^.SENTED Tq S. cL The New Y of Medicine By ^A (LUaJL^-. 19 NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of The New York Academy of Medicine i PLATE I ~:*i <;i —L.-di-...- ,y. A f. , ■> .____"UJ Florence Nightingale Established the first training-school for nurses, 1860. MODERN METHODS IN NURSING GEOI „ k.NT matron AT ADrMNftofl .Nil ' FORMPRll KnPRTVLN'lkeNfl__. FORMERLY ASSISTANT MATRON AT ADDKNfcooMttPjHOSPITAL, CAMBRIDGE, ENGLAND; FORMERkJ^ MlPEIftN'MiNfltNT OF NUKSEjp AT THE POLYCLINIC HOSPITAL,» PHILADELPHIA, MASSACHUSETTS GENERAL THIRD EDITION, THOROUGHLY REVISED , t-j£ N, Y. ACADdMi "The know^fe that. *«lLholdl^do* ;.; in working — cleave thoji to rthat " '■■" - Lir^jrt_____ PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1922 ^I\r Copyright, 1912, by W. B. Saunders Company. Reprinted September, 1912, August, 1913, March, 1914, October, 1914, January, 1915, September, 191s, and November, 1915. Revised, reprinted, and recopyrighted July, 1916. •'lte^Med September, 1917, May, 1918, March, iqiq, February, YfjfiQio, April and September, 1921. Revised, reprinted, and recopyrighted September, 1922. Copyright, 1922, by W. B. Saunders Company MADE IN U. 8. a. PRESS OF W. 6. SAUNDERS COMPANY PHILADELPHIA TO W. R. S. PREFACE TO THE THIRD EDITION In this edition the Introduction found in the previous editions has been omitted. In it were discussed various methods of training, with the object of guiding a prospect- ive student in her selection of a training-school among schools of very varying standards. At the present date the registration of nurses is an accomplished fact in practically every state, with the result that curricula^ and methods of training have become standardized, and all schools whose graduates are eligible for registration must comply with the requirements, in educational facilities and equipment, of the board of examiners for registration of nurses in their state. Such schools are known as "accredited schools." In graduating from any accredited school a nurse may be sure she has received a training that will prepare her to fulfil the requirements for regis- tration in that state and to fit her to practice her pro- fession. Particulars of the requirements for graduation and the qualifications required of a pupil nurse may be had on application to the secretary of the state board of examiners for the registration of nurses in each state. The questions, therefore, discussed in the former Intro- duction have ceased to be pertinent. The section on Bacteriology has been revised and brought up to date by Miss Elizabeth M. Yagle, assistant to Dr. John A. Kolmer (Professor of Pathology and Bac- teriology and Instructor in Bacteriology in the Graduate School of Medicine of the University of Pennsylvania). The principal addition to this section is the description and laboratory methods of identification of the more com- mon pathogenic bacteria. My thanks are due to Miss Yagle for her thorough and painstaking work. 9 10 PREFACE TO THE THIRD EDITION My cordial thanks are also due to the nursing stall of the Massachusetts General Hospital and the Peter Bent Brigham Hospital, Boston; and of the Pennsylvania University Hospital and the Polyclinic Hospital, Phila- delphia, for courteous help in various departments; to Dr. David Riesman, of Philadelphia, to whom I am indebted for advice on the section on "Diet in Disease," and to Miss Roberta M. West, Secretary to the Penn- sylvania State Board of Examiners for the Registration of Nurses, for helpful discussion and information on the subject of auriculae at the present day. The chief contribution in practical nursing from the field surgery of the late war is, probably, the Carrcl- Dakin method in the treatment of infected wounds. As this treatment is in general use in civil practice1 at the present day a description of the method is given in detail. The technic followed is that described in "Technic of the Carrel Method," by I. Dumas and Madame Carrel. Georgiana J. Sanders. Bryn Mawr, Pa., September, 1922. PREFACE In preparing a text-book that shall fit the curriculum required by a modern training-school, one has to face the drawback that some of the subjects which must be pre- sented can be but very superficially appreciated by the writer. Properly speaking, such subjects as bacteriology, or materia tnedica, presented in however elementary a form, should be treated by those whose special study of the subjects qualifies them to speak with authority, a vantage ground which we as nurses are, obviously, far from claiming. The same is true of such matters as de- scriptions of symptoms and suggestions of remedies. At the same time, those of us who have been for many years engaged in adapting such knowledge to the require- ments of nursing, realize that it is often as important to have an interpreter as to have exact scientific information on these subjects. As such an interpretation the chapters on elementary bacteriology and theories of immunity are specially presented, leading as they do to the principles governing all our modern methods of nursing, and deter- mining in particular all the details of surgical technic. In writing the chapters I am indebted to many excellent lectures given in one or other training-school with which I have been connected, while for the practical and tech- nical details involved I have gone as carefully as I could into those adopted by the leading hospitals in America, as well as those with which my own work has made me familiar, especially the Polyclinic Hospital, Philadelphia, and the Massachusetts General Hospital, Boston. On this point my thanks are specially due to the Johns Hop- kins Hospital, Baltimore, the Pennsylvania Hospital, Philadelphia, and the Philadelphia Hospital. Where I have used a text-book I have, for the sake of simplicity, kept to the one with which I was most familiar in teaching, H. U. Williams' Manual of Bacteriology. 11 12 PREFACE In the chapters on food and food values I have, for the same reason, used chiefly Miss Farmer's well-known book on invalid cookery. The chapter on dieting is compiled chiefly from the dietaries in use in various hospitals, es- pecially the Polyclinic Hospital, Philadelphia, and the Massachusetts General Hospital, Boston. Other text-books that have been used are Dock's Materia Medicafor Xurses, the various text-books on nursing, and A. A. Stevens' Manual of the Practice of Medicine. A great deal of matter used has, however, been so long in my own note-books that, gathered originally merely for practical purposes, the source has been lost sight of, and I have made use of it not without some misgiving that, in so doing, I may prove myself an unwilling and unconscious plagiarist. My thanks are also due to members of the nursing staff of the Massachusetts General Hospital, the Children's Hospital, Boston, and the Johns Hopkins Hospital for the charts reproduced; and te the authorities of the Polyclinic Hospital, Philadelphia, for permission to make many of the illustrations in their wards. Georgiana J. Sanders. CONTENTS ('HA ITER 1 pa«Je Practical Methods..................................... 17 Beds and Bed-making, 17. CHAPTER II Baths and Packs....................................... 50 CHAPTER III Local Application's. . . >................................. 77 Inflammation, 77—Application of Cold, 81—Hot Appli- cations, 86—Hot Compresses, 97—Counterirritants, 98— Rubefacients, 98—Vesicants, 107—Escharotics, 109— Liniments, 110—Plasters, 110. CHAPTER IV Enemata, Entiokoclykis, Continuous Rectal Infusion, Suppositories, Douches, Tampons, Catheteriza- tion, Lavage, Cavage, Nasal Feeding........... 113 Enemata, 113—Enteroelysis, 125—Continuous Rectal Infusion or Seepage, 128—Suppositories, 129—Douches, 130—Tampons, 138—Catheterization, 140—Lavage, 146 — Oavage, 150—Nasal Feeding, 150. CHAPTER V Temperature.—Pulse.—Respiration.—Charts............ 152 Temperature, 152—Pulse1, 160—Respiration, 168— Charts, 174. CHAPTER VI Observation and Examination.......................... 170 Symptoms, 179—Physical Signs, 183—Examination of Special Organs, 189—Examination of Organs of Special Sense, 199—Observation of the Skin, 204—Examination of the Blood, 208—History-taking, 214. CHAPTER VII Examination of Vomitus, Sputum, and Excreta......... 216 The Vomitus, 216—The Sputum, 220—The Feces, 224— The Urine, 229—Examination of the Urine, 234—Test for Acetone, 244—Test for Diacetic Acid, 244—Ehrlich's Diazo-reaction, 245. 13 14 CONTENTS CHAPTER VIII page Bandages and Splints.............................24S Bandages, 24S—Plaster-of-Paris Bandage, 266—Splints, 270—Extension, 280—Fracture Boards, Sand-bags, Cra- dles, 284—Strapping, 285—Knots, 289. CHAPTER IX Medicines............................................ 292 Weights and Measures, 292 -The Metric System, 296 — Names of Preparations, 300—Dosage, 301—-Time of Ad- ministration of Drugs, 307—Relative Values of Different Forms of Preparations, 30S—Abbreviations, 309—Familiar Preparations, 311—Administration of Drugs, 313—Hypo- dermic Injection, 316—Inhalation—Anesthesia, 321—In- unction, 333. CHAPTER X Poisons and Their Antidotes........................... 335 Corrosive Poisons, 338—Irritant Poisons, 341—The Functional Poisons, 347. CHAPTER XI Elementary Bacteriology and Theories of Immunity. 353 Classification, 353—Bacteria, 355—Protozoa, 360— Cestodes—Nematodes, 361—Examination of Bacteria, 362 —Preparation of Specimens for Examination, 364—Cul- ture of Bacteria, 368—Infection, 373—Cocci, 379—Ba- cilli, 382—Widal Reaction, 383—Spirilla, 386—Pathogenic Protozoa, 386—Modes of Transmission, 388—Prophylaxis of the Infectious Diseases, 391—Immunity, 396—Action of Pathogenic Bacteria, 407—Nursing in Infectious Dis- eases, 409. CHAPTER XII Surgical Bacteriology, Asepsis......................... 415 Micro-organisms Met with in Surgery, 415—Wound Infection, 415—Antisepsis and Asepsis, 418—Sterilization, 422—Antiseptics in General Use, 430—Disinfecting a Room, 440—Disinfection of Excreta, 442—Measuring Solutions, 445. CHAPTER XIII Preparation and Sterilization in Surgical Work.....447 The Hands, 447—The Field of Operation, 449—Instru- ments, 454—Rubber, 459—Glass, China, and Enamelware, 463—Sutures and Ligatures, 463—Dusting-powders, 472— Oils and Ointments, 473—Solutions, 473—Dressings, 473— Sea-sponges, 476—Hand-brushes and Nail-cleaners, 477— Cultures, 477. CONTENTS 15 CHAPTER XIV ,.AOhi Surgical Technic and Minor Surgical Events.......... 478 Principles of Technic, 478—Preparation of the Skin, 485 —Dressings, 485—The Carrel Method, 490—Hypodermo- clysis or Subcutaneous Infusion, 497—Intravenous In- fusion, 502—Venesection; Phlebotomy, 504—Blood-culture, 504—Transfusion, 506—Injection of Antitoxin Serums, 509 —Minor Surgical Procedures, 510—Exploration, 511— Lumbar Puncture, 512—Paracentesis or Tapping, 514— Aspiration, 516. CHAPTER XV The Operating-room.................................... 523 Equipment of the Operating-room, 523—Duties of the Nurses, 533—Operations in the Patient's Home, 541. CHAPTER XVI The Care of Operation Cases.......................... 551 Preparation of the Patient, 551—Etherization, 554— Immediate Care After the Operation, 556—Abdominal Section or Laparotomy, 561—Eye Operations, 570— Tracheotomy, 572—Intubation, 575. CHAPTER XVII Nursing in Accidents and Emergencies................. 578 Shock, 578—Hemorrhage, 580—Treatment of Hemor- rhage, 582—Special Forms of Hemorrhage, 598—Perfora- tion, 610. CHAPTER XVIII Nursing in Accidents and Emergencies (Continued)...... 612 Fractures, 612—Treatment of Fractures, 617—Disloca- tion or Luxation, 657—Wounds, 634—Treatment of Acci- dental Wounds, 636—Repair of the Wound, 638—Com- plications of Wounds, 641—General Infections Developing from Wounds, 645. CHAPTER XIX Nursing in Accidents and Emergencies (Continued)...... 648 Burns and Scalds, 648—Bites and Stings, 657—Frost- bite and Exposure, 659—Boils, Styes, Carbuncles, Whit- low, 660—Convulsions, 663—Removal of Foreign Bodies, 671—Artificial Respiration, 676—Fainting or Syncope, 682 —Cerebral Concussion, Heat-stroke, Starvation, 683. CHAPTER XX Symptoms and Conditions Frequently Met With........ 687 Pain, 687—Delirium, 689—Delusion, Illusion, Hallu- cination, 690—Coma, 691—Insomnia, 692—Paralysis, 695 —Edema, 697—Vomiting or Emesis, 698—Hiccup; Singul- tus, 701—Constipation, 702—Diarrhea, 703—Rigor, 705— Sweating, 706—Fever, 708—Eruptive Fevers, 713—Other Skin Eruptions, 716. 10 CONTENTS CHAPTER XXI paof Food.................................................. 72:; ^ Chemical Composition of Food, 724—Caloric Value of Food, 733—Digestibility of Food, 730 Absorption of Food, 743. CHAPTER XXII The Preparation of Pood............................ 7 46 Proteins, 747—Carbohydrates, 747—Fats, 749 -Milk, 750—Milk as a Food for Infants, 756—Eggs, 763--Gruels, 764—Meat Broths and Extracts, 765—Water, 760 — Beverages, 767 CHAPTER XXIII Diets and Dieting.................................... 770 __General Division of Diets, 770—Some General Points 774—Diet in Special Diseases, 775. CHAPTER XXIV The Head Nurse and Ward Management............... 801 Division of Labor, 802—The Orderly, 805—The Ward- maid, 805—Hours Off Duty, 807—Reporting, 808—Stock- books and Inventories, 812—Care of Linen, 816—Blankets, 818-Patient's EtTerts, 819—Special Duties of a Head Nurse, 820—The Patient's Visitors, 822—Domestic Work, 823—Ventilation and Temperature, 833—The Visiting Rounds, 834. APPENDIX Recipes................................................ 836 Milk, 836—Eggs, 838—Gruels, 839—Meat-teas, etc., 840—Beverages, 841. Index.................................................. 843 MODERN METHODS IN NURSING CHAPTER I PRACTICAL METHODS Beds and Bed-making—A Medical Bed—A Surgical Bed—To Turn a Sheet—To Turn a Mattress—To Give a Fresh Mattress— Bed-bath—To Change the Shirt—Care of the Mouth—Care of the Back—Bed-sores—A Water-bed—To Give a Bed-pan—Care of the Hair—Treatment for Pediculi—Lifting—To Arrange a Patient Up- right in Bed. The following lessons are specially designed to be taught to the pupils in classes: first, where practical, in the demon- stration or class-room, and, afterward, practised under trained supervision at the patient's bedside. From the beginning the pupil should be trained to use her power of intelligent observation, probably her most valuable practical quality as a nurse, and com- monly latent at the beginning of her training. For example, in the simple matter of bed-making the pupil should be directed to notice the kind of bedstead used, the material of which the mattress is made, the quality of the bed-clothes, and the chief reasons for such selection pointed out. When each piece of work is finished, she should be taught to look at it and decide for herself it is perfectly finished or in what way defective. The habit of mind so formed is a solid gain. BEDS AND BED-MAKING The essential, indispensable part of the equipment of a sick-room or ward is the bed. It must be comfortable for the patient, practical to clean or disinfect, and con- venient to handle. The bed accepted as most suitable for nursing the sick is a single bed, made of enameled iron, with a wire spring mattress, and specially constructed to be easily taken apart and put together; the advantages are that they are light to move, easy to clean and disinfect, and do not harbor 2 17 18 PRACTICAL METHODS dirt or insects,as did the older wooden bedsteads. A height of from 24 to 27 inches from the ground to the wire mat- tress is an immense help to either doctor or nurse in carry- ing out the offices and treatment required, and not gener- ally objected to by the patient. The bedstead is usually o feet 4 inches long by 3 feet wide. Wooden bedsteads, although not unknown in hospital work, are not infrequently met with in the homes of private patients. After any case of illness such a bedstead should be taken apart and subjected to thorough cleans- ing and disinfection (sec Disinfectants), and, when prac- tical, set in the sun, out-of-doors, for some hours. If animal life is discovered, the fumes of sulphur will kill the animals better than any other disinfectant, but nothing has yet been found to destroy the eggs. A wooden bed- stead that is really infested with bed-bugs cannot be saved, and, when practical, should be burned. Mattresses.— Mattresses are made of hair, cotton, wool, or wool and hair material, feathers, fiber, or straw, and usually covered with stout linen ticking. Cotton ticking may be used, but is neither so cool nor so durable. Straw can never be described as a comfortable bed, but has an advantage that, being inexpensive, it can be destroyed and renewed with each case, the covering, ticking, being washed as regularly as the bed-clothes. For this reason its use is sometimes advocated in epidemics of serious in- fections, such as small-pox. In the form of a palliass, a stiff mattress of closely packed straw, it is frequently used under a top mattress when it is required, as in fracture of a thigh, to use a mattress that will not sag. The mattress of palm fiber, or of palm fiber mixed with hair, is less expensive than that altogether of hair, and ii well made, is not uncomfortable and wears well. The cotton mattress is also comfortable until beginning to wear, when it gets lumpy. Its disadvantages are thai it is hotter than hair, considerably heavier, and absorbs and retains any discharges which may soak through the ticking. Being less expensive than hair, it is frequently used in dormitories, where its disadvantages are not of practical importance. BEDS AND BED-MAKING 19 The feather mattress is not practical in the sick room on account of its heat, its tendency to form into hollows and lumps, and from the fact chat it is very difficult and often impossible to make it comfortable with the patient in bed. It is never seen in a hospital. Persons, however, who are used to a feather mattress find anything else chilly and hard, and it requires much tact and judgment to introduce a more practical and hygienic form of mattress. In old people it may frequently be an ill it is wise to make the best of. In such a case half the mattress can be shaken up at a time, and the patient rolled on to the prepared half while the other is shaken. A well-made mattress of wool and hair mixed is the most comfortable form of mattress, but, in hospital work, is considered less sanitary than one entirely of hair. The mattress stuffed with horsehair is comfortable, hygienic, and cleanly, and the one in ordinary hospital and domestic use. That for hospital use is made slightly smaller than the spring mattress, as from frequent press- ing it spreads somewhat, is usually four inches thick, and weighs from 20 to 26 pounds, 22 pounds being a usual average. It is lighter and does not soil so readily as the other varieties, horsehair being non-absorbent. All mattresses should be protected by a washable cover, which may be made inexpensively of stout, unbleached muslin, and, well shrunken before making, fits the mattress as a pillow-cover does a pillow. By this means the life of a mattress will be materially prolonged. In some hospitals, generally those devoted to maternity cases, the mattress is dispensed with altogether. Instead of the wire mattress or slats, a heavy piece of sack-cloth, canvas, or ticking is laced with cord to the four sides of the bed-frame. On this is laid a thick blanket covered by a rubber sheet and the usual bed-clothes. It is claimed that it is comfortable, cool in summer, economic, and certainly hygienic, as every part is washed after each case. Pillows.—Pillows are made of hair, feathers, or down, the hair being useful to support limbs or retain the patient in a fixed position: they may also be used under a feather pillow for the head. Down is generally considered too ex- pensive for hospital use unless for small pillows for the 20 PRACTICAL METHODS head and for infants. The pillow in common use is the feather pillow, in size usually 30 inches by 20 inches. Pillows should be covered with linen ticking and not with cotton, as linen is perceptibly cooler to lie upon. Besides the pillow for the head, even- ward should possess a num- ber of small pillows, both of hair and of feathers, of varying sizes, from 8 inches square upward, to be used for special support. Where necessary, the mattress or pillows are protected by- rubber sheeting. These should be dispensed with, how- ever, as soon as possible; not only are they uncomfortably heating, but they favor a tendency to bed-sores. In the interests of cleanliness and economy, however, their use is frequently unavoidable, and care should be taken to see that they are in a proper condition to fulfil their pur- pose. (See Ward Management, Chap. XXIV.) Pin- pricks and cracks from careless folding make a rubber as useless as a bucket with a hole in it. Bed-clothes.—The bed-clothes needed in the sick-room are the same as those required in health, with the addition of the draw-sheet. This is a narrow sheet, either single or double, folded across the bed under the patient's hips, where naturally the greatest pressure of his weight is felt. Its object is, by drawing it to one side or another, to enable the sick person to have a cool and smooth spot given him to lie on without remaking the whole bed. It is made a yard longer than the width of the bed, and tucked with the larger portion under one side of the mattress, in order that it can be drawn at intervals to the other side. For hos- pital purposes a good cotton drill a yard wide is very prac- tical. It is firm enough not to get easily into wrinkles, and takes, in mangling, a smooth polish agreeable to rest upon. Old sheets may be used, but are so soft as to wrinkle quickly. The habit of using half-soiled sheets as draw- sheets is not a good one. The sheets are of finer material than the draw-sheets and get unduly worn, besides fre- quently being stained in a way that makes them unsightly, and unfit for their own use. Draw-sheets are also of use in protecting parts of the bed in danger of soiling, as from hemorrhage, surgical dressings, discharging wounds, and so forth, their advantage BEDS AND BED-MAKING 21 again being that they can be changed with little disturb- ance to the patient. Where necessary for the further protection of the bed, a small rubber sheet, at least four inches narrower than the draw-sheet, can be placed below the draw-sheet above the under sheet. It must be sufficiently long to tuck in firmly on either side, otherwise it will wrinkle and become a source of discomfort. About the remainder of the bed-clothes a few details must be noted. If the bed is to be smooth, the sheets must be of sufficient size to tuck in firmly at the top and bottom and at the sides. A stout quality muslin, three-quarters of a yard wider than the mattress, should be chosen, and well shrunken before making up. The sheet should be cut three-quarters of a yard longer than the mattress, and hemmed with a two-inch hem at one end and a one-inch hem at the other. If the material is not shrunken before the sheet is made, one yard instead of three-quarters of a yard must be allowed. The spread should be washable and light. The cotton spread manufactured by the Allandale Company is emi- nently suitable. It is made of stout white dimity, which wears well, is both dainty and serviceable, and has the advantage over the heavier and more loosely woven spreads of not perceptibly shrinking. Though slightly dearer than some other varieties to purchase, it is less expensive in the long run, as it wears much better. Where the blankets can be obtained entirely of wool, they have the advantage of being lighter in proportion to their warmth, and wearing better. For practical purposes, however, a cheaper variety of blanket meets all the re- quirements. The care of the blankets is such an import- ant part of the economy of a hospital ward that it will be treated at greater length in another chapter. (See Ward Management, Chap. XXIV.) Bed-making.—The simple process of making a bed may be a slovenly, ineffectual performance, or, in skilful hands, a real source of healing and comfort. In teaching a class, and for the routine bed-making of a ward, the nurses should work in pairs; the beds in this way are made more 22 PHACTICAL MKTHODS efficiently and quickly, and with considerably less fatigue on the part of the nurses. Standing opposite each other on either side of the bed. with a chair placed at the bottom of the bed, on which is laid the clean linen that will be required, the lesson may proceed as follows: First: Remove the upper clothing, one at a time, by taking the top and bottom corners, laying them together, and folding neatly; lay each article over the back of the empty chair. Second: When the top sheet is reached, loosen it all round, slip the patient's bed-socks or slippers over his feet, put on his wrapper or other suitable covering, and help him out of bed. Third: Remove the remaining clothes in the same manner. If any are to be replaced by clean linen, lay the soiled, tidily folded, on one side. Fourth: Brush the mattress with a whisk-broom and turn it top to bottom. Fifth: Replace the clothes in their order, thus: rubber sheet, sheet, rubber draw-sheet, and draw-sheet, tucking them all very firmly under the mattress; beat up the pillows and lay them in place. Sixth: Lay the upper clothes, with the exception of the spread, in order on the bed, turning back the upper border of the sheet over the blankets; the upper margin of the blankets should come just below the pillow; the upper margin of the sheet should reach to the top of the mattress before folding back. Do not tuck them in until the patient has been put back to bed. Seventh: Return the patient to bed and divest him, un- der cover of the bed-clothes, of slippers and wrapper. Eighth: Tuck the clothes in and cover with the spread, which is tucked firmly at the bottom of the mattress and at the top is turned over the upper margin of all the blan- kets, and in its turn covered by the reversed border of the upper sheet. (This helps to keep the blankets clean, a cotton spread being a simpler thing to wash than a woolen blanket.) Adjust the corners of the spread smartly and the bed is made. BEDS AND BED-MAKING 23 Points which have always to be emphasized in teaching a class are the following: Have everything at hand before you begin. See that the temperature of the room is sufficiently warm. Take care that the patient is not exposed to a draught. Do not beat up pillows on the patient's bed while he is in it. All folding must be done at the bottom of the bed, not over the patient's face. Never lean on a bed, jerk it, or touch it unnecessarily: such practices are always annoying, and in some instances, such as, for example, in rheumatoid arthritis and some forms of septicemia, cause acute pain. It is also never too early in a nurse's training to point out the necessity of a dignified and quiet demeanor, and a habit of consideration toward the patient. Personal topics should not be discussed while at work. When the simple making of beds has been mastered with some proficiency, the next lesson may show the methods of changing a bed with a helpless patient in it. This may first be practised with a dummy, or with one of the pupils acting the part of the patient in the demonstration room, or by using a convalescent patient, if one is found who does not object to assisting at a demonstration. To Change a Medical Bed.—First: Arrange a chair and remove the top coverings, as in the first lesson: retain the undermost blanket and untuck it and the upper sheet all round; holding the blanket over the patient by its upper margin, slip the sheet out from under, leaving the patient covered by the blanket. Second: Loosen the underclothes and remove the pil- lows (one is practical to retain if preferred). Third: Turn the patient on one side, keeping the blanket over him, one nurse supporting him by the shoulders and pelvis. Fourth: Roll the undersheet and draw-sheet from the side farthest from the patient to the middle of the bed, whisk the mattress free of dust, and straighten the rubber sheet; if it is necessary to change it, roll in the same manner as the sheet, 24 PRACTICAL METHODS Fifth: Prepare the clean sheet and draw-sheet by roll- ing one-half from either side toward the middle; lay the rolls by the side of the rolled-up soiled sheet. Sixth: Unroll the sheet and draw-sheet over the exposed half of the mattress and tuck them firmly in, turn the patient on to the clean sheet, remove the soiled sheets, and unroll and adjust the other half of the clean ones in the same way. Seventh: Turn the patient on his back and lay the upper sheet over him, not covering his face; slip the cover- ing blanket from under the sheet, and finish the; bed in the usual manner (Fig. 1). Fig. 1.—Changing the under sheet, medical method. This method is known as changing a medical bed, most medical cases being able to be turned on the side. It is also applicable to the majority of surgical cases. What is known as the surgical method is employed where turning on the side is impracticable, the majority of cases which, from one reason or another, are forced to retain a fixed position being surgical. It is a somewhat more difficult method, and should not be taught until the pupil has been given some instruction in lifting. BEDS AND BED-MAKING 25 Instead of from side to side, the sheets, by the surgical method, are changed from top to bottom; in other respects the process is the same. To Change a Surgical Bed.—After proceeding in the usual manner until the pillows are removed and the pa- tient covered with one blanket, the sheet is rolled from the top of the bed down under the patient's head to his shoulders, and the clean one, folded crosswise, is laid beside it and the top tucked in, covering the upper part of the bed. Standing one on each side, the nurses place the hands nearest the head of the bed under the patient's shoulders and raise him sufficiently, and no more, to enable them with their free hands to roll the soiled and the clean sheets under the shoulders to the hips. The pelvis is then raised in the same manner and the limbs in their turn, and the bed is completed in the usual way. When it is necessary to keep a joint or limb at absolute rest, a third nurse is required to support the limb and keep it immovable during the process. A medical bed can and should have its under sheet removed and replaced or changed once every day. For cases such as have just been described, where immobility is part of the treatment, it should be performed as seldom as is consistent with comfort and cleanliness. A judicious use of draw-sheets will produce like results with much less disturbance of the patient. Nurses have invariably to be checked in an extravagant use of bed linen. That it is extravagance is difficult to bring home to them in a hospital ward where the supply of linen is bountiful, and the disadvantages of too frequent washing are not evident to the pupil. In a properly organized ward there are set days and intervals for the changing of spreads, curtains, and sheets, and while soiled and stained sheets must obviously always be re- moved, the pupils should be taught that a sheet may be kept clean and fresh for double the length of time by such simple means as folding it smoothly over a chair during the bath and bed-making; turning it; preventing visitors from sitting on the bed; protecting it with the dinner napkin when food is given, or with a draw-sheet during various 26 PRACTICAL METHODS treatments. This may sound a trivial lesson, but if really learnt, its usefulness is far reaching. As one of the results we might cease to hear of private nurses taxing beyond bearing the resources of a small establishment by demanding fresh sheets, etc., at least daily. To Turn a Top Sheet Without Exposing a Patient.- This is most easily done by two nurses. Standing one on either side of the bed, with the blanket and spread removed, the upper hem of the sheet is taken by the hands furthest Fig. 2.—Turning top sheet without exposing the patient. from the head of the bed. The other hands are held extended under the reversed upper border of the sheet and the sheet is drawn by the upper hem over the extended hands toward the bottom of the bed, much as if the upper- most hands formed a roller (Fig. 2). Where a patient has to remain any length of time in bed, it is often an immense comfort to turn his mattress, or to put him on a fresh mattress. Instruction in the method of so doing follows naturally the lessons in bed- making. BEDS AND BED-MAKING 27 To Turn a Mattress Under the Patient.~-First: Proceed as in bed-making until the pillows are removed and the patient covered with the single blanket. Second: Move the patient to one side of the mattress, loosen the clothes, and roll them from either side close-- up to him. Third: Take hold of the mattress from the side furthest from the patient^ and draw it across the bed until half the wire mattress is exposed. Fig. 3.—Turning a mattress without removing the patient from the bed. Fourth: Cover the exposed wire mattress with pillows (three are enough) and move the patient, with the bed- clothes under him, on to the pillows. Fifth: Turn the mattress from top to bottom (if advis- able, make it up with clean sheet and draw-sheet), move the patient on to it, remove the pillows, and draw the mattress back into position (Fig. 3). To Give a Fresh Mattress.—In a ward it is usually as simple a matter to give a fresh mattress as to turn one already in use'. Two methods may be employed: 28 PRACTICAL METHODS First Method: Proceed as though turning the mattress, but, instead of using the pillows, when the mattress is drawn across the bed, place a fresh mattress already made up with sheet, etc., beside it, and move the patient upon it. Remove the old mattress and draw the fresh one into place. Second Method: Roll a second bed on which is a mattress without covers close to that of the patient. Divest the bed of the upper clothes and pillows, cover the patient with a single blanket, and loosen the under bed-clothes. Two nurses standing at the further side of the empty bed take hold of the under sheet by the sides, and, slightly raising it, pull it toward them with the patient on it, helped, at the same time by a third nurse, who remains at the further side of the patient's bed. Where the bedstead is of cot formation with low railings at top and bottom, two nurses stand at the patient's head and feet and lift him in the sheet as though on a stretcher. Where a patient can be lifted bodily from one bed to another (or on to a couch or stretcher), the second bed is wheeled up in such a manner that the bottom of one is opposite the top of the other. Three nurses standing between the two beds lift the patient, one at the shoulders, one sup- porting the pelvis, and one at the feet; with the beds so arranged, by the nurses simply turning round in a half wheel, the patient is in the right position to be laid on the fresh bed. The Bed-bath.—After bed-making has been mastered, instruction in giving the ordinary cleansing bed-bath follows: The requirements for its performance are,—a covering for the patient, a covering to protect the bed-clothes, hot water in a deep basin, a further supply in a pitcher, a slop jar, a face towel, and a second towel, thicker and heavier, two wash-cloths, a bottle of alcohol, and a box of talcum or starch powder. The water in the basin should be 105° F., that in the pitcher, 110° F. The bath may be greatly elaborated with scented soaps and powders, and a variety of towels and sponges, or BEDS AND BED-MAKING 29 greatly simplified, as where a bowl, a small piece of soap, and a fragment of towel are all the implements procurable. The coverings usually employed are old blankets, one placed under the patient and one kept over him during the bath. Where not obtainable, a half-soiled sheet, folded in four thicknesses, or a large bath towel, may be used under the patient and one of his bed blankets used to cover him, care being taken by the use of towels to prevent the latter becoming damp. Fig. 4.—Washing a patient without exposure. Where obtainable, a hot-water bag ready filled should be at hand, and in most instances may with advantage be kept at the patient's feet during the whole process. Care must be taken that the room is warm and draughts excluded. The upper bed-clothes removed and the blankets in place, the night-shirt is removed and the bathing proceeds as follows, the nurse standing at the right-hand side of the bed (Fig. 4). 