinding the teeth, or starting nervously in 
 the sleep and boring the head into the pillow are all 
 noteworthy symptoms in children. No departure from 
 the usual habits of the child is unimportant. Note 
 whether it is unusually stupid, restless, or irritable, in 
 what position it seems most easy, whether the light oc- 
 casions distress, and whether the general symptoms of 
 disorder increase in severity toward night. The tem- 
 perature should be taken in the rectum. If a child 
 complains of pain anywhere, and has a rise of tempera- 
 ture, it is safe to examine the throat. The pulse of an 
 infant can only be taken with any approach to accuracy 
 during sleep. A very slow pulse is more ominous in a 
 child than a rapid one. Children gain and lose flesh 
 with great rapidity, showing it first on the inner side 
 of the thighs, where two or three days' illness will have 
 a marked effect. 
 
 In dealing with sick children the utmost gentleness
 
 SICK CHILDREN 297 
 
 is necessary. They ought never to be frightened or 
 startled. It is a bad time to introduce a stranger to a 
 shy baby when it is sick, and the first thing to be done 
 often a very difficult thing to do is to acquire the 
 child's confidence. Until it has become accustomed to 
 your presence, it may be best to allow everything to be 
 done for it by the mother or usual attendant, while you 
 merely give directions. A child accustomed to unlim- 
 ited indulgence, afraid of strangers, and fretful from 
 pain is not an easy patient to manage; it will require 
 winning tact and a genuine sympathy for the little one 
 to get even the possibility of caring for it helpfully. 
 Whatever excites or alarms, does the child harm, mak- 
 ing it nervous and feverish. Do not give too many toys 
 in the effort to divert, one at a time is better than a 
 dozen, and, above all, do not let the child see any that 
 it can not have. Children may be attacked by many of 
 the same diseases as older people; there are also some 
 which are peculiar to them, and others which appear 
 most frequently in early life. When a child first ex- 
 hibits indisposition, it is always safe, and often sooth- 
 ing, to put it in a warm bath. This will tend to bring 
 out any latent rash, for which the whole body should 
 be carefully examined. The room should be warm and 
 free from draughts, the temperature of the bath 100 
 Fahr., and the child allowed to remain in it about five 
 minutes. If the baby is afraid of the water, prepare 
 the bath out of sight, and cover it with a blanket. The 
 child can then be gradually let down into the water, 
 blanket and all, without any shock. When taken out, it 
 should be wrapped in a soft dry blanket for a few mo- 
 ments, and then dried with soft towels. Guard against 
 exposure, keep as quiet as possible, on the simplest diet, 
 and watch carefully for further signs of disorder.
 
 298 A TEXT-BOOK OF NURSING 
 
 Thrush or sprue is a sort of fungoid growth appear- 
 ing in the form of white spots on the tongue and inside 
 of the mouth. It may result from improper food, or 
 from neglect to wash out the child's mouth after eating. 
 Particles of milk remaining in the mouth decompose, 
 and set up fermentation. The remedy most frequently 
 prescribed is a wash of borax water, gr. xx- j. Errors 
 of diet should be corrected, and great attention paid to 
 the cleanliness of feeding-bottles, etc. If it is allowed 
 to spread, it may extend into the throat and cause dif- 
 ficulty in swallowing, or even attack the stomach, when 
 it may prove fatal. It is a serious indication if an erup- 
 tion appears about the anus simultaneously with thrush 
 in the mouth. 
 
 Ophthalmia neonatorum. Soreness of the eyes in a 
 young child is a serious matter, requiring prompt atten- 
 tion. A purulent exudation may occur, inflaming the 
 lids and gumming them together. This is usually in 
 consequence of some infection received at the time of 
 birth from the maternal discharges, and first manifests 
 itself about the third day. It is in order to guard 
 against this that so much care is taken to cleanse the 
 eyes thoroughly immediately after delivery. Should 
 the least sign of such inflammation be observed, the 
 eyes must be frequently bathed with warm water or a 
 solution of boric acid, and the greatest care be taken to 
 prevent the spread of the disease, for the discharges are 
 highly infectious, and the danger of contagion is not 
 confined to children. In bathing the eyes, separate the 
 lids without making any pressure on the eyeball, and 
 let a stream of clean warm water trickle over the 
 surface, always in the direction from the nose to the 
 outer angle. Do not rub them in the least, but re- 
 peat the syringing until they are entirely free from
 
 SICK CHILDREN 299 
 
 matter. It may be necessary to do this every hour. 
 A little absorbent cotton will serve to hold the water, 
 or a perfectly clean medicine dropper may be used. 
 If they do not show improvement promptly, the gran- 
 ulations should be touched with a solution of nitrate 
 of silver, gr. xl- j. Burn at once the cotton and any 
 cloths used about the eyes, and disinfect your own 
 hands most carefully, scouring the nails with a 
 brush. Do not touch your own eyes with your fingers 
 before they are cleaned, and if one eye only of the 
 child is affected, lay it down always on that side, 
 that the other may not be contaminated. Neglect of 
 this trouble for a few days may result in total loss of 
 sight. 
 
 The most common troubles of children are disor- 
 ders, more or less severe, of the digestive tract. In the 
 case of a feeble child unable to take or retain food, 
 " gavage " or forced feeding may have to be resorted 
 to. For this purpose a rubber catheter is used, con- 
 nected at the open end with a small glass funnel. The 
 point of the catheter introduced at the back of the 
 tongue or through the nose will be instinctively swal- 
 lowed, after which the food is poured into the funnel, 
 and after a few seconds quickly removed. If skillfully 
 done, the food will be retained. Washing out the stom- 
 ach by the aid of a similar apparatus has in some cases 
 been found beneficial. 
 
 Colic. The wind colic of infants, though distress- 
 ing, seldom requires medical treatment. If persistent, 
 it is probably due to unsuitable food; or, in the case of 
 a nursing baby, to the condition of the mother. Do not 
 give soothing-sirups. Eubbing and the application of 
 hot flannels to the abdomen will usually relieve it. A 
 Uttle hot water flavored with peppermint or anise may
 
 300 A TEXT-BOOK OP NURSING 
 
 be given, or, if this fail, try two or three drops of gin 
 in hot water. 
 
 Diarrhoea. When diarrhoea is present, a little cal- 
 cined magnesia or castor oil may be given. Put a flan- 
 nel band about the bowels, and be sure to keep the 
 child warm. The skin is apt to become chafed and sore; 
 scrupulous attention must be given to cleanliness. In 
 place of soap and water, very thin starch may be used 
 and will be found soothing. Dry carefully, and dust 
 with talcum powder, or dry starch. If the diarrhoea is 
 long continued, it will be exhausting. Have medical ad- 
 vice, and do not give paregoric without it. 
 
 Constipation. When there is a tendency to consti- 
 pation, rub the bowels night and morning with warm 
 olive oil. Oatmeal gruel will be a helpful diet. A small 
 suppository of Castile soap will usually induce a move- 
 ment. Gluten or glycerin suppositories are also good. 
 Water, given abundantly, helps to regulate the intes- 
 tinal action. It is well to establish regular habits in 
 children, and with a little pains it can be done early; 
 but it is most injudicious to urge them to strain until 
 something has been accomplished. 
 
 Protrusion of the bowel may be caused by straining. 
 If it has occurred, lay the child on its back, with the 
 hips elevated, wash the parts carefully in tepid water, 
 and replace the bowel very gently, after oiling the fin- 
 gers. If it can not be done readily, the child must be 
 kept quiet, and the doctor sent for. 
 
 Worms. Delicate children are sometimes troubled 
 by worms in the intestine. Eound and pin worms are 
 the most common. The tape-worm is more often found 
 in adults. It is desirable for the nurse to become ac- 
 quainted with these parasites, in order that she may 
 recognize them. The only positive indication is their
 
 SICK CHILDREN 301 
 
 presence in the stools. A dose of castor oil may be 
 given, and, after it has operated, injections of warm 
 water and salt daily until the trouble is at an end. An 
 infusion of quassia chips may be injected twice daily 
 for three days. 
 
 Incontinence of Urine. Nocturnal incontinence is 
 a common trouble among children, and one for which 
 medical advice is necessary. It should be cured before 
 it becomes a confirmed habit, but scolding or punishing 
 the child will not do it. The simplest plan is to make 
 the child rise during the night to pass its water. 
 
 Cholera Infantum is one of the most fatal diseases 
 among young children. It usually begins with diar- 
 rhoea or indigestion. It comes from overfeeding, heat, 
 and impure air, and is aggravated by teething, though 
 never caused by it. The child loses flesh rapidly, be- 
 comes restless and feverish, has intestinal pain and ex- 
 cessive thirst, but no appetite, and the food is not as- 
 similated. Medical advice should be summoned early. 
 The child should be kept cool and much in the open 
 air. Entire change of air is advisable. 
 
 Convulsions in children may result from indigestion, 
 worms, difficult dentition, fright, or any extreme nerv- 
 ous excitement. Muscular twitchings come on sudden- 
 ly, sleeping or waking. The fits usually last only a few 
 moments; a succession of them is alarming. The doc- 
 tor should be at once sent for, but treatment should 
 not await his arrival. Eemove the clothing with as 
 little disturbance as may be, and put the child in a 
 warm bath. Keep the head cool. An enema of soap- 
 suds may be given, or a dose of castor oil. If the tem- 
 perature rises to 103, put in a cold pack. 
 
 Croup is an inflammation of the larynx and trachea. 
 It may come on gradually, with a cold in the head,
 
 302 A TEXT-BOOK OF NURSING 
 
 wheezing, hoarseness, and short, dry cough, or the child 
 may be wakened in the night by sudden dyspnoea and 
 violent choking. There will be a long-drawn inspiration, 
 accompanied by a characteristic sound, a ringing cough, 
 the voice will be husky, the skin hot and dry. There 
 are two varieties membranous croup, usually fatal, 
 and spasmodic croup, rarely so. The former is of rare 
 occurrence as compared with the latter. The treat- 
 ment until the doctor arrives is in either case the same. 
 Keep the temperature of the room not lower than 65, 
 and a tea-kettle boiling to moisten the air. If the 
 breathing is labored, give an emetic the sirup of ipecac 
 in drachm doses is in common use and repeat at in- 
 tervals of half an hour until there is free vomiting. 
 Give a hot bath. Hot stupes around the throat will 
 sometimes afford relief. Prop the child up with pillows, 
 and keep it quiet, avoiding everything that will excite 
 crying or coughing. Simple spasmodic croup usually 
 yields readily to treatment, though the attacks are like- 
 ly to recur, and the child must be protected with extra 
 care for some days. Membranous croup is character- 
 ized by an exudation of false membrane in the throat, 
 and is by many authorities considered identical with 
 diphtheria. The early symptoms are much the same 
 as those above described; as the disease progresses, the 
 child becomes dull, irritable, and disinclined to speak. 
 The head is thrown back, the face distressed and bathed 
 in cold perspiration. In the last stages stupor comes 
 on, from which the child must be roused for nourish- 
 ment. This can only be given in small quantities. 
 When the air passages become obstructed, tracheotomy 
 is sometimes resorted to, or more commonly now intu- 
 bation of the larynx. 
 
 Whooping-cough begins like an ordinary cold, the
 
 SICK CHILDREN 303 
 
 peculiar whoop not being heard until after the first ten 
 days. It lasts from one to three months. The child 
 should be kept out of doors if the weather is fit, and 
 should have a light, unstimulating diet, special care be- 
 ing taken to avoid constipation. The chief danger is of 
 bronchitis or inflammation of the lungs supervening. 
 
 In all diseases of the lungs or air passages the child 
 should be kept quiet, in an even temperature, with pure 
 air. The head should be well elevated, as the breathing 
 will be less labored in a nearly upright position. The 
 sputa will generally be swallowed by young children, 
 and will sometimes be vomited up in quantity. 
 
 Mumps is another common juvenile disease, not 
 very dangerous. It is an inflammation of the salivary 
 glands, chiefly the parotid, and may affect one or both 
 sides, together or successively. There will be pain and 
 swelling under the ear, with difficulty in swallowing, 
 or even in speaking. Hot applications afford the most 
 relief. If there is suppuration, which is rare, poultice. 
 There will be more or less fever, and some slight laxa- 
 tive may be required. The disease reaches its height 
 in three or four days, then declines rapidly. 
 
 Chicken-pox, or varicella, commences with slight 
 fever. After twenty-four hours "an eruption of reddish 
 pimples appears, generally thickest on the back. In a 
 day or two these become blisters, and within a week 
 disappear. Little medication is called for. A warm 
 bath may be of service. Isolate the patient if there are 
 other children. 
 
 Measles (rubeola) is a disease not confined to chil- 
 dren, but is most common among them. It begins like 
 an attack of acute catarrh, with sneezing, coryza, 
 hoarseness, sore throat, cough, dyspnoea, and some 
 fever. The average period of incubation is eight days.
 
 304 A TEXT-BOOK OP NURSING 
 
 The eruption of pimples comes out not later than the 
 fourth day from the appearance of the first symptoms, 
 in dark, somewhat crescent-shaped patches, first on the 
 face, neck, and arms, later on the trunk and legs. This 
 lasts from two to five days, then fades in the order of 
 appearance, leaving a brownish stain and mealy des- 
 quamation for a week. At this time diarrhoea is apt to 
 set in. The disease itself is not likely to be severe in 
 a child, but is often complicated or followed by bron- 
 chitis, pneumonia, gastric troubles, ophthalmia, or otor- 
 rhoea inflammation of the ear. To avoid such sequelae, 
 great care is required, even after convalescence is es- 
 tablished. The child should be kept in bed, and on light 
 diet, until all feverishness has left it. Great warmth is 
 not required, but protection from draughts is impor- 
 tant. The eyes should be shielded from strong light, 
 and care be taken not in any way to strain them. A 
 generally lowered tone of the system may persist for 
 some time. 
 
 Roseola, or German measles, is a fugitive eruption, 
 lasting a few hours or days, very mild, but is supposed 
 to be contagious. A second attack of either this or true 
 measles is rare. 
 
 Acute meningitis is" a disease also most common in 
 children under five years of age. The symptoms vary 
 vejy much. It most often comes on gradually, with 
 wasting of the body, disordered bowels, capricious ap- 
 petite, nausea, headache, fever, irritability, intolerance 
 of light and noise. The child may seem constantly 
 drowsy, but the sleep is restless and disturbed. Squint- 
 ing and enlarged glassy pupils are common symptoms. 
 As the disease progresses, convulsions or paralysis may 
 occur, or the patient sink into a comatose condition. 
 Perfect quiet is an essential part of the treatment.
 
 SICK CHILDREN 305 
 
 Keep the child in a dark room, in bed, with the head 
 elevated. Do not rock or walk about with him, or in 
 any way move him unnecessarily. Do not startle or 
 excite him. Cold applications to the head will probably 
 be ordered, and purgatives. Only the lightest food 
 should be given. 
 
 Hydrocephalus. Water on the brain is an affection 
 of early childhood due to an abnormal accumulation of 
 fluid in the brain. The head in these cases will be 
 very large, and the fontanelles fail to close. Intelli- 
 gence does not develop, and death usually takes place 
 soon. 
 
 Rachitis. The disease commonly known as rickets 
 is most commonly met with among the poorer classes, 
 and is due chiefly to bad feeding and bad air. There 
 are the general symptoms of malnutrition and digestive 
 derangements with marked tendency to pulmonary com- 
 plications. The child is feeble and irritable, with en- 
 larged head and distended abdomen, sallow and emaci- 
 ated, and perspires profusely. The bones lack firmness, 
 in consequence of a deficiency of lime-salts, and are 
 often misshapen and deformed. The treatment consists 
 in improving the general hygienic condition, correcting 
 the diet, and insisting upon cleanliness and fresh air. 
 The disease itself is not directly dangerous to life, but 
 it lowers the resistive powers to such an extent that its 
 complications are often fatal. 
 
 "Never fear to bring the sublimest motive to the smallest 
 duty, and the most infinite comfort to the smallest trouble." 
 Phillips Brooks.
 
 CHAPTER XVIII 
 
 " And ye shall succor men: 
 Tis nobleness to serve ; 
 Help them who can not help again, 
 Beware from right to swerve." 
 
 R. W. Emerson. 
 
 THERE are a few special diseases for the care of 
 which some special directions may be needed, supple- 
 mentary to the general directions for nursing in all 
 cases. Although a slight attempt is made at describing 
 them, it is not to be expected that any given case will 
 correspond exactly with the type except in general fea- 
 tures. Variations and complications are endless, and 
 clinical diagnosis is not expected of you; but you will 
 find it an advantage to know what course a disease 
 naturally takes and what dangers are especially to be 
 guarded against. 
 
 Let us first consider the diseases of the respiratory 
 organs. 
 
 Catarrh of the nasal mucous membrane cold in the 
 head is so common as to need little description, and is 
 one of the cases in which an ounce of prevention is 
 worth many a pound of cure. Ill-ventilated and over- 
 heated houses are responsible for much of the suscepti- 
 bility to colds. Pure air, warm clothing and dry feet 
 are the best preventives. If taken in the earliest stage, 
 a full dose of quinine will sometimes abort a cold. Ten 
 grains of Dover's powder taken at bed-time will often 
 306
 
 SPECIAL MEDICAL CASES 307 
 
 cut it short. Once established, little can be done except 
 to avoid adding to it. It will usually pass off after a 
 few days without any special treatment. The discharge 
 from the nose, technically known as coryza, may be re- 
 lieved by the inhalation, through a paper cone, of the 
 vapors arising from a solution of pulverized camphor 
 or compound tincture of benzoin, about a teaspoonful 
 in a pint of boiling water. Neglected colds may result 
 in a condition of chronic catarrh, very difficult to over- 
 come, or may even lead to dangerous pulmonary disease. 
 Ozaena is a chronic form, marked by a peculiarly strong 
 and offensive odor. 
 
 Influenza, or la grippe, is an infectious epidemic, 
 caused by a specific micro-organism, characterized by 
 a catarrh al process of the respiratory tract. It begins 
 like a sudden and severe cold, accompanied by more 
 or less fever, with rapid pulse, increased and shortened 
 respirations, cough, coryza, loss of appetite, general 
 pain, especially in the head and the lumbar region, 
 marked prostration and nervous depression. Pleurisy 
 and pneumonia frequently ensue. The subsequent ex- 
 haustion and debility are extreme, and care during con- 
 valescence is especially important. There are three 
 common types, nervous, gastro-intestinal, and simple 
 febrile. 
 
 Prophylaxis is the main consideration, and should 
 consist in maintaining the best possible hygienic con- 
 ditions during the prevalence of the disease, and tak- 
 ing the greatest care in thoroughly sterilizing all eating 
 utensils, napkins, handkerchiefs, etc., before removing 
 them from the sick-room. The bacilli are in the secre- 
 tions from the mouth and nose, and are readily trans- 
 mitted through the air. The walking cases are prob- 
 ably the greatest disseminators of the disease. Absolute
 
 308 A TEXT-BOOK OP NURSING 
 
 rest in bed is the most important part of the treatment. 
 The pains may be relieved by local applications of heat 
 or cold, as may be found most effective, and the cough 
 by a mustard-plaster on the chest. The patient should 
 be encouraged to take food, and stimulants may also 
 be indicated. Whisky and milk, and quinine may in 
 most cases be given. 
 
 Bronchitis is an inflammation of the bronchial tubes, 
 acute or chronic. Capillary bronchitis is the most dan- 
 gerous form. The acute disease begins with a heavy 
 cold, sometimes ushered in by slight chills. There is 
 fullness in the head, sore throat, general malaise, with 
 pain in the chest and cough, at first dry and then ac- 
 companied by watery sputa, which later becomes viscid 
 and purulent. As the dyspnoea increases, there may be 
 high fever, rapid pulse, and profuse perspiration. The 
 patient must be kept in one room, well aired, at an even 
 temperature not higher than 68 Fahr. Free action of 
 the skin is to be secured, and the bowels opened. A 
 mustard plaster on the chest may relieve the pain, and 
 inhalations of steam allay the cough. Plenty of nour- 
 ishing food should be given. During convalescence 
 special care should be taken to avoid sudden changes of 
 temperature, as the patient will be very susceptible to 
 chills. In the majority of cases, recovery may be looked 
 for, but it is sometimes fatal, or may assume a chronic 
 form. 
 
 Asthma is a form of dyspnoea, caused by spasmodic 
 contraction of the bronchial tubes, for which you 
 should know the popular remedies in case of emer- 
 gency. It is often associated with chronic bronchitis. 
 It is rarely dangerous, but always distressing. The 
 patient gasps violently for air, his expression is anx- 
 ious, pulse feeble, the skin cold and pale or cyanosed.
 