30 PRACTICAL METHODS First: Sponge and dry the face: wash with a good lather of suds the neck and ears, rinse well, and dry, taking par- ticular care with the ears. Second: Bring each arm in turn out over the upper blanket, place the basin on the bed, and put the hand in the water, soaping and rubbing it between your own hands. Keep each hand in the water while the arm is washed. Rinse, dry thoroughly, and repeat the process with the other arm. Third (the second wash-cloth is now used): Wash the chest and abdomen. This may or may not be done under cover, at discretion. Where a patient is washed under cover, the blanket is with one hand held slightly away from the body, while the other hand performs the washing and drying. The entire patient may be washed in this way, and should be so done where discretion suggests, or where the patient is peculiarly susceptible to chill, as in condi- tions of great weakness. The axilla and umbilicus must receive special care. If the umbilicus has been neglected and allowed to become blocked with secretion and dust difficult to remove, a small soap poultice may be applied twice a day until clean. (See Preparation for Operation, p. 553.) Fourth: The chest and abdomen dried and covered, the genitals are carefully washed under cover. In many cases patients can do this for themselves with some little assistance from the nurse. With helpless or unconscious patients it must not be neglected from a false notion of delicacy, the skin in these parts becoming easily inflamed and sore from the natural secretions, unless kept scrupu- lously clean. The folds of the thighs should receive special attention. Where the parts have become irritated, or from any cause are difficult to cleanse (such as during menstruation ), such washing may be left to the end of the bath, and the patient placed on a douche pan, filled with hot water, and given a thorough local tubbing. Fifth: At this point the water usually requires changing and the basin is replenished from the pitcher. The lower limbs are now exposed in turn, washed and BEDS AND BED-MAKING 31 (tried in turn in the same way as the arms, with the basin on the bed and the foot kept in the hot water. This method of bathing the limbs demands a little more dexterity, so as not to upset the basin, and cannot be used with a rest- less patient, but it is usually found immensely comfortable for the patient, and is a good means of restoring the bodily warmth, which is always slightly lost in washing. Sixth: The patient is rolled over on his face and the back and hips washed. If it is an object, as in many cases, to spare the patient's strength, the under sheet may now be changed, and the patient turned on to the freshly made half of the bed, the under washing blanket is removed with the soiled sheet, the entire bath and bed-making being thus ac- complished with only one turning of the patient, a con- sideration when the store of strength is small. Seventh: Before the shirt is replaced the back, hips, and other points of pressure are usually well rubbed with alcohol and powdered. Eighth: The shirt is replaced and the bed made. The bed-bath is usually the most acceptable if the wash- ing is done briskly with plentiful soap, thorough rinsing, and a fairly vigorous friction with a dry towel, none of which is incompatible with gentleness; the unpleasantness and inadequacy of a dabbing wash with a wash-cloth wrung nearly dry, followed by a gentle wiping, has to be experienced to be realized. Changing the Shirt.—In removing a patient's shirt, loosen it round the neck, bring the back half over the shoulders, and draw off one sleeve, when the shirt will slip easily over the head and be withdrawn by the second sleeve. Should one arm or side be injured, begin always with the sound arm. In putting on a shirt, reverse the proceedings, thus, first one sleeve, an injured arm first, then over the head, then the second sleeve, and finally pull it down comfortably under the patient. In putting on the sleeve make it as short as possible by gathering the wristband up toward the arm-hole, and so slipping the entire sleeve over the wrist with one movement. 32 PRACTICAL METHODS Simple as this lesson sounds, usually it has to be prac- tised again and again before it is accomplished with deft- ness, and with no fatigue for the patient. For hospital use a very practical shirt is often sup- plied, buttoning behind, with the front part the usual length and the back reaching only to the waist. It is comfortable for such patients as are forced to lie down, and can be changed quickly. Its disadvantages are that it is frequently used for patients that can sit up, where it is obviously unsuitable, and that its use leads pupil nurses to believe they cannot nurse a bedridden patient with the ordinary night-shirts. As a consequence, many nurses invariably tear their patient's shirts the whole length behind, regardless of the fact that they are needlessly destroying property not their own, and incurring just censure for extravagance and wastefulness. In the few instances in which such a shirt is the best for a patient's welfare, the oldest shirts should be asked for, and should be neatly altered to suit the requirements, not, as is the too frequent method, simply torn and fastened with a safety-pin. Care of the Mouth.—Where a patient is capable of doing so, he should brush his teeth in the ordinary way at least morning and evening. Where he cannot do so, his mouth should receive the most careful attention from the nurse. In almost all forms of illness, and frequently in patients on a purely liquid diet, the tongue will be found covered with a coating or fur which is largely composed of food- particles, epithelial scales from the mucous membrane of the mouth, and bacteria, mixed with the secretions of the mouth. If the mouth is not kept sufficiently clean, the fur accumulates and spreads to the teeth, gums, and lips in the form of a thick, tenacious, brown deposit, diffi- cult to remove, and known as sordes (pronounce sordees). In health the muscular action of the tongue, cheeks, and lips in the process of chewing food keeps the mouth free from such deposits. In severe illness the tongue may become intensely dry and dark in color, while deep cracks or fissures appear, difficult to cleanse or to cure. Not infrequently a neglected BEDS AND BED-MAKING 33 mouth becomes ulcerated, the ulcers extending to the gums and cheeks and causing acute suffering. It should be borne in mind that a neglected mouth is a menace to the entire system. The mouth is freely supplied with lymphatics ready to carry the products of infection over all the body. It presents an ideal condi- tion for the development of the disease-producing germs, which require for their development moisture, warmth, absence of light, and suitable food, which they find in the body in its organic tissue; and we know that the germs of many diseases are found in the mouth, even in health. Many cases of reinfection in typhoid fever are considered attributable to a neglected mouth, while the frequency with which the adjacent glands or the middle ear become in- fected in illnesses associated with abnormal conditions of the throat or mouth is a familiar example of the necessity for vigi- lant cleanliness. A small tray (a white enamel pie-dish will serve) (Fig. 5) may be fitted up with the re- quisites for cleansing the mouth. These con- sist of a bottle of mouth- wash, a small tumbler or gallipot into which the amount required at FiS- 5.—Tray for care of mouth. one time—and no more —is poured, and a second gallipot to hold a supply of applicators. The most practical are made of short sticks of match-wood, to one end of which are attached pledgets of absorbent cotton. The pledget is formed of a strand of absorbent cotton wound on the end of the applicator. It should not be thick. As the fingers must be used in mounting the cotton on the applicators, the hands must be scrupulously clean. The habit of wrapping a piece of gauze round the finger and so cleans- ing the patient's mouth should not be permitted. It is 3 34 PRACTICAL METHODS clumsy, unpleasant for both patient and nurse, and, except with infants, inadequate. For infants it is practical, the natural sucking movements helping in the cleansing. Pass the applicator, moistened in the mouth-wash, carefully and repeatedly over the tongue and every corner of the mouth, paying special attention to the roof of the mouth and the crevices between the gums and cheek, and changing the applicator frequently. Repeat the process until all the deposit that is movable is removed. Do not dip a used applicator into the mouth-wash, but use a fresh one each time. If the patient is strong enough, let him rinse his mouth after into a small receiver. Lay each applicator after use on the tray; later it may be washed, disinfected, remounted, and used again for the same patient, the soiled pledgets being removed with forceps. Where the mouth contains an open wound, as after a mouth operation, or in a case of compound fracture of the jaw, the applicators must be sterilized like any other surgical dressing, and may be put up conveniently in packets of half a dozen ready for use. A mouth-wash should be antiseptic and cleansing and have no unpleasant taste or property injurious to the mucous membrane. Strong antiseptics or powerful drugs are not suitable, owing to the danger of absorption, and, if necessary to be used, should be followed by thorough rinsing with sterile water. They should never be employed for children who are apt to swallow the mouth-wash. The most commonly used are listerine and water; boric acid and water, alone or mixed with a little glycerin and lemon-juice; myrrh or thymol well diluted; chlorate of potash (5 grains to the ounce of water), and permanganate of potash, a few crystals to a tumbler of water. The latter is the least expensive and is frequently used in district work. Where the mouth is in danger of becoming infected, as in the case where cracks and fissures have formed, equal parts of lime-water and peroxid (dioxid) of hydrogen is the most efficacious wash, but the mouth should be carefully rinsed after its use. Where the mouth is very dry or ulcerated, a light application of albolene or dilute boroglycerid after the cleansing is beneficial. Glycerin BEDS AND BED-MAKING 35 alone, although healing, is too astringent. In cases of severe ulceration special applications are usually ordered, such as solution of chlorate of potash, nitrate of silver, sulphate of copper, and so forth. The cleansing of the mouth should precede the application. Patients on a liquid diet should have their mouths cleansed before each feeding. To cleanse after is apt to induce retching and possibly vomiting. Where the tongue is brown and cracked, marked improvement is shown if the patient is induced to drink water freely. Fever patients who from the beginning have had plenty of water much less frequently develop the brown, dry, and fissured tongue. The point should be impressed on nurses, who are somewhat apt to give water only when the patient complains of thirst. Care of the Back.—Prevention and Treatment of Bed- sores.—After the daily bath', as has already been said, the back, hips, and other points of pressure should be rubbed with alcohol and dusted with powder—usually starch or borated talcum; rice, zinc, or perfumed powders, equally efficacious, are more expensive. The reason for the rubbing is twofold: by thorough drying to prevent the skin from becoming chafed, and by friction to re- store the circulation to parts where, from continued press- ure, it is in danger of becoming lessened. The points of pressure in order of their importance are: the coccyx (the prominence at the end of the spine), the hips, elbows, heels, shoulders, the inner surfaces of the ankles and knees, and the back of the head, the latter chiefly in young children. All, it will be observed, are bony prominences protected only by a thin covering of skin. With no other cause the weight of the body for a length- ened period on one spot is sufficient to produce redness of that part, with a sensation of heat, aching, and dis- comfort. If these symptoms are neglected, we have the first stage of a bed-sore. From the beginning of her training it cannot be too emphatically laid before the pupil that for a patient in her charge to acquire a bed-sore points to culpable neglect on her part, so rare are the cases in which it may be considered unpreventable. 36 PRACTICAL METHODS Besides pressure from the weight of the body, the common causes of a bed-sore are moisture, wrinkles in the bed-clothes, crumbs in the bed, want of cleanliness, and bruising from the careless giving of a bed-pan. The most important part of the treatment of a bed-sore is to prevent its forming. To accomplish this, prevent pressure, or relieve it by change of position at the first sign of discomfort or appearance of redness, and practise a methodic and systematic routine of cleanliness. Wash the parts daily with soap and water, drying thoroughly and following the operation by a thorough alcohol rub and powdering. Repeat the alcohol rub in the middle of the day and in the evening, at the same time brushing the bed free of crumbs and drawing and smoothing the draw-sheet. For emaciated patients, or patients in whom, for a variety of causes, the circulation is feeble, the above will not be sufficient. Man^ cases occur where the posi- tion should be changed every hour, and the parts that have borne the weight carefully rubbed and powdered with each turning. In ward work the hours at which a patient's " back " is to be rubbed and attended to should be assigned as carefully as the hours at which his medicines are to be administered, and as punctually adhered to. In some patients the skin has a tendency to chafing and the formation of cracks. In these cases the skin may be preserved whole by an application of castor oil and collodion, equal parts, painted over the surface and re- applied when necessary. The dressing is not, however, any protection from pressure-sores. Bed-sores may be broadly classed under two headings: those caused by an abrasion of the outer skin and those caused by restriction of the circulation. The former appear first as a redness of the parts if over a prominence, or as a crack in a fold of flesh, such as in the groin or the fold of the buttocks. A few hours' neglect is sufficient for the skin to break, and we presently have a shallow sore with a moist surface, surrounded by sound flesh. This is the mildest form of the bed-sore, and if checked at this point, may heal quickly. Pressure must be at once removed either by change of position or a judicious BEDS AND BED-MAKING 37 arrangement of pillows. The wound must be kept surgically clean and dry, the surrounding tissues sound. If the crack is in a fold of flesh, the surfaces must be kept apart. The most satisfactory application is a sterile, mildly antiseptic dusting-powder constantly applied, such as starch or talcum and boric, starch and zinc, or stearate of zinc; the latter is, however, much more ex- pensive than the others. Ointments are at the present day out of favor, but in cases difficult to keep dry a piece of lint spread with zinc ointment the size of the sore, covered with a piece of sterile gauze, and held in place by strips of adhesive strapping, is frequently a successful dressing. If the sore is progressing favorably, the sur- face will become clean and dry, and new granulations, in the form of bright red specks, may be observed. We have, however, a wounded surface, and, as in all wounds, there is consequently danger of infection. The signs of such infection are discharge and local inflammation; the granulations are pale and unhealthy; the sore, instead of healing, grows deep. The bed-sore is treated like any other surgical wound that is not healing by first intention. It is cleansed with an antiseptic solution, and, usually after powdering, lightly packed with gauze and covered with a gauze pad. If stimulation is required, the surface is sometimes touched with nitrate of silver or blue stone, or an astringent lotion, such as zinc wash, may be used. The dressing is renewed whenever it has become damp or soiled. Such bed-sores, beginning mildly, may become large, deep ulcers, causing great suffering and taking weeks to heal. The second variety of bed-sore has, at the beginning, the appearance of a bruised spot, dark purple in color, and occurring most frequently over the coccyx. It is the result of pressure, and sometimes caused by such an apparently trifling matter as leaving a patient for a length of time with his back pressing on a bed-pan. Only rarely is it possible to avert a bed-sore once this bruised spot is noticed. This variety of sore is also caused by badly adjusted splints or mechanical appliances. Pressure must be promptly relieved, and the surrounding tissues gently 38 PRACTICAL METHODS but thoroughly rubbed to restore the circulation. The remedies advocated at this stage are bathing with very hot water for ten minutes at a time, repeated hourly, painting the surface with the three tinctures (tincture of aconite, l£ drams, tincture of opium, \\ drams, tincture of iodin, 5 drams), or strapping applied directly over the discolored spot. At the very first symptom of discolora- tion each of these remedies has been known to have good results, especially if pressure can be entirely removed. Frequently, however, it is apparent that a slough has already formed which must come away before healing can begin. A slough is a piece of dead flesh in living flesh, and is the same thing in soft tissues that a sequestrum or necrosed bone is in hard tissue (p. G43). It cannot be revitalized or absorbed. When a slough has remained attached until it has become decomposed, it is called a gangrene, and has a characteristic, very offensive odor. The separation of the slough may be hastened by the application of hot compresses or a small poultice cut exactly the size of the slough, and covered, when applied, with some moisture-proof protective, such as light mack- intosh sheeting or gutta-percha tissue. When the slough begins to separate, it must never be pulled away, or hem- orrhage, difficult to control, may result. When the slough is shed, a correspondingly deep sore is revealed, with a discharging, irregular surface. Probing will fre- quently discover small channels burrowing more deeply into the tissues. Such sores are very liable to secondary infection and to increase in size with rapidity, sometimes becoming so large as to threaten life from the drain they cause to the system, and from the toxins absorbed. The treatment aims at preventing infection and induc- ing healing: usually the bed-sore is cleaned with peroxid of hydrogen daily, and packed with sterile gauze, some- times soaked with such preparations as bovinin, balsam of Peru, or a weak solution of zinc (2 grains to the ounce), known as red wash; or the surface is dusted with sterile dusting-powder and packed with dry gauze. The dress- ing must be performed under strict surgical asepsis. If the surface is extensive, poisonous applications must be used BEDS AND BED-MAKING 39 with caution. Patients have exhibited symptoms of acetanilid poison from the use of acetanilid in the dusting- powder of a bed-sore insignificant in size. Where the surface of the wound is pale and unhealthy in appearance, it is usual, from time to time, to use a stringent applica- tion in the dressing. Usually the surface is painted with a solution of nitrate of silver (2 grains to the ounce), or the silver stick (lunar caustic) is applied directly. If, on healing, the granulations have a tendency to become redundant, the same treatment is also followed to reduce them. When the bed-sore is healing properly, the dis- charge decreases, the surface is a healthy red color, and the wound is perceptibly smaller day by day. Not only will the cavity close up from the bottom, but healing will be carried on from the margins of the wound, as in the case of an ulcer. Sometimes the first appearance of a bed-sore is a red- dened area, which is also puffy or swollen, with one or more clear blisters formed on the surface. The blister results from a pinching of the swollen tissue which has caused a small local exudation of lymph. If pressure is removed, the part rubbed thoroughly and powdered, care being taken not to break the blister, the symptoms will frequently subside and the contents of the blister be gradually absorbed. If the blister breaks, it is a sore similar to those first described. The cuticle of the blister should not be cut away unless the sore becomes infected, when a free surface is a more favorable condition than a covered surface. It should be a strict rule in all wards that the earliest symptoms of a bed-sore should be reported to the head nurse, and by her to the doctor. This is sometimes neglected from a dislike of incurring blame. To Relieve Pressure.—Where the patient may be turned, to turn him is the best means of relieving pressure. Where the position is fixed, pressure may be relieved by the ad- justment of pillows of various sizes or the use of a ring cushion. Ring cushions are made of rubber in ring shape and inflated with air. They should be inflated just suffi- ciently to relieve the pressure and no more, otherwise they 40 PRACTICAL METHODS are hard and uncomfortable. They may be covered with a clean gauze bandage wound smoothly round and round the ring. Besides the ring pillow of rubber, small rings of many sizes may be cut out of muslin and stuffed with tow pulled smooth or with non-absorbent cotton. They are invaluable in removing pressure from such points as the heels, knees, elbows, or ankle bones. Small pads and pillows may be used in the same way and can be made any suitable size, from a few inches square up. If neces- sary, they may be kept in position by a light bandage. Where, as in cases greatly emaciated, there is a tendency to redness in many parts of the body, the patient may be nursed on an air- or water-bed. Such a bed consists of a rubber mattress, either inflated with air or filled with water, and placed above the ordinary mattress, and gen- erally proves an immense comfort to the patient. To prevent sagging, two or three boards should be placed across the bed under the wire mattress, or the hair mat- tress may be replaced by a straw palliasse. The rubber mattress should be protected by a rubber sheet and a blanket tucked well in before the usual bed-clothes are arranged in place. The smallest pin-prick will spoil the entire usefulness of the mattress, each of which cost from $25 to $40. If water is used, it should be at a temperature comfort- ably warm, and watch must be kept from time to time to see that the warmth is maintained. If it becomes chilled, some of the water is removed and hot water added, which can be done without taking the patient off the mattress. In order to place a patient on a water-bed the best method is to prepare it on a second bed and then move the patient. Where this is not possible, the empty rubber bed may be placed under the patient in the same way that a sheet is rolled beneath him, and filled, when in place, with remarkably little disturbance of the patient. To Give a Bed-pan.—The careless giving of a bed-pan may so bruise the coccyx as to lead to the formation of a bed-sore. This small office for the sick may be a source of acute discomfort if done roughly or without due regard BEDS AND BED-MAKING 41 for the natural delicacy of a patient. No bed-pan should be given without a screen round the bed or the bed- curtains drawn, and this rule should be equally enforced at night and in children's wards. To give the bed-pan, place the left hand under the pelvis and raise the patient sufficiently, directing him at the same time slightly to draw the knees up and press the heels against the bed; with the right hand slide the pan under the patient, and gently lower him in the proper position. Have a folded towel or suitable pad where the patient's back will rest, and avoid knocking the back with rough or jerky movements. Where patients are unable to attend to themselves after its use it must be done for them, as quietly and as much as a matter of course as any other service rendered. Bed-pans are made in several shapes; that, however, similar to those supplied by Meinecke and Company, No. 48 Park Place, New York, and named the Perfection, is at present in almost universal use in hospitals. It is simple to clean and comfortable for the patient. It comes in either porcelain or gray or white enamel; the enamel, although more expensive to begin with, is cheaper in the end, as with reasonable care to prevent chipping the enamel will last a very long time in good condition. Another shape which fulfils an occasional want is the slipper bed-pan, made in the shape of a wedge. It is of use where, either from extraordinary weight or from the necessity of a specially fixed position, the patient cannot be raised from the bed even the few inches necessary to place the usual bed-pan in position. Bed-pans may also be obtained made entirely of rubber. They are chiefly used in cases of incontinence where it may be necessary to keep the bed-pan permanently under the patient. (See Care of Rubber, p. 459.) In carrying a bed-pan to and from a patient, it should invariably be covered. A piece of stout cotton or ticking three-quarters of a yard square makes an adequate cover- ing, and must be kept strictly for its purpose. After use, the bed-pan must be at once removed and washed, first in a stream of cold water, and then thoroughly 42 PRACTICAL METHODS mopped and rinsed with hot water. If the case is an infectious one, it may be necessary to mix the contents thoroughly with a disinfectant and allow it to stand for a given time. In this case it must be closely covered and emptied as soon as possible. (See Infection and Im- munity.) From the beginning nurses must be taught that the condition of the excreta is an important indication of many conditions of the system (see Excreta), and they should be trained to detect any deviation from the normal and to report to the head nurse, and save for her inspection any stool or specimen in any way unusual. Care of the Hair.—In a woman's ward the proper care of the patient's hair is a considerable item in the daily work. The hair should be thoroughly brushed once a day, and again, not necessarily so thoroughly, at the evening toilet. For a patient lying down it is most conveniently arranged by parting the hair from brow to the back of the neck and braiding it on either side of the head. In this way it is kept free of tangles, is easily groomed, and is out of the way of the patient. Where the hair has become badly tangled through carelessness or want of skill, it requires an immense amount of patience and considerable skill to disentangle it without torturing the patient. Vaselin or sweet oil rubbed freely into the hair will help matters. The hair should then be brushed, a small portion at a time, beginning at the ends, and not at the roots. To avoid tugging on the roots, each strand should be held firmly in the left hand just above the portion being brushed. The portion free of tangles is then braided, and the next portion attacked. It is customary to wash the heads of ward patients on admission to the ward. Where a patient is unable to get out of bed, proceed as follows (Fig. 6): First: Provide, on a convenient table, a deep basin with hot water (temp., 105° F.), a pitcher of water (110° F.), a slop-jar, a bottle of liquid green soap, a small pitcher, towels, a small rubber sheet, and a Kelly pad. Where a Kelly pad (p. 548) is not available, one can be improvised by rolling a small blanket into one end of a rubber sheet BEDS AND BED-MAKING 43 and folding into a horseshoe shape, the free end acting as the apron of the Kelly pad. Second: Place the Kelly pad under the patient's head near the edge of the bed. Arrange so that cheek and side of the neck rest on the inflated rim of the pad, with the hair brushed away from the face. The apron of the Kelly pad is directed into the slop-pail, which is conveniently placed below the bed. Fig. 6.—Washing the hair of a woman patient in bed. Third: Fold a small rubber sheet covered with a towel closely round the neck (a bath towel preferably), and pin them securely in place; roll a second small towel, pass it from the back of the neck over the ears across the brow above the eyes, taking care to cover none of the hair; secure it firmly with a safety-pin. Fourth: Wash the hair, first wetting it, then pouring on 44 PRACTICAL METHODS sufficient soap and massaging the scalp thoroughly with the hands moving in opposite directions. Repeat with fresh water until clean. A little ammonia may be added to the first water with advantage. Fifth: Rinse by pouring water over the head with the small pitcher, moving the hair about so that the roots are reached. Sixth: When thoroughly rinsed, wring the hair gentlv with both hands, remove the Kelly pad, and replace it with the small rubber sheet from the shoulders; unpin the large towel and turn it over the entire head; remove the rolled face towel and rub the hair until dry. The drying process may be hastened by fanning with one hand, at the same time separating the strands of hair with the other. In washing the hair it must be closely examined for pediculi, which are very common among ward patients. The eggs appear very much like specks of dandruff, but adhere closely to the hair and cannot be removed by a fine comb. All heads in a general ward should be closely combed on admission, and if either pediculi or eggs (nits) are found, should be treated until cured with a head lotion and care- ful combing. To Treat a Head With Pediculi.—After washing, the hair is soaked either in a disinfectant, such as bichlorid of mercury, 1 : 500, carbolic acid, 1:40, in tincture of larkspur, or in coal oil, and is then wrapped in a triangular bandage or towel. If coal oil is used, care must be taken that no friction is used and that no lamp or other light is allowed near. Frequently, in the homes of the poor, coal oil is the only available remedy. The coal oil may be applied at bedtime. The next morning the hair is soaked in hot vinegar and water (equal parts), which will soften and in time dissolve the nits, and carefully combed with a fine comb. The process is repeated until the pediculi have disappeared. In a hospital ward it is usually desir- able to use a head lotion and thorough combing daily. Tincture of larkspur or bichlorid of mercury 1 : 1000 are the lotions generally preferred. Where pediculi are found on the hair of the body, a daily bath of soap and water should be given, followed by a BEDS AND BED-MAKING 45 sponging with bichlorid of mercury 1 : 2000, and an appli- cation of tincture of larkspur to the affected parts, shaving where necessary. The clothes of such patients are best destroyed, but where this is impracticable, they may be disinfected with the fumes of sulphur, or baked in an autoclave and subsequently washed. Lifting a Patient.—Lifting, raising, or turning a patient is, it is generally conceded, rather a question of skill and knack than of actual strength, and the doing of it with the greatest degree of comfort for the patient, and the least physical strain for the lifter, comes only with repeated practice. For this lesson nurses should work in pairs. A few words of preliminary instruction should emphasize some simple rules not always remembered. First: Loosen the bed-clothes in the first place, so that your movements may be unhampered, and arrange them so that the patient will not become uncovered. Second: Work in unison. Third: Use the whole hand, not just the fingers. Fourth: Avoid all jerking, pulling, and ineffectual movement; each movement should accomplish its definite purpose. Fifth: Bend from the knees and hips, not from the back. To Turn.—One nurse is usually sufficient for this process. Stand on the side to which the patient is to turn. Reach across the patient, and place the open hands, firmly, one behind the shoulders and one over the pelvis about the end of the spine, and draw the patient toward you. In cases of extreme weakness the head must be supported by a second nurse. Where a patient is unusually heavy and helpless, a draw-sheet or stout towel may be slipped under the shoulders and under the pelvis respectively, the further ends of which are then grasped and drawn by the nurse to- ward her, thus at the same time rolling the patient into the required position. To Lift in Bed.—First: Stand on either side of the bed about the level of the patient's shoulder. Second: Place one arm below the patient's shoulders and grasp him as far toward the opposite axilla as can be 46 PRACTICAL METHODS done easily (to strain will produce a jerking movement); pass the other hand and arm as far as is easily done in the same way below the pelvis toward the opposite hip. Third: Then lift simultaneously. Patients may likewise be lifted as well as turned by the help of a draw-sheet or towel placed under the pelvis and under the shoulders. Each nurse grasps the ends of the draw-sheet on her side, and working in unison with the opposite nurse, lifts the patient slightly from the bed and lays him down in the required position. Where even such slight movement is accompanied by risk, lifting may be accomplished with the minimum amount of movement by loosening the under sheet, rolling each side toward the patient, grasping it from opposite sides on a level with the shoulder and just below the pelvis, and lifting the patient with the sheet. To Raise a Patient into a Sitting Posture.—One nurse is generally sufficient. Stand beside the patient's right shoulder, pass the left arm over the shoulder to the oppo- site axilla, and the right under the near arm below the shoulder, toward the middle of the back; direct the patient to pass his right arm under the nurse's right, and bring his hand over on to her shoulder, and the raising, even of a heavy patient, is accomplished very easily. Lifting may also be made more easy when the patient can help himself slightly in this way. The amateur method, which is to direct the patient to place his arms round the nurse's neck, hampers her movements and leaves both the nurse and patient breathless. In many hospitals each bed is provided with a pulley attached to a strong iron bracket or hanging from the ceiling. By holding on to this a patient can, with very little exertion on his part, immensely help the nurse in lifting. To Lift From the Bed.—For this purpose the nurses must both stand on the same side of the bed. When the patient can sit up, he can be placed sitting at the edge of the bed. The nurses pass their arms be- hind the shoulders and below the pelvis, and grasp each other's arms firmly. The patient helps by placing his hand on the shoulders of the nurses—either the nearest BEDS AND BED-MAKING 47 shoulder or the further, according to the size of the patient. In this way a patient may be carried some distance with little effort. It is important to remember that, in carrying, the bearers keep step out of step, that is to say, instead of both right and both left feet stepping together, the right keeps time with the opposite left, otherwise the patient will be jerked. To return a patient to bed, first set him on the side of the bed, then lift his feet on to the bed, and finally lower his shoulders. The method of lifting a recumbent patient from his bed has already been described in the directions on changing the mattress. In carrying a patient on a stretcher, he should be carried feet foremost; again it is necessary to remember to walk moving the opposite feet simultaneously in order to avoid jerking. The reason for this is very simply demonstrated by getting two nurses to carry between them a bucket full of water. If they keep step in the usual way, the water will be spilt. To Arrange a Patient in Bed.—When a patient is too weak to support himself in the sitting posture, or in those pitiful cases where no other posture is possible, some ingenuity is required to make the position a comfortable one, and to prevent the patient slipping. While there may be fifty ways of arranging the pillows to suit one case, some simple methods of keeping a patient comfort- able in an upright position may be demonstrated. A bed-rest is more comfortable than a pile of pillows, as it better retains its shape and position. Bed-rests come in many devices, from the simple wooden frame filled in with crossed pieces of webbing and attached in a slant- ing position to the railing at the head of the bed, to the upholstered variety, something like the top of an arm- chair, which can be raised and lowered from a graduated frame. Those used in hospitals should be capable of being easily cleaned and disinfected. On the bed-rest a couple of pillows at least will be needed—one upright for the back, and one across for the head and shoulders. A tiny one, placed just below the back of the head, is a very 48 PRACTICAL METHODS comfortable addition. Small pillows should be arranged under either elbow. To maintain this position many devices have been tried, none of which are at all times successful. First: A pillow tied into a firm roll may be placed below the pelvis and kept in place by passing a bandage through the roll and tying the ends to the bed-frame. Second: A pillow filled with sand may be placed just below the pelvis, and, as it retains its shape and position, is found much more comfortable than it sounds. A second sand-pillow should be placed for the feet to press against. Third: The foot-sling may be used (Fig. 7). This con- sists of a sheet folded four or six times lengthwise, with a piece of tape tied firmly to each end. The sheet is passed across the bed and tied by the tape on either side to the raihng at the head of the bed at the right distance, so that the patient's feet may rest firmly against the sling. A small, well-filled pillow is placed below the knees. This BEDS AND BED-MAKING 49 method is usually the most reliable. The sling may be modified by wrapping in the sheet, where the feet would rest, a small pillow or a small pillow made more stiff by being attached to a small piece of board. Where the upright position is maintained, the skin over the coccyx will require the greatest care. The patient may be nursed entirely on an air- or water-bed, or press- ure may be lessened by using an air- or water-ring cushion, not too much inflated. Where this is done, the patient may complain of feeling his feet too low, a very fatiguing sensation. This can be remedied by raising the lower end of the bed on small blocks, or by placing a blanket folded into several thicknesses below the lower half of the mattress. The above demonstrations may constitute the practical lessons given to the pupil nurses in their first two weeks, and must, to insure perfection, be constantly practised during the junior and intermediate years. Quickness should not be enforced at first: it is too apt to mean scamped work. Quickness should follow when practice has made perfect. From the earliest days pupils should be taught quiet and dignified behavior while at their work, and habits of consideration and kindness toward their patients. No conversation on personal topics should be allowed in the wards, and no raised voices or noisy movements. 4 CHAPTER II BATHS AND PACKS General Rules—Hot Tub-bath for Cleansing, to Induce Perspira- tion, to Relieve Convulsions—Sitz-bath—Foot-bath—Constant Im- mersion—Local Baths—Cold Tub-bath—Brandt Bath—Medicated Baths—Hot Pack—Dry Pack—Hot-air Bath—Vapor Bath—Flcc- tric-light Bath—Cold Sponge—Drip Sponge—Affusion—Ice-rub— Ice Cradling—Paddling—Cold Pack. A bath, strictly speaking, is a means by which the body is immersed, usually in water, though in special conditions other media, such as vapor, hot air, or the mud or sand of special districts, is used. The bath may be general, including the entire body, or local, as when a limb only is immersed. The hot bath with a good simple soap is the best means of keeping the skin in a clean and active con- dition; the cold plunge bath, one of the best tonics to the skin and circulation—by stimulating the circulation, the processes of elimination and metabolism are also in- creased. The bath is also a valuable therapeutic agent, and as such is employed at different temperatures in a large variety of circumstances. The hot bath is used to induce perspiration, to relax local spasms or general convulsions, to restore bodily warmth, to relieve pain and inflamma- tion, to relieve retention of urine, as a sedative in some nervous conditions, and as a stimulant in cases of collapse. It is a simple agent in relieving fatigue and soothing ner- vous irritability, and, in the milder forms of insomnia, may induce sleep. The cold tub-bath is used to reduce temper- ature, to stimulate a sluggish circulation, to reduce inflam- mation, and as a tonic, either to invigorate the system, or in the case of some nervous conditions. For therapeutic purposes medicinal agents are frequently combined with the bath, as, for example, the hot mustard bath, for purposes of stimulation; the mercurial vapor 50 BATHS and packs 51 bath in the treatment of syphilis; the tub-bath with sulphur, bran, etc., in the treatment of some skin affections. The temperatures usually ordered for the bath may be divided as follows: Cold bath, 40°-70° F. Cool bath, 70°-80° F. Tepid bath, 80°-90° F. Warm bath, 90°-100° F. Hot bath, 100°-110° F. In giving any bath certain general conditions must be observed. A bath is not given immediately after food. One hour after a light meal and two hours after a full dinner should be allowed to elapse. The reason for this is that the bath, by causing the superficial blood-vessels of the body to dilate and become filled with blood, diverts the blood-supply from the digestive organs, which, during digestion, require an increased supply of blood for their work. In consequence we get the condition of arrested digestion, with the characteristic symptoms of acute head- ache, local pain, nausea, and vomiting. No patient should remain in hot water long enough to become exhausted. Five or ten minutes is sufficient for a cleansing bath. A nurse should understand clearly the effect to be desired in giving the bath, the most prompt and exact manner of giving it, the symptoms, toward and un- toward, to be watched for; she should also realize the importance of keeping closely to orders concerning the temperature of the bath and the length of time for which the treatment is to be continued. The bath-room should be well ventilated, free from draughts, and kept at a temperature of 60° to 65° F. A higher temperature is not advisable, the bath-room be- coming rapidly overheated while giving a hot bath. With hospital patients three rules should be strictly enforced, and may with advantage be posted in a promi- nent place in the bath-room: 1. Every patient in taking a bath must be accompanied by a nurse (or an orderly), unless by a special written order 52 BATHS AND PACKS to the contrary, in which case the door must never be locked. 2. In every case the temperature of the bath must be taken with the bath thermometer. 3. In drawing a bath, some cold water must always be run in first. The latter rule is chiefly in order to preserve the bath-tub from abuse. The boiling hot water found in institutions is sufficient to crack a glass or porcelain tub or to destroy the paint of a painted wood or metal tub. In time it will also spoil the polished surface of an enameled iron tub, which otherwise best resists it. It is also a wise precaution in another sense. Cases are on record where, the hot water only in the bath, a child has accidentally been placed in the water and scalded. The Cleansing Bath.—On admission to a hospital a patient, if he is in appropriate bodily condition, is usually ordered a tub-bath. Opinion differs greatly as to what constitutes an appropriate bodily condition. Some doctors prefer the bed-bath if the patient's temperature is over 100° F.; others consider the tub-bath beneficial in almost any circumstances where the patient's bodily strength admits of the necessary amount of movement. In the case of sick children a tub-bath may, in the majority of circumstances, be safely given, as by careful lifting and carrying they can be saved all exertion. While the bed-bath may remove as much perceptible dirt as the tub-bath, it has not the same beneficent effect on the system. The skin is one of the most important excretory organs of the body. If not cared for, the pores, which are the openings of the ducts, become blocked with dust and dried perspiration, thereby lessening the func- tional activity of the skin. The hot tub-bath not only frees the pores of any superficial accumulation, but, dilat- ing the surface blood-vessels, brings more blood to the skin, stimulating the sweat-glands to greater activity, and thus clearing the pores and ridding the body of some of the poisonous products of oxidation. In giving a tub-bath fill the bath half full of water at a temperature of 100° F., *which may be raised to 105° F. after the patient is in. Change the water if it becomes TO INDUCE PERSPIRATION 53 dirty before the washing is over. Borax, washing-soda, or a small quantity of aqua ammonia may be added to the water if the skin is very dirty or the water hard. Before beginning, cut the nails close and pin long hair on the top of the head. If it is necessary to wash the hair at the same time, it is better for a woman patient to do so first over a basin. A man or child can have the hair washed conveniently in the tub. Frequently with ward patients the admission bath is not sufficient to cleanse thoroughly susceptible portions of the body, such as the soles of the feet or the palms of the hands. Where the dirt is ingrained and the epidermis hard and thickened, it is best to soften the skin by envel- oping the parts in a soap or flaxseed poultice, if the general condition of the patient permits. The hands may be frequently soaked in hot water and washing-soda and scrubbed with nail-brush and soap. No nurse should feel satisfied until every patient in her charge is spotlessly clean, but she will frequently have to remember to pro- ceed with tact. After the bath the patient should be thoroughly dried with warm towels, warmly wrapped, and returned quickly to bed. The effect of the bath must be noted, especially such symptoms as shivering, faintness, undue fatigue, or exhaustion. The first may be avoided by having a hot- water bag in readiness in the bed; faintness is relieved by fresh air and lying still without the pillows; while for any signs of exhaustion a glass of hot milk is a good restorative. To Induce Perspiration (Fig. 8).—For this purpose the bath is filled half full of water at 100° F., and the tempera- ture brought to 110° F. or higher if well borne while the pa- tient is in the bath. Two blankets cover the bath and are pinned together at the patient's neck, thus leaving his head only exposed. The blankets are prevented from sagging by a couple of boards arranged across the bath-tub. Cold sponges or an ice-bag are kept on the patient's head, and the process is helped if, at the same time, he drinks freely either cold water, Vichy, etc., or hot weak tea. The pulse must be taken at the carotid or in front of the ear, and the 54 BATHS AND PACKS pacient removed if it becomes soft, compressible, or in- termittent. In all cases where we apply extreme heat in this manner or by similar methods to the body, cold is applied at the same time to the head in order to prevent what is known familiarly as a " rush of blood to the head," with the symptoms of giddiness and faintness. If faintness should occur, the patient is removed immediately and made to lie flat without pillows. A stimulant, such as aromatic; spirits of ammonia (30 minims in water), is frequently ordered for such an emergency. Pig. 8.—Tub-bath to induce sweating. From four to seven minutes is usually the length of time ordered for such a sweat-bath. If it is desirable that the sweating should continue, the patient is quickly wiped, wrapped in a hot blanket, and put to bed surrounded with hot-water bottles, covered with several blankets tucked closely, especially round the back, and again induced to drink. The ice-bag is kept on his head. He may be kept thus for an hour, close watch being kept on the pulse. Finally he is rubbed, under a dry blanket, first with hot towels and then with alcohol, and the ordinary clothes, well warmed, replaced. This final process is observed after all baths that have for their purpose the inducing of perspiration. HOT SITZ-BATH 55 This simple form of bath is ordered when the patient is in sufficiently good bodily condition to be moved from his bed, as in the chronic forms of kidney disease, to break up a cold, etc. In acute illness other methods are used which will be discussed presently. To Relieve General Convulsions.—For this purpose the patient, usually in a completely unconscious state at the time, lies immersed in the water, his head supported on the left arm of the nurse, while with her right hand she con- stantly sponges the head with cold water. The water is prepared at 100° F. and brought to 105° F. when the patient has been in the water a few moments. Owing to the unconscious condition of the patient it is not safe to use a higher temperature. Frequently the orders are to keep the patient in the water until the convulsion is over and the body relaxed. At other times the order may be for a bath lasting five to ten minutes, or, rarely, longer, and re- peated at intervals. If faintness occurs, evinced by sigh- ing respirations, pallor of the lips, and a pulse becoming soft, compressible, and intermittent, the patient is re- moved at once and replaced in bed, when the symptoms will usually pass. Stimulants are not generally* ordered in these cases. After the bath the patient is dried, the shirt replaced, and he is put back to bed to rest quietly. If the bath is to be repeated, the shirt may be omitted, and the patient rolled in a light blanket in which he can be carried to thp bath, it being an important consideration to carry out tne treatment with as little disturbance as possible to the already irritated nerve-centers. If such a bath is used during an attack of croup or for convulsions caused by teething, the baby is usually kept in the bath until relaxation is complete. The hot sitz-bath is used to relieve local inflammations, such as pelvic cellulitis, or to relax the sphincter of the bladder and so overcome retention of urine. The tem- perature begins at 100° F., rising gradually as high as can be borne. The patient, sitting in the bath, has the body immersed in water from the upper part of the thighs to the waist. The legs are wrapped in a blanket, and a second 56 BATHS AND PACKS blanket, pinned round the neck, is arranged to cover both bath and patient. The bath lasts ten to twenty minutes, or if for retention of urine, until the condition .is relieved. The hot foot-bath is valuable in restoring vitality, in breaking up a cold, in relieving headache, and sometimes as a remedy for insomnia. In the latter cases it acts by drawing the blood from the brain to the extremities, thus inducing a temporary anemia of the brain. The bath is prepared at 100° F., and raised as high as can be borne without faintness. The patient should recline in a chair comfortably wrapped, with a light blanket folded over the legs and bath. If the patient is in bed, the bed-clothes are turned back and the bed protected by a rubber sheet. The bath is placed conveniently, and a light blanket kept over the bath and limbs during the process. The tank or constant immersion treatment may be ordered for special cases. At one time it was in vogue for typhoid-fever patients; more generally it is used for cases with large external wounds, such as extensive burns or scalds or large infected bed-sores. The oath used is a portable, full-sized bath-tub on castors, and should-be provided with a stop-cock in order to empty it easily. If it is without a stop-cock, the con- tents may be siphoned off. To do so, attach a funnel to a piece of uncollapsible rubber tubing, place the funnel in the bath, and lower the other end of the tube over a bucket. Start by filling the tube with water from the fun- nel end, keeping the lower end pinched until the funnel is inverted in the bath water. A hammock is made of several strips of wide webbing with a ring sewn at either end; these are attached, usually by strong hooks, to the outside of the rim of the bath-tub. If there are no hooks on the tub, a stout cord can be run through the rings and firmly tied under the rim of the tub. The cord must be knotted at each ring to prevent the strips slipping to- gether. The head is supported by a rubber ring cushion, also attached in the same way to the tub. A couple of boards are placed across the tub to prevent the coverings sagging, and the whole is covered with a rubber sheet and LOCAL BATHS 57 blankets. If the ordinary bed-clothes are added, the tank can look as neat and comfortable as the ordinary bed. A thermometer must be kept suspended and an even temperature maintained—usually the temperature ordered is from 100° to 102° F. Once a day the patient is moved on to a mattress and the bath emptied, cleaned, rinsed with a disinfectant, and refilled. At this time the daily evacu- ation of the bowels should take place. If there is no im- pulse for movement, a soap or glycerin suppository may have the desired result. During this time the wounds are either dusted with sterile boric powder (2 per cent.) or covered with wet sterile gauze. Such treatment is found comfortable and peculiarly satisfactory in cases where large painful daily dressings can be thus avoided, or when it is impossible otherwise to relieve painful parts from constant pressure. A mild antiseptic is usually added to the water, which should, wherever practical, be sterile. Boric acid, about 1 per cent., i. e., about one ounce of the powder for each gallon of water, is generally preferred. A full-sized tub-bath half full usually contains 10 to 15 gallons of water. Almost the only disadvantage of such treatment is the disturbance unavoidable in moving the patient each time it is necessary to give the bed-pan. In a case of typhoid fever, where a minimum amount of movement is an es- sential part of the treatment, this is a decided drawback. Where there is loss of control of either bladder or rectum, the tank is not an appropriate treatment. Local baths, or constant immersion, are also frequently ordered for septic wounds of the limbs. Pans of suitable size and shape are sold for this purpose by surgical instru- ment-makers, but are expensive, except where they are to be frequently used, as in hospital wards. For a forearm a fish-kettle makes a good substitute, and for a leg a long box, such as is used by florists for flower-stands, may be adapted. The hammocks to support the limbs in a com- fortable position are made of strips of webbing two inches wide, each strip with its ends sewn together and made long enough to go round the vessel and dip down into the bath as low as is wanted. The weight of the limb is usually 58 BATHS AND PACKS enough to keep the strips in place; if not, a tape can be knotted at intervals round each strip and tied securely round the rim of the vessel. The arm bath should be placed on a table beside the bed, and the patient well supported with many pillows; the constrained position is always a tiring one. For a leg bath ingenuity is required to place the bath at a suffi- ciently low level. It may be placed outside the bed, on high stools, and the patient brought to the edge of the bed; or a mattress in two parts may be used and the lower half removed. The sound limb can be brought to the level of the body by adjusting folded blankets and pillows. Usually boric acid, 1 to 2 per cent, in sterile water, is used, and the temperature maintained at 100° F. The local bath is covered with a rubber sheet and small blanket. The solution is changed every six hours, and once a day the bath should 1 >e thoroughly scoured and disinfected. Where it is desired to keep the limb absolutely immovable, the bath must be emptied by siphonage. The complete tub-bath of cold water for the treatment of fever cases was first advocated by a German doctor named Brandt as far back as 1861; the method is, in con- sequence, often referred to as the Brandt bath. Within the last twenty years it has become universally popular, though possibly somewhat less so at the date of writing. It has as its object to reduce the temperature and to relieve the cerebral symptoms. It is also claimed that through stimulation of the circulation the natural processes of metabolism and elimination are increased and the skin stimulated to greater activity. It may frequently be observed that after the bath urine is more freely excreted. Its use is most generally in the treatment of typhoid fever, the mortality of which the use of the Brandt bath is con- sidered greatly to have reduced. The bath must be given with the minimum amount of disturbance to the patient. A bath-tub on castors, pro- vided usually with stop-cock for emptying, is brought to the bedside, half full of water of the required tempera- ture. Some doctors have the water cold to begin with, others begin at 90° F. and rapidly lower the temperature COMPLETE TUB-BATH OF COLD WATER 59 to 60° F. by adding lumps of ice after the patient is in the tub. The time ordered is usually five, ten, or fifteen minutes, and the treatment is carried out every three, four, or six hours if the patient's temperature rises above a certain point. Usually a temperature of 102.5° F. or 103° F. is considered an indication for the bath. The bath in readiness, the patient has a wide towel pinned round the loins and secured between the legs with a safety-pin, and the shirt removed. The limbs and chest should be free of clothing. In hospitals an appropriate stretcher is usually found, made of strips of webbing about three inches wide, attached about three inches apart to a Fig. 9.—Tub-bath for immersion, and bed arranged for return of patient. double strip of canvas or stout ticking through which the stretcher poles are run; the stretchers are provided with rings by which they are attached to hooks on the outside of the tub. The stretcher is rolled below the patient in the same way that a sheet is changed, the poles are adjusted, and he is lifted and lowered into the bath on the stretcher. The bath over, a dry sheet is laid across the bath, the loin towel unpinned under cover and left in the water, 60 BATHS AND PACKS the stretcher raised, the superfluous water allowed for a moment or two to drip away, and the patient lifted back to bed, covered with the dry sheet. Where there is no such stretcher, a stout hammock makes a good substitute, or the patient may be lifted in his sheet; the sheet, however, must be left in the water after the bath and the patient lifted under the dry sheet by grasping him under the arms, below the pelvis, and by the feet. While the patient is in the bath a rubber sheet is spread over the bed, from which the upper clothes are removed: a single blanket and a sheet are folded in readiness over the head of the bed. A hot-water bag should be at hand ready filled in case of emergency. As soon as the patient is placed on the bed the stretcher is rolled from under him and he is wrapped loosely in the dry sheet and gently but thoroughly dabbed until the moisture is absorbed. The sheet and rubber sheet are then removed, and the patient is left wrapped in a light blanket and covered with a sheet until all signs of shiver- ing or chilliness have disappeared, when the shirt is re- placed, and the bed arranged in the usual way. If the patient should fall comfortably asleep, he should be left until he wakes without disturbance. While the patient is in the bath, constant friction with the flat of the hands is applied to the limbs, chest, hips, and shoulders. The pulse must be closely watched. At first, owing to contraction of the superficial arteries from the effect of the cold, the pulse will feel small and hard, and from the nervous shock will probably be in- creased in rapidity. It should gradually improve, be- coming stronger and slower as the treatment is carried out if the bath is having the desired results. Symptoms that show the bath is having an injurious effect are cyanosis, which will be apparent first about the lips, a weak, soft, intermittent pulse, and uncontrollable shivering. If the doctor is not immediately at hand to take the responsibility of the bath proceeding, the nurse is usually expected to return the patient to bed, to notify the doctor immediately, and not to repeat the bath until COMPLETE TUB-BATH OF COLD WATER 61 she has had fresh orders. If the baths are to be continued, the doctor should be present at the next one. Untoward symptoms may frequently be averted by the administra- tion of a stimulant immediately before the bath; the dose may also be divided and given half before and half immediately after a bath. If cyanosis or shivering persist after the bath and the pulse remains feeble and small or intermittent, the patient should be briskly rubbed, two nurses working at the same time, and external heat applied in hot-water bottles ar- ranged at the feet and round the sides of the patient. In some cases it is necessary to place the feet in a hot foot- bath to restore the bodily warmth; generally an order is left for a stimulant to be administered in such an emergency. Cyanosis and shivering sometimes begin after the patient is returned to bed. In these circumstances also the doctor should always be notified, and his orders repeated before the next bath is given. Before, and immediately after, each bath the temper- ature, pulse, and respiration are taken and noted in writing. Half an hour after the patient is returned to bed this is repeated and again noted. A drop of over one and one- half degrees is not generally desirable, and should be at once reported. Should the patient be sleeping, usually the taking of the temperature is omitted and a record of pulse and respiration only made. At the same time the temper- ature to which the water was reduced, the length of time the patient was in the bath, and any symptoms, toward or untoward, that were apparent should be noted accu- rately in writing. From the gravity of the condition, the manner in which the cold bath is given in a typhoid-fever case is of special importance. No nurse should undertake the responsibil- ity of giving a bath to an adult typhoid-fever patient alone. In cases of typhoid fever it is considered of the first im- portance that in lifting the patient the body should be kept rigid, and that no strain whatever should be thrown on the abdominal muscles. The patient must not exert himself in any way. Sudden exertion, especially that causing any strain or movement of the abdominal muscles, 62 BATHS AND PACKS might cause either serious internal hemorrhage from one of the ulcers, which in typhoid fever develop on the walls of the intestines, or perforation of an ulcer through the intestinal wall into the abdominal cavity. Hemorrhage and perforation are the most dreaded com- plications of typhoid fever. The first symptoms of the occurrence of either are sudden faintness, pallor, and rapidly increasing pulse-rate and sighing. If the temper- ature is taken, it is found to have fallen probably below normal. Hemorrhage is further evinced by the passage later of blood-clots from the rectum, or of stools turned a dark tarry color from the presence of altered blood. In perforation the patient generally also complains of acute abdominal pain and has a rigor or attack of shiver- ing, the abdomen quickly becomes inflated with gas (a condition known as tympanites) and rigid. Either of these catastrophes might occur as a consequence of giving a Brandt bath carelessly. Should the patient evince any such symptoms during the giving of the bath, he must be promptly replaced in bed, lying flat and motionless without a pillow, and the doctor immediately called. All treat- ment is, in the mean time, stopped. The patient may be wiped dry without turning and then covered only with one light covering, as bodily warmth would increase the hemorrhage. For the same reason no drink or stimulant must be given. (See also pp. 600 and 610.) Cold baths are frequently ordered as part of the treat- ment of nervous cases. In ordering such treatment doc- tors vary greatly in their methods, and all orders should be minutely written down and accurately carried out. Some order one, two, or three plunges in a bath-tub nearly full of cold water, followed by brisk rubbing; in other cases the patient stands with the feet in warm or hot water and the cold water is given as a shower, or emptied from a bucket suddenly over the patient's back. Sea-salt may be ordered to be added to the water, in which case two pounds of Tidman sea-salt should be dissolved in boiling hot water, allowed to cool, and added to a bath-tub half full of water (usually reckoned at 10 gallons). If a salt- water bath is to be taken hot, the sea-salt is added when MEDICATED TUB-BATHS 63 the bath is prepared. During the salt-water bath and after the patient's skin should receive brisk friction. Medicated tub-baths are ordered in some conditions. The temperature of the bath, the quantity of the medica- ment, the length of time the bath is to be taken, are ordered in each case. Usually the bath is warm enough for comfort, and the patient remains in from fifteen to thirty minutes. The bath-tub must be carefully cleaned and disinfected immediately after use. The bath may be reckoned as 15 gallons of water. The following are the medicated baths most commonly in use: Starch Bath.—Mix half a pound of raw starch with cold water and make in the usual way by adding boiling water until thin. Add to the bath-tub. Used in certain skin diseases. Bran Bath.—Tie one pound of bran securely in a loose bag of thin muslin and place in a large deep basin; fill the basin with boiling water, and set it in a hot place for half an hour. Press the moisture from the bran and add all the fluid to the bath. Used in certain skin diseases. Alkaline Bath.—Add sufficient bicarbonate of soda to a bath-tub to give a strong alkaline reaction. Test with red litmus paper (p. 237). If litmus paper is not at hand, the bath is sufficiently alkaline when the water has a slippery feeling. Used in skin diseases, to allay itching in irritable eruptions, such as urticaria, and occasionally ordered for cases of subacute rheumatic arthritis. Sulphur Bath.—Sulphurated potash is used, it being soluble in water. Add to the bath in the proportion of half an ounce to two ounces to the 15-gallon bath. Used in skin diseases and, rarely, for purposes of general stimula- tion. It must be remembered that sulphur discolors metal substances. Stimulating Bath.—Mustard is usually employed. Tie a quarter pound of table mustard in a muslin bag and place in a basin of cold water; squeeze the bag well and add the water to the bath (15 gallons). Used at a tem- perature of 100° to 105° F. to restore vitality, especially in infants and young children. The mustard foot-bath 64 BATHS AND PACKS may be used for the same purpose (the same propor- tions), and is also valuable for breaking up a cold in the early stages. Turpentine is sometimes employed in the proportion of 4 ounces to 15 gallons of water, as an old-fashioned alleviation in chronic rheumatic affections. Care must be exercised that either mustard or turpentine is thor- oughly mixed with the water, or the patient may easily be burnt. Natural Salts.—Of recent years baths having the same chemical composition as the well-known mineral waters of Nauheim, Carlsbad, etc., and given in conjunction with a strict regime of diet, exercise, and Swedish movements, have become popular in treating certain forms of organic heart disease. The system is known as the Schott system. Bicarbonate of soda, 8 ounces, to dilute hydrochloric acid 4 ounces, is a formula frequently prescribed, but usually the salts are purchased ready prepared under the name of the special spring required. Such baths are, however, usually given in special sanatoria. After a medicated bath the patient should not be dried briskly, the object being that the skin should absorb as much of the medication as possible. After gentle wiping to remove the superficial moisture clean garments should be put on and the patient made to rest quietly in bed for an hour. In the Schott system the patient is wrapped in a hot clean sheet in order to further the process of absorp- tion. Tub-bath in Bed.—In cases where the tub-bath is re- quired and the patient unable to be moved from the bed, it may be carried out in the following manner (Fig. 10): A rubber sheet, half a yard longer and half a yard wider than the mattress, is rolled under the patient (as he lies directly on the rubber, it should be warmed first). Each corner has a ring sewed to it by which it can be tied to the bed-posts: twelve inches from each corner stout tapes are firmly sewn which, when tied in pairs, bring the sides of the sheet as high as the corners. The bath is further given shape by rolled blankets, sand-bags, or pillows placed on each side of the bed outside the rubber. Pillows are also TUB-BATH IN BED 65 arranged for the patient's head under the rubber. Two or three boards placed across the bed under the hair mattress prevent too much sagging. Under cover of a light blanket the night-dress is removed and the loin towel pinned securely in place. The bath is then quickly filled from pitchers of water of the exact temperature required. The water is emptied by lowering one end of the rubber over a bucket; or it may be siphoned off, beginning while the bath is in progress. As about 6 gallons of water are required, such a bath is a lengthy proceeding unless the patient's bed can be wheeled into a bath-room, where the Fig. 10.—Tub-bath in bed. Extemporized from rubber sheet and pillows. bath can be filled from a rubber pipe attached to the tap, and again emptied quickly into a fixed slop sink. A special rubber bath-tub supplied with a frame by which the water is kept in a fixed position is also sold for this purpose under the name of the Burr bed-bath, but, like all rubber goods, is expensive. The bath emptied, the rubber is untied and rolled from beneath the patient, who is dried and dressed in the usual manner. When emptying, the head of the bed should be raised on a chair or couple of blocks, to prevent the water collecting in the middle of the bed. In cases that have had slight hemorrhages a Brandt 5 66 BATHS AND PACKS bath may be ordered to be given in this way. The move- ment necessary is, however, greater than where a tub-bath is given skilfully with a good stretcher. In many cases of acute illness the tub-bath is imprac- tical and the therapeutic results of the bath must be at- tained by other methods. The results chiefly aimed at, we have seen, are to induce perspiration, to relax spasms, to reduce temperature, and to allay cerebral symptoms. The methods most frequently employed are as follows: The Hot Pack.—First: Arrange the patient, divested of his shirt, between two hot blankets on a rubber sheet, also warmed. Second: Wring out of scalding water three light, small- sized blankets wrung thoroughly dry, or the patient may be scalded. (For this reason heavy blankets are not practical.) Roll the blankets in a warmed rubber sheet and carry quickly to the patient's bedside. Third: Place two blankets under the patient (keeping him closely covered) lengthwise across the bed, one under the shoulders, one from the waist down; bring the upper blanket round the neck, shoulders, and sides, and roll each arm up; bring up the lower in the same way and roll up each leg and turn the lower margin up over the feet. Place the other blanket over the patient, slipping out the covering blanket, and tuck it round the legs, be- tween the sides, and the already enveloped arms, and over the shoulders very thoroughly, so that no air can penetrate. Fourth: Bring first the under dry blanket and then the rubber sheet up from either side and tuck firmly under the opposite side; turn up the lower margin over the feet. Fifth: Replace the covering blanket, tucking it firmly around the mummy-like figure, and cover with the ordinary bed-clothes. Sixth: In this and all varieties of sweat-baths cold, in the form of the ice-cap or wet compresses, is applied to the head, and unless the patient is unconscious, he is induced to drink freely during the bath. Any hot or cold drink that does not contain food requiring digestion is suitable, such as water, Vichy, tea without milk, etc. The THE HOT DRY PACK 67 pulse must be frequently taken at the temple, and the patient closely watched for symptoms of exhaustion or faintness. In cases of acute illness, where immediate action of the skin is imperative, a powerful diuretic, pilocarpin, is fre- quently ordered to be given at the same time as the sweat- bath. Pilocarpin is the active principle of jaborandi. Usually it is given hypodermically (^ to ^ grain of pilo- carpin hydrochlorid). Five to ten minutes after pilo- carpin is given the surface becomes violently flushed, the pulse full and more rapid, and the patient breaks out into profuse perspiration, beginning with the face and neck; the flow of saliva is also greatly increased. This diaphoresis may continue for a considerable time. Pilocarpin depresses the heart and nerve-centers and in rare instances has been known to cause edema of the lungs. Watch must be kept for symptoms of heart failure. The sweat-bath lasts from twenty minutes to an hour, according to conditions. On removal the patient is rolled without exposure between hot, dry blankets; when sweating has ceased, he is rubbed dry with hot towels, and, if desired, also with alcohol, and the ordinary clothes replaced. No patient should ever be left alone while in a sweat-bath. From the practical difficulty of insuring that the blankets are sufficiently hot, and sufficiently dry not to scald the patient, other methods having similar results are preferred to the hot pack. It should be remembered, too, that scalding water ruins a blanket. The Hot Dry Pack.