 SPECIAL MEDICAL CASES 309 
 
 Elevate the arms, and give all the air possible. A 
 drachm of Hoffmann's anodyne may be administered, 
 and repeated after half an hour if the condition is not 
 relieved. It may last for several hours, and is usually 
 concluded by a paroxysm of coughing and a free ex- 
 pectoration of mucus. Blotting-paper which has been 
 saturated with a strong solution of saltpetre and dried 
 affords, when burned, fumes that may give relief; stra- 
 monium leaves rolled into cigarettes, or smoked in a 
 pipe like tobacco, are sometimes ordered. 
 
 Laryngitis is an inflammation of the lining mem- 
 brane of the throat extending into the larynx. It may 
 result from cold or local irritation, or may be associated 
 with pulmonary tuberculosis. There is hoarseness of 
 the voice, sore throat, usually some fever, and .in the 
 more severe cases, difficulty of breathing in consequence 
 of the swelling. Treat with steam inhalations, and 
 rub the throat with camphorated oil. 
 
 Pleurisy is an inflammation of the serous membrane 
 covering the lungs, and often occurs as a complication 
 of pulmonary disease. The surfaces of the membrane 
 become dry and no longer slide easily over each other. 
 There is acute pain on inspiration, short, repressed 
 cough, inability to draw a long breath, some elevation 
 of temperature, often preceded by a sense of chilliness. 
 The pain may be relieved by the external application 
 of counter-irritants and the disease may subside at this 
 stage, or the inflammation may continue, and an effu- 
 sion of fluid into the pleural cavity may take ^place. 
 This may be so abundant as to embarrass the action of 
 the lungs and heart. The acute pain of the first stage 
 will be diminished, but there will be increased fever and 
 dyspnoea. In order to relieve this condition, aspiration 
 may be necessary, an operation which consists in draw- 
 21
 
 310 A TEXT-BOOK OF NURSING 
 
 ing off the fluid through a hollow needle. This should 
 always be saved for examination. It is usually simply 
 a serous fluid of amher hue, hut in some cases there 
 will be an accumulation of pus. This form of pleurisy 
 is termed empyema, and necessitates a free opening 
 and thorough drainage of the pleural cavity. It may 
 also have to be washed out with some antiseptic fluid. 
 As soon as the cavity is emptied, the temperature will 
 begin to fall. 
 
 Pneumonia, inflammation of the lung substance, is 
 one of the most serious of the pulmonary affections. It 
 may occur independently or as a complication in the 
 course of some other disease. One or both sides may 
 be affected, more often the right lung alone. It is 
 usually initiated by a chill, or sense of chilliness, with 
 deep-seated pain, and shortness of breath. High fever 
 follows, with flushed face, often on one side only, head- 
 ache, and restlessness. The respirations are shallow 
 and rapid. The urine is scanty and high-colored. The 
 cough is short and hacking, the expectoration at first 
 scanty. After twelve or eighteen hours, it may be ex- 
 pected to increase in quantity, and to assume a tough, 
 tenacious quality, highly characteristic. It may be rust- 
 colored or streaked with blood. The sputa should be 
 carefully preserved for the doctor's inspection. The 
 disease reaches its height by the end of the first week; 
 in those cases which terminate by resolution gradual 
 restoration of the inflamed part to a normal condition 
 the' febrile symptoms rapidly decline. When sup- 
 puration takes place the fever is likely to continue a 
 week or two longer. There is a tendency to delirium, 
 especially at night. The great danger is failure of the 
 heart. The patient must be kept in bed, absolutely 
 quiet, and on fluid diet. Save his strength in every pos-
 
 SPECIAL MEDICAL CASES 311 
 
 sible way; do not allow unnecessary talking, or any exer- 
 tion. Be careful not to overload the stomach, though 
 nourishment is of the first importance and stimulants 
 may be necessary. Convalescence, once established, will 
 be rapid. With pneumonia in alcoholic subjects, nerv- 
 ous symptoms are prominent, and the characteristic 
 sputa may be absent. 
 
 Phthisis, or pulmonary consumption, is a disease al- 
 most always fatal sooner or later, characterized by a 
 morbid deposit of tubercles in the lungs. These tuber- 
 culous nodules may attack other parts of the body also, 
 and have a great tendency to spread. The disease is 
 distinctly infectious, and a hereditary susceptibility to 
 it has been observed. Exposure, overwork, and intem- 
 perance favor its development. The course of the dis- 
 ease may be acute, terminating in a few weeks, or 
 chronic, lasting for several years. It most commonly 
 attacks persons under thirty years of age. The symp- 
 toms vary. The most characteristic are the cough, 
 fever, night sweats, spitting of blood, gastric derange- 
 ment, with loss of appetite, gradual emaciation, and 
 increasing weakness. The onset is usually gradual, and 
 periods of apparent improvement may occur, but it is 
 rarely permanent, and the patient finally dies either 
 from haemorrhage or exhaustion. The distressing symp- 
 toms may be alleviated, but treatment which will posi- 
 tively arrest the progress of the disease is yet to be dis- 
 covered. Change of climate may exert a beneficial in- 
 fluence. If that is impracticable, some out-of-door 
 occupation should be adopted, for life in the open air 
 offers almost the only chance for recovery. A dry at- 
 mosphere with plenty of sun and free from wind is the 
 most desirable. Defective ventilation and overcrowd- 
 ing are, of all things, to be avoided. Liberal diet is
 
 312 A TEXT-BOOK OP NURSING 
 
 important, though there is often defective assimilation 
 as well as lack of appetite. Thorough disinfection of 
 the sputum is of vital importance. Old cloths or soft 
 Japanese napkins should be substituted for handker- 
 chiefs, and the sputum cups lined with paper, all of 
 which should be promptly burned. 
 
 The most common forms of cardiac disorder are 
 pericarditis, endocarditis, valvular diseases of the heart, 
 dilatation, and fatty degeneration. They occur in the 
 majority of cases as sequelae or complications of other 
 diseases, notably of rheumatism. All that a nurse 
 needs to know about these is the special care required 
 by patients subject to them, and how to treat the alarm- 
 ing symptoms which sometimes occur. With all cardiac 
 cases, overexertion and occasions of excitement are to 
 be guarded against, and in the matter of diet the doc- 
 tor's directions should be most carefully followed. Any- 
 thing which accelerates the circulation is likely to bring 
 on palpitation and dyspnoea. In severe cases, the diffi- 
 culty in breathing may occasion great distress even 
 when the patient is in bed and entirely quiet. The re- 
 cumbent position may be rendered impossible from this 
 cause. Difficulty in the return of blood to the heart 
 may result in dropsy, and exudation of serum from the 
 veins into the connective tissue and the cavities of the 
 body. General dropsy is termed anasarca. An accu- 
 mulation of such fluid in the peritoneal cavity is known 
 as ascites; this may occasion so great distention as to 
 interfere with the movements of the diaphragm, and 
 must then be removed by tapping. Fluid in the con- 
 nective tissues produces a swelling called oedema. This 
 will be most marked where the skin is loose. Pressure 
 with the finger upon an cedematous swelling will make 
 a distinct indentation, which does not immediately dis-
 
 SPECIAL MEDICAL CASES 313 
 
 appear when the pressure is removed. Dyspnoea and 
 dropsy are two symptoms which occur either together 
 or separately in nearly all serious affections of the heart. 
 
 Angina pectoris is the name given to certain attacks 
 of intense and characteristic pain sometimes occurring 
 in connection with heart-disease. The spasms are sud- 
 den and agonizing, accompanied by extreme dyspnoea, 
 and in some instances are fatal. Relief may be obtained 
 by inhalation of chloroform or nitrite of amyl, or by an 
 injection of morphine. 
 
 Aneurism is disease of the arterial wall, producing 
 dilatation, thus forming a tumor which may give rise to 
 various distressing symptoms, and possibly occasion sud- 
 den death by its rupture. It is treated by rest and re- 
 stricted diet, and, if accessible, by surgical operation. 
 
 Indigestion, or dyspepsia, may be merely a slight 
 functional disorder, or a symptom of serious disease. It 
 is variously manifested. There may be pain, nausea, 
 regurgitation, flatulence, palpitation, headache, with 
 constipation or diarrhoea, and numerous other minor 
 symptoms, all more or less associated with the inception 
 of food. Dyspeptics are notorious for constantly study- 
 ing their symptoms. Food unsuitable in quality or 
 quantity or insufficiently masticated is a common cause 
 of indigestion. Overfatigue often produces it, and alco- 
 holism always. No general rules can be laid down for 
 treatment, as what suits one case will not another. It 
 is necessary first to discover the cause of the trouble. 
 Good sanitary conditions, regular habits, exercise, and 
 simple food are always important. 
 
 Gastritis, inflammation of the lining membrane of 
 the stomach, is one of the more serious troubles marked 
 by chronic dyspepsia. The symptoms are mainly those 
 of indigestion, with acute pain and tenderness of the
 
 314 A TEXT-BOOK OP NURSING 
 
 stomach. Food, especially solid food, aggravates the 
 pain, and in severe cases can be retained only in the 
 smallest quantities. Ulcers of the stomach may develop, 
 and sometimes perforation takes place, producing fatal 
 termination. Only the lightest and most digestible 
 foods should be allowed in severe cases fluids only; or 
 nourishment by the stomach may be entirely suspend- 
 ed and nutrient enemata be substituted. Eest is im- 
 portant. Counter-irritation over the stomach may re- 
 lieve the pain and nausea. 
 
 Peritonitis follows perforation of the stomach or 
 bowels, or any other injury of the membrane covering 
 the intestines. It is usually, if not always, of septic 
 origin, and is a very dangerous form of inflammation. 
 There is acute pain, with tenderness over the abdomen, 
 fever, rapid, wiry pulse, great depression, vomiting, and 
 constipation with tympanites. There may be retention 
 or suppression of urine. Delirium is not uncommon. 
 The patient should be moved as little as possible, and 
 not allowed to sit up for any purpose. The bedclothes 
 may be lifted from the abdomen by a cradle, and any 
 applications ordered must be made as light as possible. 
 Hot fomentations may be helpful. Nourishment should 
 be given in strict accordance with orders, and stimulants 
 may be required. It is now customary to keep the 
 bowels open with saline cathartics, and to withhold 
 opium as much as possible. 
 
 Appendicitis is an inflammation of the vermiform 
 appendix, usually accompanied by more or less peritoni- 
 tis. The symptoms and treatment are much the same. 
 The great danger to be feared is perforation. 
 
 Typhlitis is an inflammation of the caecum, occa- 
 sionally leading to perforative ulceration. 
 
 Intestinal obstruction may result from strangulated
 
 SPECIAL MEDICAL CASES 315 
 
 hernia or other causes, and unless relieved is soon fatal. 
 Obstinate constipation is present, followed by stercora- 
 ceous vomiting, abdominal distention, and pain, but 
 usually not much fever. Make hot applications ex- 
 ternally, and give sips of hot water to relieve the thirst 
 and vomiting, but little if any food, and no purga- 
 tives. Get advice promptly, as early abdominal section 
 may be the only hope. 
 
 Dysentery is an inflammation of the mucous mem- 
 brane of the large intestine. It may be preceded by 
 various digestive disorders, abdominal tenderness, a 
 sense of chilliness, and a rise of temperature at evening. 
 It usually begins with diarrhoea, followed by tenesmus 
 (which is the characteristic symptom), griping pain, 
 and discharge of mucus from the bowel, streaked with 
 blood, and lacking the healthy fascal odor. Ventilate 
 freely, and disinfect the stools. Keep the patient flat 
 on his back, warm, and quiet. Put a broad flannel 
 bandage around the abdomen. Give but little water. 
 Feed on boiled milk, corn-starch, rice-flour, arrow-root, 
 etc., * not very hot. The inflammation may lead to 
 ulceration or sloughing of the intestine, and death from 
 collapse. 
 
 Chokra morbus, or sporadic cholera, is usually 
 caused by indigestible food or impure water. It ex- 
 hibits many of the appearances of the epidemic disease, 
 but is comparatively harmless, being rarely fatal, except 
 among infants. There will be vomiting and purging, 
 with violent intestinal pain and cramps, faintness, and 
 a tendency to nervous shock. Encourage rather than 
 check the clearing out of the system, which is an effort 
 to get rid of some irritating matter, apply hot poultices 
 or stupes to relieve the pain, and recovery will usually 
 be spontaneous. Keep the extremities warm, and stim-
 
 316 A TEXT-BOOK OF NURSING 
 
 ulate moderately if required. Give but little and light 
 food, only gradually returning to solid diet. 
 
 Intestinal colic is most commonly caused by consti- 
 pation and flatulence. The pain is of a severe and 
 griping character, distinguished from that of peritonitis 
 by the fact that it is relieved by pressure, while the lat- 
 ter is increased by it. The characteristic pulse and tem- 
 perature of peritonitis are absent. A clearing out of 
 the bowels, which is most safely and promptly accom- 
 plished by enema, will usually afford entire relief. A 
 hot drink, hot applications externally, and massage of 
 the abdomen may be helpful. 
 
 Hepatic colic is a more serious trouble, due to the 
 presence of a gall-stone in the biliary duct. An agoniz- 
 ing pain comes on in the upper part of the right side of 
 the abdomen producing nausea, faintness, and profuse 
 perspiration. The attack will only subside when the 
 obstructing stone passes on into the intestine; hypo- 
 dermic injections of morphine, and hot fomentations 
 sprinkled with laudanum may be used to alleviate the 
 pain. These attacks result from a diseased condition of 
 the liver, and are often followed by jaundice. This is 
 marked by a yellow tinge of the skin and the whites of 
 the eyes, while the bile is evident in the urine and the 
 perspiration, but conspicuously absent from the stools. 
 Great depression of spirits, loss of appetite, nausea, and 
 often extreme itching of the skin accompany jaundice. 
 
 Diabetes mellitus is an affection characterized by an 
 excessive flow of urine containing glucose, or grape 
 sugar, an ingredient never found in any considerable 
 quantity during health. The condition comes on by de- 
 grees, is more frequent among men than women, and 
 at middle age, although children are subject to it. The 
 symptoms are extreme thirst and abnormal appetite,
 
 SPECIAL MEDICAL CASES 317 
 
 especially for sweets, but loss of flesh and strength, a 
 dry skin, furred tongue, bad breath, and intestinal dis- 
 orders. Is most alarming when complicated by lung 
 troubles. The chief treatment is by dieting. Every- 
 thing containing sugar, or starch, convertible into it, 
 should be prohibited. The doctor will give you a list 
 of the allowable articles, and you will have to see that 
 your patient does not get sugar surreptitiously. He 
 should have regular exercise, and take special care 
 about catching cold. The disease is chronic in its 
 course, but usually terminates fatally. Injuries and 
 acute diseases are more than ordinarily dangerous to a 
 diabetic subject. 
 
 " Bright' s disease " is a generic term including sev- 
 eral varieties of kidney trouble, presenting albumin in 
 the urine. The condition described as acute Bright's 
 disease commonly results from taking cold, or as a 
 sequel of scarlet fever, diphtheria, or rheumatism. It 
 not infrequently arises during pregnancy. The urine is 
 frequently passed, but diminishes in quantity and be- 
 comes albuminous, often containing also microscopic 
 casts. There is a peculiar waxy complexion, and a gen- 
 eral dropsical condition, evident at first about the eye- 
 lids and in the feet. Headache, gastric disorders, and 
 general debility may be looked for; bronchitis and 
 heart-disease are frequent complications. Suppression 
 of urine may follow, leading to death by uraemic convul- 
 sions or coma, or the disease may terminate in re- 
 covery or lapse into a chronic form. The danger is 
 great. The waste product must in some way be carried 
 off; for this purpose the skin is excited to action, the 
 bowels are kept open, and diluent drinks and diuretics 
 given. Hot-air baths are often prescribed, and some- 
 times a skimmed-milk diet. Only the most digestible
 
 318 A TEXT-BOOK OF NURSING 
 
 food can be allowed, and that must be given with the 
 utmost regularity. 
 
 Renal colic has symptoms not unlike those of hepatic 
 colic, except that the pain takes its origin in the kid- 
 ney. It is usually the result of a stone in the kidney or 
 ureter. The urine may be retained or discharged fre- 
 quently, a few drops at a time. It often contains blood 
 or crystalline deposits of diagnostic value, and should 
 always be saved for examination. The pain can only 
 be relieved by hypodermics of morphine. Hot applica- 
 tions or a hot bath may be given. Urinary calculus in 
 the bladder may be treated by surgical operation. 
 
 The skin, like the other organs, is liable to various 
 diseases, most of them either of nervous or parasitic 
 origin. Those of the latter class are always contagious. 
 
 Erythema is the name given to an inflammatory con- 
 dition of the skin marked by redness, with slight swell- 
 ing, burning, and itching sensations. When the ery- 
 thema is general, it is sometimes called " rose rash," 
 and bears a close resemblance to the rash of scarlet 
 fever or measles, for which it is often mistaken. It is, 
 however, not contagious nor serious, though uncomfort- 
 able. It may be the result of indigestion or a chill, and 
 is often associated with rheumatism. A warm bath and 
 a cathartic will hasten its disappearance. Local ery- 
 thema is usually occasioned by some irritant, and will 
 subside when the cause is removed. The itching may 
 be allayed by a solution of bicarbonate of soda or vase- 
 line. 
 
 Urticaria, or " nettle rash," shows patches of white 
 spots on a red ground in various parts of the body, with 
 severe itching. It is produced by irritation, indigestible 
 food (in some people by fish or strawberries), by certain 
 drugs, and even occasionally by strong emotion. It may
 
 SPECIAL MEDICAL CASES 319 
 
 be treated by the application of tincture of benzoin, 
 diluted one half. Of course, the exciting cause, if 
 known, must be removed. 
 
 Eczema is a form of eruption less transitory and far 
 more difficult to deal with. There are various forms of 
 it, acute or chronic. The most characteristic manifes- 
 tation is a raw surface with moist exudation from 
 broken-down vesicles, more or less covered with dry 
 crusts. Before any curative treatment will be of serv- 
 ice these crusts must be softened with oil (vaseline is 
 the best to use), and gently removed. The part affected 
 may then be cleaned with soft potash soap, and healing 
 ointments applied. Washing with ordinary soap and 
 water should be avoided as well as scratching or any 
 friction. 
 
 Herpes is a vesicular eruption of which there are 
 several forms. Herpes zoster, or " shingles," is the one 
 most generally known. This appears on the chest, ex- 
 tending just half-way round from the spinal column 
 to the sternum, and is almost always confined to one 
 side. The eruption is preceded by pain of a neuralgic 
 character, which may continue even for some little 
 time after the vesicles have disappeared. Soothing 
 applications may be made, but the disease is self-lim- 
 ited, and will terminate in a few days without treat- 
 ment. 
 
 Scabies, the " itch," is due to a small animal parasite 
 which burrows under the skin and sets up a peculiarly 
 irritating inflammation. It begins usually between the 
 fingers and toes, but may spread to other parts of the 
 body and become quite general. It most frequently 
 occurs in children, though, not limited to them. It is 
 commonly treated with ointments of sulphur. It is 
 highly contagious and persons affected with it should
 
 320 A TEXT-BOOK OF NURSING 
 
 be isolated until it is cured, and their clothing should 
 be afterward disinfected. 
 
 Pediculi, lice, produce a papular eruption accom- 
 panied by constant itching. They are of three varieties 
 one sort peculiar to the head, one to the hair of other 
 parts, and a third which infests the body and conceals 
 itself in the under-clothing. The usual treatment for 
 them all is with mercurial ointments, but there is some 
 danger attending their use. Lice can not live in any 
 kind of grease. Vaseline liberally applied will kill 
 them, and is a simpler and safer application, especially 
 fof children. The nits, or eggs, as well as the lice 
 themselves, must be thoroughly cleaned out to avoid a 
 return of the trouble, and where body lice are found 
 the clothing should be thoroughly baked. 
 
 Among the most serious affections which we are 
 liable to meet are diseases of the brain and nervous 
 system. 
 
 Paralysis occurs in several forms. Hemiplegia, pa- 
 ralysis of the lateral half of the body, is usually the 
 result of apoplexy rupture or obstruction of some 
 blood-vessel in the brain. A person in apparently good 
 health may be suddenly attacked with pain in the head, 
 and usually loss of consciousness. One side will be 
 found helpless and without sensation. There may be 
 gradual restoration, or coma and death. With paralysis 
 on the right side there may be aphasia, loss of the power 
 of speech, or the use of wrong words. Mental confu- 
 sion, lapsing into imbecility, may follow. The attacks 
 tend to recur, and the patient rarely survives more 
 than two or three of them. Paraplegia is paralysis of 
 the lower half of the body on both sides, in consequence 
 of injury or disease of the spinal cord. There will be 
 loss of voluntary motion and sensation below the point
 
 SPECIAL MEDICAL CASES 321 
 
 affected, and loss of control over the excretions. Re- 
 markable elevations of temperature sometimes occur, 
 and there is a very marked tendency to the formations 
 of bed-sores. Complete or partial recovery may take 
 place, but more often there is a gradual spread of the 
 inflammation, resulting fatally. Neuritis is a form of 
 paralysis due to inflammation of the spinal nerves. It 
 may be a consequence of chronic alcoholism or lead 
 poisoning or a sequel of some other disease. The trou- 
 ble comes on gradually, commencing with pain and ten- 
 derness in the limbs with increasing loss of power until 
 a condition of complete helplessness is reached. The 
 intelligence may be obscured, the appetite and diges- 
 tion impaired. Recovery may be looked for if treat- 
 ment is begun sufficiently early. In alcoholic cases, 
 total abstinence must be enforced. Mental derange- 
 ment may occur, but is usually only temporary. Liberal 
 diet is important. Massage and electricity are usually 
 employed. There may be local paralyses, wasting and 
 failure of particular groups of muscles from various 
 causes, most often treated in a similar way. Paralyzed 
 parts must be kept always warm, clean, and free from 
 pressure. In all these cases, good nursing is of the ut- 
 most importance, and much skill as well as infinite 
 patience is called for. 
 
 Neuralgia is severe and paroxysmal pain in a nerve, 
 unaccompanied by inflammation. Hemicrania and sci- 
 atica are two of the most common and distressing varie- 
 ties of it. The causes are numerous, and in treatment 
 must first be considered. The general state of the 
 health is important, neuralgia being most frequent in 
 anasmic subjects. Local applications of dry heat are 
 perhaps as useful as any general remedy that can be 
 named.
 
 322 A TEXT-BOOK OP NURSING 
 
 Locomotor ataxy is a disease of the spinal cord, dis- 
 tinguished by inability to control the movements of the 
 legs in walking; they are thrown forward in a peculiar 
 jerky way. It is accompanied by severe pain in the 
 limbs and abdomen, constipation, and bladder troubles, 
 often impairment of sight and sensation. The disease 
 comes on by degrees, and is chronic, with very slow im- 
 provement, if any. Complete cure is rare. 
 
 Cerebral meningitis is an inflammation of the mem- 
 branes of the brain. This may spread from disease of 
 adjoining parts, occur as a complication of the infec- 
 tious fevers, in consequence of alcoholism, tuberculosis, 
 injuries of the head, or other causes. The leading symp- 
 toms are high fever, violent headache with intolerance 
 of light and noise, vomiting, obstinate constipation, ir- 
 ritability, insomnia, and delirium, often terminated by 
 convulsive attacks, coma, and death. Eecovery may be 
 hoped for, except in the tuberculous form of the dis- 
 ease, but all inflammatory affections of the brain are 
 very dangerous. The patient should be kept in a dark- 
 ened room, as quiet, cool, and free from excitement as 
 possible. The head may be shaven, and ice-cold appli- 
 cations made to it. Leeches are sometimes employed. 
 The bowels must be cleared out. Cold fluid food may 
 be given. Somewhat similar symptoms, but less acute 
 in their course, may be occasioned by the presence of a 
 tumor or abscess in the brain. The symptoms in both 
 cases are variable and often obscure. 
 
 Chorea, " St. Vitus's dance," is a nervous affection, 
 occurring most frequently in young girls, sometimes 
 brought on by fright or excitement, and often asso- 
 ciated with rheumatism. It is characterized by lack of 
 control of the muscular movements, affecting one or 
 both sides of the body, with general debility, and often
 
 SPECIAL MEDICAL CASES 323 
 
 mental weakness. The twitching and jerky motions are 
 increased by any excitement, and by the consciousness 
 of being under observation. They cease during sleep. 
 In young persons the attacks tend to recur, but the dis- 
 ease is usually curable. In adults it is more serious; 
 the severe attacks may lead to a condition of mania, 
 or terminate in death from exhaustion. Bed-sores are a 
 common complication. Complete rest and nourishing 
 food are essential in the treatment. Laxatives may be 
 needed there is usually a disordered condition of the 
 stomach and bowels and tonics are thought useful. 
 
 Hysteria is the name given to a disordered state of 
 the nervous system, more common in women than in 
 men, though not entirely confined to them. It is often 
 associated with ovarian or uterine troubles. Hysterical 
 phenomena are infinitely varied. There is scarcely any 
 disease the symptoms of which it may not simulate. 
 The patient is morbidly emotional, and exaggerates her 
 symptoms more or less intentionally, but it should be 
 remembered that at the basis of all the imaginative and 
 simulated manifestations is a real, though perhaps ob- 
 scure, malady. Hysteria is not, as sometimes appears, 
 imposition pure and simple, but the patient is to some 
 extent irresponsible from defective will-power. It may 
 lead to the verge of insanity. There are two forms, the 
 one continuous, the other paroxysmal. Common symp- 
 toms are a sensation as of a ball in the throat, a dry 
 cough, very abundant and light-colored urine, flatulence 
 and borborygmi. Neuralgia, local paralyses, rigid con- 
 tractions of joints, and loss of voice sometimes occur. 
 Hygienic treatment is of great importance, exercise, 
 healthful food, and regular habits being more impor- 
 tant than medical treatment. Narcotics and stimulants 
 should especially be avoided. Hysterical fits need no
 
 324: A TEXT-BOOK OP NURSING 
 
 treatment, and will terminate more quickly without it. 
 The patient never hurts herself if left alone. 
 
 All neurasthenic patients make heavy demands upon 
 a nurse, and they are often very trying cases to deal 
 with. Various phases and degrees of nervous exhaus- 
 tion are met with. Many cases have been successfully 
 treated without medicine by rest, seclusion, dieting, 
 together with massage, electricity, and sponge baths; 
 but for this a nurse needs special experience. No one 
 should undertake to practice massage without having 
 received thorough instruction, still less to give elec- 
 tricity unless as distinctly directed. That the doctor 
 will occasionally leave the manipulation of a battery to 
 an intelligent nurse does not qualify her to set up as an 
 electrician. Electricity is a powerful agent, requiring 
 the greatest care in its management. 
 
 Insanity includes various forms of mental unsound- 
 ness, from acute mania and melancholia to dementia, 
 idiocy, and imbecility. The care of insane patients re- 
 quires special training, added to much tact and good 
 judgment. With a patient of unsound mind it is never 
 safe to be off one's guard for an instant, but there should 
 be as much freedom from restraint as is compatible 
 with safety. Delusions and hallucinations of all kinds 
 are met with which can never be argued away, and need 
 to be judiciously treated. The care of such patients is 
 very different from ordinary sick-nursing, and is best 
 provided for in a suitable institution. 
 
 Delirium is a temporary mental aberration occur- 
 ring in the course of fevers and exhausting diseases. 
 It is apt to come on or be increased at night. Delirium 
 may be quiet, or active and violent. The delusions, like 
 those of the insane, should be as far as possible hu- 
 mored. Opposition only irritates and does harm. The
 
 SPECIAL MEDICAL CASES 325 
 
 nurse must be invariably kind and gentle, but at the 
 same time firm and vigilant. In violent delirium re- 
 straint must be effectual, or it only aggravates the trou- 
 ble. A dry sheet put on like a pack will take the place 
 of a straight- jacket if needed, but with proper attend- 
 ance physical restraint is seldom necessary, and should 
 be avoided when possible. Avoid every appearance of 
 fear; keep the room quiet and dark. 
 
 Delirium tremens is a peculiar type, the result of 
 chronic alcoholic poisoning. It is marked by a nervous 
 tremor, great anxiety and restlessness, and horrible hal- 
 lucinations. Insomnia and suicidal mania are common. 
 The pulse is feeble, the skin cold, and often bathed in 
 perspiration, the pupils minutely contracted, but with 
 no intolerance of light. The nervous prostration and 
 inability to take food may become extreme, and the case 
 may end fatally, or it may terminate with profound 
 sleep and spontaneous recovery. Sleep must somehow 
 be induced; the bowels must be kept open, and nourish- 
 ing food given, even if by force. 
 
 Diphtheria is a form of blood-poisoning, often re- 
 sulting from imperfect sewerage. It is first manifested 
 by feverishness, symptoms of a cold, difficulty in swal- 
 lowing, and swelling of the tonsils, followed by an exu- 
 dation of false membrane 'in white patches on the 
 throat. The discharge from the mouth and nostrils is 
 likely to be abundant; it should be wiped away on soft 
 cloths, which are immediately burned, as it is highly 
 infectious. Take every precaution against infection, 
 and follow all orders to the letter. Give plenty of fluid 
 nourishment. Nutritive enemata may be necessary. 
 The patient may be choked by the obstruction of the 
 throat, but there is equal danger of paralysis of the 
 heart, which may occasion a fatal termination, even 
 22
 
 326 A TEXT-BOOK OF NURSING . 
 
 after convalescence from the disease is well established. 
 The horizontal position must be maintained for a long 
 while. Tracheotomy is sometimes resorted to, but there 
 is danger that the membrane will continue to form be- 
 low the point of incision. Intubation is considered 
 preferable. These cases are now much treated by the 
 hypodermic injection of antitoxin, an attenuated diph- 
 theria culture most effective when given in the in- 
 cipient stages of the disease. The part into which the 
 injection is to be made should be first scrubbed with 
 green soap and water, followed by alcohol, and the 
 syringe itself sterilized by boiling for ten minutes just 
 before using. A rise of temperature immediately fol- 
 lowing this treatment, need not occasion special 
 anxiety. 
 
 Asiatic cholera is a specific infectious disease, com- 
 municable by means of the excreta. It is characterized 
 by violent vomiting and purging, with so-called " rice- 
 water evacuations," cramps, extreme prostration, and 
 collapse. It usually commences with slight diarrhoea 
 and nausea, and, wherever the disease prevails as an 
 epidemic, these symptoms should receive prompt atten- 
 tion. If it progresses, there is intense thirst, restless- 
 ness and muscular spasm, the pulse becomes rapid and 
 weak, the temperature falls below normal, the skin be- 
 comes livid, the eyeballs sunken, and a generally ghast- 
 ly appearanqe precedes death by collapse. The mind is 
 usually clear to the last. The first endeavor is to con- 
 trol the purging, for which opium is usually given. 
 Keep the patient in bed and warm. In all cases of 
 diarrhoea, especially in cholera, insist on the recumbent 
 position. Give ice ad lib., but little water ; food strictly 
 as directed. Nutritive enemata may be necessary. The 
 stools, vomited matter, and urine must be disinfected
 
 SPECIAL MEDICAL CASES 327 
 
 most thoroughly and disposed of promptly, and all pos- 
 sible precautions taken against the spread of the disease. 
 
 Typhoid, or enteric, fever is due to a specific germ 
 associated with certain forms of decomposing animal 
 matter, and is characterized by a catarrhal inflamma- 
 tion of the mucous membrane of the small intestine, 
 with ulceration in certain spots, called " Peyer's 
 patches." It is most common in early adult life, and 
 during the latter part of the year. It may occur as an 
 epidemic, in which case there is some common cause to 
 be looked for and remedied, most often impure drink- 
 ing-water. The period of incubation is from two to 
 three weeks, the usual duration from three to four 
 weeks, dating from the first rise of temperature. 
 
 The attack most often comes on gradually, begin- 
 ning with dull headache, loss of appetite, general ma- 
 laise, sometimes nausea and slight diarrhoea, and nose- 
 bleed. The patient may not go to bed till the fifth or 
 sixth day, though the fever steadily increases during 
 the first week, having a remittent type, falling in the 
 morning, but rising every night a little higher, till it 
 gets up to 103 or 104. By this time there is violent 
 headache, intolerance of light, and, perhaps, slight de- 
 lirium, parched lips and tongue, abdominal tenderness 
 and tympanites. During the second week the fever re- 
 mains continuously high, and an eruption of rose-col- 
 ored spots may appear on the abdomen and chest. These 
 are slightly elevated, and disappear upon pressure, to 
 return again immediately. Each spot remains visible 
 for three days. Successive crops may appear for ten 
 or twelve days. The headache is less during the second 
 week, the bowels are likely to be relaxed, the motions 
 of a light ochre or " pea-soup " color. In severe cases, 
 the patient assumes a characteristic typhoid appear-
 
 328 A TEXT-BOOK OF NURSING 
 
 ance, the face dusky and indifferent, the muscular pros- 
 tration evidently extreme, the mental condition one of 
 stupor, varied by active delirium. The tongue is brown, 
 dry, and heavily coated; sordes collect on the teeth. 
 During the third week the fever again becomes remit- 
 tent, falling toward morning, though rising at night. 
 The general typhoid condition deepens, the pulse be- 
 comes frequent and feeble, the emaciation and loss of 
 strength rapid. This is the period of greatest danger. 
 By the beginning of the fourth week there should be 
 evident improvement, the fever becoming intermittent, 
 and the evening exacerbations decreasing, the tongue 
 clearing off, and the tympanites disappearing. There 
 will now be a return of the appetite and natural sleep. 
 Constipation is common. When the temperature keeps 
 a steady normal, convalescence may be regarded as fully 
 established. The strength begins to return, and the 
 appetite becomes sharp. Convalescence is always slow, 
 and likely to be complicated. There may be relapses, 
 usually milder than the original attack, and of shorter 
 duration, but running a similar course. The greatest 
 danger in typhoid is that of perforation of the bowel 
 by the intestinal ulcers, and consequent acute peritoni- 
 tis. The symptoms of perforation are severe pain, in- 
 creased by pressure, rapid distention of the abdomen, 
 rapid, feeble pulse, and other signs of collapse. It is 
 usually fatal within twenty-four hours. Intestinal 
 hasmorrhage may occur without perforation, from the 
 rupture of an artery in some ulcer. It is usually pre- 
 ceded by a sudden fall in temperature. It may be seri- 
 ous enough to be fatal, without any external escape of 
 blood. The treatment consists in absolute rest, the 
 application of an ice-bag to the abdomen, and semi- 
 narcosis by opium.
 
 SPECIAL MEDICAL CASES 329 
 
 In no case is good nursing of more vital importance 
 than in typhoid fever. There must be constant watch- 
 fulness and care from the beginning until complete re- 
 covery. The recumbent posture must be strictly main- 
 tained until the intestinal ulcers are perfectly healed. 
 The diet must be rigidly in accordance with the doctor's 
 directions, even after the patient feels quite well. 
 Many deaths occur from indiscretion or overexertion 
 during convalescence. There is no specific treatment; 
 little medicine will be given; everything depends upon 
 hygienic precautions and economizing the patient's 
 strength until the disease is exhausted. The patient 
 must be kept clean and dry there is great danger of 
 bed-sores with the extreme emaciation but in no way 
 fatigued. Wash the mouth and teeth several times 
 daily, and give cold water in small quantities even if not 
 asked for. Keep the temperature of the room low while 
 the fever is high. The stools need to be disinfected 
 with the same care as those of cholera, for the poison 
 passes out in them, and is readily communicable. 
 
 Typhus fever resembles typhoid only in name. It is 
 a highly contagious disease, associated with overcrowd- 
 ing and bad ventilation. The attack is usually abrupt, 
 beginning with a chill, followed by a temperature of 
 105 Fahr. or more, with violent headache and extreme 
 prostration. The rash appears toward the end of the 
 first week, showing first on the sides of the abdomen in 
 dirty-pink or purplish spots. When abundant, it is de- 
 scribed as " mulberry rash." Each spot persists until 
 the disease terminates in convalescence or death. The 
 head is much affected; violent delirium occurs, or in 
 some cases coma-vigil. The disease, unless it termi- 
 nates fatally, usually runs for fourteen days, after 
 which the amendment will be abrupt, as was the onset.
 
 330 A TEXT-BOOK OF NURSING 
 
 Eelapges are rare. The patient's strength must be 
 saved in every possible way, the aim being to sustain 
 the vital powers until the fever abates. Watch every 
 moment during the delirium. Keep ice-bags on the 
 head. The sleeplessness must be relieved, and nourish- 
 ment must be given, if by force. Quarantine strictly. 
 Ventilation is especially important, as the poison is 
 thrown off most virulently from the lungs and skin. 
 Fresh air is the best remedy, regardless of cold. 
 
 Scarlet fever has a period of incubation anywhere 
 from two to ten days. It begins with headache, nausea, 
 sore throat, pains in the limbs, rapid pulse, and rise of 
 temperature, more rarely with chills or convulsions. 
 The eruption generally appears on the second day 
 rarely later beginning on the chest, a bright efflores- 
 cence, rendered pale by pressure, but immediately re- 
 turning. It is most distinct on the back and at the 
 bends of the joints. The danger is somewhat propor- 
 tionate to the darkness of the eruption, but there is a 
 very malignant variety, rapidly fatal, with no eruption 
 at all. The rash lasts from four to six days, and as it 
 declines desquamation sets in. This is the most infec- 
 tious period, and the isolation must be complete until 
 it is fully over, and even for a week later. The most 
 severe cases may follow exposure to a light one. With 
 high fever may be the characteristic " strawberry 
 tongue " and sore throat, occasioning difficulty in swal- 
 lowing. The tonsils sometimes ulcerate. Hot appli- 
 cations about the throat may relieve it. Various com- 
 plicationi are common, and there is no disease in which 
 thert is greater liability to troublesome gequelffi. Kid- 
 ney troubles,* rheumatism, diphtheria, inflammation of 
 the points, and deafness from the ulcersttion extending 
 into the Eustachian tubes, are all likely to attend or
 
 SPECIAL MEDICAL CASES 331 
 
 follow it. The greatest care should be taken not to 
 let th patient get chilled during convalescence; the 
 skin is -especially sensitive while desquamation is going 
 on, and if its action is suddenly checked, the extra work 
 thrown on the kidneys is almost sure to induce conges- 
 tion of those organs. Even the lightest cases should 
 be kept in bed, and protected from the least exposure. 
 However well the patient may appear, 'watch the urine 
 carefully, and test it now and then for albumin. Should 
 it become scanty, smoky, or contain a trace of albumin, 
 it is an indication of danger. Note whether the eyelids 
 or limbs swell, and if there is any difficulty in breath- 
 ing. If diphtheritic trouble is impending, there is likely 
 to be free discharge from the nose. Very little medica- 
 tion is now employed for these cas.es. Keep up good 
 sanitary conditions, fresh but not cold air, food as di- 
 rected. Cold water may be given freely. During des- 
 quamation, the body may be sponged off frequently with 
 tepid or warm water, and rubbed with carbolized vase- 
 line or cacao-butter to allay the irritation. Scarlatina 
 is not, as commonly supposed, a lighter form of the 
 disease, but merely its Latin name. 
 
 Small-pox, or variola, begins with great severity 
 from nine to fourteen days after exposure, usually with 
 a chill, followed by high temperature, rapid pulse, gen- 
 eral feeling of lassitude, severe pains' in the back and 
 legs, vomiting, sore throat, tongue white and furred. 
 The rash appears on the third day, in small spots like 
 flea-bites, first on the face and neck, along the edges 
 of the hair, then extending downward. When the rash 
 comes out the febrile symptoms subside. The pimples 
 become vesicular, showing a depression in the center, 
 and about the fifth or sixth day suppurate. With the 
 suppuration the high fever returns, often preceded by
 
 332 A TEXT-BOOK OP NURSING 
 
 a chill. The vesicles have a marked and characteristic 
 odor. They increase in size, and may become confluent, 
 running together, or remain discrete, distinct. The 
 confluent variety is by far the most dangerous. By 
 the ninth day they reach their full size and burst, or 
 crust over, and desiccate. The secondary fever then 
 subsides, and convalescence is established. Another 
 high rise of temperature would be suggestive of some 
 complication. The danger in small-pox is greatest at 
 the beginning of the suppurative fever. The more 
 abundant the eruption, the greater the danger. The 
 pain attending the eruption may be relieved by hot 
 fomentations. When the vesicles begin to be prom- 
 inent, they may be pricked and bathed with some weak 
 disinfectant solution. On the palms and soles, where 
 the skin is thick, they should be opened early. During 
 desiccation, sponge with warm water and oil the sur- 
 face freely. Ventilate well. Keep the room dark, and 
 its temperature dpwn to 60. If there is delirium, ap- 
 ply ice to the head. Children must be kept in gloves. 
 The throat may be so inflamed as to render swallow- 
 ing difficult. But try to keep the patient's strength up, 
 and his temperature down, and isolate completely. He 
 must not come in contact with others till every trace 
 of a scab has disappeared. Infection may take place 
 during any stage, even that of incubation. Varioloid, 
 a modified form, may result from exposure after vacci- 
 nation, running a similar course, but milder, and of 
 briefer duration. 
 