—Place a rubber sheet and blanket, both hot, under a patient; roll him, divested of his shirt, in the hot blanket; place hot-water cans or bottles, rubber hot-water bags, or hot bricks wrapped in flannel round the patient; cover him with another hot blanket, and above that a second rubber sheet; tuck both firmly in under the mattress and round the neck; cover with as many blankets as may be desired. Apply, as usual, cold to the head, and give drinks freely. The cans, etc., must be carefully covered and arranged outside the enveloping blanket in such a manner that the patient cannot come in contact with them or he may be burnt. In the form of sweat-bath most in use the patient lies 68 BATHS AND PACKS on his bed in what is practically a closed cabinet, his head only exposed; the air in the cabinet is brought to a high temperature by one or other of several methods. To arrange such a cabinet three rubber sheets, three blankets, and a couple of bed-cradles, each two feet long, are required. If of metal, the cradles should be covered with a closely wound muslin bandage to protect the clothes from rust-marks. The rubber sheets and blankets should be well warmed. First: Roll one blanket and rubber sheet under the patient, the blanket next him, and cover him with one of his bed blankets; remove the shirt. Second: Place the cradles so that they extend from the shoulders to beyond the feet. Third: Tie a bath thermometer to the cradle so that it hangs where it can be easily reached. Fourth: Bring the lower blanket round the shoulders and neck and up the sides and ends of the cradles as far as they will reach. Fifth: Cover the cradles with the two remaining blankets placed lengthwise across, and arranging them so that they overlap well. Tuck them securely all round between the under blanket and the rubber sheet. Slip out the blanket covering the patient and tuck in well round his neck and shoulders. Sixth: Bring up the rubber sheet in the same manner. Seventh: Cover the cradles in the same way with the two remaining rubber sheets. By this overlapping all cold air is excluded. The reason for placing the blankets before the rubber is that, exposed to dry heat, rubber smells disagreeably, and where steam heat is used, the vapor condenses on the rubber and may drip on the patient. Any number of blankets desired and the ordinary bed- clothes may be added. The cabinet is heated by hot air, vapor, or dry heat in the following way: The Hot-air Bath.—A special apparatus is sold for this purpose. It consists of a large alcohol lamp with a metal covering, which is the expanded end of a chimney of convenient shape and sufficiently long to extend just THE HOT-AIR BATH 69 inside the cabinet at the patient's feet, about six inches above the mattress. The lamp is placed on a stool of convenient height outside the bed. The coverings are opened to admit the end of the chimney and tucked closely round. For this reason the chimney should be covered with an asbestos wrapping, or the bed-clothes may be burned. Where asbestos cannot be had, wet cloths may be wrapped round the chimney and kept damp. The temperature and the length of time the bath is to last are ordered in each case. Commonly, fifteen to thirty minutes after the required temperature is reached is ordered. The temperature ordered is frequently 120° F.; some patients, however, can stand a temperature even higher. The temperature in all cases must be closely watched and regulated by the thermometer hanging in the cabinet. It must be placed where it can conveniently be reached through a lapping of the coverings, but as far as practical from the stream of hot air. Where moist heat is desired, a croup kettle is used, the spout being directed inside the covering just above the feet. The croup kettle is a closely covered vessel furnished with a long spout, from which, when the kettle is main- tained at boiling-point, a steady stream of steam is emitted. It is placed over a lamp at a convenient height outside the bed; the temperature ordered is generally from 110° to 120° F., the duration the same as for a vapor-bath. Where steam heat is used, a square of blanket should be laid over the feet below the point where the spout enters. Droppings from the spout have been known to cause scalds. Frequently it is preferred that the whole body should be covered with a single light blanket. In places where electric light is employed the desired temperature can quickly and very simply be attained by means of an electric drop light tied to one of the cradles and suspended in the center of the cabinet. The candle power should be from 20 to 32. The method was first introduced into the Polyclinic Hospital, Phila- delphia, by Dr. Samuel Risley, where it has almost wholly replaced all other forms of sweat-bath, and is now adopted 70 BATHS AND PACKS by several other hospitals. It is simple, quickly prepared, and given with less danger of fire, burns, or scalds than the methods just described. Certain precautions, how- ever, must be borne in mind: First: If moisture touches tin' globe, it will burst and the patient may be burnt. Second: If moisture touches the cord, the insulation is destroyed, a short circuit formed, and the light will not burn. Third: The heat given out by an electric light is sufficient to set any inflammable substance with which it comes in contact on fire. Fig. 11.—Cabinet arranged tor giving sweat-bath with the electric light (Polyclinic Hospital, Philadelphia). For these reasons a detachable collar of soft lead is, at the Polyclinic Hospital, wrapped round that part of the apparatus that is to come in contact with the coverings, and a like precaution should always be taken. Sweat-baths are ordered for cases of nephritis, acute and chronic, for uremia, in some specific conditions, and, more rarely, in the treatment of chronic rheumatism or gout. The records of such treatment should be kept accurately on the charts, and, where practical, the temperature, pulse, and respiration should be taken and recorded before and immediately after each bath. Where the patient has to COLD SPONGE 71 be forcibly restrained, as in the violent convulsions of uremia, the pack is frequently more practical than the other forms of sweat-bath. If the patient is unconscious, it is important to observe whether urine has been voided during the sweat-bath. Cold Applications.—Where the tub-bath is either not practical or not desired, cold may be applied to the entire body by other methods. The following methods are chiefly employed to reduce temperature, to relieve cere- bral conditions, and frequently to induce sleep. As in the case of the cold tub-bath, the process may prove a severe shock to the patient, and he should be closely watched during the entire time. A feeble, intermittent pulse, cyanosis, and shivering are again the symptoms that the bath is not suiting the patient. As in the cold tub, also, the pulse should, after the first shock of cold, become stronger and slower and the cerebral symptoms show marked improvement. Frequently, when the process is over, the patient falls into a natural sleep. In all cases the temperature, pulse, and respiration are taken immediately before and after the bath, and again in half an hour (unless the patient is asleep), in order to observe the result. Cold Sponge.—The cold sponge is ordered chiefly to reduce temperature. The temperature of the water is usually from 70° to 60° F. or lower, and the sponging continued for from twenty minutes to half an hour (Fig. 12). First: Have in readiness a deep basin half full of water at the required temperature, a bath thermometer, a basin of chopped ice, a large wash-cloth, an ice-cap, and a hot- water bag. Second: Remove the top bed-clothes and shirt, covering the patient with a light single blanket or sheet. Roll under him, above the usual bed-clothes, a rubber sheet large enough to cover the bed. If desired, a sheet may be placed between the rubber and the patient, but is not necessary. Third: Place the ice-cap on the head and the hot-water bag at the feet. 72 BATHS AND PACKS Fourth: Sponge with a wet sponge in long, single strokes, exposing each limb in turn and the entire chest, dividing the time equally between each. For the last five minutes turn the patient and sponge the back in the same manner. Regulate the temperature of the water by adding ice. Fifth: Dry by gentle wiping, roll out the rubber sheet, and replace the shirt and covering; or, if desired, the patient may be wrapped in a dry sheet for half an hour before this is done, and the shirt replaced when the tem- perature is taken. The results on the temperature appear Fig. 12.—Cold sponge to reduce temperature. the same in either case. The covering should consist of a single sheet. Where a closer imitation of a Brandt bath is desired, the sponge is somewhat modified. The body is fully exposed except for the loin cloth; as much water as possible (temperature, 50° to 40° F.) is then taken up in the sponge, which is squeezed over the limbs, chest, and back in turn by one hand, while the other gives brisk friction to the part. The sponging over, the patient is briskly dried with rough towels. The effect desired is the same as when the Brandt bath is used. Unless two nurses can give the bath THE COLD AFFUSION 73 at the same time, the process is often found too long and chilling. The Cold Affusion (Fig. 13).—First: Place two long rubber sheets, well overlapping, under the patient, so that the bed is entirely covered; the lower rubber must be of sufficient length that one end can be gathered into a foot- bath placed on the floor. Second: Place pillows, rolled blankets, or sand-bags on either side and below the head of the patient, under the rubber sheet, so that a trough of rubber is formed. Fig. 13.—Cold affusion to reduce temperature. Third: Place an ice-bag on his head. Fourth: Pin, under cover, a loin towel round the patient and remove all the coverings. Fifth: Raise the head of the bed on blocks about 12 inches. Sixth: Attach a rubber hose to a tap of cold water and direct the stream over the patient, beginning at the chest; before ending, the patient is turned on his face and the same treatment given. Arranged in this manner, the water will run off the patient into the foot-tub. The 74 BATHS AND PACKS stream should be begun gently. From three to five minutes is usually prescribed. Where no tap is conveniently near, a garden watering-can may be substituted, or water may be siphoned over the patient by a bath hose from a bucket or tank placed a couple of feet above the patient's head. The cold affusion is not much employed in the course of a long illness associated with high temperature. It is of great value in treating sudden accesses of hyperpyrexia, as in thermic fever, where the temperature may rise to 110° F. and over. In this condition the affusion may be kept up a much longer time, the pulse being closely watched. The Ice-rub.—The patient, exposed except for the loin towel, is placed on a rubber sheet and the limbs, chest, and back in turn rubbed for from three to five minutes with flat pieces of ice wrapped in gauze. An ice-bag should be kept on the head and a hot-water bag at the feet. This process is sometimes preferred to the cold sponge. Ice-cradles.—A process known as cradling is sometimes effective in keeping a temperature for hours at a time two or more degrees below that otherwise maintained. Large bed-cradles are placed over the body and covered with a single sheet turned back somewhat at the feet and neck. The night-shirt is rolled up under the arms or re- moved. From the cradles are suspended several small, uncovered buckets filled with lumps of ice. The buckets must be well made or they will leak unpleasantly; and the ice will require constant renewal. If the patient complains of shivering and discomfort, a hot-water bag may be placed at the feet. An ice-cap is usually applied to the head. Ice Paddling.—Where better means are not procurable, a temperature may be reduced by inducing the patient to paddle his hands in cold or iced water. A basin half full of water the required temperature is placed on the bed under each hand, and the patient directed to " paddle " the water about. The water should be sufficiently deep that the wrist may be covered. This simple method often has surprising results where the patient is not too ill to make the necessary exertion. In district nursing it is a method that can, with less risk than any other, be carried out in the nurse's absence. COLD PACK 75 Cold Pack.—The cold pack consists in wrapping a patient in a cold wet sheet, with the object either of reducing temperature or relieving nervous conditions: frequently both results are desired at the same time (Fig. 14). First: Wring two sheets in cold tap-water and bring them in a basin to the patient's bedside, together with an ice-cap, a cold drink (Vichy, water, etc.), and three single blankets. Second: Roll the three single blankets under the patient, remove the shirt, covering him with a single sheet. Third: Roll one wet sheet under him, bring it up over his feet, shoulders, and sides, and fold it over the limbs: cover with the second wet sheet, removing the dry sheet at the same time. Tuck well in round the neck, under the axilla and sides, and between the legs. Every inch of the body should thus be in contact with the wet sheet. Fourth: Bring the right side of one blanket across the body and tuck it very firmly in on the left side; bring the left side up and tuck it also very firmly in on the right; turn the end over the feet: in this way not an inch of the sheet should be uncovered, the object being to exclude 76 BATHS AND PACKS all air. Do the same with each remaining blanket in turn. Fifth: Cover with sheet or bed-spread; place the ice- cap on the head and give the patient the drink. Take the pulse at the temple and watch it closely. As a rule, the pack is well borne. The patient may be left in the pack for an hour, or for longer if, as frequently happens, he falls asleep. After the first shock the sensation induced is pleasant and very soothing. While such a pack has sometimes but little immediate effect on the temperature, the cerebral symp- toms, even violent delirium, are usually greatly reduced, and the rest thus procured eventually exerts a good influ- ence on the temperature also. The temperature, pulse, and respiration are, as usual, taken immediately before and after the pack, and again after half an hour's in- terval. In some nervous conditions, not associated with pyrexia, a cold pack is ordered at bedtime to induce sleep, often with excellent results. It may also be ordered in the treatment of chorea. When the pack is over, the patient is lightly dried, rubbed briskly with alcohol, and the usual clothes replaced. Where the first object is the immediate reduction of a high temperature, the pack is given by a somewhat different method: First: Place the patient, covered with a single sheet, on a large rubber sheet and remove the shirt. Second: Bring in a basin two sheets wrung out of cold tap-water, place one below and one over him, tucking the sheets in between the legs, arms, and sides. Third: Have a third sheet in a foot-bath full of iced water. Every three minutes change one or other sheet. The upper sheet is usually changed twice as frequently as the lower. Instead of the upper sheet large towels may be used, one for each limb and one for the body, and are changed in turn. Lumps of ice wrapped in gauze or old muslin may be placed in the axilla and round the sides, and the ice-bag is applied to the head. The pack is com- monly ordered for from fifteen to twenty minutes. After it is finished the patient is dried, rubbed with alcohol, and the ordinary clothes again replaced. CHAPTER III LOCAL APPLICATIONS Inflammation—Heat and Cold: Cold Compress, Stupe, Ice-bag, Ice-coils—Ice Poultice—Heat—Hot-water Bag—Bran—Salt—Cot- ton Jacket — Poultices — Stupes—Compresses—Counterirritants— Rubefacients —Sinapism—Cupping—Leeches—Iodin—Ironing—Ac- tual Cautery—Vesicants — Blistering Fluid — Ointment — Flying Bl ister—Pustulants—Escharotica—Liniments—Plasters—Antiphlo- gistine. In the following chapter it is suggested that a lesson be preceded, or directly followed, by a demonstration in which all the varieties of applications mentioned should be viewed and handled by the class, and, where necessary, prepared. During the succeeding weeks the lessons should be constantly practised in the wards, accurate methods closely insisted on, and the effects of the applica- tions employed pointed out. Local applications to the skin's surface are constantly employed to relieve pain and allay inflammation, to pro- mote absorption of fluids, to overcome certain spasmodic or nervous conditions, and to stimulate the activity of an organ. It seems practical here to give a brief sketch of the cause and process of inflammation, for the relief of which the larger number of the applications to be described are employed. INFLAMMATION Inflammation is the local result of some local lesion, which may be due to an injury to the tissues, as in a sprain, a fracture, or a burn, or to bacterial invasion, as in pneu- monia, a boil, etc. Inflammation is always described as possessing five classic symptoms: redness, heat, swelling, pain, and interference with function. In order to under- stand the effect of local applications on inflammation and their proper use we must understand to some extent the cause and process of inflammation. 77 78 LOCAL APPLICATIONS The first demand of an injured part is to have a larger supply of blood to repair the ravage. By the action of the vasomotor nerves the blood-vessels of the affected area become dilated, and the rush of blood to the part produces the first two symptoms enumerated above—redness and local heat. Swelling quickly follows as the result of the blocking of the vessels with the oversupply of blood. More is accumulated than can quickly be carried off by the arterioles and capillaries; pressure results, and the fluid portion of the blood is squeezed out of the vessels into the interstices of the tissues. At the same time certain of the white corpuscles, by their independent movements, migrate from the blood-vessels and accumulate in large numbers at the seat of lesion. The smaller blood- vessels are blocked with closely packed red corpuscles. It will be remembered that the property of many of the white corpuscles is to act as the scavengers of the body; they perform this act by fastening on any foreign body, such as bacteria, inflammatory processes, etc., when they either destroy them by ingestion or carry them to other parts of the body. The white corpuscles that possess this property are called phagocytes. The accumulation of fluid and corpuscles in the tissues causes swelling, and consequently pain, from the pressure of the swollen parts on the nerve terminations. Pain not the result of inflammation may be present from the be- ginning as the result of direct injury to the nerves them- selves, as in a burn, a fracture, etc. From these conditions interference with function results and is usually easily demonstrated: a swollen hand cannot be used or a swollen eyelid opened. These examples demonstrate only loss of motor power. Interference with the functions of the vital organs of the body is a more serious condition. Inflammation of the lungs cuts off the supply of oxygen from the body. In the kidneys it diminishes the secretion of urine and checks the excretion of urea. Inflammation of any part of the heart deranges the entire circulation, and so on, throughout the whole anatomy. Under benign conditions inflammation terminates in INFLAMMATION 79 what is known as resolution. The inflammatory processes and exudations are carried off by the lymphatic circula- tion, and are partly eliminated from the system by the excreta, and partly absorbed; the swelling subsides, and the circulation resumes its normal course. Frequently, however, resolution is not attainable. The injury may be so severe that the wounded tissue can- not be revitalized, and forms a foreign body too extensive to be absorbed by the white corpuscles; or the affected area may become invaded with bacteria. A greater number of white corpuscles migrate to the seat of lesion, many of which die, and, together with the injured tissues, break down or disintegrate into a thick, greenish-yellow fluid that we know as pus. The process by which pus is formed is called suppuration, and a local, circumscribed collec- tion of pus is known as an abscess. The cardinal treatment of inflammation consists of absolute rest of the affected part and the local application of cold, heat, or a counterirritant; continuous pressure is also sometimes used, especially in connection with cold applications. An intelligent understanding of the application of cold and heat will enable one to determine which to apply to the individual case. Both act to some extent as a local anesthetic to the irritated nerve terminations, thus re- lieving pain. Heat, however, penetrates further than cold, and moist heat further than dry. Cold acts by causing contraction of the peripheral blood-vessels, thus reducing the blood-supply, and by this means lessening the conges- tion. Heat dilates the blood-vessels and reduces inflam- mation by enlarging their capacity for an increased blood- supply. It also causes a still greater increase of blood to the parts, with a larger outpouring of white corpuscles, a condition which, as a consequence, also promotes suppu- ration when continued long. Heat has further the valu- able effect of relaxing muscular spasm or rigidity. In superficial inflammations, where the skin is not denuded, cold is preferred. Where the injury has not involved large areas of tissues, and sudden acute pain bears evidence of wrenched or torn nerves, a profuse 80 LOCAL APPLICATIONS blood-supply is not necessary to repair the damage, and the less exudation there is to absorb, the quicker will the normal condition be reestablished. A sprain is a typical example of such an injury. When larger areas of tissues are injured, as in extensive bruises or contused wounds, the nutrition of the tissues is impaired, and, if the blood-supply is lessened or cut off, death of the parts will take place and the tissues slough. Heat applied will minimize the danger by bringing to the seat of lesion a large supply of blood, which will not only help to revitalize the tissues, but, where local death has already occurred, will, by promoting suppuration, hasten the separation of the slough from the living tissues. In deep-seated inflammation cold is usually ordered where the consequence of an overstimulated circulation are dangerous or distressing, as in conditions of cerebral in- flammation and some heart affections; and heat, where pain is a prominent symptom, as in pleurisy or perito- nitis, in which latter instance heat also helps to relax muscular rigidity. In some circumstances heat and cold may be used together: for example, in cerebral conditions, such as threatened apoplexy, cold may be applied to the head to reduce the local blood-supply, while heat, applied at the same time to the abdomen or to the lower extrem- ities will, by dilating the blood-vessels in a remote region, still further restrict the circulation of blood in the head. Generally, heat and cold, when used as local applications, are applied directly over the affected area, generously overlapping it. The action of the third form of local irritation, the coun- terirritant, is more prompt than either heat or cold. A counterirritant is an application which irritates the per- ipheral nerves, stimulates the circulation by dilatation of the superficial blood-vessels, and causes, by reflex action, changes in adjacent or in more distant tissues. The effects of a counterirritant are various: First: Through the stimulation of the circulation the processes of absorption and secretion are hastened. Second: The dilatation of the superficial blood-vessels relieves congestion and the pain due to pressure, and causes, APPLICATION OF COLD 81 by reflex action, contraction of the blood-vessels in more remote regions. Third: By the dilatation of the lymphatic vessels effusions and inflammatory products are more quickly removed from the seat of lesion. Fourth: Irritation of the peripheral nerves produces a reflex action by which the sensitiveness of overirritated nerves in other parts is reduced. A counterirritant may be applied directly over the affected area, or to a part more or less remote, with which it has some nervous communication, either direct or in- direct. For example of the latter: acute frontal headache may be relieved by a counterirritant applied at the back of the neck, or cerebral congestion by a mustard poultice applied to the abdomen. Applied over the heart, a counterirritant acts as a stimulant to that organ in conditions of syncope or col- lapse. Applied over the epigastrium, it is efficacious in checking nervous vomiting. In this condition the effect is produced in two ways: By stimulation of the circulation in the stomach it increases the natural secretions of the organ, and, secondly, it has a soothing effect, through reflex action, on the overirritated nerve-centers which control the act of vomiting. APPLICATION OF COLD MOIST COLD Cold is applied wet in the form of compresses and stupes. Ice Compress.—For ice compresses a bowl with a large lump of ice and a small quantity of sterile water is required, and several pieces of lint, gauze, or old, clean muslin, cut the required .size. If gauze is used, about six thicknesses are required and the gauze should be folded so that no unraveled edges are left. The compresses are kept in the iced water. In applying they are squeezed nearly dry, and changed before they have time to become warm. In the majority of cases ice compresses are used for eye affections and applied constantly over the closed 6 82 LOCAL APPLICATIONS eyelid for many hours at a time. The compress should be cut slightly larger than the eye. Should both eyes be affected, the same compress must not be used for both eyes. In infectious cases each compress must be used only once and discarded; the hand, also, should be protected by a rubber glove and frequently rinsed in a disinfectant solution: boric acid (a 2 per cent, solution) may be or- dered in place of sterile water. In operative cases or cases in which there is any wound strict aseptic methods must be observed. Constant ice compresses are frequently ordered in the early stages of ophthalmia of the new-born. The treat- ment may be carried out efficiently, and without over- fatigue, in the following manner: The baby is wrapped in a light blanket so as to pinion the arms, and placed on a pillow on a table. The nurse sits at the table directly behind the infant's head. A piece of rubber sheeting is placed under the head and over the shoulders, to avoid dampening the clothes, and tin light is carefully shaded. A basin containing the com- presses and one for the soiled pledgets are at hand on the table. In this position a nurse may work for hours comfortably for both herself and the child. Compresses of a larger size, applied in the same way, may be ordered for the relief of frontal headache and for other local inflammations. Iced water may be used alone or diluted with vinegar, alcohol, or a toilet water that is not too heavily scented, either of which forms an evaporating lotion. In the treatment of sprains and injuries of like nature, the compress is frequently applied with a firm bandage, which, by constant pressure, assists in preventing the swell- ing due to exudation. The limb should be raised, and, where practicable, the affected part should be uncovered, except for the dressings. The compress can be kept wet by sopping the bandage frequently. Vinegar, alcohol, a solution of subacetate of lead, or alcohol and subacetate of lead combined, may be used with the iced water, an evaporating lotion causing more intense cold than water alone. APPLICATION OF COLD 83 Opium is also used with lead where the pain is severe (lead and laudanum lotion), and chlorid of lime, one ounce to one quart, is useful for its astringent properties. Where the surface has become broken, however, sterile water or a mild antiseptic lotion only can be used. Ice Stupe.—An ice stupe is a covered compress and may be made of gauze, cotton, or old muslin. It is squeezed until just dry enough not to drip, and covered with a piece of thin rubber sheeting, oiled silk, rubber tissue, or wax paper; any material, in fact, that will keep in the moisture. The cover should overlap the stupe one inch in all direc- tions. It may be kept in position by a bandage, and should be changed before it feels warm. The ice stupe is frequently ordered as a throat application; applied closely round the neck it gives great relief in painful forms of tonsillitis, etc. DRY COLD The most common methods of applying dry cold to the surface locally are by the ice-bag or the ice-coil. An ice poultice is also used, but more rarely. Ice-bag.—An ice-bag is made of rubber or of waterproof material, and may be had in various sizes, suitable for ap- plication to the head, the spine, the abdomen, the throat, or the ear. The round, medium-sized ice-bag or cap may, however, be adjusted to most uses. When an ice-bag is not procurable, one may be improvised from the bladder of a sheep, taking care to tie the opening securely. In filling an ice-bag it should be remembered that the less the amount of air admitted into the bag, the longer the ice will last. When filled, the bag should be gathered closely in one hand to press out the air while the top is adjusted. For the same reason water should be emptied out of the bag as soon as it forms. Small lumps of ice without sharp edges are used to fill the bag unless the patient has to rest or lie upon it, when crushed ice only must be used and the bag not more than half filled; in this circumstance it will require to be very frequently re- plenished. In many instances the weight of the ice- bag cannot be borne and should then be suspended so that it' just touches the surface of the affected part. An 84 LOCAL APPLICATIONS ice-bag for a limb or the abdomen may be hung from a bed-cradle, or for the head from the railing of the bed- stead. When it is desired to keep the ice-bag closely on one spot (as over a special area of the lung in pneumonia), it may be kept in place by two turns of a bandage round the body, and can be removed for filling without undoing the bandage. An ice-bag should be used with a slip-cover of muslin or Canton flannel, or, failing these, should be wrapped in a clean towel. Except when applied over the hair, a fold of lint or flannel should be placed between the bag and the bare skin, to prevent the risk of freezing small portions of the surface. An ice-bag applied to the head is a common means of relieving cerebral congestion or of reducing the general temperature of the body. Placed over the epigastrium, it may allay persistent vomiting, and over the abdomen may also be used to reduce temperature. It is a valuable application to all forms of local inflammation where cold treatment is indicated. After use the ice-bag must be carefully dried and packed, until again required, with sufficient cotton or gauze to keep the surfaces apart. Ice-coils.—An ice-coil consists of a coil of rubber tubing (Fig. 15) through which iced water can be kept continually flowing. It can be laid over an affected area, and from its lightness is usually an acceptable applica- tion to the patient. It is most frequently used over the abdomen, either for local application or to reduce the gen- eral bodily temperature, but it may be applied to any part free from pressure. Obviously, the water will not flow if the tubes are compressed from the patient lying on any part of them. A special coil is sold under the name of Letter's coils. Fine rubber tubing is used, coiled round and round from the center, and kept in place by double pieces of webbing radiating from the center and sewn together between each coil. It has the appearance of a large solid spider's web. The center portion only of the tubing is coiled, a free length at either end communicating, the one with a tank or bucket containing water and ice, placed a couple of APPLICATION OF COLD 85 feet higher than the patient, the other with a bucket on the floor. A funnel covered with gauze to prevent impurities from the ice from entering the tube is attached to the upper length of tubing and inverted in the tank of water. The upper tube should also be fitted with a U-shaped connecting tube of glass or hard rubber, placed over the edge of the tank, as the soft tubing will become compressed against the sharp edge. By loosely knotting the tubing the flow may be regulated. It is sufficient if the water just trickles through. The temperature of the water is regu- lated by lumps of ice. To start the water flowing it is Fig. 15.—Application of the cold-water coil to the chest in croupous pneumonia or pleurisy. Leiter coil. generally necessary to run water through the coil from a pitcher; when running freely, the lower end of the tubing is pinched and the funnel placed in the tank. Once started, the flow will continue, unless the tube becomes blocked. When the upper bucket is nearly empty, the buckets can change places, and the same water, with the addition of fresh ice, be used again. Small coils, for application to the ear, etc., or for chil- dren can be easily contrived. Fine rubber tubing should be used and should be coiled in the manner described on a piece of firm muslin. Each coil can be kept in place by *a few loose stitches over the tubing. While making the 86 LOCAL APPLICATIONS coil, the " web " should be laid flat on a table in order to avoid twisting the rubber. A piece of lint or flannel should also be placed between the coils and the surface of the skin in applying. Ice Poultice.—An ice poultice consists of small pieces of ice freely mixed with flaxseed meal or with bran. Salt is frequently added, and gives a more intense cold. The mixture is spread between two pieces of gutta-percha tis- sue, the lower of which is cut two inches larger than the upper. The edges of the lower are folded over the upper, and the two pieces sealed together with chloroform or turpentine, or by passing quickly over the edges a lighted match. The ice poultice is not so frequently used as other cold applications, but it may be a valuable substitute when little ice can be had, and is sometimes preferred as an application for bruises about the face and eyes, or in ear affections, especially among country practitioners. HOT APPLICATIONS DRY HEAT The Hot-water Bag.