 Vaccination, properly performed, renders one im- 
 mune to this poison, for a time at least. It consists in 
 introducing into the circulation lymph taken from the 
 udder of a cow which has been inoculated with the dis- 
 ease. This attenuated culture produces in a suscep-
 
 SPECIAL MEDICAL CASES 333 
 
 tible subject a mild type termed vaccinia, which pro- 
 tects against the more virulent infection. The opera- 
 tion is in itself simple, and a nurse might easily perform 
 it, but it involves a responsibility which she will be 
 wiser not to assume, owing to the risk of introducing 
 into the system other germs than those of the vaccine 
 virus. Very ill effects have been known to follow the 
 use of an imperfectly sterilized preparation. 
 
 The lymph now comes put up in sealed tubes of 
 gelatine, in which medium the vaccine germs retain 
 their vitality after others have become inert. This is 
 well rubbed into a spot previously scrubbed and scraped 
 till the serum exudes, left exposed to the air till it dries, 
 and then covered, preferably by a light bandage. After 
 the usual period of incubation, mild constitutional 
 symptoms may be expected to appear, and the spot 
 treated to develop a typical pustule. This should be 
 protected from friction until the scab separates, a 
 variable time. This scab should be burned, as also band- 
 ages soiled from the discharging pustule. 
 
 Malarial, or intermittent, fever is a non-infectious 
 fever of an endemic type, usually originating in marshy 
 regions. The most common form of attack exhibits 
 three stages. The patient is first seized with a chill, 
 more or less violent and prolonged, during which, 
 though he feels cold, his temperature will be found to 
 be rapidly rising. Severe headache, nausea, and pains 
 in the limbs often occur. The feeling of chilliness 
 passes away, and is succeeded by a hot stage. The tem- 
 perature keeps up, the face is flushed, the skin hot and 
 dry. Finally, perhaps after several hours, profuse 
 sweating ensues, during which the temperature falls 
 and the other acute symptoms subside. These attacks 
 occur periodically, with intervals of fairly good health.
 
 334: A TEXT-BOOK OF NURSING 
 
 Constitutional treatment is called for, and sometimes 
 change of climate. During the chills the nurse can do 
 something to alleviate the discomfort by the use of 
 warm blankets, hot bottles, etc., and during the fever 
 by tepid sponging and cooling drinks. 
 
 Inflammatory rheumatism, or acute rheumatic fever, 
 usually results from exposure to cold and damp. It 
 may possibly, when latent in the system, be developed 
 by malarial poisoning. The fever often runs high be- 
 fore the local symptoms appear. These are heat, red- 
 ness, swelling, and intense pain in one or more joints, 
 having a tendency to shift about from one spot to an- 
 other. There is profuse perspiration, having a charac- 
 teristic odor. The urine is likely to be scanty, high 
 colored, and strongly acid. Nervous disorders and mild 
 delirium at night may accompany severe cases. The 
 greatest danger is of cardiac complication. A horizontal 
 position should be maintained, and the patient lifted as 
 little as possible, as the slightest motion is agonizing. 
 He should be kept warmly dressed in flannel. The 
 bowels should be kept open, and only light and digesti- 
 ble food given. Avoid all excitement, and in no case 
 give stimulants except under the doctor's direction. 
 
 In giving stimulants in fevers, note the following 
 points: If, after taking, the tongue and skin become 
 moist, the pulse steadier, the breathing more tranquil, 
 if delirium is quieted, and sleep induced, they may be 
 recognized as helpful, and their use continued if called 
 for. If the reverse effects follow, the skin and tongue 
 becoming dry, the pulse quicker, the breathing hurried, 
 they are doing harm, and should be stopped. 
 
 " Be strong and do your best, 
 With honest heart and childlike faith 
 That God will do the rest."
 
 CHAPTER XIX 
 
 " But how much unexpected, by so much 
 We must awake endeavor for defense, 
 For courage mounteth with occasion." 
 
 Shakespeare. 
 
 SOME exceptional cases will arise, in which whatever 
 is to be done must be done at once, without waiting for 
 the arrival of skilled service, and in these emergencies, 
 if a nurse is present, she will naturally be looked to in 
 the place of a doctor. How much the nurse is justified 
 in doing, it is difficult to say; it depends upon the case 
 and upon the nurse. You will not wish to assume re- 
 sponsibilities that do not belong to you, but, when a 
 doctor can not be at once obtained, prompt action on 
 your part may save life. Do not try intricate experi- 
 ments. Eemember that the simplest things are often 
 the most useful, and that it is usually safer to do too 
 little than too much. As a rule, if you do not feel sure 
 what ought to be done, do nothing. But if you have 
 made any use of your opportunities, you will know at 
 least more than the utterly uninstructed crowd. Now 
 is a chance to practice the coolness and presence of 
 mind which your training has led you to cultivate. 
 Above all things do not get excited, or you will forget 
 all that you would otherwise know. 
 
 In case of any accident, send a written message to 
 the doctor, describing as well as you can the nature and 
 urgency of the case, so that he may come prepared with 
 
 335
 
 336 A TEXT-BOOK OF NURSING 
 
 the necessary appliances. A verbal message sent by an 
 excited bystander is never delivered intelligently. Try 
 to get rid of everybody who can not be made useful, 
 so as to secure plenty of fresh air and room to work. 
 If respiration is suspended, or the danger imminent, 
 treatment must be begun at once, on the spot, without 
 loss of time; otherwise the patient may be carried to 
 the nearest convenient house. For this purpose, a 
 stretcher, or something which will take its place, on 
 which he can lie horizontally, should be provided. The 
 bearers should be instructed to carry it in the hands, 
 not on the shoulders, and to avoid unnecessary jolting. 
 It is better for them not to keep step. 
 
 Have a warm bed ready to put him in. Eemove the 
 clothes with as little disturbance as may be, and do not 
 cut anything that can readily be ripped. If a foot is 
 hurt, the shoe and stocking will generally have to be 
 sacrificed, but almost everything else can be ripped 
 without ruining. Take the clothes from the sound side 
 first, but in putting on a garment begin with the in- 
 jured side. Special directions for undressing a woman 
 are hardly needed; in case of a man, remember to un- 
 fasten the suspenders behind as well as in front. All 
 the clothing can then be easily removed under cover of 
 a sheet. 
 
 Severe injury of any kind may be followed by that 
 complete prostration of the vital powers known as 
 shock. The patient lies in an apathetic state, though 
 not unconscious, the surface of the body pale and cov- 
 ered with cold perspiration. There will be an abnor- 
 mally low temperature, weak and irregular pulse and 
 respiration, dilated nostrils, drooping lids, with eyes 
 dull and sunken, mental and muscular weakness, and, 
 in less severe cases, nausea and vomiting are present.
 
 EMERGENCIES, SURGICAL AND MEDICAL 337 
 
 Death may be caused indirectly by failure to rally from 
 this condition. Lay the patient on his back, the head 
 low, and give stimulants till the heart's action is re- 
 vived. Loosen all clothing. Apply heat to the extremi- 
 ties by means of hot water bottles, hot flatirons, or 
 bricks, and put a hot plate covered with a towel over 
 the epigastrium. Rub with a hot flannel to stimulate 
 the circulation. Hot tea, coffee, or beef-tea may be 
 given if it can be retained. When there is nausea, 
 brandy is the best form of stimulant. If the patient 
 can not swallow, inject brandy or whisky well up into 
 the rectum, a teaspoonful at a time, diluted with four 
 or five of warm milk or water. This may be repeated 
 every twenty minutes until the patient shows signs of 
 improvement. 
 
 Syncope, or fainting, manifests many of the same 
 signs as shock, and mild forms of the latter are often 
 confounded with it. There is unconsciousness, occa- 
 sioned by an insufficient supply of blood to the brain. 
 Do not raise the head; keep it as low as, or lower than, 
 the feet; this position alone, with plenty of fresh air, 
 will often restore consciousness. If the condition per- 
 sists, proceed as in case of shock. Ammonia may be 
 given by inhalation, but not too strong, as the irritation 
 may occasion dangerous bronchitis. Sprinkle the face 
 sharply with cold wtaer. In either case, bind up broken 
 bones, dress wounds, and control haemorrhage before 
 making efforts to revive the patient. 
 
 Haemorrhage is the escape of blood from its contain- 
 ing vessels. According to the kind of vessel ruptured, 
 it may be described as arterial, venous, or capillary 
 haemorrhage. It is usually easy to distinguish these. 
 Blood from an artery will be of a bright-red color, and 
 will spurt out in jets of considerable force from the side
 
 338 A TEXT-BOOK OF NURSING 
 
 of the wound nearest the heart. The jets will corre- 
 spond to the beats of the heart, not entirely intermit- 
 ting, but subsiding into a steady flow between them. 
 Venous blood is of a dark-purplish hue, and moves in 
 a sluggish continuous flow, mainly from the side farthest 
 from the heart. Capillary haemorrhage is a mere oozing 
 of blood. The first is by far the most dangerous. Haem- 
 orrhage from a large artery, if not promptly checked, 
 may prove fatal in a few moments. 
 
 All wounds are attended by more or less bleeding. 
 Besides such, described as traumatic, there may be haem- 
 orrhage caused by rupture of the blood-vessels, either 
 from disease of their coats or of surrounding parts. 
 Haemorrhage following shortly after an operation, when 
 it has been once completely checked, is known as sec- 
 ondary. It arises either from giving way of the liga- 
 tures or from the extension of sloughing to parts not 
 previously implicated. The danger of this is greatest 
 during the first twenty-four hours, but is by no means 
 over until the wound is well healed. 
 
 The amount of bleeding from a wound depends not 
 only upon the kind and size of the cut vessels, but upon 
 the manner in which they are divided. A wound cross- 
 ing an artery will occasion more severe haemorrhage 
 than a longitudinal one, an incised wound more than 
 one contused or lacerated, and a mere puncture more 
 than a completely severed artery. 
 
 The arteries are always in a state of tension, and, 
 when cut, the edges retract from each other and con- 
 tract upon themselves, so lessening their caliber. The 
 outlets are choked by the coagulating blood, and, when 
 there is much loss of blood, fainting ensues, the action 
 of the heart becomes slower, and less blood is sent to 
 the wounded part. In these three ways Nature tries to
 
 GENERAL PLAN OF THE CIRCULATION
 
 CHART OF MAIN ARTEKIES 
 
 339
 
 340 A TEXT-BOOK OP NURSING 
 
 arrest haemorrhage, and moderate bleeding will soon be 
 checked spontaneously when the blood is in a normal 
 condition. 
 
 The application of heat or cold favors the formation 
 of clots and the arterial contraction; elevation of the 
 injured part reduces the force with which the blood is 
 sent to it; these will often be the only treatment re- 
 quired, but in more severe cases, when blood is spurting 
 from a wounded artery, further measures become neces- 
 sary. 
 
 The most important of these, and one usually call- 
 ing for no further apparatus than one's own fingers, is 
 pressure upon the bleeding point or the vessels which 
 supply it. There is no danger of serious haemorrhage 
 from a wound to which forcible digital pressure can be 
 applied. If the bleeding vessel is too deep to be reached 
 by the finger, the wound can be plugged by a compress 
 of lint. To make this most effectively, cut a number 
 
 Direct compression of a wound by means of what surgeons call a graduated 
 compress, made of pads of lint, folded in different sizes, with the largest 
 one on top. 
 
 of small bits, each a little larger than the preceding, 
 and, beginning with the smallest, press them well into 
 the wound. The pile should extend to some little height 
 above the surrounding level, and be secured by a tight 
 bandage. Such compression can only be made success- 
 fully over a bony surface; where the artery is imbedded 
 in muscle, it becomes difficult if not impossible to con- 
 trol it. Wounds of the head and face, though they are
 
 COURSE OF THE ARTERIES 341 
 
 apt to bleed profusely, can almost always be controlled 
 by direct pressure, as the skull affords firm counter- 
 pressure. If the bleeding artery can not be reached in 
 this way, it, or the branches leading to it, must be com- 
 pressed at some point nearer the source of supply. 
 Thus, bleeding from a finger or toe can be stopped by 
 making pressure on both sides of it, above the wounded 
 point. So, in any case, firm compression of the bleed- 
 ing vessel between the wound and the heart will ar- 
 rest the flow of blood. In order to be able proper- 
 ly and promptly to apply such pressure in time of need, 
 every nurse should familiarize herself practically with 
 the course of the main arteries, know where to find 
 them and how to control them. Actual experiment 
 is the only way of rendering the knowledge of much 
 utility. 
 
 The aorta, the main trunk of the arteries, ascends 
 from the upper part of the left ventricle for a short 
 distance, then forms an arch backward over the root 
 of the left lung, and descending upon the left side of 
 the spinal column passes through the diaphragm into 
 the abdomen. It is known in its different parts as the 
 ascending and descending arch, the thoracic and ab- 
 dominal aorta. From the arch of the aorta arise five 
 branches: the arteria innominata, the right and left 
 coronary arteries, the left common carotid, and the left 
 subclavian. Of these the innominata is the largest. It 
 extends for only about two inches, and then divides into 
 the right common carotid and right subclavian. The 
 common carotids run up each side of the neck, and 
 divide into the external and internal carotids, the one 
 with its branches supplying with blood the face and 
 outside of the skull, and the other penetrating to the 
 brain, through an opening in the temporal bone. The 
 23
 
 342 A TEXT-BOOK OF NURSING 
 
 coronary arteries return and supply the walls of the 
 heart. 
 
 Each of the subclavians runs along a groove in the 
 first rib, and it is against this that pressure is made to 
 control the circulation in the shoulder and arm. It 
 turns downward over this rib, and takes the name of 
 axillary fgr a short distance and then brachial. The 
 brachial proceeds down the arm along the inner border 
 of the biceps muscle to the front of the elbow, just 
 below which it divides into the radial and ulnar arteries, 
 which continue down the arm, one on each side, to the 
 hand. In the hand, they and their branches reunite 
 into a semicircle called the palmar arch. From this 
 small arteries are sent off to each of the fingers. All 
 these can be traced back to their origin at the arch of 
 the aorta. 
 
 The aorta reaches as high as the third dorsal verte- 
 bra, then, descending, passes through the diaphragm at 
 about the level of the twelfth dorsal. Opposite the 
 fourth lumbar vertebra it divides into the right and left 
 primitive or common iliac arteries.. These are about 
 two inches long. They diverge outward and downward, 
 and, opposite the fifth lumbar vertebra and the sacrum, 
 divide into the external and internal iliacs. The in- 
 ternal iliacs, after a course of about an inch and a half, 
 are split up into numerous branches supplying the pel- 
 vic viscera. 
 
 Each external iliac continues downward and out- 
 ward along the brim of the pelvis, and, half-way be- 
 tween the anterior spine of the ileum and the symphy- 
 sis pubis, runs under Poupart's ligament, and takes the 
 name of femoral. The pulsations in this can be dis- 
 tinctly felt at the groin. It descends along the inner 
 side of the thigh in a nearly straight line till it reaches
 
 HEMORRHAGES 343 
 
 the lower third, where it again changes its direction 
 and its name, becoming the popliteal, and passing to 
 the back of the thigh and down behind the knee. Here 
 it divides into the anterior and posterior tibials, which 
 run down either side of the leg, and finally anastomose 
 into the plantar arch, as do the ulnar and radial arteries 
 into the palmar. From the plantar arch branches go 
 to the toes. 
 
 The other principal branches of the descending 
 aorta are the intercostals, the phrenic artery, the cceliac 
 axis, and the superior and inferior mesenteries. These 
 supply various internal organs. 
 
 The arteries most commonly compressed for the re- 
 lief of haBmorrhage are the subclavian, the brachial, 
 
 Manner of compressing an artery with a handkerchief and stick. 
 
 and the femoral. You should at least know how to find 
 and manage these. If pressure can not be made forcibly 
 enough by the fingers, or if it needs to be maintained 
 for any length of time, a tourniquet can be used upon 
 the brachial or femoral arteries. Before applying it, 
 elevate the limb as high as possible, make a few turns 
 of bandage about it to protect the skin, and place a 
 hard pad directly over the course of the artery. In the 
 absence of the regular apparatus, an impromptu tourni-
 
 344 A TEXT-BOOK OF NURSING 
 
 quet may be made of a handkerchief or strip of muslin, 
 with a hard knot or a smooth stone tied in the middle. 
 Fasten this rather loosely around the limb and twist it 
 with a stick on the opposite side, keeping the knot over 
 the injured artery until pressure enough is made to 
 completely occlude it. This is sometimes called a field 
 tourniquet. It will be of no use whatever unless so 
 fixed as to make pressure directly upon the main trunk 
 of the artery. A tourniquet may remain on the arm 
 for an hour, on the thigh for two hours not more, as 
 the part will die if its nutrition is cut off too long. 
 
 The subclavian artery can not be reached by a tour- 
 niquet. The handle of a large key, or a blunt stick, 
 suitably covered, may be pressed forcibly against it, 
 behind the clavicle at the outer third of the first rib, in 
 case of severe haemorrhage from the shoulder or axilla. 
 
 Esmarch's plan for preventing haemorrhage during 
 an operation upon a limb is to apply a very tight rubber 
 bandage spirally from its extremity to a point above 
 the site of the proposed incision. Where this stops, a 
 piece of rubber tubing, with hooks at the end, is wound 
 several times tightly around the limb and fastened. 
 The bandage is then removed, when the circulation will 
 be found to be almost completely cut off. Where there 
 is danger of secondary haemorrhage from a limb, it is 
 well to keep at hand a piece of heavy rubber tubing, 
 which can be used as a tourniquet in case of need. A 
 piece of tubing cut from a syringe will answer. 
 
 With any secondary haemorrhage the first thing to 
 be done is to remove all dressings so as to expose the 
 wound to the air. Make digital pressure upon the 
 wound, if it can be reached, assisted by pressure on the 
 main artery, and notify the surgeon at once. 
 
 Flexion of a limb will sometimes aid in arresting
 
 HEMORRHAGES 345 
 
 haemorrhage. Put in the joint a firm roll of lint, 
 against which the pressure will come when the limb 
 is bent. In case of bleeding from tb.e palm of the hand, 
 which will sometimes be profuse, direct the patient to 
 clasp closely a wad of lint, at the same time holding 
 the hand high above the head. 
 
 Besides those named heat or cold, position, and 
 pressure there is still another means of arresting 
 hemorrhage to which a nurse may in an extremity re- 
 sort, namely, use of astringents. Astringents used ex- 
 ternally are called styptics. The most useful are the 
 subsulphate or the perchloride of iron, alum, gallic acid, 
 and matico. Wring out a piece of lint in the dilute solu- 
 tion, and, having first wiped out the blood-clots, stuff it 
 into the wound. The mode of action is by increasing 
 the contractile power of the vessels. Nitrate of silver 
 or lunar caustic acts somewhat similarly. Obstinate 
 bleeding from a small point, as a leech-bite, may be 
 checked by touching with this. Lunar caustic is some- 
 times spoken of as the potential cautery, having the 
 effect, though more superficially, of cauterization. 
 
 The actual cautery the application to the wound of 
 a hot iron is sometimes employed by surgeons when 
 the bleeding is from many vessels over a large surface, 
 or from a porous part which will not hold a ligature. 
 Both styptics and the cautery prevent primary union, 
 and are only employed when no other means will an- 
 swer. General oozing from a large surface or cavity can 
 nearly always be checked by packing it with iodoform 
 gauze. 
 
 The method most commonly used by surgeons for 
 the arrest of haemorrhage from an artery of any size is 
 ligation. The artery is picked up by a pair of forceps, 
 and a ligature tied firmly about it. A ligature should
 
 346 
 
 A TEXT-BOOK OF NURSING 
 
 be about eighteen inches long. It was formerly made of 
 strong, soft silk, but catgut is now employed in wounds 
 which are to be completely closed, since the latter is 
 absorbed and does not require to be removed. Test its 
 strength well, so as to leave no chance of its breaking 
 when strained; and, if you have it to tie, be sure and 
 make a firm knot. Surgeons use generally the " reef 
 knot," a square knot in which both ends of one string 
 
 pass either over or under the loop made by the other; 
 if the ends are separated by the loop, you get a " gran- 
 ny " knot, which will slip. The string in the right hand 
 should be held over the other in the first twist, and un- 
 der it in the second, or vice versa. This knot may be 
 made additionally secure, by making the second turn 
 twice instead of once before drawing it tight the so- 
 called " surgeon's knot." You should practice these 
 knots, and also the " clove hitch," which is often called 
 for. For this, make two loops in the cord from right to 
 left, and put the first over the second. Loops in oppo- 
 site directions will make, if they hitch at all, the much 
 less reliable " cat's paw."
 
 HAEMORRHAGES 34:7 
 
 Another mode of arresting haemorrhage, frequently 
 employed, is that of torsion, the artery being seized in 
 the forceps and twisted, rendering a ligature unneces- 
 sary. Still another way, though now rarely adopted, is 
 by acupressure. A harelip pin is placed about the open 
 mouth of the vessel, and a wire twisted over it in the 
 shape of a figure 8. 
 
 The most dangerous form of venous haemorrhage is 
 that from rupture of large varicose veins. Pressure 
 should be made ~bdow the bleeding point, cold or heat 
 applied, and the limb elevated. Pressure above the 
 point of injury is here useless and absurd. Ligation is 
 avoided, as it is likely to occasion inflammation of the 
 vein. In cases where there is danger of such rupture, 
 an elastic stocking or bandage should be worn, to sup- 
 port and make equable pressure upon the distended 
 vessel. This should be put on before getting up in the 
 morning. 
 
 Capillary haemorrhage is never dangerous, and can 
 easily be checked by cold and position, or by hot water, 
 an especially valuable haemostatic in such cases. It 
 must be used as hot as it can be borne. Warm water 
 will only increase the flow of blood. 
 
 There are some persons who have what is called the 
 hgemorrhagic diathesis that is, an excessive tendency 
 to bleed so that even a slight cut or scratch may be 
 followed by haemorrhage difficult to control. This is 
 more common in male subjects, especially children. If 
 such a case comes into your hands, you will probably 
 have to resort to styptics. To stop the bleeding after 
 a tooth has been extracted, a good application is a little 
 piece of burnt alum pressed well into the cavity and 
 packed down with lint. 
 
 The constitutional symptoms of extreme haemor-
 
 348 A TEXT-BOOK OF NURSING 
 
 rhage are those of shock, pallor, coldness of the ex- 
 tremities, clammy sweat, feeble or sighing respiration, 
 small and rapid pulse, restlessness and thirst, vertigo, 
 dimness of vision, ringing in the ears, difficulty in ar- 
 ticulation, followed, if the trouble is not before this 
 brought to an end, by unconsciousness, slight convulsive 
 movements, and death. The haemorrhage usually 
 ceases, or is much lessened, with syncope. The same 
 effects follow internal haemorrhage, and may be the only 
 evidence of its existence, though usually the blood will 
 somewhere find an outlet, unless the bleeding is intra- 
 peritoneal. Convulsions may be the first conspicuous 
 indication. A dangerous, often fatal, form of internal 
 haemorrhage results from the rupture of an extra-ute- 
 rine pregnancy. Suspicion should be aroused if the 
 patient has missed a menstrual period and complains 
 of a sudden agonizing pain in the abdomen. 
 
 If blood comes from the lungs hcemoptysis it is 
 usually coughed up, is bright red, and more or less 
 frothy from the admixture of air. It is always a serious 
 symptom, though the quantity of blood lost is rarely 
 great; but blood supposed to be from the lungs is not 
 infrequently from the mouth or throat. 
 
 The vomiting of blood, hcematemesis, is usually some- 
 what less ominous. The patient is likely to have a sense 
 of fullness and oppression in the epigastric region, and 
 then to throw up, without much nausea, a large quan- 
 tity of dark blood, mixed with food, but containing no 
 air, acid in reaction, and incoagulable. 
 
 In either case, keep the patient quiet and cool, the 
 head elevated. Give bits of ice, having them swallowed 
 whole if possible; and if the haemorrhage is repeated, 
 apply ice-cold cloths externally. Give only fluid food, 
 cold, and in small quantities.
 
 HAEMORRHAGES 349 
 
 In cases of internal haemorrhage, particularly from 
 the lungs, much may he done to arrest it by partially 
 cutting off the venous return from the limbs, by means 
 of straps or bandages applied tightly around their proxi- 
 mal extremities. This procedure, by diminishing tem- 
 porarily the amount of blood in the circulation, will di- 
 minish its force, and give an opportunity for coagula to 
 form in the bleeding vessels. Ordinary shawl-straps 
 will answer the purpose well. They should be applied 
 to one arm and the opposite thigh, left in position for 
 not more than five minutes, then removed, and the 
 other arm and thigh similarly treated. This may be 
 continued until the haemorrhage ceases, alternating the 
 sides, and taking off one pair of straps before putting 
 on the others. 
 
 When an exhausting haemorrhage has occurred, after 
 its source has been controlled, the limbs may be tightly 
 bandaged from their distal extremities to the trunk, in 
 order to prevent the circulation in them of blood which 
 is needed by the vital organs. The object in both the 
 above procedures is to gain time. The same care must 
 be taken not to leave the bandages on too long. 
 
 With haematemesis some blood will almost invaria- 
 bly appear in the next stool as a dark, tarry substance. 
 For haemorrhage from the bowels, ice-cold injections 
 may be given, and in the same way solutions of vege- 
 table astringents as oak bark, tannic acid, catechu, 
 etc. Make cold applications over the abdomen. It 
 may be well to give a small dose of opium to diminish 
 the peristaltic action. This may occur in the course 
 of typhoid or yellow fever, but is more common from 
 haemorrhoids than from any other cause. 
 
 With hatmaturia, keep the patient lying down, and 
 give hot or ice-cold injections into the rectum or va-
 
 350 A TEXT-BOOK OF NURSING 
 
 gina. Blood in the urine may come either from the 
 kidneys, bladder, or urethra. Note whether it appears 
 at the beginning or end of micturition, and whether its 
 passage is accompanied by pain. Blood from the kid- 
 neys is dark and clotted; from the bladder it is clear, 
 as a rule. 
 
 In case of uterine haemorrhage, especially when fol- 
 lowing operations, a vaginal douche of hot water, or a 
 hot solution of alum, is especially indicated. The fluid 
 extract of ergot, or gallic acid, may be given internally. 
 It may be necessary to plug the vagina. One way of 
 doing this is to introduce as far as the mouth of the 
 uterus the center of a soft handkerchief, leaving the 
 ends projecting. Pack this with small pieces of com- 
 pressed sponge, gauze, or cotton, and tie the projecting 
 ends together. Cotton is best, but not absorbent cotton. 
 After a sufficient time the plugs can be removed, one 
 at a time, and, finally, the handkerchief. Another way 
 is by means of a kite-tail tampon a series of bunches 
 of cotton tied at intervals of a couple of inches along 
 one string. These are introduced, one at a time, till the 
 vagina is distended, and the end of the string left hang- 
 ing. Upon pulling this, the plugs easily come out in 
 succession. Ordinary lamp-wicking, sterilized, makes a 
 good tampon. Haemorrhage following childbirth is 
 called post-partum. Special directions for its treatment 
 are given in the chapter on obstetrics. 
 
 There is one other local hemorrhage which demands 
 some special attention epistaxis, bleeding from the 
 nose. This may be either the result of an accident or 
 a spontaneous outbreak. In the latter case it may be 
 looked upon as an effort of nature to relieve the head, 
 and need seldom be regarded with any uneasiness. To 
 check it, make pressure on the facial artery at the root
 
 EMERGENCIES, SURGICAL AND MEDICAL 351 
 
 of the nose, with cold applications to the forehead and 
 back of the neck. The ordinary position taken lean- 
 ing over a basin is the worst possible. Make the pa- 
 tient stand erect, throw his head back and elevate his 
 arms, while you hold a cold, damp sponge to the nos- 
 trils. If the bleeding still persists beyond a reasonable 
 time, the nostrils should be syringed with salt and 
 water, ice cold (3 j-0 j), or a solution of alum or iron. 
 There are very few cases that these measures will not 
 control. Avoid blowing the nose, and so disturbing the 
 formation of clots. If all other means fail, the surgeon 
 may find it necessary to plug the nares. To do this, he 
 will need a small flexible catheter, a strong cord, and 
 some lint. The cord is passed through the eye of the 
 catheter and carried by it through the nostril to the 
 pharynx, where the end of the string can be caught and 
 brought out through the mouth. By means of this a 
 plug of lint is drawn into the posterior naris; another 
 is pushed into the anterior, and the two tied together 
 so as to hold each other in place. They should be left 
 in for twenty-four hours. The process is a very pain- 
 ful one, and is only resorted to when all other means 
 prove ineffectual. 
 
 Broken bones are among the most common casual- 
 ties. It is a mistaken impression that a fracture must 
 be set immediately. It will do less harm for it to be 
 left a day or two without splints than for them to be 
 awkwardly applied. Handle the injured part as little 
 as possible, and do not attempt to do more than to keep 
 the patient comfortable and quiet until a competent 
 surgeon can be obtained. Temporary splints may be 
 put on, made of pasteboard, shingles, or any smooth and 
 stiff material at hand, to prevent the spasmodic twitch- 
 ing of the muscles, which adds to the pain. If it is a
 
 352 A TEXT-BOOK OF NURSING 
 
 limb that is broken, place it in a natural position, mak- 
 ing some extension, and support it firmly, elevating the 
 limb slightly. A broken leg may be laid on a pillow, 
 which is then bandaged closely around it, or it may be 
 bound to a straight padded stick, or even to the other 
 leg. In fracture of the patella, the foot should be ele- 
 vated to a considerable height, and the leg kept straight 
 by a long splint at the back. Put a pad under the knee. 
 For a fractured thigh, extend the limb and bind it 
 against a splint long enough to reach from the axilla 
 to the heel. With a broken arm, bend the elbow, keep- 
 ing the thumb up, fasten a well-padded splint on each 
 side, and place the arm in a sling. With a fractured 
 clavicle, lay the patient on his back, without a pillow, 
 with the arm of the injured side bound across the chest. 
 For fractured ribs, keep the patient quiet in bed; put 
 a broad bandage tightly around the chest to limit its 
 movements; note whether any blood is raised. If skull 
 fracture is suspected, keep the patient in a quiet, dark 
 room, on his back, with the head slightly raised; apply 
 cold cloths to the head. If blood or serum is oozing 
 from the ears, do not let it putrefy, or it may set up an 
 inflammation in the brain. Wash the external ear, and 
 put in a little antiseptic pad. For fracture of the jaw, 
 close the mouth, and fix in place with a bandage. 
 
 When a dislocation occurs, it is much more impor- 
 tant for it to be speedily reduced, as the muscular ten- 
 sion increases and the reduction becomes more difficult 
 with each hour that passes. There are one or two which 
 you may try yourself to put in place. Dislocation of 
 the jaw is one easily managed, and in which delay is 
 particularly trying to the patient, as it will be fixed 
 immovably, rendering him unable to speak. To reduce 
 this, place the thumbs on the back teeth and the fingers
 
 EMERGENCIES, SURGICAL AND MEDICAL 353 
 
 under the jaw. Depress forcibly the angle of the jaw, 
 at the same time lifting the chin. The thumbs need 
 to be well protected, for the jaw will slip in place with 
 a snap, and unless they are quickly moved aside they 
 may get badly bitten. Dislocations of the fingers can 
 generally be reduced by forcibly pulling them. A 
 thumb out of place is more difficult, sometimes impos- 
 sible to return. Too much force should not be used in 
 the attempt. Larger joints you will hardly dare to 
 meddle with, owing to the difficulty of making a posi- 
 tive diagnosis and the danger of creating complications. 
 After any dislocation the joint will for some time be 
 weak, and liable to a recurrence of the accident, so that, 
 when it has once been reduced, the parts should be 
 firmly bandaged or strapped in place, until they have 
 grown quite strong again. 
 
 Sprains occur most frequently at the wrist and 
 ankle-joint. They should not be made light of, for, if. 
 neglected, their results may be permanent. Put the 
 joint in such position that it will have complete rest. 
 Soak in water as hot as can be borne, gradually increas- 
 ing the temperature, for half an hour, then apply hot 
 cloths for another half hour, and finally a moist band- 
 age, keeping the part elevated. Massage is useful later, 
 and when the swelling goes down the joint should 
 be supported by rubber bandages, adhesive straps, or 
 a plaster-of-Paris splint. 
 
 Contusions, or bruises, are best treated by rest and 
 hot applications. After a general contusion a warm 
 bath may be found helpful. Severe contusion is often 
 followed by symptoms of shock. A painfully crushed 
 finger or toe may be wrapped in soft cloths wet with 
 hot water and a little laudanum. Do not use arnica or 
 any of the strong patent liniments. Listerine is excel-
 
 354 A TEXT-BOOK OF NURSING 
 
 lent, and a mixture of alcohol and water or salt and 
 water, will be found stimulating. 
 
 With contused and lacerated wounds there must be 
 especial care in cleaning out the blood-clots. In the 
 case of all wounds there are five points to be attended 
 to: To arrest the haemorrhage, to cleanse the wound, 
 to bring the cut surfaces together, to see that there is a 
 way of escape for any discharge, and to protect the 
 wound from the air. With all extensive wounds, espe- 
 cially those of the thoracic and abdominal cavities, rest 
 is important. When the chest is injured, lay the pa- 
 tient on the wounded side rather than the other. 
 
 A ghastly effect is often produced by a wound which 
 bleeds freely, but which, when it is cleansed, proves un- 
 important. This is apt to be the case with cuts about 
 the head and face. In washing, do not touch the wound 
 itself, but irrigate or squeeze a stream of antiseptic 
 solution over it. When you are sure that no dirt or 
 other foreign matter is left in it, bring the edges as 
 nearly as you can to their original position; if the 
 wound is but slight, they may be held in place by ad- 
 hesive strips, leaving room between them for the es- 
 cape of blood and pus. Over this put some simple dress- 
 ing, to exclude the air. On the scalp, the hair must be 
 cut or shaved off about the wound before the strips are 
 applied. For a deep incision, or one that can not be 
 held together by adhesive plaster surgeons use sutures 
 of silk, catgut, or fine wire. To introduce these, a 
 needle with a cutting edge is required. A cut finger 
 needs only to have the edges brought snugly together 
 and bandaged. For slight wounds, collodion is some- 
 times used in place of plaster after the bleeding is 
 checked. This is a solution of gun-cotton in ether. 
 When applied, the ether evaporates, leaving an adhe-
 
 EMERGENCIES, SURGICAL AND MEDICAL 355 
 
 sive, transparent, and highly contractile film. One 
 layer only is to be used, as it contracts so forcibly that 
 a second will drag off the first. The parts must be 
 held together until it is dry. It is useless to apply it 
 over a wet surface. With a little absorbent cotton, it 
 makes an excellent dressing, more durable than the col- 
 lodion alone. If a finger, a portion of the scalp, or any 
 small part is almost entirely cut off, there is still a 
 chance of its growing on again, if it is cleaned, imme- 
 diately replaced in the proper position, and so bound 
 on that a firm and even pressure is made. The experi- 
 ment is at least worth trying, for even if it fails there 
 is no great harm done. 
 
 With a punctured wound, the important point is to 
 keep it open until it heals from the bottom. If made 
 by a splinter or thorn, this must be entirely removed, 
 not by poking at it, but by making a sharp incision 
 along its course, so that you can get at and withdraw 
 it. The incision, though it seems like increasing the 
 wound, is likely to heal sooner and. better than the 
 puncture. If the splinter goes under the finger-nail, 
 trim or split the nail down to the end of the splinter. 
 
 Never try to extract a fish-hook or any barbed in- 
 strument by the hole at which it entered. Push it all 
 the way through and break off the head. 
 
 In case of the bite of a venomous snake or other 
 probably poisoned wound, the bleeding should be en- 
 couraged rather than checked. Bathe it in warm water. 
 Ligate the limb, if possible, above the point of injury, 
 and suck it, being careful not to swallow the poison. 
 If the heart's action seems affected, keep the patient 
 lying down, and give stimulants to the verge of intox- 
 ication. Ammonia-water may be used both externally 
 and internally. Cauterize the wound deeply, and then
 
 356 A TEXT-BOOK OF NURSING 
 
 poultice it. Prompt excision of the wounded area has 
 been recommended. The bite of any animal may be 
 regarded with suspicion. That of the cat or rat is said 
 to be more dangerous than that of the dog. Treat the 
 bites and stings of insects with ammonia or soda. Take 
 care that the sting of a wasp or bee is not left in the 
 wound, as it may set up serious irritation. A good way 
 to remove it is to make strong pressure around the spot 
 with the barrel of a watch-key. Listerine or peroxide 
 of hydrogen will relieve the pain. 
 
 The eruption from the Rhus toxicodendron (poison 
 ivy or mercury) or of the Rhus venenata (poison oak, 
 dogwood, or sumach) is commonly treated with a satu- 
 rated solution of bicarbonate of soda or an acetate of 
 lead wash. I have found listerine more soothing, and 
 a strong hot decoction of sweet fern leaves is also good. 
 
 Perhaps the most alarming accidents are those re- 
 sulting from fire. If your own clothes catch fire, lie 
 down on the floor and roll, keeping your mouth shut. 
 If you see another woman in the same danger it is 
 most likely to be a woman throw her down, and wrap 
 around her a shawl, rug, or any heavy woolen thing at 
 hand, to stifle the flames. Begin at the head, and keep 
 the fire as much as possible from the face. The great 
 danger is that of inhaling the flames. 
 
 In the treatment of burns or scalds, the first object 
 is to exclude the air. This will at once allay the pain. 
 If the injury is superficial, mere reddening of the sur- 
 face, sprinkle it thickly with bicarbonate of soda and tie 
 a wet bandage over it till the pain subsides. Then the 
 part may be protected from the action of the air by 
 painting it over with the white of an egg. As one layer 
 dries, a second and third may be added. Flexile collo- 
 dion, similarly applied, is even better, but it is not one
 
 EMERGENCIES, SURGICAL AND MEDICAL 357 
 
 of the things likely to be at hand in an emergency. 
 Another plan is to dust with flour and cover with a 
 thick layer of cotton wool. If the burn is severe enough 
 to have blistered or destroyed the cuticle, the latter 
 remedy should not be employed, for the discharge will 
 harden the flour into crusts, and the fibers of the cotton 
 stick to the wound, and can not be detached without 
 pain. Carron oil linseed oil and limewater in equal 
 parts is a popular remedy, but pure olive oil or vase- 
 line is as good, or perhaps better, as linseed oil often 
 contains irritating impurities. From severe burns great 
 deformity sometimes results, through the contraction 
 of the skin in healing. It may be quite unavoidable, 
 but something can be done toward preventing it, by 
 keeping the burned parts in the best position, not al- 
 ways the easiest. A severe burn is usually accompanied 
 by more or less shock, to be treated according to the 
 directions already given. 
 
 The burns produced by strong acids are treated in 
 the same way as those by fire, further caustic action 
 being prevented by first bathing with some weak alka- 
 line solution, as of soda or ammonia. Common earth, 
 picked up almost anywhere, contains alkali enough to 
 be useful. 
 
 Lime or caustic potash may make a severe burn. 
 The treatment is still the same, the alkali being first 
 neutralized by some acid, as diluted vinegar or lemon 
 juice, about a teaspoonful to a cup of water. 
 
 If a fragment of lime gets into the eye, bathe it at 
 once with such a solution, without wasting time in try- 
 ing to pick it out. Any foreign body in the eye will 
 occasion a great deal of pain. The irritation gives rise 
 to an abundant secretion of tears, which will sometimes 
 
 wash out the cause of trouble. Dust or small cinders 
 24
 
 358 A TEXT-BOOK OF NURSING 
 
 may be cleared out by drawing the upper lid well down 
 over the lower, and at the same time blowing the nose 
 forcibly. If a particle gets caught under the lower lid, 
 draw it down by the lashes, direct the patient to turn 
 the eyeball toward the nose, and the offending body 
 can then be wiped out with a soft handkerchief. If it 
 is under the upper lid, that can be turned up over a 
 knitting-needle, or a small pencil, and treated in the 
 same way. Drawing the upper lid over the under, sev- 
 eral times, at the same time pushing up the latter, 
 may brush it out. Always wipe the eye toward the 
 nose, as the natural secretions flow in that direction. 
 If the particle is embedded in the surface of the eye- 
 ball, it will have to be picked out by a sharp instrument. 
 It takes a surgeon to do this safely. The eyes may be 
 bathed with rose-water or a saturated solution of bora- 
 cic acid. 
 