—Familiar as are its uses, simple as it is to handle intelligently, probably more than one-half the accidents in nursing are caused by careless use of the hot-water bag. Patients are either scalded by the bag bursting, or burnt by prolonged contact with the bag while in an unconscious or helpless condition. More than one hospital has been heavily fined and subjected to expensive litigation by just such an accident, an accident that the simplest intelligent care should make impossible of occur- rence. It is hardly too much to say that in nursing the abuses overbalance the usefulness of the hot-water bag. The employment of the hot-water bag should be covered by strict rules with which each nurse should be made personally acquainted. The following are suggested by experience. First: The water used must not be hot enough to scald should the rubber burst; boiling-hot water will also injure the rubber. HOT APPLICATIONS 87 Second: The bag must not be more than half full, and the superfluous air must be pressed out before the screw top is adjusted. Third: Every bag must have a covering, and never, on any pretext, be given to a patient without it. Fourth: If ordered for an unconscious patient, a blanket or sheet must intervene between the body of the patient and the covered hot-water bag. No one but one of the nurses (i. e., neither another patient nor a friend), may place it in position; wherever practical it should be a rule that a second nurse is called to overlook the proceeding and pronounce that the bags are in proper position. Fifth: A hot-water bag must never be left in the bed with an ether patient unless by a special written order of the doctor, covering the particular case. If such an order has been given, the bags are placed as for an un- conscious patient, and the patient must not be left alone one moment, however urgent the pretext, as long as the bags are in the bed. The reason for such a stringent rule as the last is that an ether patient is usually restless, and it is impossible to place the bags where he cannot reach them. In the rest- less stage he is in a semiconscious condition only, and the hot-water bag may easily rest long enough against his flesh to cause a deep burn without his being aware of the fact. There are instances where a patient has been kept in a hospital many weeks after complete recovery from his operation owing to burns received while recovering from ether. That he should bring a suit for damages against an institution in these circumstances is not sur- prising. The hot-water bag is used for restoring the general bodily warmth in conditions of lowered vitality (several bags being placed round the body and at the feet), for the relief of local pain and inflammation, and to counteract the depress- ing effect on the circulation of cold applied to the body generally, as in packing, sponging, etc. When used as a stimulant to the general circulation, it is best placed at the feet. It is applied to the perineum or over the bladder to overcome retention of urine. 88 LOCAL APPLICATIONS For restoring the bodily warmth the hot-water bag can be adequately replaced by bricks or soapstone made hot in the oven and protected by a flannel cover, or by cans or bottles filled with hot water. The same precautions must be observed in their use. Bran Bag. Salt Bag.—Small pillows made of flannel and filled with bran or salt may be made hot in an oven and used as a soothing application, especially in neuralgic pain of the face, toothache, or earache. They retain heat for a considerable time. A second bag should be kept in the oven to replace the other when it begins to cool. Fig. 16.—Pneumonia jacket. Cotton Jacket.—Raw cotton, heated at the open fire or over hot-water pipes, retains the heat for a long time, and applied with a flannel bandage affords a grateful applica- tion for faceache, earache, painful glands, etc. Sewed into a "cotton" or "pneumonia jacket" (Fig. 16), it is often used as a matter of routine treatment in cases of pneumonia, es- pecially if poultices or stupes have been previously ap- plied. The pneumonia jacket is made of cotton, between two layers of gauze or thin muslin, cut to fit closely to the body, with arm-holes and shoulderpieces so as completely to cover the thorax. One side is left open and is fastened by tapes under the arm and over the shoulder. The HOT APPLICATIONS 89 jacket is usually lightly quilted to keep the cotton in place (Fig. 16). When it is desirable to wash the jacket, it should be put into a tub of suds, not too hot, and kneaded, never rubbed; it should be rinsed thoroughly, and the water squeezed out between the hands instead of wrung, well shaken, and quickly dried. In cases of pneumonia the value of a cotton jacket is especially in protecting the skin surface from chilling, due to changes of temperature. Thermostat.—A patent invention consisting of a rubber bag (in various sizes) containing some substances which, by a chemical process, engender heat when the bag is lightly rubbed up, is on the market as a substitute for either of the above. It is claimed that in these bags heat can be retained at a high temperature for hours and even days at a time. The invention, known as a thermostat, is hardly as yet perfected. MOIST HEAT Poultices.—A poultice or cataplasm may be made of any substance which, when parboiled, is capable of hold- ing heat and moisture. The most satisfactory poultice is made of flaxseed (linseed) meal, which, on account of the oil it contains, retains heat for a longer period than such substances as bread, etc. If the flaxseed meal is mixed with from one-half to one-third the quantity of bran, an equally satisfactory poultice is achieved at less cost. In making a poultice the water must be boiling, the basin, etc., used heated before beginning, and all required at hand, so that the poultice may not cool during the preparation. Poultices may be spread on old muslin, linen, lint, ab- sorbent cotton (extravagant except for fingers, ears, and other minute portions), or tow, smoothly pulled into strands which readily hold together. The latter is light, inexpensive, and is especially useful where the poultice is applied over discharging wounds, as free drainage is not impeded. The material used is prepared two inches larger than the required poultice, to allow for turning in the margins. The poultice bowl should be kept entirely 90 LOCAL APPLICATIONS Figs. 17 and 18.—Making a poultice. for such a use, together with a spatula or flexible knife for spreading the poultice. HOT APPLICATIONS 91 Sufficient boiling water is poured into a heated basin and the meal run in quickly through the fingers of the left hand, the right hand stirring all the time with the spatula. When the mixture is cohesive and will come clean from the side of the basin or drop clean from the spatula, it is of the right consistency. It is then turned on to the muslin or tow, which has been prepared on a flat board, such as'a pastry board, and evenly spread with the spatula, dipping the spatula in boiling water once or twice during the process. The margins are turned tidily in all round and the poultice rolled up in a warm towel and carried to the patient (Figs. 17, 18). Before applying it the nurse should hold it against her own cheek to insure its not being too hot. If it is gradually applied to the patient's skin, a higher temperature can be borne than if placed, all at once, quickly over the surface. A poultice that does not contain an ingredient irri- tating to the skin should be applied directly to the skin surface; it is not correct to cover it first with thin muslin or gauze, which absorbs the moisture and soon becomes wet and uncomfortable. In order to retain the heat and moisture the poultice, when in place, is covered with a piece of thin rubber sheeting (the rubber side next to the poultice) overlapping the poultice one inch each way, and again with a layer of cotton overlapping the rubber covering. It is kept in its place with a binder or a bandage (see Bandages, Chap. VIII). For application to the ex- tremities, etc., poultices may be spread half an inch thick or more; a chest poultice should not be more than a quarter of an inch thick, while those for the abdomen or tender surfaces should be spread as lightly as possible—not more than an eighth of an inch thick. Except over wounds, a poultice should not remain on over an hour, and should be removed even sooner if the heat is not retained. A cold poultice is uncomfortable and inefficacious. On removal, the surface is dried and covered with a layer of well-warmed absorbent cotton, which is left on until the next poultice is applied, usually at regular intervals of two, three, or four hours, according to circumstances. If the skin is red,—and it 92 LOCAL APPLICATIONS must always be carefully inspected,—an application of sweet oil or vaselin is made, and if another poultice is necessary, the poultice itself should have a little sweet oil spread over its entire surface. The redness should be reported, and no further poultice applied without fresh orders. As a treatment in pneumonia, especially in the lobular pneumonia of children, poulticing is still popular with some doctors, though not nearly so common as fifteen or twenty years ago. If continuous treatment is required, it is usual to apply the poultices alternately to the front and back of the chest. To a, flaxseed poultice a further counterirritant effect may be given by the addition of mustard. Preparing the poultice in the usual way, mustard flour, broken free of lumps, may be stirred into the poultice just before it is spread: the proportion of mustard may be from one-tenth to one-sixth of the whole. The active principle of mustard is a volatile oil, the properties of which are, to a great extent, destroyed by boiling water. A poultice containing mustard should have the surface covered with a thin piece of muslin, otherwise there is a risk of particles of mustard adhering to the skin and causing burns or intense irritation. It should be removed as soon as the skin is reddened, a corner of the application being raised from time to time to ascertain the condition. From fifteen minutes to half an hour is the average time such a poultice is retained, unless the proportion of mus- tard is very small. A soothing or anodyne property may also be given to the flaxseed poultice by sprinkling over the surface one dram of tincture of opium, or spreading the surface of the poul- tice with a thin layer of glycerin and belladonna (official). Neither should be used over a broken surface. Although the absorbent power of the unbroken skin is not great, if such a poultice is used, the patient must be watched for symptoms that would indicate too free absorption of the drug. The absorbing property of the skin is considerably raised by the moist heat of the application. One of the actions of moist heat being to encourage HOT APPLICATIONS 93 suppuration, the poultice may be used to hasten the sepa- ration of foul-smelling sloughs or gangrenous tissues from wounds. The flaxseed poultice is usually used frequently mixed with one-sixth part of powdered wood-charcoal, which acts as a deodorizer. The charcoal is stirred in just before spreading and well mixed. A charcoal poul= tice is applied directly to the surface of the wound with- out the covering of muslin necessary in a mustard poultice. At the present day poulticing is not a common treatment for wounds. Oatmeal, wheatmeal, ground corn, and such vegetables as carrots, peas, beans, etc., may be used to make poultices where flaxseed is not procurable. They should be cooked until soft and all superfluous moisture then drained away, when they can be spread the required thickness and applied. Being more apt to stick to the skin than flaxseed, the surface of the poultice should be spread with warm sweet oil and covered with a layer of thin muslin. If an onion is used, it is boiled until it falls apart, or cut into slices, fried, and applied while hot. A bread poultice is prepared by placing a thick slice of bread on a board or over a sieve, and pouring on it boiling water until it is sufficiently soft. The board is held so that the water can run off into a basin or sink. The bread is then spread on muslin and applied, usually directly to the surface. This is entirely a domestic remedy and not greatly efficacious. It is a favorite method of drawing splinters from fingers. Soap Poultice.—A soap poultice is used for its cleansing effects. It may be applied to portions of the body difficult to cleanse, such as the heels, palms of the hands, or the umbilicus; or to soften and remove the crusts of ringworm or scabs of neglected wounds. It should not be used to remove scabs due to skin diseases other than ringworm. A piece of clean, soft old muslin is soaked in tincture of green soap (warmed) and applied directly to the part. The poultice is covered with gutta-percha tissue, etc., cut to overlap an inch in all directions, and kept in place with a bandage. It should be changed before becoming dry, but usually it is sufficient to change the 94 LOCAL APPLICATIONS poultice night and morning until the desired result is attained. Oil Poultice.—Muslin or gauze soaked in warm sweet oil may be used instead of the soap poultice, for the same purposes, and applied in the same manner. Starch Poultice.—A starch poultice is made of laundry starch cooked in the usual way, i. e., mixed to a paste with cold water, and sufficient boiling water added to bring it to the required consistence. It is spread about half an inch thick between two folds of muslin and covered, like the soap poultice, with some protective when in place. It may be applied hot or just warm, according to cir- cumstances. It is ordered in some skin affections for removing scabs and crusts and to allay itching. It is applied directly to the part. Poultice of Digitalis Leaves.—A poultice of dried digi- talis (foxglove) leaves is sometimes ordered in cases of nephritis, applied over the loins to stimulate the activity of the kidneys. To the leaves sufficient hot water is added to barely cover them, and they are allowed to sim- mer gently until soft enough to break into pulp. The pulp may be spread between two folds of muslin and applied to the surface, or may be incorporated with a flaxseed poultice in the same manner as mustard or charcoal. The water in which they are cooked should be used in mixing the poultice. Stupes or Fomentations.—A . stupe or fomentation affords a clean, economical, and efficient method of ap- plying local heat. It consists of two or more layers of soft old flannel or blanket wrung as dry as possible out of boiling water, applied directly to the skin, and cov- ered, to retain the heat and moisture, with a piece of light rubber sheeting at least an inch larger in each direc- tion than the stupe, and again with a pad of absorbent cotton; the whole kept in its place by a binder or bandage. To prepare, a wringer and a fairly deep basin are re- quired (Figs. 19, 20). The wringer is best made of one and one-half yards of stout roller toweling, the ends sewn together. This forms a double wringer three-quarters of a yard long. It is laid open in a well-warmed basin, the HOT APPLICATIONS 95 ends hanging over the sides; on it, at the bottom of the basin, is placed, folded, the dry flannel. Boiling water is then poured on, the sides of the wringer are folded over the *v r, IP fii. - .• j Jn id jk§5 "^ £&9| 1 1 Us. Shasal KfcN 2LW v H flannel, and the ends grasped and twisted firmly in oppo- site directions until all the water is wrung out of the stupe. •If managed with any care, the ends are easily kept dry, and the stupe sticks, so often advocated, are not necessary. 96 LOCAL APPLICATIONS If the stupe has to be carried any distance, it should be wrung out at the bedside, as it rapidly cools. Great care must be taken that the stupe is wrung really dry, if not, the patient may be scalded. It should be shaken a moment or two in the air before applying, to let the steam escape. Where a stupe is ordered over a broken surface, sterile gauze instead of flannel is used, and a sterile towel may serve as a wringer. An antiseptic solution is often pre- ferred to the plain boiling water. Such a stupe is a surgical dressing, and the same strict asepsis must be observed in applying it as in any other variety of dressing. Stupe as a Counterirritant.—Turpentine sprinkled over the stupe is a common form of the mild counter- irritant. One to two drams of household turpentine (measured) is freely sprinkled over the dry flannel on the surface which is to be next the patient. The flannel is then folded and the stupe prepared in the usual way. In sprinkling before the water is added there is less risk of the turpentine collecting in one or two spots, an accident which may cause a troublesome burn. The turpentine stupe is frequently used for the relief of intestinal disten- tion. It-is useless in the true abdominal tympanites of peritonitis except to soothe pain. Sedative Stupe.—Tincture of opium, belladonna, or infusions of poppy heads are sometimes added to the stupe when it is used for the relief of acute local pain, such as over painful glands or for earache, where the skin surface is unbroken. Tincture of opium, one to two drams, is freely sprinkled on the prepared stupe immediately before applying. By this method none of the drug is lost in the water used for the stupe. Belladonna and glycerin (the official preparation) is spread thickly over the flannel before the water is added. A second method is to spread the belladonna and glycerin on a piece of lint, apply it first to the part, and over it a plain stupe. Medicated stupes are prepared by using an infusion of a raw substance containing a drug in the place of plain boiling water. Digitalis leaves and the heads of the white poppy, from which opium is obtained, may be used in this wav. HOT APPLICATIONS 97 Digitalis Stupe.—To the dried leaves is added sufficient boiling water to cover them, they are kept simmering until soft, then broken up with a fork and allowed to cool. When cool, the fluid is strained, heated to scalding point, but not boiled, and used for the stupe. It is used for the same purpose as the digitalis poultice. Poppy-head Stupe.—To two dried poppy heads is added a pint of boiling water. The capsule should be freely slit with a sharp knife before adding the water. The heads should simmer until soft, then stand until cool, when the fluid is strained, heated to scalding point, and used for the stupe. It is employed, though not very commonly, to relieve tne pain of earache, neuralgia, or enlarged glands. Alkaline Stupe.—Sufficient washing-soda (or bicarbon- ate of soda) may be added to the stupe water to give it a strong alkaline reaction, and the stupe is prepared in the usual manner. The alkaline stupe is a homely remedy for painful joints in chronic and subacute rheumatism, and often appears to give great relief. When no litmus paper is at hand to test the reaction, sufficient soda to give the water a slippery feeling is the indication. When a poultice or stupe is discontinued, the part should be covered for a time with a piece of absorbent cotton or flannel. HOT COMPRESSES Hot compresses are frequently ordered as an eye appli- cation, especially in inflammatory conditions caused by wounds from foreign bodies. Except that the compresses are wrung out of hot water, they are applied in the same way as cold compresses. The water may be kept at a correct temperature by placing the basin over an alcohol lamp, Bunsen burner, or electric heater. The compresses are applied as dry as possible and as hot as can be borne without scalding the eyelids. The hand should be pro- tected by a rubber glove, or a wringer may be made of a small piece of sterile muslin, to each end of which a pair of artery forceps is clipped; by twisting these in opposite directions, the compress is efficiently wrung. The appli- 98 LOCAL APPLICATIONS cation is frequently ordered for from ten to twenty minutes at regularly repeated intervals. Between the intervals the lids may be smeared with sterile vaselin or albolene. COUNTERIRRITANTS Counterirritants are divided into rubefacients, those that redden the skin surface; vesicants or epispaxtics, those that produce a blister or exudation of serum between the cuticle and the dermis; and escharotics, those that destroy the soft tissues and cause sloughing. A vesicant that, instead of a clear blister, causes a pustule or milky exudate is also called a pustulant. A pustule contains serum and white corpuscles, takes longer to heal, and is more liable to cause a scar than the clear blister, which heals quickly and leaves no scar. RUBEFACIENTS Heat.—Heat in many of the applications mentioned above may also correctly be considered as a rubefacient; this is especially the case where it is employed in com- bination with a counterirritant, as in the mustard poultice or the turpentine stupe, both of which are, prop- erly speaking, counterirritants and in common use. Sinapisms or Plasters of Mustard.—Mustard Paste.— A paste is made of flour and warm water, into which is stirred a proportion of dry mustard, broken free of lumps. The proportion of mustard varies from an eighth to a half. The half-in-half paste is used when only one appli- cation is desired, as, for instance, when applied to the chest to help in breaking up a bronchial " cold." The usual pro- portion is one part of mustard in four of flour for an adult, and in from six to ten parts of flour for a young child. The paste is spread on thick muslin and the edges turned over; the surface next the skin is covered with gauze or thin muslin. It may be left on for from five minutes to a quarter of an hour, a corner being raised from time to time to watch the results, and the sinapism removed as soon as the skin is well reddened. If the skin is easily affected, as in children, the white of one egg may be mixed with the paste or a little sweet oil spread over the surface. RUBEFACIENTS 99 It must be remembered that mustard is not a counterirri- tant in the dry form. Its active principle or irritating property is contained in a volatile oil set free only on the addition of water. This is easily demonstrated by smelling mustard before and after water is added. Where very hot or boiling water is used, much of the active property is destroyed, as also where vinegar is used to mix it, as in " French mustard." An official preparation known as the mustard-leaf is a simple method of using mustard as a counterirritant. Cut to the required size, the leaf is dipped in tepid water, allowed to drip for a moment or two, and applied directly to the skin surface, or, if the skin is delicate, with a layer of thin muslin between. It cannot usually be borne more than for from four to eight minutes. After the removal of a mustard paste or mustard-leaf, warm, dry cotton or a soft handkerchief should be kept on the part until the redness has disappeared. If deeply reddened, an application of sweet oil or vaselin may be made. A sinapism should not be left on long enough to cause a blister. Spice Poultice.—This is a form of mild counterirritant not met with in modern nursing, but still used among old- fashioned people to relieve the pain of muscular rheuma- tism, especially lumbago. The poultice is made of one- half the quantity of flour, the other half of equal parts of various spices, cloves, allspice, ginger, cinnamon (pow- dered), with a smaller proportion of either capsicum or Cayenne pepper. The flour is first made into a paste with hot water, the spices stirred in, and the Cayenne pepper or capsicum sprinkled over the surface. The poultice is spread on muslin and the surface covered with gauze. It may be kept on as long as comfortable. Dry Cupping.—For cupping, a set of glass cups, five to seven in number, are used. Special rimmed cups of thick glass with a capacity of from one to four ounces are used, but any glass of convenient size may be substituted. The inside of the cup is rubbed over with a little cot- ton sponge soaked in alcohol, the sponge conveniently mounted on a small applicator; to the cup a light is then 100 LOCAL APPLICATIONS applied, the alcohol flames up, and in so doing exhausts entirely the air in the cup. The rim of the cup should be wet with water to prevent it becoming so hot as to burn the skin. Just before the flame dies out the cup is quickly inverted over the affected area, to which it will readily adhere. The skin and tissues covered by the cup arc drawn up into the vacuum, the superficial blood-vessels become greatly dilated, bringing an increased quantity of blood to the surface. Five to seven cups arc usually applied at one time, and left in place until the skin is well reddened. To remove a cup, the tip of the finger is in- serted under the rim; air being then admitted, the cup is no longer adherent (Figs. 21-24). Fig. 21 .—Cupping. First step, swabbing the interior of the cupping glass with alcohol (Morrow). Wet Cupping.—If, before the application of the cups, several incisions with a sharp knife are made over each space, blood will be drawn from the tissues into the vacuum when the cups are in place. The process is known as wet cupping. The skin should previously be scrubbed with sterile soap and water (shaving if necessary) and washed with bichlorid of mercury. On account of their inflam- mable qualities neither alcohol nor ether should be used in the preparation of the skin, as if not entirely removed, the skin may be burned. On removal of the cups the parts are covered with a sterile dressing, the blood with- RUBEFACIENTS 101 Fig. 22.—Cupping. Second step, igniting the alcohol in the cup- ping glass (Morrow). Fig. 23.—Cupping. Third step, the application of the cups (Morrow). drawn carefully measured, and note made of the quan- tity. 102 Local applications Cupping is used chiefly in the treatment of pneumonia, acute nephritis, or edema of the lungs, to which end the cups are best placed on the flat surface of the back or loins. Wet cupping may also be used in the treatment of inflam- matory conditions of the eye or ear, small-sized glasses being applied over the temple or behind the ear. Where they can be procured, leeches are, however, preferred. Leeching.—While not a rubefacient, leeching may conveniently be considered in this group. The leech, or hirudo, is a blood-sucking worm found in the ponds and marshlands of special districts. Those used in medicine Fig. 24.—Instruments for wet cupping: 1, Cupping glasses; 2, swab in alcohol; 3, alcohol lamp; 4, scalpel (Morrow). usually come from Sweden, those native to America being considered to have only one-sixth the strength of 1 lit; Swedish leech. Until ready for use they should be kept in a jar of clean fresh water, with some sand at the bot- tom, closely covered with a perforated top. As a leech-bite is liable to bleed, care must be taken to apply the leech to such parts as can readily have pressure applied to them. The temple or forehead, and not the eyelids, for example, is used in applying leeches to relieve inflammatory conditions of the eye. The skin is prepared by washing with un.sccnled soap, RUBEFACIENTS 103 rinsing thoroughly with water, and drying with sterile* cotton. If necessary, as behind the ear, the part must be shaved. Disinfectants or applications with an odor will prevent the leech biting. The leech may be held in a piece of gauze, but usually will bite more quickly if placed in a test-tube which is inverted over the spot. Care must be taken to apply the head, and not the tail of the animal. The head is recognized by the three-cornered or Y-shaped mouth peculiar to the leech. If the leech does not bite, he is usually hot, uncomfort- able and irritable, probably from having been kept out of water. He may be coaxed by smearing the part with milk, or by pricking the part until a drop of blood comes, or by gently stroking his back, but if still obstinate, it is quicker eventually to return him for a time to the water, and allow him to cool himself off in a dark place. A leech will frequently refuse to bite if the atmosphere of the room is heavy with tobacco or disinfectants, etc. The Swedish leech will draw from half an ounce to an ounce of blood, the American about a sixth as much. When full, he will drop off, and is then usually destroyed by covering him with salt and burned. He should not be thrown alive down the soil-pipe. If it is desired to remove a leech while sucking, he is sprinkled with a little table- salt. He should never be pulled off, as the teeth are then liable to be left, causing hemorrhage, slight but difficult to control, and subsequent inflammation. After removal, if there is no hemorrhage, a minute dressing of gauze and collodion (p. 489) is applied. If there is any tendency to bleed, a dry graduated compress (p. 584) may be tightly bandaged over the part, and if obstinate, ice compresses or some styptic such as alum, tannic acid, etc., is also applied. Occasionally a further quantity of blood is withdrawn by applying poultices to the bite after the leech is removed. A patient to whom a leech is applied should not be left alone. If, for any reason, this is inevitable, the ears and nostrils should be plugged with absorbent cotton in case of the leech straying. Many patients object to the sensation of the leech's body; this can be obviated by placing a fold of gauze or 101 LOCAL APPLICATIONS handkerchief under the leech once he is seen to be holding firmly. Leeches are most commonly employed in inflammatory conditions of the eye or ear, and are applied to the temple, forehead, or behind the ear. They are also, though not so frequently, applied behind the ear to relieve cerebral congestion, and over the pericardium in the treatment of acute pericarditis. In gynecologic work they are some- times applied to the cervix uteri; this is, however, never left to the nurse. Tincture of Iodin.—Tincture of iodin, painted on the skin surface, is used as a mild counterirritant in many conditions, especially those in which it is desirable to check the formation of effusions, as in pleurisy or inflammation of a synovial membrane. It is also generally used in the treatment of enlarged glands. It is of little value for the relief of acute pain. The amount required for one application is poured in a small saucer and painted quickly (it evaporates on stand- ing) on the surface with a camel's-hair brush, care being taken not to allow the application to run beyond the specified area. If necessary, this can be prevented bv previously outlining the space with sweet oil or vaselin. A light application stains the skin yellow; usually the iodin is applied until a mahogany hue is reached. Each layer should be dry before the next is applied. It should not be applied sufficiently thickly to cause a blister. For the same reason the surface should be painted evenly— not too thickly on one spot. Usually the application is made two or three times at intervals of twenty-four hours. If a mistake has been made and too much applied, it can be removed with alcohol. The painted area should be covered with a piece of muslin or a bandage to protect the linen from staining. If a stain occurs, it should be removed before washing by covering with a paste made of raw starch and alcohol. Ironing.—Ironing the surface as a remedy for pain, especially that of muscular rheumatism, is not often ordered in hospital work, but is a common remedy in home nursing. RUBEFACIENTS 105 The painful surface is covered with a piece of thick paper, just above which a hot laundry iron is repeatedly passed until the skin is reddened. The iron must not be pressed down on the paper. The Actual Cautery.—Cauterization, or the searing of the flesh, is a form of counterirritant which may be rube- facient, vesicant, or escharotic, according to the degree employed. The instrument generally used in medical practice is the Paquelin cautery, though a metal, such as iron or steel, capable of sustaining a high degree of heat, may be sub- stituted in any practical form. The Paquelin cautery Fig. 25.—Paquelin's cautery. Note that the benzene is contained in the handle of the apparatus (W. E. Ashton). consists of a hollow, flattened tip of platinum, which is screwed on to a small metal cylinder, or connected by a rubber tube with a bottle, either containing a small quantity of benzene. Attached to the cylinder or bottle is an air- pump, by working which the fumes of benzene are blown into the tip. If the tip is previously heated over an alco- hol lamp, the fumes will ignite inside the hollow tip and maintain, by this simple process, the tip at the required degree of heat. The air-pump consists of a length of rubber tubing fitted with two rubber balls, one hard and one soft, the soft one being protected from overdistention by a netting of strong silk. The hard bulb is squeezed 106 LOCAL APPLICATIONS from time to time, thus pumping air into the soft bulb, which acts as a reservoir, and simply from the effect ot atmospheric pressure passes the air in a steady current over the benzene. By keeping the soft bulb moderately dis- tended, sufficient force of air and benzene is blown into the tip to keep it at a steady heat. Very little benzene is re- quired; usually the required amount is soaked up on a small sponge or absorbent cotton and placed in the bottom of the cylinder or bottle. If too much is used, the benzene itself may ignite and cause an explosion. The cautery is generally used just below red heat. After use the tip should be brought to white heat for a few moments, in order to burn off any shreds of tissue which may adhere. While cooling, it should be kept in a safe place. It should be allowed to cool slowly, and when quite cold, may be washed and cleaned like other instruments. The platinum tips are very costly, platinum being a more highly priced metal than gold; they require the greatest, care in handling, as when heated, the smallest knock or fall will dent them, thus destroying the even surface necessary. For this reason the cautery should always be in charge of a reliable nurse, but every pupil should be taught how to put it together for use and the proper care of the different parts. In hospitals and doctors' offices a modification of the Paquelin cautery is now often found, the platinum tip being screwed on to a convenient handle connected with an electric current. Where the heat is supplied by elec- tricity, it is not necessary to heat the tip, in the first place, over an alcohol flame. The cautery is employed for the relief of pain, especially that of muscular rheumatism, to promote the absorption of inflammatory products, and for the arrest of hemorrhage from any vascular surfaces, as, for instance, after the use of the clamp in operations for hemorrhoids. As an eschar- otic it is used in surgery as an application to wounds when it is desirable to destroy the superficial tissue. To cauterize was, until recently, the classic treatment for all wounds caused by the bites of animals, dogs, cats, ser- pents, etc. At the present day it is less in favor, free incision being generally preferred. VESICANTS 107 If a nurse is directed to disinfect the skin before cauter- ization, she should understand to do so only with soap and water and a disinfectant solution. Alcohol and ether must be avoided, as, on account of their inflammable proper- ties, an accident might happen if they had not been thor- oughly removed. VESICANTS This form of counterirritation. is most generally em- ployed where it is desirable to check the formation of effusion, as in pleurisy, pericarditis, or synovitis of one of the joints. Blistering may be accomplished by using a rubefacient in a more concentrated form or over a longer period, but most commonly a preparation of a Spanish tiy, cantharides, is employed. It may be obtained in the form of a fluid, an ointment, or a plaster. Where the order to " apply a blister " is given, cantharides is under- stood. Before applying a blister the skin should be carefully cleaned with soap and water, alcohol or ether, and a dis- infectant, shaving, when necessary, in order that the ap- plication may act the more readily, and that the area may be aseptic when the blister is opened. The site chosen should be over a well-covered surface, plentifully supplied with blood-vessels, and not over a bony prominence, where healing would be slow. The blister is always a small application, usually one to two inches square. This is both on account of the des- truction of tissue, and because of the poisonous effect of the drug, which, when absorbed too freely into the system, causes acute nephritis. The symptoms of cantharidal poisoning are headache, vomiting, fever, and scanty urine, containing albumin (p. 239). Cantharidal Collodion or Blistering Fluid.—The canthar- idal collodion is painted on the skin with a camel's-hair brush. In order to keep exactly to the required size and prevent the fluid running, the space may be outlined first with sweet oil or vaselin. Allowing a very few moments for the application to dry, the blister is then covered with gauze and finally with waxed paper, or some convenient protective, and a bandage applied lightly, in order to allow for the rising of the blister. 108 LOCAL APPLICATIONS Cantharides Plaster.—The plaster is cut to the required size and applied directly to the surface; it is held in po- sition with a lightly applied bandage. Cantharidal ointment or cerate is also applied directly to the surface, the application being first spread on muslin or lint. It is not so reliable a preparation as either the plaster or the collodion. After either of the above forms of application the area must be examined from time to time to ascertain if the blister has risen. From four to eight hours is usually required to form the single large bleb desired. If it has not formed at the end of eight hours, the application should be removed and a poultice or a hot fomentation applied to the site. These should not be applied over the appli- cation itself, as sloughing and symptoms of poisonous absorption may result. With young children a blister is best removed as soon as the skin is thoroughly reddened, and a poultice applied until the blister has formed. The collodion or ointment may be removed with ether. When the blister is well risen, it is opened and dressed with strict aseptic precautions. In opening, a snip is made at the most dependent point of the blister, and the fluid gently pressed out on a piece of sterile cotton. A dry sterile dressing is usually applied, and either changed every day or left in place until the blister is healed, or a daily dressing of boric ointment may be preferred. In some instances the blister is left uncut, and the fluid allowed to be reabsorbed. In this case it is covered with a dressing of sterile cotton and a light bandage which pro- tects it from breaking and aids, by elastic pressure, in the process of absorption. Where it is desirable to keep up the counterirritation, the cuticle of the blister is cut en- tirely away and the surface dressed with savin ointment, an ointment made from the volatile oil found in the tops of the Juniperus sabina, intensely irritating, especially to the denuded surface. This dressing should be exactly the size of the denuded surface, covered with an overlap- ping piece of gauze. On account of the physical effect of the drug the condi- tion of the kidneys must be carefully watched when blister- ing is used in the treatment of a patient, ESCHAROTICS 109 In conditions where effusion is extensive it is frequently desirable to apply the treatment over a greater length of time. In these cases a flying blister is ordered. A space is mapped out, divided into four or six two-inch squares, to each of which, on successive days, a blister is applied. After the last space is blistered the first space is usually ready for a second application, if still necessary, or a fresh square may be begun beside the first. A mixture of guaiacol and glycerin is sometimes used as a vesicant, applied and treated in the same way as canthar- idal collodion. Ammonia {aqua) or chloroform can be used as vesi- cants where cantharides is unattainable. They may be applied by saturating a piece of gauze the necessary size with one or the other; the gauze is then applied directly to the surface and covered with some protective and a bandage. A group of small vesicles should rise in from ten to fifteen minutes. Blistering may be also accomplished by pouring a few drops of ammonia water (aqua fortis) directly on the skin, excluding the air by holding a watch-glass over the appli- cation until the vesicles rise. Kerosene oil may also be employed with equal parts of sweet oil. It is applied on gauze and covered with some protective. Pustulants.—Croton oil {oleum tiglii) is a powerful vesicant, producing, instead of a blister of clear serum, a collection of small vesicles which quickly become pustulous. Tartar emetic applied to the skin has the same effect. Croton oil may be mixed with equal parts of olive oil and applied on muslin or gauze, covering the application with some protective; more commonly, a piece of flannel or absorbent cotton is soaked with a small amount and rubbed briskly over the skin until the surface is well reddened. The pustules should appear about four hours after the application. If there is no result, the process is repeated. ESCHAROTICS Certain drugs brought in contact with the skin destroy the soft tissues and cause sloughing. They are termed caustics or escharotics. While not applied as remedial no LOCAL APPLICATIONS agents to healthy tissue, drugs with this property should be known and recognized in order to avoid accidents. The following list may be memorized: Acids (undiluted)—acetic, arsenous, carbolic, chromic, nitric, sulphuric; bromin, caustic potash, caustic soda; antimony chlorid, zinc chlorid, lime, mercuric nitrate, silver nitrate, copper sulphate. LINIMENTS It must not be overlooked that friction with the open palm of the hand is, in many instances, one of the most valuable forms of mild counterirritant. Its efficacy is increased if oil or alcohol is used. Frequently the oil or alcohol is made the vehicle of a drug with anodyne or stimulating properties, forming what is known as a lini- ment. A sufficient quantity of the liniment is taken on the palm and rubbed into the skin over the affected area. The application is specially employed for affected joints in conditions of subacute and chronic rheumatism, and is applied to the chest in chronic bronchitis. The medicinal substances most commonly incorporated in liniments are aconite, ammonia, arnica, belladonna, camphor, chloro- form, hartshorn, mustard, opium, and turpentine. The soap liniment so frequently employed contains alcohol, camphor, opium, and tincture of green soap. Friction should be given with the whole hand flat, and should, generally speaking, follow the direction of the lymphatic circulation, i. e., from the extremities toward the heart. PLASTERS Local application to the unbroken surface is also made in the form of a plaster, or emplastrum. The remedial agent is mixed with an adhesive substance such as resin (pitch), which melts at the temperature of the body, and with rubber. The preparation is spread on kid or swansdown and applied directly to the skin surface, where it ad- heres, as a rule, without other support. If kid is used, it should be freely perforated. Drugs with counterirritant, anodyne, astringent, and other properties are frequently applied by this means. The most commonly employed PLASTERS 111 plasters are the following, all of which are official prepa- rations : Asafetida plaster combines the properties of counterirritant and antispasmodic. It is used to some extent to relieve gastric and intestinal distention. Belladonna plaster, employed for anodyne purposes and for the property possessed by belladonna of drying up secretions; fre- quently applied to the breasts in order to dry up milk, or to enlarge painful glands. Applied locally to the muscles it re- lieves pain, such as lumbago, and affords comforting support. Cantharides plaster (see above). Capsicum plaster, employed as a counterirritant to relieve mus- cular pain. Diachylon or lead plaster contains acetate of lead, soap, and water. Mercury and ammonia plaster (18 per cent, of mercury), used where, besides the counterirritant property, the action of mer- cury on the system is desired. Mercury plaster (30 per cent, mercury). Mustard-leaf (see above). Opium plaster, applied for anodyne purposes, but less generally than the belladonna plaster. Soap plaster, a milder form of the lead plaster; both are mildly astringent applications used chiefly in surgery. The adhesive plaster in general use is made of rubber. petroleum, and either lead acetate or zinc oxid. The astringent property is very slight. Adhesive plaster is used chiefly for support, to exert pressure, and in the ap- plication of splints and other external appliances (Chap. VIII). In applying a plaster care must be taken that it fits the surface smoothly without wrinkles. Snipping the margin freely will generally accomplish this result. A plaster applied to the breast should be cut circular and a hole made in the center to avoid covering the nipple. Most usually this is the belladonna plaster used to dry up [he secretion of milk. A plaster is left on until the result for which it was applied is attained. An anodyne plaster (belladonna, opium) may be retained as long as it is comfortable unless there are symptoms of too free absorption of the drug. (See Poisons.) In removing, if a plaster does not come away readily, a little turpentine or chloroform will dissolve the adhesive substance, when the plaster can be removed 112 LOCAL APPLICATIONS without pain. If a mustard, capsicum, or cantharides plaster sticks, it should be moistened with sweet oil. Most plasters adhere more readily and an" more comfort- able if slightly warmed before applying. The skin should be previously washed with soap and water and dried. Antiphlogistine is a patent preparation (formula un- published) of medicinal substances and a natural Denver mud, which possesses the property of relieving pain and reducing inflammation. It is spread thickly on stout material, cotton or linen, and applied directly to the skin surface. Unless warmed before applying, it has a dis- agreeable, clammy feeling. It may be left on for from six to twenty-four hours, after which it becomes dry and uncomfortable. Should some of the preparation adhere to the surface after the plaster is removed, it may be washed off with soap and water. At the present day its use has a certain vogue, especially in the treatment of subacute inflammations. CHAPTER IV ENEMATA, ENTEROCLYSIS, CONTINUOUS RECTAL INFUSION, SUPPOSITORIES, DOUCHES, TAM- PONS, CATHETERIZATION, LAVAGE, GAVAGE, NASAL FEEDING Simple, Purgative, Nutritive, Medicated Enemata—Supposi- tories—Douches, Vaginal, Intra-uterine—Vaginal Tampon—Vaginal Packing—Nasal, Ear, and Eye Douches—Catheterization—Bladder Irrigation — Guarded Catheter — The Male Catheter — Lavage - (lavage — Nasal Feeding. ENEMATA An enema, or clyster, is a fluid injected into the lower bowel by way of the rectum. It is employed to relieve constipation, to check diarrhea, as a vehicle for the ad- ministration of food, water, medicine, or stimulation to the general system, and as a local application. More rarely it is used as a means of reducing temperature. The rectum, it will be remembered, is the lowest division of the large intestine; the opening is known as the anus, and is guarded by a sphincter or ring muscle called the sphincter ani. It is a straight passage, occupying the posterior portion of the pelvic cavity, and running in a direction from the anus backward and toward the left of the abdomen. About eight inches above the anus the rectum is connected with the descending branch of the colon, or large intestine, by an S-like curve, called the sigmoid flexure, which passes over the bony brim of the pelvis into the abdominal cavity. The walls of the large intestine contain no secreting glands for the digestion of food; in common, however, with all other portions of the intestinal tract, they have the power of absorption. Food, water, medicine, etc., in- troduced into the large intestine become absorbed and distributed over the general system in the same manner 8 113 Ill ENEMATA, ETC. as when absorbed through the small intestine. Poison- ous products present in the colon, as, for example, those formed by decomposing food-particles, are also readily absorbed, and produce symptoms of general systemic toxemia, the earliest manifestations of which are the headache, malaise, and nervous irritability which accompany constipation. To keep the intestines free of such accumulation is a first necessity if health is to be preserved, and to aid in so doing is the most common use of the enema. The enema is best administered by a tube of soft rubber sufficiently thick to be non-collapsible. Special tubes of various sizes are sold fortius purpose, known as rectal tubes. If a very small size is necessary, a large-sized "soft" catheter is used, while for colonic flushing a stomach-tube may be required. Fig. 26.—Rectal tube with funnel for nutritive or medicated enemata. The best rectal tube for most purposes has the end of solid rubber, cone-shaped, and the opening on the side about an inch from the tip. When the opening is directly at the end, the opening more readily becomes blocked with the contents of the rectum. The rectal tube may be connected with the tubing of a douche-can or " fountain " bag by a short glass connect- ing tube, and where a considerable quantity of fluid is to be ejected, the bag or can is usually used. It should be hung from two to three feet higher than the patient. For the simple enema to relieve constipation the hard- rubber nozzle sold with the fountain syringe bag may be used instead of the rectal tube. For small enemata, especially those containing drugs, when it is of importance that the entire enema should ENEMATA 115 reach the bowel, the long tubing has obvious disadvantages. In these cases a funnel is attached to the end of the rectal tube and the enema poured into it from a pitcher. The barrel of a large-sized glass syringe makes the best funnel for the purpose (Fig. 26); its capacity is known accurately, and its shape lessens the risk of spilling. For very small medicated enemata the tube should not be more than eight inches long, and some prefer to use, for this pur- pose, the ball syringe. The ball syringe is a hollow ball of soft rubber, to which is attached a short, hard-rubber rectal nozzle. The fluid is drawn into the ball by expressing the air and allowing the ball gradually to expand, while the nozzle is held below the surface level of the fluid. When filled, superfluous air must be expressed by holding the ball with nozzle directly up- right and pressing gently until the fluid appears at the end. The pressure must Fig 27—"Ball not be relaxed or air will be sucked into syringe. the vacuum. In giving an enema, care must be exercised to avoid injecting air into the bowel, which causes cramping pains and may produce distention difficult to relieve. To pre- vent this the tube must be filled with fluid first, and either clamped or pinched between the finger and thumb to retain the fluid while inserting the tube. For the same reason, where the funnel is used, it must be replenished from the pitcher always before it has become empty. If these details are not attended to, the air already in the tube is directly forced into the bowel by the more solid column of water behind it; where a douche-can or bag is used, a considerable quantity may be thus injected. A second point to be borne in mind is that the first flow of fluid will be chilled by running through the tube and should be run off before the rectal tube or nozzle is inserted if the enema is to be given warm or hot. Where the enema is a measured quantity to be retained, the 116 ENEMATA, ETC. portion run off must be returned to the bulk of the enema. The temperature may, where practical, be tested by running the fluid over the back of the hand. The above details are equally important wherever fluid is injected into the body, either by douche, etc., into the cavities, or subcutaneously into the tissues. The passage of the tube is made easier by lubricating the end well with soapy water. If the mucous membrane is delicate, as in young children, sterile oil or vaselin may be used and the anus should also be lubricated. There is a preju- dice against using oil or vaselin unnecessarily; principally because they afford too good a medium for the develop- ment of bacteria, but also because all oils have a destruc- tive effect on rubber. In giving an enema the patient should be on the left side, toward which the rectum is directed, or flat on the back; in either case with the knees flexed in order to relax the abdominal muscles. For special purposes the knee-chest position is ordered. (See Positions, p. 191.) In many cases it is necessary to have the pelvis elevated higher than the natural position of the body; either the pelvis may be raised on pillows, or the lower end of the bed may be elevated on blocks. Under the patient is placed a small rubber sheet covered with a draw-sheet or thick towel; the night-dress is rolled up out of the way, and a single blanket or sheet is used as a covering. The enema may be given entirely under cover; where this is considered undesirable, the covering can very easily be arranged so that only the anus is exposed. The; bed-pan or commode should be at hand before the injection is begun. The tube inserted, it should be pushed gently in one direction upward, backward, and toward the left, using no force. If resistance is felt from the contents of the rectum, some fluid should be run in through the tube; this will dilate the rectum and make room for the tube to pass up beside the impaction. Resistance should not be overcome by moving the tube or nozzle about; this irri- tates and may injure the mucous membrane, causes pain, ENEMATA 117 and generally leads to blocking the eye of the tube with feces. If, after insertion, the fluid does not run, the eye has become blocked. The tube must be withdrawn and water run through the tube until the impaction is washed out, after which it can be again inserted. Instances occur where the rectum is so packed with hard, dry feces that it is impossible to pass the tube. In these cases it becomes necessary to unload the rectum first with the finger, carefully protected by a glove or rubber finger-stall, and freely lubricated. The finger should not be inserted unless thus protected, and this not only from principles of cleanliness, but because the finger- nail may easily scratch the delicate mucous membrane. Peristalsis1 is frequently excited on first beginning an enema, leading the patient to imagine he cannot retain it. If this occurs, by pinching the tube the enema can be stopped until the desire to expel it has passed, when it can be continued. By proceeding slowly and frequently pausing, a much larger quantity can be retained than if the enema is injected rapidly and with force into the rectum. On finishing, the tube is slowly and gently withdrawn, pinching it between the fingers to avoid spilling any fluid remaining. If it is desired to retain the enema, a folded towel is held for a few moments in such a manner that the buttocks are pressed together over the anus. An enema is prescribed to be given either low or high, terms which signify which part of the colon it is desired to reach. In giving a low enema the tube is passed only into the rectum, a distance, that is, of from four to eight inches. In giving a high enema the object is to reach as far up the colon as possible, and the tube must be passed beyond the sigmoid flexure, more than eight inches. To do so requires patience and skill; the curve must be passed by gentle manipulation, and force on no account used. Frequently the tube appears to slip easily into place, 1 Peristalsis is the rhythmic, wave-like contraction of the muscu- lar walls of the stomach and intestines by which food is propelled forward in the direction of the anus. It is excited by the presence of food, etc., in the stomach and intestines. 118 ENEMATA, ETC. but if an examining finger is passed into the rectum, it will be found to have coiled back on itself and to be lying entirely in the rectum. Sometimes a tube of large caliber is more easily passed than a small one. Once past the sigmoid flexure, the tube should be pushed forward as long as it meets no resistance. When resistance is met, the tube is withdrawn an inch or two and the enema started. The simple enemata for relieving temporary constipa- tion, and those employed as a local application, are given low; practically all other enemata should be given high. The temperature of an enema varies with the results to be attained. A purgative enema is given hot—from 100° to 105° F.; a stimulating enema, from 105° to 110° F.; an enema for the arrest of local hemorrhage,.! 10° to 120° F.; an enema for nutritive purposes should be about the normal temperature of the body; a bland enema is usually given cool, that is, the chill just off, while for special purposes, such as the reduction of the temperature of the body or the arrest of local hemorrhage, and in the treatment of acute dysentery or cholera, an enema may be ordered cold or even iced. In the majority of cases an enema which is the vehicle for a drug is given cold or cool, in order not to risk altering the active properties of the drug by heat: to this rule the medicated purgative enema is an exception. The quantity given by enema also varies greatly. The common purgative enema is usually from two to four pints for an adult, from one to two pints for a child, and half a pint for an infant. When given in order to empty the bowel before an operation, the enema is repeated until it returns clear. If it is desired to retain the enema, the quantity is small, anything above six ounces being liable to be rejected or to excite peristalsis, which may cause the whole to be returned. In the care of an infant the giving of an enema may be a frequent duty, and is one which requires to be performed with the greatest care and attention to details. A small- sized rubber catheter is used, attached (Mther to the glass funnel or to the douche-bag. The infant is laid com- fortably on its left side on the lap, on which is a small r ENEMATA 119 blanket covered by a rubber sheet, both warmed; the cloth- ing is'rolled up out of the way, and a warm diaper placed under the buttocks. The legs are flexed and the baby held by the feet. The anus, the adjacent parts, and the tube are carefully lubricated with sterile vaselin or cold cream. The enema is then given in the usual way. If the tube and funnel are used, the nurse will require an assistant to help her; if the bag or can is used, it should be hung about a foot higher than the lap, and the tube ap- propriately shortened. The injection over, a suitable vessel is placed under the buttocks, and the baby, covered with a warm blanket, is held on the lap until the enema has acted. Owing to the smallness of the limbs a large pro- portion of the baby's body is necessarily exposed during the process. Care should, therefore, be taken that the proceeding takes place in a well-warmed place, free of drafts, preferably by an open fire, and that all that comes in contact with the baby is well warmed. A baby should not run the risk of sudden chilling of the surface of its body. The following are the more commonly ordered enemata; the quantities given are those for an adult. Simple Enema.—Plain hot water may be used as an enema to relieve mild constipation or to empty the rectum before rectal feeding. It is sometimes ordered for invalids who imagine that the soap-suds enema causes griping. Quantity, two to four pints; temperature, 100° to 105° F. Soap-suds Enema.—Hot water is made soapy with Castile or any pure soap. No soaps containing much soda, such as scrubbing or laundry soap, should be used, as they are irritating to the mucous membrane. The froth} suds which contain air-bubbles should not be injected, as they will cause unnecessary griping. The soap-suds enema is used to induce an action of the bowels. Quantity. two to four pints; temperature, 100° to 105° Y. Normal Salt Solution Enema.—To two pints of water are added two and one-quarter teaspoons of common table-salt (^ of 1 per cent.). The normal salt solution enema is \ixec\ for various purposes: to irrigate the lower 120 ENEMATA, ETC. bowel in conditions of chronic enterocolitis, to cleanse the bowel before rectal feeding, for the destruction of intestinal worms, for the relief of thirst, especially follow- ing an operation or severe hemorrhage, and as a means of stimulating the system in conditions of collapse; usual temperature, 110° to 105° F.; as a general stimulant, 110° to 120° F. Nutritive Enema.—Nutritive enemata may be composed of any concentrated food substance in liquid form. They commonly contain peptonized milk, egg, some concentrated protein, such as a beef essence, beef-juice, peptones, or liquid peptonoids. As absorption only, and not digestion, is carried on in the large intestine, the food used is first partially digested or peptonized, unless already in the form of peptones or albuminoids, which are ready for absorption without being subjected to the action of digestive secretions. A common formula for a nutritive enema is as follows: Peptonized milk, 3 ounces. Beef-juice, 2 drams. White of one egg. Salt, half a level teaspoon. The beef-juice may be omitted altogether or bouillon (2 ounces), liquid peptonoids (half an ounce), beef pep- tones, or some beef-extract (1 to 2 drams) may be used in its place. Half an entire egg is sometimes preferred to the white only, or the egg may be omitted and a larger quantity of beef-juice used. (To peptonize milk see Appendix.) In preparing the enema the milk is warmed in a double boiler to the required temperature (95° F.), and the salt and beef-juice added when ready. The egg-albumen is broken in a cup with a spoon and added last, slowly, stirring all the time. If stimulants or medicines are to be given in the enema, they are added immediately before administration and not subjected to the process of predigestion. Stimulants —whisky or brandy—must be added slowly, stirring all the time to prevent curdling. Medicines should be given with the first quantity injected, so that nothing may be lost in the tube. ENEMATA—STIMULATING ENEMATA 121 A nutritive enema should not exceed from four to six ounces, a larger quantity being liable to be rejected, and should be given high; it should be about the consist- ence of thick cream. If not sufficiently thick, a little cooked starch or flour may be added. To insure reten- tion it must be given very slowly, almost drop by drop, regulating the speed by pinching or clamping the tube. The pelvis should be raised higher than the shoulders during the process. The enema is usually given at intervals of four, six, or eight hours, according to cir- cumstances. The nutritive enema, or rectal feeding, is ordered in cases where, from any cause, the patient cannot be fed through the stomach. Such a condition may be the re- sult of gastric ulcer, cancer of the stomach, stricture of the esophagus, persistent vomiting, and similar causes. Rectal feeding may be the only means of nourishment for weeks at a time. In these cases it is important to keep the bowel free from accumulations of food-particles, which, when not absorbed, must decompose, and, as a consequence, set up diarrhea, which will render rectal feeding impossible. To prevent this, the bowel is cleansed at least once a day by a simple enema, or, if preferred, by an enema of soap- suds or salt solution. Some doctors order a small (half a pint) simple enema half an hour before each feeding, but such frequent passing of the tube is liable to irritate the mucous membrane. After the enema is given, the patient should lie quite still for half an hour. Stimulating Enemata.—No. 1: The normal salt solu- tion enema, given at a temperature of 110° to 120° F., is a valuable general stimulant in conditions of shock, low- ered vitality, or collapse. It should be injected as high as possible into the colon, and not more than one pint given at a time to favor retention. No. 2: Strong black coffee, four to six ounces, to which may be added brandy or whisky, one to two ounces. It is also given high, at a temperature of 105° to 110° F. To make a coffee enema quickly tie a cupful of ground coffee loosely in a piece of muslin, place in the coffee-pot, and pour on two cups of boiling water; cover and set on 122 ENEMATA, ETC. the stove three minutes, then strain. Less coffee is neces- sary if more time is available. No. 3: Brandy or whisky (one to two ounces) is fre- quently ordered as an emergency stimulating enema. They are usually given diluted with hot normal salt solu- tion; hot milk, hot tea, or hot coffee may also be used as vehicles. The total quantity should not be more than six ounces. If the stimulant is to be frequently repeated, it is best given in four ounces of cooked starch, to lessen the irritating effects of alcohol on the mucous mem- brane. Medicated Enemata.—Drugs or medicinal preparations may be given by enema (Mther for local action or for general systemic effect. When for the latter use, a larger dose is given than when the drug is administered by the mouth or by subcutaneous injection. In the majority of in- stances the dose by rectum is twice that given by mouth. Medicated enemata are given high, unless for local action only. Oil Enema.—From six ounces to a pint of olive oil is warmed to a temperature of about 90° F., and given very slowly as a high enema. In from two to six hours it is followed by a suds enema. The oil enema is given to soften hard masses of feces, and is frequently ordered before the first bowel movement after rectal operations. The tube used must be immediately cleaned, as oil quickly destroys rubber. Glycerin Enema.—Glycerin, •> ounce, diluted with an equal quantity of warm water, is frequently used for the relief of chronic constipation affecting the lower bowel. It is most conveniently given with a special glass syringe fitted with a hard-rubber nozzle slightly curved, and about four inches long. Medicated purgative enemata are used in cases of obstinate constipation. Salts, either Rochelle or magne- sium sulphate, or castor oil are used for this purpose. Salts Enema.- To from 4 to 6 ounces of Rochelle salts, or from 2 to 4 of sulphate of magnesia, add suffi- cient hot water to make a saturated solution. The enema MKDICATKD ENEMATA 128 is given at bedtime and followed in the morning by a suds enema. Castor-oil Enema.- Make an emulsion of castor oil by- adding to the quantity ordered an equal quantity of hot milk or hot strong coffee, and shaking well together in a corked medicine bottle, (iive slowly, like a nutritive enema, and follow by a suds enema in from one to four hours. Compound Purgative Enema.—An enema that has excellent results in relieving post-operative constipation without giving an aperient by mouth consists of magne- sium sulphate, 1 ounce, glycerin, 1 ounce, turpentine, \ ounce, in hot water, 4 ounces. Carminative enemata are used to dispel collections of gas in the bowel and so relieve distention. Turpentine, asafetida, and alum are the drugs most commonly used. Turpentine Enema.—First method: Beat with a knife from 2 drams to \ ounce of turpentine into a pint of a hot suds enema; give in the usual way, and follow, without removing the tube, by another pint or pint and a half of the suds enema. Second method: Add from \ ounce to 1 ounce of tur- pentine to 4 to 6 ounces of warm olive oil, mixing well with a knife or by shaking in a corked medicine bottle. Follow in from half to one hour with a suds enema. Asafetida Enema.—The milk or emulsion of asafetida, which contains 10 grains of asafetida in each ounce, is the preparation generally used. From 1 to 2 ounces are given in equal quantity of hot water at a temperature of 100° to 105° F. Other medical substances may be com- bined in the asafetida enema, as in the following formula, known as the compound asafetida enema: Milk of asa- fetida, 3 ounces; magnesium sulphate, 1 ounce; oil of tur- pentine, 30 minims; glycerin, 1 ounce. The enema is warmed by standing in hot water. It should be given high and slowly, and followed by a suds enema in about twenty minutes or half an hour. Alum Enema.—Alum, from 2 drams to \ ounce in 1 pint of hot water, is sometimes ordered for the relief of obstinate and dangerous distention. It must be used with caution on account of the poisonous properties of the drug 124 ENEMATA, ETC. when taken in large doses. If the enema is retained, it should be siphoned off after half an hour. To remove an enema by siphoning the rectal tube is passed and the free end lowered over a vessel placed at a lower level than the pelvis. Gelatin Enema.—In cases of hemorrhage from the stomach or upper bowel or other points where the bleeding point cannot be reached gelatin, which aids in the clot- ting property of blood, is frequently given as a rectal injection. The gelatin is dissolved in hot water until sufficiently thin to run through a tube, and from 4 to 6 ounces at a time given, generally every eight to twelve hours. Astringent Enema.—Astringent injections are most frequently given in the form of rectal irrigations or douches. An exception is the quassia enema for the destruction of seat-worms. An infusion is made from chips of quassia wood, a tree native to Jamaica, by pouring a pint of boil- ing water over one ounce of the chips (by weight). When cold, the water is strained off and injected cold. The bowel should first be cleared by a simple enema. Half a pint is given at a time, and the enema generally repeated daily until all the worms have been hatched out and destroyed. The enema is retained half an hour, the patient during that period being kept quietly lying down. If not re- turned naturally, it should then be siphoned off. Starch, Emollient, or Bland Enema.—A starch enema is used to relieve local irritation, to check diarrhea, and as a vehicle for the introduction into the rectum of drugs given in small doses, as, for example, the tinctures. The starch is cooked in the usual manner, by dissolving a small quantity in cold water and adding boiling water until it is sufficiently thin to run through the tube. When it has cooled to the normal bodily temperature, it is ready for use. When a drug is used, it is added, immediately before the injection is given, to about \ ounce of the starch; this quantity is first injected, and followed immediately by 2 ounces more of starch. By this means the risk of some of the drug being left in the tube is lessened. ENTEROCLYSIS 125 A starch enema containing from 10 minims to 1 dram of tincture of opium is used to check obstinate diarrhea. It soothes the local irritation, checks peristalsis, and allays pain. The poisonous properties of opium must be borne in mind, and close watch kept for the premoni- tory symptoms of an overdose, especially if ordered for children, who, it cannot be too frequently emphasized, stand opium very badly. As the starch does not flow easily, this enema is best given with an ordinary glass or a ball syringe attached to a short length of a rectal tube, a method that may also be employed in giving either an oil or a nutritive enema that proves difficult to inject in the usual way. Other drugs, ordered in larger doses, when given by rectum, are dissolved in warm (not hot) water or warm milk. The quantity of fluid should not be more than two or three ounces; the drug is dissolved in half the quantity, and that half given first, the remainder follow- ing immediately. Sedatives, such as bromid, chloral, chloralamid, trional, etc., are given in this way. As in administering narcotics in any form, the patient must be composed for sleep before a sedative enema is given. ENTEROCLYSIS Enteroclysis, or intestinal irrigation, by which is meant the flushing out of the lower bowel with a quantity of fluid, is a form of treatment used in many conditions. The more important are as follows: in the treatment of intestinal disorders, especially those associated with chronic diarrhea or chronic constipation; for the destruction of seat-worms; as a local application to the mucous mem- brane; as a disinfectant to the bowel; to restore fluid to the body after hemorrhage; as a general stimulant in conditions of shock and collapse; and to reduce high temperature. The irrigation is continued for a specified time—usually from five to fifteen minutes; in some con- ditions a continuous irrigation is ordered to be maintained for many hours. The quantity ordered may vary from a couple of pints to several quarts. The greater portion 126 ENEMATA, ETC. of the fluid is returned at once, though a certain amount is necessarily absorbed. The patient lies on the back or on the left side, unless specially ordered in the knee-chest position (p. 191). In giving an enteroclysis a second rectal tube is generally used to carry off the return flow. The irrigating tube is connected to the douche-can or bag containing the fluid, while the second or return tube is attached to a piece of tubing sufficiently long to carry the fluid to a bucket or convenient receptacle placed lower than the pelvis. The return tube is introduced only a few inches up the rectum. A bed-pan or douche-pan is placed under the patient, as some leakage of the fluid is very apt to take place from the anus. If the fluid does not return easily, the return tube is removed and the free end of the irri- gating tube lowered over the bucket. In this way the contents are siphoned off. The enteroclysis may also be given adequately by in- jecting a pint at a time and siphoning off the amount. Special double tubes can be obtained to be attached to the rectal tube, and connected by separate arms to the irrigating and return-flow tubes. If such a tube is used, the lower or return-flow tube should be clamped while the fluid flows in, otherwise there is some risk that the fluid may return immediately without irrigating the bowel. An enteroclysis should be given slowly and without force. The funnel or douche-can should be about two feet above the body. To assist in sending the irrigation as high as possible, the pelvis should be raised higher than the shoulders. Plain sterile water, normal salt solution, and either astringent or bland solutions are used for enteroclysis. Normal Salt Solution.