 Foreign bodies in the ear are often very trouble- 
 some. If an insect gets in, hold a bright light close to 
 the ear, and it may be attracted outward. Then try 
 syringing it with warm salt water. If these measures 
 are not successful, lay the sufferer down on the other 
 side, straighten the tube of the ear by pulling the tip 
 upward and slightly backward, and fill it with warm 
 olive oil or glycerin. The insect will be drowned in 
 this and float to the surface. If some hard substance 
 is in the ear, hold it downward and syringe gently with 
 warm water, taking care not to close the opening with 
 the nozzle of the syringe. Do not try this if the object 
 is anything that will swell with moisture, as a bean 
 or a pea, as it will then only make a bad matter worse. 
 Neither poke at it, as it may be easily driven in beyond 
 reach. Bend the head over to the affected side, and 
 shake it. Jump up and down, and it may be jarred out.
 
 EMERGENCIES, SURGICAL AND MEDICAL 359 
 
 Otherwise, get a doctor as soon as possible, as perma- 
 nent injury to the ear may result if the obstruction is 
 not removed. 
 
 When a foreign body is in the nostril, make the pa- 
 tient take a full breath, then close the mouth and the 
 other nostril firmly, when the air, having no other way 
 of escape, may expel the obstruction. Try at the same 
 time to blow the nose. Tickling it with a feather, or 
 giving snuff to cause sneezing may help. If this fails, 
 and the object is in sight, compress the nostrils above 
 to prevent its being pushed farther up, and hook it out 
 with a hairpin or a bent wire. 
 
 Anything stuck in the throat, or oesophagus, may 
 sometimes be hooked out in the same way, if it is too 
 far down to be reached by the fingers. A pair of blunt 
 scissors may be used in the place of forceps. It is hard- 
 ly safe to try, as is often advised, to push the object 
 down, unless it is some digestible substance which may 
 be trusted to soften under the action of the secretions. 
 If a piece of bread can be swallowed, it may carry down 
 with it the obstruction. Once swallowed, there need be 
 no further apprehension on account of the size of the 
 body, as whatever will pass through the gullet will get 
 through the rest of the alimentary canal without diffi- 
 culty. Do not give purgative medicine in such case, 
 but food a little more solid than usual, in which it will 
 be imbedded and carried along without irritating the 
 passages. 
 
 A foreign body in the windpipe will usually be ex- 
 pelled by the coughing which its presence excites. The 
 trachea is very sensitive, and the entrance even of a 
 drop of water excites great irritation. A blow on the 
 back will be of use if the person is choking. A child 
 may be taken up by the feet and tfeld head down
 
 360 A TEXT-BOOK OP NURSING 
 
 while a succession of blows are administered between 
 the shoulders. This will seldom fail to dislodge the 
 object unless it has been sucked deeply into the air 
 passages. 
 
 If the trachea is so obstructed, from any cause, that 
 the supply of air is cut off from the lungs, and the blood 
 fails to be oxygenated, asphyxia results. This is what 
 occurs in drowning, strangulation, and suffocation by 
 irrespirable gases. The action of the lungs may under 
 such circumstances have ceased some time before death 
 ensues, and, even when animation is too far suspended 
 for the movements of the chest to be of themselves re- 
 newed, the lungs may sometimes be forced into action 
 by artificial respiration. There are two methods com- 
 monly employed; the most practiced is that known as 
 " Sylvester's ready method." The first thing to be done 
 is to pull the tongue forward and keep it there, so that 
 it will not fall back and obstruct the trachea; an elastic 
 band over the tongue and under the chin is advised for 
 this purpose. Loosen all the clothing, and lay the 
 patient on his back, with head and shoulders slightly 
 raised. Then, standing behind him, grasp the arms 
 just above the elbows, and draw them slowly away from 
 the sides of the body in an upward direction till they 
 meet over his head. Hold them in this position for 
 about two seconds, then bring them back slowly till 
 the elbows meet over the chest, making firm pressure. 
 With the first motion the ribs are raised by the pectoral 
 muscles, and a vacuum is created in the lungs, into 
 which the air rushes. As the arms are brought back to 
 the sides, the air is again forced out, as in natural 
 respiration. The two movements should be repeated 
 slowly and steadily, not more than sixteen times in a 
 minute, and persisted in until respiration takes place
 
 EMERGENCIES, SURGICAL AND MEDICAL 361 
 
 naturally, or until all hope of establishing it must be 
 given up. It is not to be considered hopeless under two 
 hours. 
 
 " Marshall Hall's method " is sometimes used as a 
 substitute for or alternating with Sylvester's. The 
 body is laid flat on the face, and gentle pressure made 
 on the back, after which it is turned over on the side; 
 then again on the face, and the pressure reapplied. Ee- 
 peat these motions at a rate of sixteen to the minute. 
 The principle is the same, whichever method is adopted. 
 It is well to practice one or both of them, that the mo- 
 tions may be familiar if suddenly called for. Cessa- 
 tion of breath for more than two minutes is usually 
 fatal. 
 
 When a person is apparently drowned, before begin- 
 ning artificial respiration, turn the face down for a mo- 
 ment, and clean out with the finger any accumulation of 
 mucus that may be at the base of the tongue. Hold the 
 body in such a way that by gently moving it back and 
 forth, any water that may be in the lungs will run out 
 through the mouth. The mucus must be removed from 
 the throat in the same way in case of strangulation. 
 Kemove all constriction from the neck. If hanging, 
 cut the body down, but do not let it fall. In poisoning 
 from carbonic-acid gas (choke damp) or carbonic oxide 
 (the fumes of burning charcoal), loosen the clothing, 
 and, if the body is still warm, dash cold water over it 
 forcibly and frequently. If it is chilled, use hot appli- 
 cations instead. In all cases apply artificial respira- 
 tion, and give stimulants and nourishment as soon as 
 they can be swallowed. 
 
 Sunstroke or heat prostration is in most cases pre- 
 ceded by headache, dizziness, and more or less mental 
 disturbance. Direct exposure to the rays of the sun is
 
 362 A TEXT-BOOK OF NURSING 
 
 not essential; it may be produced by intense heat of any 
 kind. Fatigue and foul air aggravate the tendency. 
 The alcoholic habit renders one especially liable to it. 
 Persons who have once been so affected are liable to a 
 recurrence of the attack upon exposure to heat. The 
 preliminary symptoms either become intensified until 
 delirium sets in, or the patient falls suddenly uncon- 
 scious, the face pale or dusky, or intensely red, the skin 
 very hot, the breathing evidently difficult, and the pulse 
 weak and fluttering. There are occasionally convul- 
 sions, but more often no movement after the first in- 
 sensibility till death. The danger is imminent, the 
 bodily temperature sometimes rising to 112 or 114. 
 The first thing to be done is to reduce this. Remove 
 the patient into the shade, take the clothing from the 
 head and chest, and throw cold water over the body, or 
 put it in a cold bath, gradually reducing the degree of 
 cold. Have all the fresh air possible, and as soon as a 
 decline in heat is evident, artificial respiration may be 
 resorted to, if necessary. If, after consciousness is re- 
 stored, the temperature again rises, the cold applica- 
 tions must be repeated. Do not give alcoholic stimu- 
 lants without medical advice. Aromatic spirits of 
 ammonia may be used if a stimulant seems called for. 
 When death takes place from a stroke of lightning, 
 it is the result of shock to the nervous system. This 
 may be enough to produce unconsciousness without be- 
 ing fatal, and, even when life is apparently extinct, 
 efforts at resuscitation should be made and kept up 
 for not less than an hour, the important point being 
 borne in mind to preserve the warmth of the body by 
 all methods, such as by applications of the hot water 
 bottle or cloths, hot flannels or warm salt-bags. Em- 
 ploy artificial respiration, and treat otherwise as
 
 EMERGENCIES, SURGICAL AND MEDICAL 363 
 
 directed for shock. The principal lesions may be burns, 
 which need the same attention as burns from any other 
 source. 
 
 Any one suffering from the effects of severe cold 
 must be kept away from the heat, as there will other- 
 wise be danger of sloughing of the frost-bitten parts. 
 A person found frozen should be taken to a cold room, 
 undressed, and rubbed with snow, or cloths wrung out 
 in ice-water. The friction should be continued, espe- 
 cially about the extremities, until the circulation seems 
 restored; at the same time artificial respiration may be 
 resorted to if the natural is at a standstill. Give 
 brandy and beef-tea as soon as the patient is able to 
 swallow. Only by degrees bring him into warmer air. 
 The same plan is pursued with any frost-bitten part, 
 the aim being to restore vitality without inducing 
 sloughing. Parts of the body may be frozen without 
 the sufferer's knowledge, as numbness and insensibility 
 precede the later stages. 
 
 With a tendency to chilblains, cold feet should not 
 be too quickly heated. They should be warmly and al- 
 ways loosely clad, bathed with cold water and ammonia, 
 rather than hot water and soap. In the early stages, 
 painting them with iodine will relieve the itching. If 
 neglected, they may develop painful and intractable 
 ulcers. 
 
 Hernia, rupture of the peritonaeum, with protrusion 
 of the abdominal contents, takes place either in the 
 groin, the lower front of the abdomen, or at the umbili- 
 cus. The tumor most often contains a loop of small 
 intestine. The symptoms are intense pain, obstinate 
 constipation, and persistent, sometimes stercoraceous 
 vomiting. Put an ice-bag over the swelling, give no 
 food, no physic, very little drink, and send at once for
 
 364: A TEXT-BOOK OF NURSING 
 
 a surgeon, as prompt operative measures may be neces- 
 sary. 
 
 Convulsions in the adult are most commonly either 
 from epilepsy or hysteria. An epileptic seizure may be 
 distinguished from fainting syncope by the convul- 
 sive movements, which are absent in the latter. The 
 patient falls with sudden loss of consciousness, and 
 often with a peculiar sharp cry. The face is at first 
 pale, but may afterward become flushed; there is froth- 
 ing at the mouth, with jerking motions of the whole 
 body or parts of it. This stage only lasts a few mo- 
 ments, after which the patient may recover conscious- 
 ness or lapse into stupor. The only treatment is to keep 
 the patient from hurting himself during the convul- 
 sions. Lay him on the back, the head slightly elevated; 
 loosen the clothing, and allow plenty of fresh air. In- 
 sert a folded towel between the teeth, to keep him from 
 biting his tongue. Give no fluid. These attacks are in 
 some subjects preceded by warning sensations of vary- 
 ing character, known as the "aura." When the aura 
 begins in a hand or foot, tying a tight ligature around 
 the limb above may sometimes abort the attack. Con- 
 firmed epileptics are usually in an impaired mental con- 
 dition, and occasionally these seizures are followed by 
 acute mania. 
 
 Hysterical fits, most common in young girls, may be 
 much the same in appearance, but the patient is not 
 really unconscious, and never hurts herself. Any effort 
 to open the eyelids will usually be resisted, and the eye- 
 ball will be found sensitive, as it is not in epilepsy. 
 There is so little treatment needed in either case that it 
 is of little account whether or not you are sure which it 
 is. Keep the patient quiet, and free from sympathetic 
 spectators. The mere suggestion of some disagreeable
 
 EMERGENCIES, SURGICAL AND MEDICAL 365 
 
 remedy will often terminate the seizure. It may be 
 followed by the involuntary passage of a large amount 
 of pale urine. 
 
 In apoplexy there are rarely convulsions. There is 
 sudden loss of consciousness, without heart failure, the 
 face is flushed, or, more rarely, very pale, the respira- 
 tion stertorous, the pulse slow and full, the temperature 
 at first lowered, the pupils fixed and one or both di- 
 lated, with paralysis of one side. There may be reten- 
 tion or involuntary passage of urine. The patient 
 should be moved no more than is absolutely necessary. 
 Loosen the clothes, elevate the head and chest, apply 
 cold to the head and warmth to the extremities. Act 
 on the bowels, but do not give stimulants or emetics. 
 Apoplexy may be confounded with intoxication, espe- 
 cially when the patient has recently been taking liquor 
 and carries the odor of it in his breath. In an intoxi- 
 cated subject the pupils are evenly dilated, and the 
 stertorous breathing is absent. He can generally be 
 roused, though he sinks back again into stupor. The 
 temperature is likely to be two or three degrees below 
 normal. Lay the patient on the side, the head some- 
 what elevated, and induce vomiting. 
 
 A person found insensible may be suffering from 
 one of these affections, from concussion or compression 
 of the brain following injury to the head, or from nar- 
 cotic poisoning. In all cases, keep the head cool and 
 the feet warm, and get medical advice as soon as pos- 
 sible. 
 
 Poisons may be classified as irritant, those destroy- 
 ing the tissues with which they come in contact, pro- 
 ducing death by shock to the nervous system; narcotic, 
 those producing insensibility and death by their action 
 on the brain, without local effect; and aero-narcotic,
 
 366 A TEXT-BOOK OF NURSING 
 
 those which combine the action of the two. Treatment 
 has three things in view: to remove the injurious sub- 
 stance, neutralize its further action, and remedy such 
 ill effects as it may have already produced. The stom- 
 ach is to be evacuated by emetics. You will be able 
 to get nearly everywhere, at short notice, warm water 
 and salt, or ground mustard, either of which is an ex- 
 cellent emetic. Stir up a tablespoonful in a cup of the 
 warm water, and give repeatedly. The same quantity 
 of wine of ipecac in water, or sulphate of zinc, twenty 
 grains at a time, may be given. Tickling the back of 
 the throat with the finger or a feather will sometimes 
 induce emesis. Emetics should be condensed and fre- 
 quent. Half a pint to a pint at a time is enough. Too 
 large a quantity may distend the stomach to the point 
 of paralyzing the muscular walls, and too dilute solu- 
 tions will act as purgatives instead of emetics. It may 
 be desirable in some cases, after the stomach has been 
 cleared, to evacuate the bowels also, as some of the 
 poison may have passed into them. Do not stop to dis- 
 solve emetics fully, but stir them up in water and give 
 as quickly as possible. After any irritant poison give 
 some bland fluid to soothe the injured parts. White of 
 egg, milk, mucilage and water, flour and water, gruel, 
 olive or castor oil, may be used. Oil must not be given 
 in case of poisoning by phosphorus or cantharides. For 
 all the acids, alkalies are the chemical antidote, and 
 vice versa. The antidote to a poison is either chemical, 
 uniting with it to form a harmless compound, or phys- 
 iological, correcting its effects upon the system. 
 
 " Be bold f 
 
 Be bold, be bold, and evermore be bold I 
 BE NOT TOO BOLD!" 
 
 Spenser.
 
 EMERGENCIES, SURGICAL AND MEDICAL 367 
 
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 CHAPTER XX 
 
 " Not by deeds that gain the world's applauses, 
 Not by works that win thee world renown, 
 Not by martyrdom or vaunted crosses, 
 
 Canst thou win and wear the immortal crown. 
 Daily struggling, though unloved and lonely, 
 
 Every day a rich reward will give ; 
 Thou wilt find by hearty striving only, 
 And truly loving, thou canst truly live." 
 
 H. W. Sewall. 
 
 DISEASE may terminate either by complete restora- 
 tion to health, by subsidence into a chronic form, by a 
 lapse into some other disease, or by death. When the 
 seat of disorder is suddenly transferred from one part of 
 the body to another, the change is called metastasis. 
 Convalescence may be abrupt or gradual, it may go on 
 steadily, or be delayed by complications or interrupted 
 by relapse. Sudden convalescence is most common in 
 nervous affections, while in nearly all acute diseases it 
 is established by gradual resolution. 
 
 The care of a convalescent is not the least weari- 
 some kind of nursing, although it does not involve the 
 hardest work. You miss the exciting interest which 
 sustained you during the crisis of danger, yet, even if 
 you are already fatigued, your watchfulness must not 
 be relaxed, for the patient will be left more than ever 
 to your responsibility, while he is more likely to risk 
 imprudence and relapse. Convalescents are very apt 
 not to realize their own weakness and to want to do 
 
 371
 
 372 A TEXT-BOOK OP NURSING 
 
 more than they are really able. You must see that they 
 do not overexert themselves in any way. A patient 
 beginning to improve will at first be allowed to sit up 
 in bed, then may be lifted to an easy chair or a sofa for 
 a short time perhaps an hour at first gradually in- 
 creased each day. Then he may walk across the room, 
 or into the next room, and be taken out for a quiet 
 drive on a bright day. The time when an invalid is 
 first allowed to leave his bed is one when special care is 
 required. All the clothing should be well aired and 
 warmed. If the patient has something bright and pretty 
 to put on, it will make him feel better, though any- 
 thing elaborate and difficult to get into is objection- 
 able; everything should be loose, easy, and not cumber- 
 some. A wrapper with a heavy train will be enough 
 of a burden to fatigue a feeble woman and prevent her 
 from walking as much as she otherwise might. Walk- 
 ing is less fatiguing than standing. The room should 
 be warmer than when the patient is in bed. Let him 
 sit where he can see the fire, unless the eyes are weak, 
 but not too near. To provide against a draft under the 
 legs, put a blanket in the easy chair, reaching well to 
 the floor, which can be folded up over the feet. A foot- 
 stool is always desirable. 
 
 When the patient only sits up in bed, some extra 
 covering will be needed about the shoulders and chest. 
 For this purpose a loose flannel jacket is much better 
 than a shawl, as it does not confine the arms or slip off. 
 The " Nightingale " wrap is a very convenient and 
 easily adjusted shape. For this, two yards of flannel of 
 the ordinary width are required. Cut a straight slit 
 six inches deep, in the middle of one side, turn back 
 the points so formed for a collar, and those of the cor- 
 ners farthest from it for cuffs; bind or pink it around
 
 THE TERMINATIONS OP DISEASE 373 
 
 the edges, and add buttons and buttonholes, as illus- 
 trated in the diagram. It can be made as ornamentally 
 or as simply as desired. 
 
 The patient, upon first getting up from an acute 
 disease, should not be allowed to receive visitors, as 
 the unwonted exertion is in itself as much of an ex- 
 
 ooo 
 
 Nightingale. 
 
 citement as is safe. It is best to have no one in the 
 room but yourself and your patient, unless you need an 
 assistant. 
 
 You should have full authority on the question of 
 visitors, and it will be often your duty to protect the 
 patient from his friends. Do not let him feel obliged 
 to receive every one who calls. An invalid can always 
 be politely excused. Some visitors will be unobjection- 
 able, and even good for him, while others, with equally 
 kind intentions, will do all the harm possible. Do not 
 let anybody stay too long, nor admit too many at a time. 
 Three in succession will be less wearisome than two at 
 a time, who claim divided attention. Provide a seat for 
 the visitor, facing the patient, so that he can see and 
 hear without effort. Do not give the patient's easy 
 chair, nor let the visitor stand at the foot of the bed, 
 or lean against it. A small table at the foot of the bed, 
 with a few things on it, is an excellent arrangement to 
 25
 
 374 A TEXT-BOOK OP NURSING 
 
 prevent this, and to keep people from taking hold of 
 the bed and jarring it as they pass. 
 
 See that visitors do not smuggle in contraband arti- 
 cles. It is not only in hospitals that there is danger of 
 this, though it is a most common trouble there. You 
 may find all your work undone by some injudicious gift 
 which you only discover too late. A handful of fresh 
 flowers, a new picture, or some pretty decoration for the 
 room, is always a better token of remembrance to send 
 an invalid than delicacies to eat, which are very likely 
 to be unsuited for him. 
 
 No visitors should be admitted after dark, as a rule. 
 As night approaches, you should try to get the patient 
 into a quiet, unexcited state of mind. It is not advis- 
 able to hush every sound as soon as he drops asleep, for 
 absolute quiet is very hard to maintain, and slight noises 
 will be less likely to disturb him if he is accustomed to 
 sleep through ordinary sounds. If you are obliged to 
 wake him, do not rouse him suddenly or sharply. You 
 will seldom have occasion to do it at all. You should 
 not wake a sleeping patient for anything unless by spe- 
 cial orders. In the great majority of cases, healthy sleep 
 is a better restorative than any you can administer. 
 This does not apply to the insensibility of stupor. 
 
 Before settling down for the night, see that every- 
 thing likely to be needed is where it can be readily 
 found. Have food and fuel enough to last through the 
 night; matches and a candle at hand, if a night-light is 
 not kept burning. In the latter case, see not only that 
 the light is carefully shaded, but that there are no re- 
 flections of it to shine in the patient's eyes. Dress your- 
 self for the night in a warm wrapper, not a shawl, and 
 easy, noiseless slippers. A nurse should be warranted 
 not to snore.
 
 THE TERMINATIONS OF DISEASE 375 
 
 If the patient expresses any wish to see a clergy- 
 man or a priest, he should be sent for, especially if there 
 is any apprehension of death. If he is very sick, it is 
 no time for religious exhortation, and any excitement 
 should be avoided; but, if the clergyman has any tact 
 and sense of propriety, his visit may be a comfort to 
 the patient, as well as to his friends. 
 