—At a temperature of 100° to 105° F. enteroclysis of normal salt solution is used to cleanse and disinfect the bowel in many diseases of the intestine; to restore fluid to the body after severe hemor- rhage; and to allay thirst after abdominal operations: given cold (70° to 60° F.), it is employed to reduce bodily temperature, and hot (110° to 120° F.), as si general bodily stimulant in conditions of shock or collapse. In ENTEROCLYSIS 127 these cases the enteroclysis must be given with caution, and the pulse as closely watched as when heat or cold is applied to the body by any of the methods described in the previous chapter. Astringent Enteroclysis.—Tannic acid, half a dram of the crystals to the pint of water, is the most commonly used astringent in the treatment of various diseases of the intestines associated with diarrhea, and especially in the treatment of infantile enterocolitis. In the latter case from 1 to 4 pints, 5 to 10 grains to the pint, is given once a day, care being taken to siphon off the injection if it does not return freely. Nitrate of silver (10 to 20 grains to the pint—adult) is also ordered in cases of dysentery. The temperature usually ordered for an astringent entero- clysis is the normal bodily temperature, but in some cases (dysentery, cholera) it is especially ordered cold. The treatment may be ordered daily or two or three times a week. Bland Enteroclysis.—The bland enteroclysis is ordered as a local application in chronic irritated or ulcerated con- ditions of the intestinal mucous membrane, especially of the rectum. Flaxseed tea, barley-water, and thin gruels are used, from 1 to 4 pints being given once a day or on alternate days, generally at the normal bodily temperature. Flaxseed Enteroclysis.—Pour 1 quart of boiling water over 2 ounces of flaxseed (use the seeds and not the meal), stand in a warm place until thickened, then cool to the desired temperature, and strain. Use undiluted. Barley-water.—Wash 2 ounces of pearl barley in cold water until clean, and strain off the water. Pour over the barley 2 quarts of boiling water, simmer until reduced to 1 quart, cool and strain; use undiluted. Gruels.—Stir two teaspoons of oatmeal flour in a pint of cold water, bring to the boil, and boil ten minutes, stirring all the time. Cool and strain; dilute if too thick to run through the tube. The bland enteroclysis may be ordered high or low, according to which part it is desired to subject to the treatment. 128 ENEMATA, ETC. A nurse may be required to get a patient ready for colonic flushing, often inaccurately called abdominal flush- ing. Normal salt solution at a temperature of 100° F. is generally used, and the flushing given with a small-sized stomach-tube, well lubricated and passed high up the colon. The patient is placed in the knee-chest position and covered with an examining sheet (p. 191). The operation is both a trying and a tiring one. Everything to be required should be at hand before beginning, so that the nurse is free to give all her attention to the patient. CONTINUOUS RECTAL INFUSION OR SEEPAGE A continuous flow, usually of hot normal salt solution (105° to 110° F.), into the rectum is a form of treatment after some major abdominal operations and in other conditions of lowered vitality. A douche-can containing the fluid is attached to the head of the bed, a very little higher than the patient's pelvis. The tube is loosely knotted or partially clamped, so that the fluid flows drop by drop. The can must be closely covered to retain the temperature, and the bed protected with a rubber sheet in case of oozing. A special short rectal tube of hard rubber with an olive-shaped expansion at the nozzle is generally easily kept in place. At one hospital a large-sized " ther- mos" bottle is ingeniously used for the purpose of seepage. The cork is fitted with two pieces of glass tubing, to one of which the tubing is attached, the other introducing the necessary air to cause the solution to flow. The bottle is attached to the railing at the head of the bed, a few inches higher than the mattress. The method is simple to handle, and has the advantage of keeping the solution at the required temperature. The fixed position the rectal infusion entails makes it a trying process for the patient. Whether in the recumbent or the upright position, every effort must be employed to make him as comfortable as possible by a judicious arrangement of pillows, etc. SUPPOSITORIES 129 SUPPOSITORIES A suppository is a solid, conical preparation, about an inch long, for introducing small doses of drugs, concen- trated foods, or local applications into the rectum, vagina, or, more rarely, the urethra. They are usually made with cocoa-butter, which melts at the bodily temperature, setting free the drug contained. A rectal suppository should be lubricated with oil and passed as far into the passage as the finger will reach, the patient lying on the left side. The finger should be protected by a finger-cot and also lubricated. Drugs are administered in this way either for general systemic effect or for local action. Drugs frequently given in this way are morphin, opium, cocain, gall, lead, tannin, and iodoform. To keep them from melting, suppositories should be kept on ice. Glycerin jelly, in the form of a suppository, is frequently used as a remedy in mild forms of constipation due to muscular inertia of the lower bowel, for which purpose also a suppository of white household soap is effectual. To make the latter, cut a splinter of soap and wash it in hot water until it is smoothly rounded. It may be about three inches long and shaped like a pencil. An ice suppository may be ordered for local hemorrhage or to relieve local inflammation. A lump of ice of suitable size and shape is washed until all sharp corners are rounded off, and introduced by the finger into the rectum. In treating local hemorrhage the suppository is repeated at short intervals. Suppositories larger in size are also used for introduction into the vagina, and are a form of application frequently used in treatment of the cervix uteri. In giving a vaginal suppository the patient lies on her back with the knees flexed; the suppository is inserted as far as the finger can be introduced. Smaller suppositories are also made for urethral applications, but are not so generally employed. They are shaped like a fine pencil and are inserted as far as they can be pushed from the outside. 9 130 ENEMATA, ETC. DOUCHES A douche is a local bath of running water, and is used as a means of applying treatment to the various cavities of the body. A douche maybe used to cleanse the cavity- free of discharge, to apply heat or cold to inflamed sur- faces, to arrest local hemorrhage, or to apply medicinal treatment to the parts. The parts to which douching is applicable are the vagina, uterus, bladder, the nose, the ear, and the conjunctival cavity or sac. Vaginal Douche.—The vagina is a passage or cavity situated between the bladder and urethra in front, and the rectum behind, and curves backward, upward, and finally slightly forward. The length of the anterior wall is about four inches. It terminates in a dome or pouch from the center of which the cervix or neck of the uterus hangs free. The walls of the vagina are capable of enor- mous distention. When not distended, the mucous mem- branous lining lies in numerous folds, which readily form a lodging-place for secretions or discharges. In giving a vaginal douche, even for simple cleansing purposes, everything used should be scrupulously sterile. The special reason for this is that in many conditions the cervix is slightly relaxed, in which case there is some danger that a portion of the douche may be washed into the cervix, and so on into the uterine cavity. It will be remembered that the uterine cavity has two openings at the fundus, one into each Fallopian tube, the fine terminations of which open directly into the peritoneal cavity and form thus a direct channel of communication from the mouth of the vagina to the peritoneal cavity, the largest and most im- portant closed cavity of the body. We remember that these closed cavities present ideal conditions for the de- velopment of bacteria, and a douche carelessly prepared or administered may be the means of introducing bacteria into the peritoneal cavity, and setting up septic peritonitis. While the percentage of such accidents is very small, no patient should be allowed to run the most remote risk. For the same reason, in giving the vaginal douche, no force of water should be used; the can or receptacle for the water should not be elevated more than two feet, and where DOUCHES 131 infectious discharges are present, it should be held just sufficiently high to allow the water to flow. The douche is usually given from a douche-can of enameled iron, to which is attached a piece of tubing of sufficient length connected with a vaginal nozzle. The vaginal nozzle is usually of glass, about 6 to 8 inches long, and curved to follow the line of the vagina: the end is rounded, with perforations at the side, which prevents the stream of water being directed immediately on to the cer- vix. Can, tubing, and nozzle are sterilized, usually by boiling, immediately before use. The patient is placed in the dorsal position (p. 189) on a douche-pan, the knees drawn up, and the pillows removed; she is covered with a single sheet, and the night-dress rolled out of the way. In this way she lies with the pelvis slightly elevated. The douche-pan is a flat receptacle of porcelain or enameled iron, differing somewhat in shape from a bed-pan, and of a larger capacity: it may be made more comfortable if a small pillow or folded towel is placed where the back rests. If there is any discharge, the external parts should be carefully cleansed before the douche is given, using either hot sterile water or boric solution (2 per cent.). As in the case of a rectal injection, air must be excluded by filling the tube and nozzle before starting the douche; some of the fluid also should be run over the back of the hand until it runs hot, the first flow being chilled by running through the cooler tube. The sheet is turned back to the knees and a sterile towel laid across the pubes: the nozzle is then gently introduced for about 6 inches, and the douche given without removing it. The vagina not being guarded by a sphincter, the douche returns easily by the side of the nozzle, and a continuous flow is kept up. As the fluid dilates the cavity the walls of the vagina are stretched and cleansed and the cervix lies in a continual bath, while the adjacent parts receive the benefit of a hot application. When the douche is over, the nozzle is removed and the patient dried with the sterile towel. A douche is generally given at a temperature of from 105° to 110° F. and higher (115° to 120° F.).if ordered for the arrest of local hemorrhage. Very rarely it is ordered cold. 132 ENEMATA, ETC. The thermometer used in ascertaining the temperature of sterile solutions should be kept in alcohol or an antiseptic solution and handled only with freshly sterilized hands or forceps. Sterile water, normal salt solution, or a mild antiseptic is usually employed for douching. Boric acid is the mildest antiseptic and probably the most frequently used, in a 2 per cent, solution. (See Solutions.) Stronger antiseptics, such as carbolic or bichlorid of mercury, if ordered, are used at from one-half to one-fourth the strength used for the external surfaces; again on account of the risk of reach- ing the uterine or peritoneal cavities, and their absorption into the system through these channels. A douche of tin1 bichlorid of mercury, 1 : 4000, has been known to produce symptoms of general mercurial poisoning. The A B C douche in common use in some hospitals contains alum, 1 ounce; boric acid, 4 ounces; carbolic acid crys- tals, 3 drams; oil of peppermint, \\ drams; two drams of the powder are added to one quart of sterile water. The quantity used for a douche varies—commonly one to two quarts once or twice a day are ordered. Intra-uterine Douche.—The intra-uterine douche is never ordered as a matter of routine treatment, and is, except in grave emergencies, always given by the physician. Unless for an immediate emergency, such as a uterine hemorrhage, when every moment is valuable, the parts are usually prepared as carefully as for a vaginal or uterine operation, the strictest asepsis being observed throughout. The patient should void her urine before the preparation is begun. The external parts of the vagina are washed with green soap and hot sterile water, followed by a hot vaginal douche, usually of bichlorid of mercury, 1 : 5000. To cleanse the vagina pledgets of gauze are used on a pair of long curved forceps known as uterine dressing forceps. The thigh and pubes are covered with sterile towels or by an examining sheet. Under the patient is placed a Kelly pad (p. 548), covered also with a sterile sheet, and with the apron directed into a bucket. As it is necessary to have the vagina in a good light, the patient, if the douche is given in the room, lies in the dorsal (p. 189) DOUCHES 133 position across the bed, the buttocks brought to the edge of the mattress; the legs are flexed and supported at the knee and heel by two assistants. A sterile gown and gloves are usually worn by the operator. A speculum (p. 196) is passed into the vagina and adjusted until the cervix is seen in a good light, and the douche nozzle is then passed without force into the cavity of the uterus as far as the fundus, a distance of between 2 and 3 inches from the cervix in the non-gravid uterus. The nozzle must be full when passed, and the first chilled fluid have been carefully run off. The temperature of the douche is usually 115° to 120° F. Special long curved douche nozzles are used for the intra-uterine douche; if none are available, the female glass catheter is often substituted. After the douche a sterile perineal pad is applied; in some cases the vagina is lightly packed with sterile gauze, the packing remaining until the next day. The return flow of the intra-uterine douche should never be thrown away until inspected by a responsible person. All shreds, etc., it may contain should be saved and shown to the physician. When given immediately after parturition for the arrest of hemorrhage, the procedure is more simple, as the cervix is not only already dilated, but obliterated, the mouth of the uterus being as wide as the cavity, and the parts have generally been kept sterile. In this instance, if alone with t he case, a nurse may have to act for herself. The hands and arms must be thoroughly disinfected, and the hands, if possible, covered with rubber gloves. The vaginal douche nozzle will pass easily, and should be directed backward and then forward in the line of the birth-canal until the fundus is felt. The douche is given at a temper- ature of 120° F. It acts by exciting uterine contractions and so closing the large, open uterine blood-vessels. In this instance, while giving the douche with the right hand, the left hand should apply massage to the fundus through the abdominal wall in order to help in exciting uterine contractions. It must then be remembered that only the right hand is sterile. When it is desirable to enlarge the opening to the vagina, 134 ENEMATA, ETC. either for purposes of cleansing, to apply treatment, or for examination of the cavity, a speculum is passed (p. 190). In passing the vaginal speculum the patient may lie equally conveniently on her left side or on her back. The Nasal Douche.—Except for cases of chronic nasal discharge, the nasal douche is not at the present greatly used. For other affections the spray is preferred. In giving it the usual douche-can may be used, and the tub- ing attached to a special nasal nozzle, or the douche may be given with a rubber-ball syringe fitted with a fine nozzle. The douche-can should be elevated just sufficiently high Fig. 28.—Nasal douching with fountain syringe (Manhattan Eye, Ear, and Throat Hospital nursing book). for the water to flow; the usual precaution of filling the tube and nozzle before beginning must be observed, and the first chilled flow run off. A basin for the return flow is held below the chin. The head of the patient should be bent forward and his mouth open; the tip of the nose is tilted upward, and the nozzle introduced directly back- ward. In this position the fluid enters at one nostril, irrigates the posterior nares, and returns through the other nostril. Each nostril is treated in turn. A child may be told to breathe audibly during the process through his mouth. This will prevent his swallowing the douche or DOUCHES 135 choking. Usually the douche is given at a temperature of 105° to 110° F., and consists of sterile water, normal salt solution, or some mild antiseptic or astringent solution. If given to arrest hemorrhage, as after some local operation, or in persistent epistaxis, the nasal douche may be ordered ice cold, or contain some styptic, such as iron, tannin, or adrenalin. More commonly, styptics are applied by spray or direct application The Ear Douche.—To give an ear douche properly is a delicate matter and one not often intrusted to the pupil nurse. At the end of the short auditory canal is the deli- cate tympanum or drum, upon the integrity of which de- pends largely the power of hearing, the sound-waves be- ing transmitted through its vibrations to the middle ear. In a normal condition it is kept in a state of equal tension by pressure of air on either side—air which enters from the auditory canal externally, and internally through the Eustachian tube at the back of the throat to the cham- ber of the middle ear. If this even relation is altered, as, for instance, from the blocking of a Eustachian tube, we get deafness resulting. A volume of water directed against the tympanum from one side must immediately alter the evenness of this pressure, and if directed with sufficient force or violence, may injure or even permanently impair the delicate membrane. A small douche-can and tube may be used, placed only a few inches higher than the ear, but usually the douche is given either with a glass or ball syringe of soft rubber- The douche commonly used is boric-acid solution (2 per cent.). The temperature of the douche is usually from 100° to 105° F., the skin being more sensitive to heat than is the mucous membrane. The patient sits with the head erect in a good light, the clothing protected by a small rubber sheet and towel laid round the shoulders and pinned round the neck. Under the ear is held a small basin, kidney-shaped, if it is procurable, for the return flow. The auricle or outer ear is held slightly backward and upward in giving the douche, which brings the auditory- canal in a straighter line with the irrigating nozzle. The 136 ENEMATA, ETC. nozzle must not be pushed beyond the opening of the audi- tory canal and the irrigation be carried out very gently. When it is finished, any moisture is sopped up from the canal with small pledgets of cotton, changing them until perfectly dry. A small dry pledget is generally left tem- porarily in the ear. The ear is douched for the removal of discharges, in inflammatory conditions, to allay pain, and for the removal Fig. 29.—Syringing an ear (Manhattan Eye, Ear, and Throat Hos- pital nursing book). of impactions of wax and of foreign bodies, in which latter condition the procedure is a little different. (See Foreign Bodies, p. 671.) The facility with which the ear may be injured by careless douching cannot be too greatly em- phasized. The Eye Douche.—Few details of nursing are more important and more often inadequately performed than the eye douche. The purpose is thoroughly to irrigate every corner of the conjunctival sac; in point of fact, the DOUCHES 137 average douche does little beyond cleansing the surface immediately behind the margin of the lids. The conjunc- tiva may be described as beginning at the margin of one lid, lining the lid, doubling back to cover the eyeball, and again folding to line the second lid, at the margin of which it terminates. By thus folding, the conjunctiva presents two surfaces which are continuously rubbing together. If the margins of both lids are picked up separately and held away from the eyeball, a small pouch is formed lined entirely by the conjunctiva. This constitutes the con- junctival sac. If irrigation is attempted while the lids lie against the eyeball, the upper and lower corners of the sac are not reached. The upper lid first should be held well away from the eyeball, taking the margin gently between the finger and thumb, and the douche thoroughly administered. The lower portion of the sac can be thor- oughly opened by pulling the loose tissue of the under lid gently down against the cheek bone. The stream should be directed from the inner corner of the eye outward. The patient may sit on a chair with the head held backward and slightly to the side of the eye under treatment, a basin being held conveniently to catch the overflow. A small douche-can with about three feet of tubing fitted to a medicine-dropper or fine glass nozzle is generally used, though a small rubber ball syringe is also practical. A glass syringe may be used, but has the disadvantage that it takes two hands to fill it. Some small sterile cotton or gauze sponges are required to cleanse the lids and dry them after the douche, each sponge being used only once and discarded. If both eyes are to be treated, as in in- fectious cases, a second nozzle or syringe should be used to avoid infecting one eyre from the other, and the hands should be thoroughly rinsed in bichlorid of mercury so- lution between the treatment. Strict asepsis must be observed. In douching before or after an operation the douche-can should be elevated about 6 inches: where purulent discharge has to be washed away, a height of from 12 to 18 inches is generally ordered. Force must not be used. The only instance ii?. which force is beneficial is where highly irritating matter, such as quicklime, has 138 ENEMATA, ETC. got into the eye. In these cases frequently the only im- mediately available treatment is to hold the eye open under a faucet of running water. (See Emergencies, Chapter XIX.) In irrigating an infant's eye the nurse, seated on a low chair, should hold the baby across her lap, the head at the edge of the knee, with the face turned from her. Rolling the babv in a small blanket will pinion the arms and prevent struggling. A piece of rubber sheeting with a circular piece cut out of one end is fastened round the baby's neck so that the clothes are protected, and at the same time the cheek rests on the rubber. The free end of the sheeting is caught into a clean vessel on the floor. The nurse has then both hands free—one to open the lids, the other to manipulate the nozzle. In order that dis- charge may not run across the nose from one eye to be other the head must be turned toward the side of the eye to be treated. The nozzle is directed toward the inner corner, so that the discharge is washed outward. If only one eye is to be treated, the sound eye should be pro- tected by a sterile pad or covered with a watch-glass during the process. In the case of ophthalmia neonatorum, the ophthalmia of the new-born, when want of thoroughness may result in permanent blindness, it should be a strict rule that the douching should be done by two nurses. To open the swollen lids thoroughly takes one pair of hands en- tirely, and it is of the first importance that every corner of the sac should be freely exposed to the douching. TAMPONS The Vaginal Tampon.—The tampon is, at the present day, not in constant use; a nurse should, however, be instructed how to prepare and how to insert one. Tampons are usually made of absorbent cotton, cut into strips three inches wide, rolled tightly into little bolsters, and tied round the center with securely knotted silk or string, the ends of which are sufficiently long to come beyond the mouth of the vagina when the tampon is in position. Two or three may be tied a few inches apart TAMPONS 139 on one string, forming what is known as a kite-tail tampon. The tampon is sterilized and usually saturated with gly- cerin (sterile), 1 part, to sterile water, 2 parts, but it may also be soaked in any solution which it is desirable to apply to the parts. Strict aseptic technic is, of course, to be observed. To introduce the tampon the patient lies on her back with the knees flexed and separated; the speculum is passed and held in position with the left hand. The tam- pon is then taken by the right hand in a pair of long for- ceps,—those usually called uterine dressing forceps,—and passed up to the pouch-like cavity between the cervix and the posterior vaginal wall. The speculum is withdrawn, and the ends of string looped together and laid just inside the vagina, where they will not be soiled by urine, etc. A record must always be made on the chart of any tampon inserted in the vagina; if more than one, or a kite-tail tampon is used, the number must be noted and carefully counted on withdrawal. The withdrawal also should be noted on the chart. The withdrawal is done by gently pulling on the strings, and presents no difficulty. If the tampon is for continuous treatment it is changed daily, and usually given in connection with a daily douche. To Pack a Vagina.—This is not often left to a hospital nurse unless in small hospitals, where there is no resident medical staff. She should, however, be taught how to do it in case of just such circumstances. Under strict aseptic precautions the speculum is passed, the patient lying on her back in a good light, with the knees flexed and separated; a long strip of sterile gauze or a narrow gauze bandage is then packed into the space between the cervix and vaginal walls, using a pair of uterine dressing forceps and playing out the packing inch by inch. The rest of the cavity is then packed, withdrawing the speculum gradually. If more than one strip is used, the number must be recorded on the chart and counted when they are removed. If, on removal, any odor is noticed on the packing, it should be reported at once, when an anti- septic douche will generally be ordered. It should not, however, be given without special orders; the conditions 140 ENEMATA, ETC. which necessitate packing would frequently not be bene- fited by the relaxation of the parts by douching. CATHETERIZATION A catheter is a slender hollow instrument of small cal- iber, open at either end, used in the treatment of certain tube-like passages in the body or of the cavities to which the passages lead. The hollowness of the instrument permits the evacuation of the contents of the cavity, and of the introduction of certain forms of treatment, such as douching, etc. The catheters in most common use are those for introduc- tion into the bladder through the urethra, and are what are implied when the word catheter is used unqualifiedly. Those used for a female patient are made of glass, silver, soft rubber, or hard rubber. The glass catheter is gener- ally preferred, being easily cleaned or sterilized and in- expensive. It is about 6 inches in length and J inch in diameter; the tip is solid, rounded, and slightly bent, with an opening or eye on one side. If a less rigid instrument is desired, as after an operation on an adjacent part, the soft-rubber variety is substituted. Soft-rubber or gum-elastic catheters are about 12 inches long, and come in various sizes; the sizes are indicated in numbers printed on the catheter. Three scales of number- ing are in use—American, English, and French; it is CATHETERIZATION 141 important in ordering catheters to mention which scale is intended, as each is different. A pupil should not be trusted to pass a catheter until she has had some instruction in the principles of asepsis, and been carefully taught the technic of this particular process. It is recommended that a list of the articles required for catheterization with simple directions for the technic to be observed should be written down and hung in some readily available position (Chapter XIV). Time is saved if a tray is kept in readiness with all the articles neces- sary. Such a tray should contain: 2 towels, ■) 6 gauze sponges, >• Sterile, in sterile wrappers. 1 small flat bowl (to receive the urine) ) 1 bowl of hot boric lotion (2 per cent.) for cleansing the parts. 2 glass catheters (boiled five minutes and placed in the boric lotion). 1 large bowl or graduate measure of sufficient capacity to contain all the urine. A bowl of hot antiseptic lotion (bichlorid of mercury, 1 : 2000, etc.) must also be prepared, in case the nurse accidentally breaks the technic. The hands are prepared according to the ward formula (p. 484, formula B, in ordinary circumstances); gown and gloves are not usually required. Before cleansing her hands the nurse prepares her tray, unpins the sterile wrappers, and places everything in readiness by her patient's bedside; if she works alone, she must also place her patient in position, covering her tem- porarily with a single sheet, which the patient can herself usually turn out of the way when the nurse is " clean," the sheet not being, surgically considered, " clean." A second nurse, when available, should, for the patient's comfort, carry out this part of the technic so as to avoid the necessary waiting. The patient lies on her back, with the knees drawn up and separated; the night-dress is rolled up round the waist, the heavier bed-clothes, for convenience, turned back over the feet. The covering sheet is turned back to the knees just sufficiently for the necessary exposure. The 142 ENEMATA, ETC. sterile towels are arranged one across the pubes, one on the bed below the vulva; the small sterile basin is placed close to the vulva, to receive the urine, which is emptied, as required, into the larger bowl. The sterile area must be kept sterile during the entire proceeding. To pass the catheter the nurse stands on the right of the patient; passing her left hand between the knees, over the pubes, she separates the labia and with her right hand thoroughly cleanses the parts of all secretion, using the sponges wrung nearly dry in the hot boric lotion. The opening of the urethra (urinary meatus) is seen as a small round depression or " dimple " with slightly raised edges immediately in front of, or, as the patient lies, above, the larger opening of the vagina. The catheter is taken in the right hand and introduced into the urethra, pushing it gently forward a few inches until the urine flows, and no further; no force must be used. When the urine stops, the catheter should be withdrawn slightly, when the flow will probably begin again; as the bladder empties the level of the urine may be lower than the edge of the catheter, so that the first stopping of the flow does not necessarily mean that the bladder is quite empty. When no more urine comes, the catheter is withdrawn, keeping the finger over the free end of the catheter in order not to lose the last small quantity remaining in the catheter: being the last left in the bladder, it is often of special diagnostic importance. The vulva is then once more sponged and dried with one of the sterile towels, after which the nurse rinses and dries her own hands and arranges her patient comfortably. When catheterization is ordered for the relief of an over- distended bladder, the entire quantity should not be with- drawn at one time, some being left in the bladder, which is, if necessary, removed later by catheter. The tumor formed by a distended bladder may be observed through the abdominal wall. When empty, the bladder lies behind the pelvic bone. The greatest care must be taken to keep the catheter clean during the entire proceeding; that the catheter should C ATH ETERIZ ATION 143 be clean and strictly sterile is the most important part of the technic. If it becomes soiled with blood or vaginal secretion, it is not enough to rinse it clean in solution: the catheter must not be used unless resterilized by washing and boiling. It is, for this reason, a wise precaution always to prepare more than one catheter each time. Where any- vaginal discharge is present, a gauze sponge must be held over the vaginal orifice during the whole operation. After an operation on the perineum or adjacent parts nurses are usually required, in passing the catheter, to wear a gown and gloves, and the hands are prepared by a stricter formula (p. 484, formula A). An extra packet of sponges and a perineal pad should then be prepared. In these circumstances a soft-rubber catheter may be preferred to the rigid glass catheter. A rubber catheter requires to be lubricated with a very little sterile oil; with a glass catheter it is sufficient to wet the catheter in the boric solution. The nurse should observe the stream of urine closely. If blood, pus, or any sediment is present, it is of importance to know if such was mixed with the entire quantity of urine, or was present only- at the beginning or only at the end of the catheterization. She should observe whether the urine was passed clear or cloudy, and whether it changed in any way on becoming cool. (See Urine.) She may be directed to keep the first or last of the flow separate from the rest of the urine, in which case the desired specimen is passed from the catheter directly into a sterile test-tube, corked at once with sterile cotton. If a speci- men of the urine is required for examination, a sufficient quantity^ (6 ounces) is passed directly into a sterile bottle or jar and closely covered or corked with sterile cotton; a note must be made on the label that the specimen was obtained by catheterization. Where strict aseptic cleanliness is observed, catheteriza- tion is followed by no untoward consequences. Care- lessly performed, with impartially cleansed catheter or hands or imperfect technic, the simple process may be a source of infection by introducing germs or impurities into the bladder. The signs of such infection are rigor 144 ENEMATA, ETC. (or shivering), followed by high temperature, alkaline urine, and the general physical symptoms of a septic condition. The cystitis or inflammation of the bladder thus induced may last many weeks. A few patients are subject to shivering attacks of ner- vous origin after prolonged catheterization. Frequently this may be averted by covering the patient warmly dur- ing the operation and giving a glass of hot milk afterward. Bladder Irrigation.—The same technic as above is observed in irrigating a bladder, and catheterization is always performed as a preliminary proceeding. Irriga- tion is most simply performed with the double catheter, a catheter, that is, having a double channel and double opening, each opening having an independent short arm. They can be obtained in glass or metal, glass being pre- Fig. 31.—Double catheter for bladder irrigation. ferred. To each arm a piece of tubing is attached, one connected with a douche-can or a funnel, the other reach- ing to a convenient receptacle for the return flow. The return tube is clamped until the quantity that can be retained without pain has been injected into the bladder. The quantity is usually about half a pint. Sterile water or boric solution, 2 per cent., is generally used, at a tem- perature of 100° to 110° F., and 1 or 2 pints given at a time. The catheter must be filled before insertion and the fluid run off it until it runs hot. The douche-can should not be elevated more than two feet. When a double catheter is not attainable, the funnel and tube may be used. About half a pint (8 to 10 ounces) is injected first; the tube is then lowered, and half the quantity siphoned off; injections of 4 or 5 ounces are re- peated and siphoned off until the bladder is sufficiently CATHETERIZATION 145 irrigated. In order to keep the tube filled with fluid it must be carefully pinched between the siphoning and the injection, but even with this precaution, it is difficult to avoid introducing air into the bladder unless the catheter is reinserted each time, which is obviously undesirable. The Guarded Catheter.