 The friends of the dying might be spared much 
 anxiety if they realized how seldom the severance of 
 soul and body is attended by any agony. To many a 
 weary sufferer death comes as a glad release from the 
 burden of pain, and even where the patient has clung to 
 life, and seemed to fear the end, it comes almost al- 
 ways peacefully and painlessly. Death itself the last 
 ebbing of the vital force is not painful, even though 
 intense suffering may have preceded it. Death-bed 
 scenes are rarely either edifying or agonizing, though 
 always solemn. 
 
 Death approaches through one of the three vital 
 organs, the heart, lungs, or brain by asthenia, apncea, 
 or coma. Among the signs of approaching dissolution 
 are coldness of the extremities, a certain sharpness of 
 the features, a dusky shade about the face and finger- 
 nails, cold perspiration, restlessness, and muscular 
 twitchings or stupor. 
 
 Do not unnecessarily alarm the friends; but, when 
 you are sure that the end is near, it is best that they 
 should be informed. Disturb the dying as little as pos- 
 sible, though you must not give up working while there 
 is the slightest ground for hope. Note the exact time 
 at which death takes place, and take care not to an- 
 nounce it prematurely. The failure is sometimes so 
 gradual as to lead to error in this respect. In a hos- 
 pital, the attending physician, if not present, must be
 
 376 A TEXT-BOOK OF NURSING 
 
 notified at once. After a few hours there can rarely be 
 any doubt whether or not death has taken place. The 
 only condition at all likely to be confounded with it is 
 that of catalepsy, which is most often associated with 
 hysteria. 
 
 Shortly after death there may be a high rise of tem- 
 perature, produced by chemical changes within the 
 body; but it soon assumes the temperature of other 
 inanimate objects, and the rigor mortis sets in a pecul- 
 iar stiffening of the muscles. As a rule, the sooner it 
 comes on, the quicker it disappears, leaving the limbs 
 quite lax. Before it takes place, the body should be 
 prepared for burial. Wash it with a weak solution of 
 carbolic acid, or chlorinated soda, close the eyes, ar- 
 range the lips naturally, and smooth the hair. If there 
 is any difficulty in keeping the eyes shut, put a tiny 
 wisp of cotton upon each eyeball under the lids. This 
 will keep them from slipping. To keep the mouth shut, 
 put a firm wedge under the jaw, resting in the hollow 
 of the throat, not a bandage about the head, which is 
 difficult to adjust, and always leaves marks of pressure. 
 After the jaw is firmly set, the wedge can be removed. 
 Straighten the limbs, tying the feet together with a 
 broad tape or a bandage. Pack all the orifices of the 
 body with absorbent cotton, or coarse salt, to prevent 
 discharges, and bind a cloth firmly around the hips, 
 putting it on like a child's diaper. Over this can be 
 any clothing desired; a clean night-dress or a simple 
 shroud is more suitable than anything else. Cover face 
 and all with a sheet. If the death occurs in a hospital 
 ward, all this must, of course, be done behind screens. 
 Do not send for the stretcher to remove the body until 
 everything is quite ready, and then have it taken away 
 as quickly and quietly as possible. Have the door of
 
 THE TERMINATIONS OP DISEASE 377 
 
 the opposite ward closed. See that the patient's name 
 is on the shroud. 
 
 In a private house, the final arrangements will all 
 be put into the hands of an undertaker, but it is quite 
 likely the friends will wish you to superintend them, 
 and perhaps even lay out the body. If it is to be kept 
 for any length of time, it must be packed in ice. After 
 twenty-four hours on ice, the body assumes a much 
 more natural appearance. Any slight discolorations can 
 be made less conspicuous by dusting them over with 
 toilet powder. After the body has been taken out, the 
 room must be put in order, all the appliances of sickness 
 removed, the bedding sent out to be disinfected, and 
 the windows left wide open for twelve hours. 
 
 " The world goes on; and happiest is he 
 Who in such wise wins immortality, 
 That, should he sleep forever in the grave, 
 His work goes on and helps the world to save." 
 
 J. W. Chadmck.
 
 VOCABULARY 
 
 Abnormal. Unnatural. 
 
 Abortion. Premature expulsion of a foetus. 
 
 Abscess. A circumscribed cavity containing pus. 
 
 Acids. Chemical agents which redden vegetable blues. They 
 are usually sour in taste. 
 
 Acronarcotic. Combining irritant and narcotic action. 
 
 Actual Cautery. A hot iron used in cauterization. 
 
 Acute. Sharp. A disease having rapid progress and short dura- 
 tion is said to be acute. 
 
 Adhesion. Sticking together of unlike particles. 
 
 Albuminuria. The presence of albumin in the urine. 
 
 Alkalies. Substances which have the power of restoring the 
 blues reddened by acids. 
 
 Alimentary Canal. The tube extending from the mouth to the 
 anus. 
 
 Alterative. A medicine producing gradual change. 
 
 Amenorrhcea. Absence of the menstrual discharge. 
 
 Amorphous. Without regular shape. 
 
 Amylaceous. Starchy. 
 
 Anaemia. A lack of red corpuscles in the blood. 
 
 Anaesthesia. Loss of sensibility. 
 
 Anasarca. An accumulation of serum in the cellular tissue. 
 
 Anastomosis. Communication of vessels. 
 
 Anatomy. The science that describes the form and position of 
 parts. 
 
 Aneurism. A dilatation or rupture of an artery. 
 
 Anodyne. Medicine to allay pain. 
 
 Antacid. A remedy against acidity. 
 
 Anthelmintic. A remedy against worms. 
 
 Antipyretic. Opposed to fever. 
 
 379
 
 380 A TEXT-BOOK OF NURSING 
 
 Antiseptic. Preventing putrefaction. 
 
 Anus. The opening at the inferior extremity of the rectum. 
 
 Aphasia. Loss of the power of speech. 
 
 Aphonia. Loss of voice. 
 
 Aphthae. Small white ulcers of the mucous membrane. 
 
 Apnoea. Absence of breath. 
 
 Apyrexia. Absence of fever. 
 
 Areola. 1. A circle around the nipple. 2. An inflamed circle 
 
 around an eruption. 
 
 Areolar Tissue. Cellular or connective tissue. 
 Articulation. The joining of bones. 
 Ascites. A collection of serous fluid in the abdomen. 
 Asepsis. Absence of putrefactive germs. 
 Asphyxia. Without pulse. Suspended animation. 
 Assimilation. The process by which bodies appropriate and 
 
 transform other matters into their own substance. 
 Asthenia. Want of strength. Exhaustion. 
 Astringent. Having the power of contracting organic tissues. 
 Atrophy. Wasting away. 
 Auscultation. The act of listening, as applied to the heart and 
 
 lungs. 
 Autopsy. The examination of a body after death. 
 
 Ballottement. The falling back of the foetus in utero when dis- 
 placed by the examining finger. 
 
 Benign. Of a mild character. 
 
 Bistoury. A small, narrow-bladed knife used in surgery. 
 
 Borborygmus. A rumbling in the intestines. 
 
 Bougie. An instrument, shaped like a candle, for dilating mu- 
 cous canals. 
 
 Bulimia. Abnormal appetite. 
 
 Bursa. A small sac containing fluid, found near the joints. 
 
 Cachexia. A generally bad condition of the body. 
 
 Cadaver. A dead body. 
 
 Csesarean Section. The operation of removing a child from the 
 
 uterus by incision through the abdomen. 
 Calcareous. Having the nature of lime. 
 Calculus. A stone. 
 Callus. The new material thrown out to unite the fracture of a 
 
 bone.
 
 VOCABULARY 381 
 
 Capillary. Hair-like in size. 
 
 Capsule. 1. A membranous expansion inclosing a part. 2. A 
 gelatinous envelope in which medicines may be given. 
 
 Carcinoma. Cancer. 
 
 Cardiac. Pertaining to the heart. 
 
 Caries. Ulce ration of bone. 
 
 Carminative. A remedy which allays pain by causing the ex- 
 pulsion of flatus from the alimentary canal. 
 
 Cartilage. A smooth, elastic tissue, somewhat softer than bone. 
 
 Catalepsy. A disease in which there is sudden suspension of the 
 senses and of the will, the body remaining in whatever posi- 
 tion it is placed. 
 
 Catamenia. The menstrual discharge. 
 
 Cataplasm. A poultice. 
 
 Cataract. An opacity of the crystalline lens. 
 
 Catarrh. Increased secretion from a mucous membrane. 
 
 Cathartic. A medicine producing free discharges from the 
 bowels. 
 
 Caustic. A substance which burns living tissues. 
 
 Cellulitis. Inflammation of the cellular or connective tissue. 
 
 Cholagogue. A medicine increasing the flow of bile. 
 
 Chorea. St. Vitus's dance. 
 
 Chronic. Of long duration. 
 
 Chyluria. Milky urine. 
 
 Cicatrix. A scar. 
 
 Cilia. Hair-like projections. 
 
 Circumscribed. Distinctly limited. 
 
 Clinical. At the bedside. 
 
 Clyster. An enema. 
 
 Coagulation. Curdling of a fluid. 
 
 Coaptation. Fitting together. The act of adapting to each 
 other the ends of a broken bone. 
 
 Cohesion. The force which holds like particles together. 
 
 Collapse. Complete prostration of the vital powers. 
 
 Colloid. Jelly-like. 
 
 Collyrium. Eye-wash. 
 
 Colostrum. The first milk secreted after confinement. 
 
 Coma. A state of profound insensibility. 
 
 Comminuted. Broken in small pieces. 
 
 Confluent. Running together. 
 
 Congenital, Existing from birth.
 
 382 A TEXT-BOOK OF NURSING 
 
 Congestion. The accumulation of blood in any organ. 
 
 Connective Tissue. A lace-work of fibrous threads which ex- 
 tends through all the organs of the body, binding their- ele- 
 ments together. 
 
 Contagion. The communication of disease by contact. 
 
 Continuity. An uninterrupted connection of parts. 
 
 Centra-indication. An indication against. 
 
 Convulsions. Involuntary contractions of the muscles. 
 
 Coryza. Inflammation of the mucous membrane of the nose, 
 with free discharge. 
 
 Counter-irritation. Irritation excited in one part of the body 
 to relieve another. 
 
 Crepitation. 1. The sound of air passing through fluid. 2. The 
 grating made by rubbing together the ends of a broken bone. 
 
 Crepitus. Crepitation. Chiefly used in the latter sense. 
 
 Crisis. The turning-point in a disease. 
 
 Cumulative. Increasing by successive additions. 
 
 Cyanosed. Blue. 
 
 Cystitis. Inflammation of the bladder. 
 
 Decoction. 1. The operation of boiling certain ingredients in a 
 
 fluid. 2. The result of such boiling. 
 Decomposition. Separation of a body into its component 
 
 parts. 
 
 Decubitus. Manner of lying. 
 Defecation. The discharge of fecal matter. 
 Defervescence. The decline of fever. 
 Dejection. The act of emptying the bowel. 
 Demulcent. Soothing. 
 Deodorant. Destroying odors. 
 Desquamation. Scaling off of the skin. 
 Desiccation. Drying up. 
 
 Determination. Strong and rapid flow of fluid to any part. 
 Diagnosis. Distinguishing one disease from another. 
 Diaphoretic. A medicine which excites perspiration. 
 Diaphragm. The large muscle separating the chest from the 
 
 abdomen. 
 Diastole. The dilatation of the heart and arteries on entrance 
 
 of the blood. 
 
 Diathesis. A peculiar disposition or condition of the system. 
 Dicrotic. Rebounding.
 
 VOCABULARY 383 
 
 Dietetics. A branch of medicine comprising rules of diet. 
 Digestion. Dissolving. The change which food undergoes in 
 
 the alimentary canal. 
 Digital. Pertaining to the fingers. 
 Dilatation. Expansion in all directions. 
 Discrete. Distinct. 
 
 Disinfectant. An agent which destroys septic germs. 
 Dislocation. Displacement. 
 Distal. Farthest from the heart. 
 Diuresis. An increased excretion of urine. 
 Dorsal. Pertaining to the back. 
 Douche. A column or shower of fluid. 
 Drastic. Strongly active. 
 Duct. Any tube or canal. 
 
 Dysmenorrhoea. Difficult or painful menstruation. 
 Dyspepsia. Difficult digestion. 
 Dysphagia. Difficulty in swallowing. 
 Dyspnoea. Difficulty in breathing. 
 Dysuria. Difficult and painful passage of urine. 
 
 Ecchymosis. An extravasation of blood into connective tissue. 
 
 Effervescence. The escape of gas through liquid, independently 
 of heat. 
 
 Effusion. A pouring out. 
 
 Electrolysis. Decomposition by electricity. 
 
 Embolus. A plug obstructing a blood-vessel. 
 
 Embrocation. A liniment. 
 
 Embryo. The fecundated germ in its early stages of develop- 
 ment. 
 
 Emesis. The act of vomiting. 
 
 Emetic. Producing emesis. 
 
 Emmenagogue. A medicine promoting the menstrual dis- 
 charge. 
 
 Emollients. Substances which relax and soften the tissues. 
 
 Emphysema. Air escaped into the connective tissue. 
 
 Emulsion. A mixture of oil and water. 
 
 Endemic. Peculiar to a locality. 
 
 Enema. A fluid preparation for injection into the rectum. 
 
 Enteric. Intestinal. 
 
 Enuresis. Inability to hold the urine. 
 
 Epidemic. A disease attacking many people.
 
 384 A TEXT-BOOK OP NURSING 
 
 Epigastrium. The region near the stomach. 
 Epispastics. Blistering agents. 
 Epistaxis. Haemorrhage from the nose. 
 Eructation. Bringing up gas from the stomach. 
 Escharotic. A substance which occasions sloughing. 
 Exacerbation. An increase in the symptoms of a disorder. 
 Exanthemata. The eruptive fevers. 
 Excoriation. An abrasion of the skin. 
 Excretion. The throwing off of waste matter. 
 Expectant. Treatment by leaving disease to nature. 
 Expectorant. A medicine facilitating the expulsion of sputa. 
 Extirpation. Complete removal. 
 Extra-uterine. Outside the uterus. 
 
 Extravasation. The escape of the contents of vessels into the 
 surrounding tissues. 
 
 Peaces. Evacuations from the bowels. 
 
 Fasciae. Fibrous membranes binding parts together. 
 
 Fauces. The throat. 
 
 Febrile. Pertaining to fever. 
 
 Fistula. A narrow canal lined by false membrane. 
 
 Flatulence. Gas in the alimentary canal. 
 
 Fluctuation. The undulation of fluid as felt by the hands. 
 
 Foetus. The young of any animal in the uterus. 
 
 Fontanelles. Spaces between the cranial bones in the young 
 
 child. 
 
 Fumigation. Charging the air with gas or vapor. 
 Function. The office or duty of an organ. 
 Fundus. The base. 
 
 Galactorrhoea. An excessive flow of milk. 
 Gall-stones. Biliary concretions. 
 Gangrene. The first stage of mortification. 
 Gastric. Pertaining to the stomach. 
 Genital. Pertaining to the function of reproduction. 
 Germ. The undeveloped rudiment of a new being. ; 
 Gestation. Pregnancy. 
 
 Gland. An organ having the function of secretion. 
 Globus hystexicus. The sensation as of a ball in the throat. 
 Granulations. Small red eminences forming on the surfaces of 
 suppurating wounds.
 
 VOCABULARY 385 
 
 Haematemesis. Vomiting of blood. 
 
 Heematuria. Blood in the urine. 
 
 Haemoptysis. Spitting of blood. 
 
 Haemorrhage. The escape of blood from its vessels. 
 
 Haemostatic. An agent to stop haemorrhage. 
 
 Hemicrania. Pain in one side of the head. 
 
 Hemiplegia. Paralysis of the lateral half of the body. 
 
 Hepatic. Relating to the liver. 
 
 Hernia. The displacement and protrusion of a viscus from its 
 
 natural cavity. 
 
 Histology. The minute anatomy of the tissues. 
 Hydragogue. A medicine causing watery evacuation. 
 Hydrated. Combined with water. 
 Hydropathy. Water-cure. 
 Hygiene. The preservation of health. 
 Hypersemia. An excess of blood in the capillaries. 
 Hyperaesthesia. Excessive sensibility. 
 Hyperpyrexia. Very high fever. 
 Hypnotic. Sleep-producing. 
 Hypodermic. Subcutaneous. 
 
 Impacted. Wedged in. 
 
 Imperforate. Without an opening. 
 
 Incontinence. Inability to restrain. 
 
 Incubation. Hatching. The period between the reception of a 
 poison and the appearance of the symptoms. 
 
 Indolent. Giving little or no pain. 
 
 Induration. Hardness. 
 
 Infection. The communication of disease. 
 
 Infiltration. The escape of fluids into connective tissue. 
 
 Infusion. 1. The process of steeping a substance in fluid. 2. 
 The resulting liquor. 
 
 Inoculation. Injection of a virus into the body. 
 
 Insertion. The attachment of one part to another. Of a 
 muscle, the movable point toward which its force is di- 
 rected. 
 
 Insomnia. Sleeplessness. 
 
 Inspiration. Drawing in the breath. 
 
 Intermittent. Ceasing at intervals. 
 
 Intravenous. Within a vein. 
 
 Inunction. The rubbing in of an ointment
 
 386 A TEXT-BOOK OF NURSING 
 
 Involution. The gradual return of parts to a normal size and 
 
 condition. 
 
 Irreducible. Not to be replaced. 
 Irrigation. Regular and continuous washing of a part. 
 Irritation. Excess of vital movement, usually manifested by 
 
 increase of circulation and sensibility. 
 Isothermal. Having the same temperature. 
 
 Jaundice. Yellowness resulting from some obstruction in the 
 course of the bile. 
 
 Laceration. A breach made by tearing. 
 
 Lactation. Suckling. 
 
 Laparotomy. Opening the abdomen. 
 
 Lateral On the side. 
 
 Laxative. A gently evacuating medicine. 
 
 Lesion. Injury or disorder. 
 
 Lethargy. Stupor. 
 
 Leucorrhcea. A white vaginal discharge. 
 
 Ligation. Tying. 
 
 Ligature. The thread used for tying a vessel. 
 
 Litmus. A vegetable blue pigment. Acids turn it red. 
 
 Lochia. The discharge of blood and serum following child- 
 
 birth. 
 
 Luxation. A dislocation. 
 Lymph. 1. The fluid contained in the lymphatic vessels. 2. 
 
 The fluid poured out in adhesive inflammation. 
 
 Maceration. Making soft by steeping. 
 Malaise. Indisposition. 
 Malaxation. Kneading. 
 Malformation. Irregularity in structure. 
 Malignant. Serious in character. 
 Malingery. Feigning disease. 
 Malnutrition. Poor nourishment. 
 Marasmus. Wasting away. 
 
 Median Line. An imaginary line dividing the body longitudi- 
 nally into two equal parts. 
 Menorrhagia. Excessive menstruation. 
 Menstrual. Monthly. 
 Metastasis. A change in the seat of a disease.
 
 VOCABULARY 387 
 
 Miasm. A poisonous emanation. 
 
 Micturition. The act of passing water. 
 
 Miscarriage. Premature expulsion of a foetus. 
 
 Mole. 1. A fleshy growth in the uterus. 2. A rounded fatty nevus 
 
 Morbid. Diseased. 
 
 Morbific. Causing disease. 
 
 Moribund. About to die. 
 
 Mortification. Loss of life in a part. 
 
 Mucus. A viscid fluid secreted by mucous membranes. 
 
 Multipara. A woman who has given birth to several children. 
 
 Naevus. A birth-mark. 
 
 Narcosis. The condition produced by narcotic substances. 
 
 Narcotic. Stupefying. 
 
 Nares. The nostrils. 
 
 Nates. The buttocks. 
 
 Nephritic. Pertaining to the kidneys. 
 
 Neuralgia. Non-inflammatory pain in a nerve. 
 
 Neurasthenia. Nervous debility. 
 
 Neuroses. Diseases of the nervous system. 
 
 Normal. Natural. 
 
 Nucleus. 
 
 Obstetrics. Midwifery. 
 
 Occipital. Relating to the back of the head. 
 
 Occlusion. Shutting up. 
 
 QSdema. Swelling from the infiltration of serum into the areolar 
 
 tissue. 
 
 Officinal. Authorized by the pharmacopoeia. 
 Opiate. A medicine containing some form of opium. 
 Organ. Part of a living being exercising some special function. 
 Origin (of a muscle). Its fixed or central attachment. 
 Orthopcedic. Correcting deformity. 
 Orthopncea. Inability to breathe lying down. 
 Osmosis. The passage of fluid through a porous solid. 
 Osseous. Bony. 
 
 Ossification. Conversion into bone. 
 Ovulation. The formation of ovules in and their discharge from 
 
 the ovary. 
 
 Ovum. The embryo and its membranes. 
 Oxidation. Combining with oxygen.
 
 388 A TEXT-BOOK OP NURSING 
 
 Ozsena. An offensive discharge from the nose. 
 Ozone. A peculiar modification of oxygen. 
 
 Palpation. 1. The sense of touch. 2. Exploring diseases by 
 
 pressure with the hand. 
 Panacea. A universal remedy. 
 
 Papilla. 1. The nipple. 2. A small eminence on the surface. 
 Paracentesis. The operation of tapping. 
 Paralysis. Loss of voluntary motion or sensation. 
 Paraplegia. Paralysis of the lower half of the body. 
 Parasiticide. An agent that kills parasites. 
 Paroxysm. A periodical attack or exacerbation of a disorder. 
 Pathogenic. Producing disease. 
 Pathology. The physiology of disease. 
 Patulous. Wide open. 
 
 Percussion. Striking on a body to elicit sounds. 
 Peristaltic. Undulating or worm-like. Applied particularly to 
 
 the motions of the alimentary canal. 
 Pessary. An instrument to support the uterus. 
 Petechiee. Spots on the skin occurring in the course of severe 
 
 fevers. 
 
 Pharmaceutics. The science of preparing medicines. 
 Physiology. The science of life. 
 Pipette. A small glass tube. 
 Placenta Praevia. The attachment of the placenta over the 
 
 mouth of the uterus. 
 Plastic. Formative. 
 
 Polypus. A kind of tumor occurring in mucous membranes. 
 Post mortem. After death. 
 Primipara. A woman who bears her first child. 
 Process. An eminence of bone. 
 
 Prognosis. A prediction of what course a disease will take. 
 Prolapse. A falling down. 
 Prophylaxis. Prevention. 
 Proximal. Nearest the heart. 
 Ptyalism. Salivation. 
 Purgative. Cathartic. 
 Purulent. Having the character of pus. 
 Pustule. A minute abscess. 
 Pyaemia. Contamination of the blood by pus. 
 Pyrexia. Fever.
 
 VOCABULARY 389 
 
 Quarantine. Enforced isolation as a preventive of contagion. 
 Quickening. The first movements of the foetus felt in the 
 uterus. 
 
 Bales. Sounds in the air-passages produced by air passing 
 
 through fluid. 
 
 Rectification. The process of refining liquids. 
 Reduction. The restoring of displaced parts. 
 Recuperative. Tending to recovery. 
 Refrigerant. Producing cold. 
 Regimen. Regulation of diet. 
 
 Regurgitation. Throwing back a portion of the contents. 
 Relapse. A return of disease. 
 
 Relaxation. Remitting tension. Opposed to contraction. 
 Remission. Abatement of symptoms. 
 Resolution. Gradual disappearance of a disease. 
 Rigor. A chill. 
 
 Rigor mortis. A stiffening of the muscles occurring after death. 
 Rubefacient. Making red. 
 
 Sac. A bag or pouch. 
 
 Saccharine. Containing sugar. 
 
 Salivation. Excessive secretion of saliva. 
 
 Saturation. The union of one substance with another until it 
 
 can take no more. 
 
 Scarification. Making several small incisions. 
 Scybala. Hard lumps of fecal matter. 
 Secretion. The process by which substances are separated from 
 
 the blood. 
 Secundines. The placenta remaining in uterus after the birth 
 
 of the child. 
 Sedative. Quieting. 
 Sepsis. Putrefaction. 
 Septic. Producing putrefaction. 
 Sequelae. Morbid phenomena resulting from disease. 
 Shock. Sudden depression of vital powers. 
 Show. A vaginal discharge occurring just before labor. 
 Sinapism. A mustard plaster. 
 Singultus. Hiccough. 
 
 Sinus. Any cavity the interior of which is larger than the opening. 
 Slough. A dead portion separating from the living. 
 26
 
 390 A TEXT-BOOK OP NURSING 
 
 Sordes. An accumulation of the secretions of the mouth upon 
 the teeth. 
 
 Spasm. An involuntary muscular contraction. 
 
 Speculum. An instrument for dilating cavities. 
 
 Sphincter. A circular muscle constricting a natural opening. 
 
 Sporadic. Occurring in single or scattered cases. 
 
 Sputum. Matter spit out. 
 
 Stercoraceous. Fecal. 
 
 Stertor. A deep snoring sound accompanying inspiration. 
 
 Stethoscope. A tube for conveying sounds from the chest to 
 the ear. 
 
 Strangury. Slow and painful passage of urine. 
 
 Stricture. Contraction of a duct or tube. 
 
 Stupe. The cloth used in fomentations. 
 
 Stupor. Profound unconsciousness. 
 
 Styptic. Astringent. 
 
 Subcutaneous. Under the skin. 
 
 Subsultus. Muscular twitching. 
 
 Sudoriferous. Sweat-bearing. 
 
 Suppository. Medicine in a solid form intended for introduc- 
 tion into the rectum. 
 
 Suppression. The stoppage of a secretion or discharge. 
 
 Suppuration. The formation of pus. 
 
 Sutures. 1. The articulations of the bones of the skull. 2. 
 Stitches for holding together the edges of a wound. 
 
 Syncope. Fainting. 
 
 Syphilis. An infectious venereal disease. 
 
 Systemic. Pertaining to the body generally. 
 
 Systole. The contraction of the heart and arteries. 
 
 Tactile. Relating to the sense of touch. 
 
 Tampon. A plug. 
 
 Tenesmus. Frequent, vain, and painful efforts to evacuate the 
 
 bowel. 
 
 Tension. State of being stretched. 
 Tent. A cylinder for dilating parts. 
 
 Tetanus. A disease characterized by continuous muscular spasm. 
 Therapeutics. The treatment of disease. 
 Thoracic. Belonging to the chest. 
 
 Thrombosis. The obstruction of a blood-vessel by a clot. 
 Tidal Air. The air expired and inspired in ordinary respiration.
 
 VOCABULARY 391 
 
 Tincture. A solution in spirit. 
 
 Tissue. The peculiar structure of a part. 
 
 Tone. A proper state of tension or firmness. 
 
 Torsion. Twisting. 
 
 Toxic. Poisonous. 
 
 Transfusion. Process of transferring blood or salt solution into 
 
 the veins. 
 
 Traumatic. Resulting from a wound. 
 Trituration. Reducing to a fine powder. 
 Tubercle. A deposit of degenerate matter in the substance of 
 
 organs. 
 
 Tumefaction. Swelling. 
 Tumor. A morbid enlargement. 
 Tympanites. Oistention of the abdomen by gas. 
 
 Ulcer. A solution of continuity of the soft parts resulting from 
 
 perverted nutrition. 
 Unguent. An ointment. 
 Uraemia. Poisoning by urea in the blood. 
 Urea. The nitrogenous constituent of the urine. 
 Utero-gestation. Pregnancy. 
 
 Vaccination. Inoculation with the virus of cow-pox. 
 Vascular. Full of vessels. 
 Venereal. Pertaining to sexual intercourse. 
 Venesection. Blood-letting by opening a vein. 
 Vermifuge. Driving out worms. 
 
 Vernix Caseosa. A fatty deposit found on the foetus or new- 
 born child. 
 Vertigo. Dizziness. 
 Vesicant. A blistering agent. 
 Vesicle. A very small blister. 
 Viable. Sufficiently developed to live. 
 Virus. A morbid poison. 
 Viscera. The internal organs. 
 Vital. Pertaining to life. 
 Vivisection. The dissection of a live animal 
 
 Wisdom Teeth. The last of the true molars. 
 Wound. A solution of continuity in the soft parts resulting from 
 injury. 
 
 Zymotic. Resulting from fermentation.
 
 INDEX 
 
 Abbreviations, 138. 
 Abortion, 270. 
 Abscess, 237. 
 Absorbent cotton, 244. 
 Accidents, 335. 
 Acids, 367. 
 
 burns from, 357. 
 Adhesions, 52. 
 Affusion, 82. 
 After-pains, 272. 
 Albuminoids, 173. 
 Alkalies, 367. 
 Anaesthetics, 250. 
 Anastomosis, 51. 
 Anchylosis, 205. 
 Aneurism, 313. 
 Angina pectoris, 313. 
 Antidotes, 367. 
 Antipyretics, 60. 
 Antiseptics, 225, 241. 
 Apnosa, 66. 
 Apoplexy, 365. 
 Appendicitis, 314. 
 Appetite, 119. 
 Arteries, 49. 
 
 chart of, 339. 
 Ascites, 312. 
 Asepsis, 241. 
 Asphyxia, 66, 360. 
 Asthma, 308. 
 Attitudes, 112. 
 
 characteristic, 116. 
 
 Bacteria, 223. 
 Ballottement, 270. 
 Bandages, 205-222. 
 
 in haemorrhage, 218. 
 
 plaster, 202. 
 
 Baths, 78. 
 
 babies, 291, 297. 
 Bedding, 31. 
 Beds, 28. 
 
 Bedside notes, 123. 
 Bed-sores, 39. 
 
 Bichloride of mercury, 228, 242. 
 Bites, 355. 
 
 Bladder, to wash, 100. 
 Blisters, 164. 
 Blood, 44. 
 
 Blood-poisoning, 252, 265. 
 Blood-vessels, 49. 
 Blue baby, 47. 
 Bones, 192. 
 
 Brand method of bathing, 80. 
 Breasts, care of, 282. 
 Bright's disease, 317. 
 Bronchitis, 308. 
 Burns, 235, 356. 
 
 Callus, 201. 
 
 Canal, alimentary, 108. 
 
 Capillaries, 49. 
 
 Carbolic acid, 242. 
 
 Cardiac diseases, 312. 
 
 Catarrh, 306. 
 
 Catheterization, 98. 
 
 Cauterization, 345. 
 
 Chemical elements, in air, 65. 
 
 in food, 172. 
 Chicken-pox, 303. 
 Chilblains, 363. 
 Children, diseases of, 289. 
 Chills, 116. 
 Cholera, Asiatic, 326. 
 
 infantum, 301. 
 
 morbus, 315. 
 
 393
 
 394 
 
 A TEXT-BOOK OP NURSING 
 
 Chorea, 322. 
 Circulation of blood, 44. 
 Cleanliness, of person, 6, 76. 
 
 of ward, 24. 
 
 surgical, 239, 247. 
 Clergy, visits of, 375. 
 Clothing, changing, 76, 336. 
 
 disinfecting, 228. 
 
 for convalescent, 373. 
 
 for infant, 273, 292. 
 Cold applications, 161. 
 Colic, intestinal, 316. 
 
 in infant, 299. 
 
 hepatic, 316. 
 
 renal, 318. 
 Collyria, 162. 
 Coma, 122. 
 
 Compress, graduated, 340. 
 Congestion, 51. 
 Consciousness, disorders of, 
 
 122. 
 Constipation, 120. 
 
 in child, 300. 
 
 Contagious cases, care of, 225. 
 Contusions, 353. 
 Convalescents, 371. 
 Convulsions, 364. 
 
 in child, 301. 
 
 puerperal, 287. 
 Condy's fluid, 228. 
 Coryza, 307. 
 Counter-irritants, 163. " 
 Couveuse, 290. 
 Crepitus, 200. 
 Croup, 301. 
 
 Cumulative action, 134. 
 Cupping, 167. 
 Cystitis, 96-100. 
 
 Dead, care of, 376. 
 Death, 375. 
 Delirium, 324. 
 
 tremens, 325. 
 Dentition, 295. 
 Diabetes, 316. 
 Diarrhoea, 300. 
 Digestion, 178. 
 Diphtheria, 325. 
 Disinfectants, 225-227. 
 Dislocations, 204, 352. 
 Dosage, 139. 
 
 Douche, 82. 
 
 nasal, 167. 
 
 vaginal, 263. 
 Drainage tubes, 238. 
 Draw-sheets, 31. 
 Dressings, surgical, 240. 
 Dropsy, 312. 
 Drowning, 361. 
 Drugs, care of, 134. 
 
 list of, 139. 
 Dusting, 24. 
 Dysentery, 315. 
 Dyspepsia, 313. 
 Dyspnoea, 66. 
 
 Eczema, 319. 
 Electricity, 324. 
 Emergencies, 335. 
 Emetics, 366 
 Enemata, 101. 
 Epilepsy, 364. 
 Erysipelas, 252. 
 Erythema, 318. 
 Eye, in disease, 117. 
 
 Facial expression, 113. 
 
 Fainting, 337. 
 
 Feeding the helpless, 176. 
 
 the infant, 292. 
 
 by force, 132. 
 Fever, 56. 
 Fire, 356. 
 Fomentations, 159. 
 Food, 172. 
 
 for infant, 292. 
 Foot-bath, 83. 
 
 Foreign matter in the ear, 
 358. 
 
 in the eye, 357. 
 
 in the nose, 359. 
 
 in the throat, 359. 
 
 in a wound, 238. 
 Formaldehyde, 232. 
 Fractures, 199. 
 Friction, 87. 
 Frost-bites, 236, 363. 
 Fumigation, 231. 
 Furniture of sick-room, 17. 
 
 Gargles, 166. 
 Gauze, 244.
 
 INDEX 
 
 395 
 
 Gastritis, 313. 
 Germicides, 241. 
 Granulation, 237. 
 Gynaecology, 260. 
 
 Haemorrhage, 121, 337. 
 
 internal, 285, 348. 
 
 in typhoid, 328. 
 
 post-partum, 284. 
 
 uterine, 265, 350. 
 Hair, care of, 77. 
 Healing, modes of, 236. 
 Health, 1. 
 
 Hearing, disturbances of, 118. 
 Heart, 46. 
 Hernia, 363. 
 Herpes, 319. 
 Hiccough, 115. 
 Hot applications, 161. 
 Hydrogen peroxide, 243. 
 Hydrocephalus, 305. 
 Hypodermic injections, 127. 
 Hysteria, 323. 
 
 Ice, 161. 
 
 Incontinence of urine, 96. 
 
 in child, 301. 
 
 Incubation, period of, 224. 
 Indigestion, 313. 
 Infant, care of, 289. 
 Infection, 224. 
 Inflammation, 52. 
 Influenza, 307. 
 Inhalation, 129. 
 Insanity, 324. 
 
 Insensible, person found, 365. 
 Instruments, care of, 246. 
 Insufflation, 167. 
 Intestinal canal, 101. 
 
 obstruction, 314. 
 Inunction, 163. 
 Involution, 272. 
 Icdoform, 243. 
 
 Knots, 346. 
 
 Labor, 271. 
 Laparotomy, 253. 
 Laryngitis, 309. 
 Leeches, 168. 
 Ligatures, 244. 
 
 Lightning stroke, 362. 
 Lime, burns from, 357. 
 Liniments, 163. 
 Locpmotor ataxia, 322. 
 Lotions, 162. 
 Lungs, 62. 
 
 Malaria, 333. 
 Massage, 85. 
 Measles, 303. 
 
 German, 304. 
 Measures, 136. 
 Medicines, 125. 
 Meigs's mixture, 294. 
 Meningitis, 322. 
 
 in child, 304. 
 Metric system, 136. 
 Milk, 181. 
 
 Miscarriage, 264, 270. 
 Moisture in air, 73. 
 Mouth, in disease, 118. 
 
 care of, 119. 
 Moving patients, 36. 
 Mumps, 303. 
 Mustard as an emetic, 366. 
 
 poultice, 159. 
 
 Narcotics, 133. 
 Nausea, 119, 129. 
 Neuralgia, 321. 
 Neuritis, 320. 
 Nightingale wrap, 373. 
 Night nursing, 374. 
 Noise, 18. 
 Nose-bleed, 350. 
 Nourishment, 173. 
 
 rectal, 258. 
 Nurses, 2. 
 
 surgical, 247. 
 
 Observation of symptoms, 110. 
 Obstetrics, 268. 
 CEdema of lungs, 114. 
 
 of tissues, 312. 
 Ointments, 163. 
 Operating-room, 249, 255. 
 Operating cases, 247. 
 
 gynaecological, 265. 
 Ophthalmia neonatorum, 298. 
 Osmosis, 65. 
 Oxaena, 307.
 
 396 
 
 A TEXT-BOOK OP NURSING 
 
 Pain, 121. 
 
 Paralysis, 320. 
 
 Passive motion, 87. 
 
 Pediculi, 320. 
 
 Perforation of bowel, 328. 
 
 Peristaltic motions, 101. 
 
 Peritonitis, 314. 
 
 Perspiration, 116. 
 
 Phlegm asi a dolens, 286. 
 
 Phthisis, 311. 
 
 Pillows, 37. 
 
 Placenta, 280. 
 
 Pleurisy, 309. 
 
 Pneumonia, 310. 
 
 Poisons, 365. 
 
 Poison vine, eruption of, 356. 
 
 Poultices, 155. 
 
 Pregnancy, 268. 
 
 Protrusion of bowel, 300. 
 
 Puerperal fever, 286. 
 
 mania, 288. 
 
 state, 272, 283. 
 Pulse, 52. 
 Pus, 238. 
 Pyaemia, 252. 
 
 Kachitis, 305. 
 Recipes, 182. 
 Respiration, 62. 
 
 artificial, 360. 
 
 Cheyne-Stokes, 114. 
 Rheumatism, 334. 
 
 Scabies, 319. 
 Scalds, 236, 356. 
 Sepsis, 241. 
 Septicaemia, 253. 
 Sheets, 31. 
 
 to change, 35. 
 Shock, 251, 336. 
 Sick-room, model, 14. 
 Sims's position, 261. 
 Sitz bath, 83. 
 
 Skin, appearance of, in dis- 
 ease, 116. 
 
 construction and function 
 of, 75. 
 
 diseases of, 318. 
 Skin-grafting, 237. 
 Sleep, 375. 
 
 Slings, 219. 
 Small-pox, 331. 
 Specula, 262. 
 Spica, 210. 
 Splinters, 355. 
 Splints, 201. 
 
 temporary, 351. 
 Sponge bath, 82. 
 Sponges, 245. 
 Sprains, 353. 
 Sputa, 114. 
 Stains, to remove, 33. 
 Sterilizing, 181. 
 Stimulants, in collapse, 252 
 
 in fever, 334. 
 Stools, 120. 
 
 to disinfect, 230. 
 Strangulation, 360. 
 Strapping, 221. 
 Stupes, 159. 
 Styptics, 345. 
 Suckling, 281. 
 Sunstroke, 361. 
 Suppositories, 107. 
 Suppression of urine, 96. 
 Surgical cases, 234. 
 Sutures, 244. 
 Symbols, 138. 
 Symptoms, 111. 
 
 in children, 295. 
 Syringe, care of, 127. 
 
 hypodermic, 127. 
 
 Tampons, 262, 350. 
 Taste, disordered, 118. 
 
 to disguise disagreeable, 131. 
 T-bandage, 217. 
 Teeth, care of, 77. 
 
 development of, 295. 
 Temperature, bodily, 54. 
 
 of baths, 78. 
 
 of room, 73. 
 
 post-mortem, 376. 
 Terminations of disease, 371. 
 Tetanus, 253. 
 Thermometers, 58. 
 Thirst, 177. 
 Thrombosis, 45. 
 Thrush, 298. 
 Tidal air, 64. 
 Tongue in disease, 77.
 
 INDEX 
 
 397 
 
 Tourniquet, 343. 
 Typhlitis, 314. 
 Typhoid fever, 327. 
 Typhus fever, 329. 
 
 Urine, 90. 
 Urticaria, 318. 
 Uterine examinations, 261. 
 in labor, 275. 
 
 Vaccination, 332. 
 Veins, 49. 
 
 varicose, 347. 
 Ventilation, 69. 
 Vermin exterminator, 29. 
 Visitors, 373. 
 Vital signs, 114. 
 
 Vocabulary, 379. 
 Vomiting, 119. 
 to control, 256. 
 
 Ward work, 20. 
 Water, cold, externally, 79, 
 161. 
 
 internally, 177. 
 
 Water, hot, externally, 161, 
 347. 
 
 internally, 79, 257. 
 Water-bed, 38. 
 Weights, 136. 
 Whooping-cough, 302. 
 Worms, 300. 
 Wounds, 234, 354. 
 
 poisoned, 355. 
 
 (5) 
 
 THE END
 
 This book is DUE on the last date stamped below 
 
 JAN 2 6 1952 
 
 Form L-9-15wi-ll,'S7
 
 
 001429931 7 
 
 of CALIFORNi/ 
 AT 
 
 T.OS ANGELES 
 TJBRARY