—After operations on the bladder or adjacent parts, it is sometimes necessary to leave a catheter permanently in place. In order that it should not slip, a special rubber catheter may be used, made with an enlargement just below the eye, usually shaped either like an arrow-head or a button. To insert or withdraw such a catheter the enlargement is for the moment obliterated by stretching the upper part of the catheter tightly over a long dressing probe or similar in- strument, and passing it while still stretched. As soon as the tension is removed by withdrawing the probe the shape is resumed. The catheter is connected by a glass connection tube with a piece of tubing, which may be in- serted in a bottle tied to the frame of the bedstead; it is removed at least once in twenty-four hours, cleansed, ster- ilized, and reinserted. As the eye of the catheter may easily become blocked, especially after operations where small blood-clots may be present, it is always necessary in these cases to keep close watch that the urine is flowing regularly. To pass a guarded catheter or to pass a catheter over a surface where tissues have been stitched requires a great deal of skill, and should never be intrusted to young, in- experienced nurses. All nurses should also be taught to pass the catheter with the patient lying on her side, a position which presents no real difficulties. Where a fixed position is necessary, it may be impossible to turn the patient, even for so short a time, on to her back. After use, a catheter must be immediately washed under a running stream of cold water, since hot water would coagulate any albumin which might be present, then washed in hot soap and water, and boiled for five minutes; before use it is again sterilized by boiling. (See Care of Catheters, p. 462.) The Male Catheter.—To pass a male catheter is not 10 146 ENEMATA, ETC. taught to pupil nurses, and is never included in the duties expected of a nurse. On the very rare occasions in which an emergency should force this duty on her, she should employ the same careful technic taught her in passing the female catheter. A soft-rubber catheter lubricated with a sterile lubricant is used. The penis is washed (boric lotion, 2 per cent.) and the foreskin gently pushed back. The glans and meatus are then cleansed. Holding the penis rather more than halfway between horizontal and perpendicular, the cath- eter is gently inserted and pushed forward. If resistance is met, as usually happens, force must on no account be used; if the catheter is held in position for a short time and again gently pushed forward, it will, in ordinary con- ditions, slip into the bladder. If it cannot be passed without force, the attempt must be abandoned; matters will not be improved, and serious harm is easily done. LAVAGE In certain conditions, such as in cases of poisoning, or in the treatment of some diseases of the stomach and for purposes of diagnosis, it becomes necessary to remove the gastric contents and thoroughly to irrigate the stomach. The process is known as lavage. A rubber tube of fairly large caliber and a yard or more in length is used. The special tubes sold for the purpose are of non-collapsible soft rubber; the end for in- sertion is conical, with an opening in the center; the other is furnished with a funnel. The tubes come in several sizes, which are numbered according to French, English, and American scales, like the soft catheters. A mark 18 inches below the insertion end of the tube indicates the length to be swallowed. The operation is carried out most conveniently with the patient seated on a low chair, but in many circumstances the recumbent position is necessary and presents no real difficulty. If a lavage is given quietly and skilfully, there should be no mess; it is well, however, in case of accident to protect the clothing with a rubber sheet, and to have a second also on the floor. A bucket LAVAGE 147 is required to receive the contents of the stomach, and a pitcher of a suitable size for pouring with one hand contains the fluid for the lavage. The tube is moistened with hot water or lubricated with glycerin (oil is unpalatable), and passed to the back of the tongue. If the patient remains quiet and will help by swallowing, the tube then slides easily over the epiglottis into the esophagus by way of the phar- ynx and so into the stomach. From 18 to 20 inches of the Fig. 32.—Lavage, first step. Introduction of tube (Crandon). tube are sufficient to reach the stomach. Many patients, however, struggle violently, and to pass the stomach-tube requires patience and skill. If the patient is unconscious, the tube should be left in position a few minutes after passing, to make certain that it has not by accident been passed into the trachea, where, if the lavage was given, the patient would be instantly drowned. If the patient breathes naturally and does not become cyanosed, and if it is ascertained, by holding the tube against the cheek, that 148 ENEMATA, ETC. no air is being breathed through the tube, all is well and the operation can proceed. To pass a tube into the trachea is an extremely difficult thing to do, and were it not that such accidents are on record, the warning would seem to have little practical significance. The danger, however, must not be overlooked. The funnel is held about one foot above the patient's head, and as much water is poured into the stomach as it will easily contain. This varies from \ pint to 2 pints, according to the age of the patient; Fig. 33.—Lavage, second step. Tube in stomach; wash-water being poured into funnel (Crandon). a still larger quantity is used if the stomach is dilated. The funnel is then lowered over the bucket, and the con- tents of the stomach in this manner siphoned off. The process is repeated usually until the water is returned per- fectly clear. In some cases of chronic gastritis or dilata- tion of the stomach several gallons may be used at one time. LAVAGE 149 In some chronic affections of the stomach lavage is given as a regular treatment; it should then be performed daily before breakfast. Warm sterile water is generally used for regular treatment, or warm normal salt solution. A weak solution of nitrate of silver (1 : 5000 to 1 : 10,000 of plain sterile water) is ordered in many chronic conditions. For acute indigestion bicarbonate of soda (30 grains to a quart of water) is efficacious. If the lavage is given for Fig. 34.—Lavage, third step. Suction and siphonage (Crandon). the removal of poisons from the stomach, the lavage will probably contain an antidote to the drug. (See Poisons, Chapter X.) (For Test-meals, see Chapter VII, p. 218.) It is a nurse's duty to see that all the details of a lavage are accurately charted, such as the amount used before returning clear, etc.; in cases of suspected poisoning the gastric contents must invariably be saved for inspection. 150 ENEMATA, ETC. GAVAGE Gavage, or forced feeding, is resorted to in those con- ditions when, from circumstance or existing impediment, a patient cannot be fed in the natural way: for example, in feeding insane patients who refuse their food, in tetanus where the jaws are locked, after some operations on the jaw, in feeding unconscious patients, and sometimes in cases of extreme weakness, where to feed otherwise causes a struggle exhausting to the patient. Where the stomach-tube can be passed, a short stomach-tube and glass funnel may be used, but usually nasal feeding causes less disturbance to the patient. NASAL FEEDING A soft-rubber catheter attached to a funnel, the most practical of which is the barrel of a large glass syringe, is passed through the nostril straight backward to the back of the throat, and thence to the esophagus and stomach. The catheter may be lubricated with glycerin or simply wet with water. When in position, a few moments are allowed to elapse until any reactionary retching induced has passed, and also to make certain the tube is in position, and the food in liquid form is poured down the funnel. The food should be given slowly, the flow being easily regulated by pinching the tube. Milk, eggs, thin strained broths, beef- juice, or beef-essences may be administered in this way. The feeding is generally repeated every three or four hours. After the food is administered the catheter is quickly withdrawn, unless, as may be ordered in certain conditions, the tube is left in position. When this is the case, a strand of silk is threaded through the tube and looped round the ear. To pass the tube for nasal feeding is not difficult, but must be done with watchful care. The tube is apt to curl on itself at the back of the throat; if the fluid is poured down while in this position, it escapes into the mouth, causing choking, gasping, and the consequent almost certain introduction of some of the fluid into the trachea. A sufficient quantity would drown the patient at once, but even a very small quantity has dangerous re- NASAL FEEDING 151 suits. No digestion goes on in the trachea or lungs; food, therefore, that lodges in any part of the respiratory tract undergoes decomposition, which may result in septic pneumonia. The finger should be passed to the back of the tongue after the tube is inserted, to make sure it is in the right position. In giving a feeding it is not necessary that the tube should reach as far as the stomach. If it is merely passed 3 or 4 inches into the esophagus, there is less risk of excit- ing regurgitation. The possibility of passing the catheter into the trachea must again be borne in mind, as to give the feeding in this position would cause instant death by drowning. Unless unduly flustered by nervousness, it would be nearly im- possible to overlook the symptoms enumerated above, caused by such an accident. The risk of accidents is lessened by turning the head during the entire process to one side, or, if the patient is in a chair, by keeping the head bent slightly forward. With irritable, semiconscious patients in conditions of serious weakness nasal feeding is generally less exhausting to them than any other method of feeding. Especially is this the case with young children or infants too feeble to suck. In giving nasal feeding to an infant it should be laid across the knees, the head turned slightly with the face away from the nurse, and the tube introduced in the nostril uppermost. In many people the bony cavity of one nostril is larger than the other; if any difficulty is encountered in passing the tube, it may be removed and inserted in the other nostril, and in most cases is then easily passed. CHAPTER V TEMPERATURE.—PULSE.—RESPIRATION.— CHARTS TEMPERATURE By the temperature of the body we mean its degree of heat. Normally, this is 98.5° F., that is to say, higher than the atmosphere in which the average human being can live with comfort. This temperature is maintained by the perfect balance between the heat-producing and heat- losing properties of the body. Heat in the body is the result of chemical changes in the tissues. The production of heat is increased by the digestion and absorption of food and by exercise. Heat is lost through the skin surface by evaporation, by perspiration, and through the lungs by expired air. Some of this loss is checked by clothing. A deviation from the normal temperature means a devia- tion from the normal condition of the body, though in health there is a fractional degree of difference between the temperature taken in the morning and that taken in the evening. Deviations from the normal temperature are described in the following terms: Algid collapse, below 95° F. Collapse, ' 95°-97°F. Subnormal, 97°-98.5° F. Normal, 98.5° F. Slightly raised, 99°-100° F. Fever, 100°-103° F. Pyrexia, 103°-106° F. Hyperpyrexia, 106° F. and over. The extremities of temperature, if maintained, are fatal to life. 152 TEMPERATURE 153 The temperature in health is affected by age, tempera- ment, and idiosyncrasy. In infancy the temperature is normally from one to one and one-half degrees above that of an adult, gradually decreasing as childhood progresses. In old age a subnormal temperature is common. Per- sons of an excitable temperament are apt to have a temper- ature higher than those who are not excitable. A few persons are met in whom the temperature is very easily upset, and these show a high degree of fever for slight causes. This may be idiosyncrasy, or the result of a previous illness associated with hyperpyrexia, such as sunstroke. Persons leading sedentary or confined lives usually show a lower average temperature than those who live out-of-doors or take much exercise. In health the temperature is elevated as a result of exercise, excitement, and the absorption of food; it is lowered during digestion and sleep, after perspiration, after cold bathing, and from the effects of starvation and exposure to cold. The temperature may be reduced artificially by the use of certain drugs, known for this reason as the antipyretics, such as phenacetin, acetanilid, etc., and by the application of cold to the surfaces. Cold, we have seen, is applied locally in the form of ice-bags, ice-poultices, ice-compresses, and ice-coils, and generally by baths, sponging, ice-crad- ling, ice-sprinkling, rubbing with ice, by cold packs, and by enteroclysis of cold normal salt solution. The tem- perature is also lowered by large doses of alcohol, and frequently also after the use of morphin. The temperature may be raised artificially by small doses of alcohol, by hot drinks, and by the ingestion of food, by the use of cardiac stimulants, such as atropin, strychnin, etc., and by external heat, as in the form of hot-water bags, hot foot-baths, hot mustard-baths, hot coffee enemata, hot enteroclysis, and the subcutaneous injection of hot sterile normal salt solution. Certain diseases are characterized by a marked rise in temperature. Among the most important of these are the acute infectious fevers, acute inflammations, such as peritonitis and appendicitis; toxic conditions, such as septicemia, uremia, and ptomain poisoning; acute func- 154 TEMPERATURE.—PULSE.—RESPIRATION.—CHARTS tional disturbances, such as heart disease and nephritis; heat apoplexyT, and, frequently, hysteria. Long-continued pain is also frequently accompanied by a rise of tempera- ture. The temperature is subnormal in conditions of sudden loss of vitality, such as shock, and in chronic diseases which are accompanied by impaired vitality, such as chronic nephritis, some forms of heart disease, etc.; in conditions accompanied by unusual loss of fluid to the body, such as Asiatic cholera and severe hemorrhage; in anemia, jaundice, diabetes, and in many forms of men- tal derangement. It is subnormal during convalescence from diseases where the temperature has been high, and after a crisis. A condition of extreme low temperature accompanied by marked depression of vitality is spoken of as collapse. After the temperature has been raised, it will return to normal in one of two ways: First: By direct fall to normal or below in comparatively few hours, accompanied by a decrease in the pulse-rate and the number of respirations per minute, by a general improvement in the patient's condition, and, usually, by profuse perspiration (diaphoresis), and by the passage of an increased quantity of urine (diuresis); this is known as a crisis. Diseases in which the fever falls in this way are pneumonia, measles, malaria, and typhus fever. Ery- sipelas and influenza also frequently terminate by a crisis when uncomplicated. A crisis must not be confused with a very serious condi- tion in which the temperature falls suddenly, while the pulse-rate increases, and the patient's condition is alarm- ingly worse instead of improved. Such a fall is seen as a characteristic symptom in severe hemorrhages, in perfora- tion, and frequently occurs immediately before death; it is always a grave symptom. Second: In practically all other fevers the temperature declines gradually, taking several days to reach the normal, and maintaining, in its descent, the usual difference be- tween the morning and evening temperature. Tempera- ture falling in this way is said to fall by lysis. Where the temperature rises abruptly at the beginning TEMPERATURE 155 of an illness, we say the disease is characterized by a sudden onset; where the temperature rises slowly from day to day, with morning remissions, we speak of the onset as gradual. The sudden onset is generally accompanied by rigors, or in children by convulsions or vomiting; the gradual onset by malaise, shiveriness, loss of appetite, and headache. Pneumonia is a good example of the sudden onset, and typhoid fever of the gradual onset, of fever. The course of fever characterizing different diseases varies in three different ways. These are spoken of as con- tinuous, intermittent, and remittent fevers. In continuous fever the temperature remains at about the same elevation, with little variation between the morn- MTt 108 107 106 105 104 M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E 108 107 106 105 m 102 101 100 99 98 97 102 101 100 99 98 97 Fig. 35.—Temperature chart of lobar pneumonia (Paul). ing and evening temperatures. The temperature in pneumonia is a good example (Fig. 35). In remittent fever the highest point in the daily tempera- ture is followed by a steady fall or drop of two or more degrees. The lowest point of the temperature is, however, always above normal. The highest temperature-point in remittent fever is usually in the evening, the lowest in the morning. Usually the temperature in typhoid fever runs such a course (Fig. 36). In intermittent fever the temperature, having mounted steadily to its highest point, falls again to normal or sub- 156 TEMPERATURE.—PULSE.—RESPIRATION. CHARTS normal. The rise of temperature followed by the remis- sion may occur daily (usually at the same hour) or after a Day 1 z J 4 5 6 7 8 9 10 // a 13 /4 IS 16 17 A* 19 .W 21 *2 ^j i* 15 2« » ^* T lOt 105 IOH-103 M.E ME ME ME ME M.E M.E WE ME ME ME M.E- M.E ME ME Mi ME M.f ME ME ME ME ME ME ME ME M.E ME lot 100 99 n EZ EE EEE 1 = 1 ~\ Fig. 36.—Temperature-curve in a typic case of typhoid fever (Register). lapse of a regular number of days. Intermittent fever is characteristic of the common forms of malarial fever and of long-continued septic conditions, such as the later stages DAY MB 108 107 106 I0S 4 e 12 4 8 12 4 a 12 4 8 12 4 a 12 4- a 12 4- 8 12 4 8 12 4 a 12 4 8 12 4- a 12 4 8 12 108 107 106 105 104 103 102 101 ioo 99 104 103 102 101 100 99 98 97 98 97 Fig. 37.—Temperature chart of intermittent malaria (tertian) (Paul). of pulmonary tuberculosis. The rise of temperature is in the nature of a sudden onset, and the fall of a crisis. TEMPERATURE 157 The usual physical manifestations accompanying the sud- den onset and the crisis are commonly present (Fig. 37). Prolonged conditions of intermittent fever are fre- quently described as hectic fevers. There is usually a great discrepancy between the morning and evening tempera- ture, the fall in the temperature being accompanied by profuse sweating. The condition is most frequently seen in cases of prolonged suppuration, such as the later stages of pulmonary tuberculosis (Fig. 38). F. l i = - Day I 5 s of Fever. 6 7 $ t 10 n 1 A __ „ / i TT i t 7T 1 _ o II 1 I n 1 lOl n h-TA □ / T\ tt- i r JZ r^ \ i L_ 1 : D L_ t \/ i I / n j r 1 r Y I \ / ioo° / \ K \ t \ h / \l / 1 i \ \ jt I r v/ \/ ' / , v I \ , A 1 V V / \ V /\ / i _. V V n / 99° \ ' / t L \ 1 V , \ 1/ \ J W V V / jt 98° / I > 97° -39" 38c -37c -36c Fig. 38.—Hectic fever in phthisis (Sahli and Potter). Diseases accompanied by a characteristic rise of tem- perature are roughly classed together as fevers. Besides the onset or invasion period, where the temperature rises, and the decline, where the temperature falls, either by crisis or by lysis, there is an intermediary period when the temperature remains raised for a certain time. This is known as the fastigium or the stadium. During the fastigium period all the physical manifestations char- acteristic of the special fever are intensified. 158 TEMPERATURE.—PULSE.—RESPIRATION.—CHARTS Clinical Thermometer.—The temperature of the body is ascertained by the clinical thermometer. This is the same as the ordinary atmospheric thermometer, with, for the sake of convenience, only those degrees, usually from 95° to 110° F., possible to the body temperature, 35 100 US Fig. 39.—Clinical thermometer (Pyle's Personal Hygiene). indicated. The scale is larger, the lines between the degrees being marked off into fifths, for a greater minute- ness of record. The Fahrenheit, Centigrade, and Reaumur Scales Com- pared.—In America, Great Britain, and the British col- onies the Fahrenheit scale is exclusively used. It is said to have been preferred first by the army surgeons, who, in reading daily reports, found it a convenience that all fever temperatures were recorded by three figures, thus quickly catching the eye in long lists of names. On the continent of Europe the Centigrade scale is used, and in Switzerland the Reaumur thermometer may be met with. In comparing these scales it must be remembered that while in the Centigrade and Reaumur scales freezing- point is at zero, in Fahrenheit it is placed at 32°; there is, therefore, an initial difference of 32° between the Fahren- heit scale and that of either of the other two. Further, there is a difference in the actual value of the degrees, a whole degree Fahrenheit equaling only f the degree Centi- grade and | the degree Reaumur. Bearing these points in mind, the conversion from one scale to another is very simple. To convert Fahrenheit to the Centigrade scale, 32 is first subtracted from the degree Fahrenheit, and the remainder is multiplied by f. To convert the Centigrade scale to Fahrenheit, the degree Centigrade is multiplied by f and 32 is added to the sum. Examples: C. 40° 40 X | = 72 72 + 32 = 104—104° F. F. 100'4° 1004 - 32 = 684 68'4 X | - 38—38° C. TEMPERATURE 159 For the Reaumur scale 4 is substituted for 5, otherwise the calculation is the same. In taking the temperature the thermometer may be placed under the tongue with the lips closed for five min- utes, under the axilla or in the groin for ten minutes, or in the rectum for three minutes. The mouth is usually the most convenient place for taking the temperature. It cannot, however, be used with very young children, where the patient is delirious, where local inflammations are present, or where, after certain operations or from extreme weakness, the mouth cannot be closed, nor should it be used immediately after eating or drinking. Where the axilla is used, it should be wiped free from perspiration and converted into a closed cavity by crossing the arm over the chest, the fingers grasping the opposite shoulder. If the thermometer is placed in the groin, the area should be dry, and the thigh flexed and held against the abdominal wall. The rectal temperature is best for infants, young chil- dren, and restless or delirious patients. The thermometer is oiled and inserted for about two inches, and held in place by a piece of cotton or a towel. This method cannot be employed after rectal operations or where there is disease or local inflammation of the rectum. It should not be employed where diarrhea is present, or where the rectum contains feces. The temperature in the mouth is usually about half a degree higher than that of the axilla, and the temperature in the rectum again half a degree higher than that in the mouth. A further method employed sometimes where absolutely accurate record is essential (as in collecting statistics), and otherwise impossible, is to have the urine voided over the bulb of the thermometer, the urine in passing being at the bodily temperature. The thermometer must be washed in cold water after using, and kept in an antiseptic solution, from which it is rinsed in cold water and wiped dry before using again. It should be as scrupulously clean as a glass or a spoon. 160 TEMPERATURE.—PULSE.—RESPIRATION.—CHARTS Those used for rectal temperatures should be marked and kept apart from other thermometers. For hospital use a practical means of insuring care in this respect is to use as rectal thermometers those made with the bulbs of colored glass. These may be procured from A. Bayer and Son, 66 Beekman St., New York. The colored bulbs arc also a convenience where a thermometer has to be kept strictly for one patient, as in an infectious case. PULSE By the term pulse we understand the beat or impulse that is felt on the expansion of an artery; it is produced by the systole, or contraction of the left ventricle of the heart. The condition of the pulse is an indication of the state of the circulation, and the condition, to a large ex- tent, of the heart and blood-vessels. Of any one symptom, the pulse is probably the most important indication of the physical condition of the patient. The arteries most conveniently used for taking or exam- ining the pulse are those lying near the surface of the body and immediately over a bone, against which the artery can be compressed. That most often used is at the wrist, where the radial artery can be felt lying over the radius on the inner surface of the thumb side of the wrist. The femoral artery may be easily felt in the groin, where it slips over the rim of the pelvis. The temporal artery is felt against the bony prominence immediately in front of the external opening of the ear, and the facial artery on the edge of the lower jaw, usually on a line with the corner of the mouth. The femoral artery may frequently be felt when no pulse can be detected at the wrist, owing to the larger size of the vessel. The common carotid arteries on either side of the throat, although not lying over a bone, are valuable, as in cases of profound prostration the pulse may be felt in them after it has become impercep- tible at points more remote from the heart. Taking the Pulse.—The pulse is taken by placing two or three fingers steadily over the artery for not less than one minute, and alternately making and relaxing a mod- PULSE 161 erate pressure against the underlying bone. The body should be at rest at the time, and the arm, if it is the radial pulse, recumbent. An excitable patient should have his attention diverted and the examination be made for a longer period. The examination of the pulse should ascertain: First: Condition of the artery. Second: Amount of tension. Third: Volume of the pulse. Fourth: The number of beats to the minute. Fifth: Their character, regularity, and irregularity. In a normal pulse the artery should feel firm, round, and elastic, the blood-stream should fill it with moderate force, and the beat still be perceptible under moderate pressure from the fingers. There should be about 72 beats to the minute of perfect rhythm and regularity. Instead of feeling firm and elastic, the arterial walls may be found hard and unyielding, twisted, and giving the impression of brittleness. To some extent this occurs normally in old age. It indicates a condition of arterial degeneration known as arteriosclerosis. This condition is also found as a result of disease, such as Bright's disease, etc., and is an important symptom. Tension is caused by the resistance of arterial walls to the blood-pressure. By the degree of tension the force of the blood-pressure is estimated. Tension is said to be high when the artery remains distended between the pulse- beats, and low when between the beats it feels empty and is easily compressed. Tension may be altered by the size of the blood-stream, as after loss of blood from hemorrhage, by changes in the regularity or force of the heart's action, as in some forms of heart disease, and by changes in the arterial walls, affecting their elasticity. From the latter condition a high-tension pulse is found in those forms of chronic disease associated with arteriosclerosis. A low-tension pulse is characteristic of conditions of low vitality, such as collapse, or the prostration occurring at the close of a long illness, such as typhoid fever. Drugs which strengthen the condition of the heart raise the tension of the arteries, such, for example, as digitalis 11 162 TEMPERATURE.—PULSE.—RESPIRATION.—CHARTS The tension of a pulse may be lowered either by drugs such as nitrate of amyl and nitroglycerin, which reduce tension by dilating the blood-vessels, or by drugs which act as sedatives to the heart, of which aconite is an ex- ample. The tension of a pulse is estimated by the amount of pressure necessary to obliterate the beat. Sphygmomanometer.—A special instrument for estima- ting the blood-pressure is known as a sphygmomanometer, of which there are several varieties. Fig. 40.—Technic of sphygmomanometry with the Stanton instru- ment (Morrow). The instrument in general use at the present day consists of three parts: a dial with a mercury column like an atmo- spheric thermometer, the scale marked out in millimeters (a), a wide pneumatic cuff (6), and an air pump consisting of a double rubber bulb, the first (c) the pump, the second bulb {d) acting as an air-reservoir to equalize the air-pressure, and protected from overexpansion by a silk netting. The three pieces are connected together by tubing, so that when air is introduced by the pump, it is at the same pressure in every part of the apparatus. PULSE 163 The cuff, the inner surface of which is an air-bag, is secured round the upper arm and inflated until the pres- sure so produced on the brachial artery causes obliteration of the pulse at the wrist; at the same time the column of mercury is also raised by the air-pressure, and the amount of pressure necessary to obliterate the radial pulse can be read off on the scale in millimeters. In " taking " the blood-pressure the fingers are kept on the radial pulse, while the air is pumped simultaneously into the cuff and the mercury chamber. When the pulse is obliterated, air is very gently allowed to escape, keeping the finger on the wrist and watching the column of mer- cury closely. On the first faint sensation of pulse under the finger, the height of the mercury is noted and is taken as the estimate of the blood-pressure. The average blood-pressure in a healthy adult is be- tween 120 and 140; it is lower in children and higher with increasing age. In diseases associated with high blood- pressure it may rise to between 200 and 300. The instrument is valued as a more accurate means of gaging the blood-pressure than merely "taking" the pulse with the finger, especially in conditions where the blood-pressure may be subject to frequent and abrupt changes. A pulse of high tension may be described as hard and resistant, a low-tension pulse as soft, or compressible. The volume or size of the pulse is greater at the onset of fevers, in threatened apoplexy, heat-stroke, and other conditions usually associated with rise of temperature; and less in conditions of lowered vitality and great prostration. Where the volume is great, the pulse is spoken of as full; if at the same time accompanied by increased frequency of beat, it is sometimes described as full and bounding. This type is common at the beginning of feverish condi- tions. A pulse of lower than the usual volume is called a small pulse. After severe hemorrhage and in conditions of collapse it may be so small as to be almost imperceptible, the artery feeling like a little thread under the examining finger; such a pulse is known as a thready pulse. The tension of a pulse may be low, while the volume is large 164 TEMPERATURE.—PULSE.—RESPIRATION.—CHARTS and vice versa. A hard pulse of very small volume is described as wiry. The number of beats to the minute in a normal pulse is about 72. It varies, however, with age, sex, and idiosyn- crasy. In a new-born baby the number is from 120 to 140 a minute; in young children below the eighth year, between 90 and 100; from the eighth to the fourteenth year, be- tween 80 and 90, while in old age the pulse is usually below normal. In young children there is no difference between the pulse-rate of the sexes; in adult life a woman's pulse- rate is perceptibly higher than that of a man. Persons may be met with in whom, in an otherwise normal con- dition of health, the pulse-rate is abnormally quick or ab- normally slow. In health the pulse is accelerated by exercise, excitement, emotion, eating, the action of drugs which stimulate the heart, such as strychnin and atropin, and by small doses of alcohol. It is slower during repose and sleep, and in conse- quence of fatigue, exposure, or fasting. These conditions should be borne in mind in examining the pulse. Drugs which either quiet or strengthen the heart reduce the pulse-rate—such drugs, for example, as aconite and digi- talis. An attempt to give a table of conditions stating the diseases in which the pulse-rate is high or low would be misleading. It would be difficult to make it sufficiently complete to be of value, and it must be remembered that in diseases the same conditions may be found that affect the pulse in health, and will have the same effect to a greater extent, the body being in a more susceptible con- dition. Varieties of Pulse.—As a rule, the pulse rises with the bodily temperature at the rate of ten beats of pulse to one degree of temperature, though exceptions are often noted in diseases, such, for example, as typhoid fever, where the pulse is low in proportion to the temperature, or in scarlet fever, where the pulse is disproportionately high. We notice an increased frequency of pulse in all acute diseases, in almost all forms of valvular heart disease, in exophthal- mic goiter, in many disorders of the nervous system, in reaction from conditions of lowered vitality, such as shock, PULSE 165 etc., and frequently on approaching death. We find a slow pulse generally where we find a lowered vitality, as in the convalescence following acute diseases, after severe hemorrhages, in many conditions of chronic diseases, and in depressed mental conditions. A slow pulse is usual in jaundice and in diseases of accidents causing pressure at the base of the brain. The condition of persistent increased rate of the pulse is termed tachycardia (quick heart); the condition of per- sistent infrequency is known as bradycardia (slow heart). The pulse is said to be slow where the number of beats is considerably below normal; quick or frequent, where the pulse runs from 100 to 120; rapid, from 120 to 160, above which it is very difficult to count, and is spoken of as running. The terms quick and frequent are loosely employed in this way. Accurately, quick should be em- ployed where the beat occupies a shorter time than usual; frequent, where the number of beats is greater in a given time. Where each successive beat of the pulse is of equal value, the pulse is said to be regular. The regular pulse, as a rule, is accepted as a good symptom. The more common forms of irregularity are as follows. The most common deviation from regularity is an inter- mission of a beat, either at regular or irregular intervals. While occurring in many diseases due to organic lesion, the intermediate pulse may also accompany causes of trifling significance, such as fasting, dyspepsia, the use of tobacco, and may frequently be observed in the pulse of young children or of aged persons during sleep, especially toward morning, possibly caused by the length of time they have been without food. In the irregular pulse the pulsation may be unequal in time and in character. Some beats may follow each other with great rapidity, to be followed by slow beats and by a long intermission; at the same time the pulsation may be of varying force and volume, the latter condition requiring more experience to recognize than irregularity of time, which is easily detected. An irregular pulse is a symptom of serious disease, most commonly of some form of heart 166 TEMPERATURE.—PULSE.—RESPIRATION.—CHARTS disease. It may also be caused by an overdose of certain drugs, such, for example, as digitalis, which has a powerful effect upon the action of the heart. The dicrotic pulse is a variation from the normal pulse frequently met with in conditions of prolonged fever and low vitality, such as typhoid fever or septicemia. It is characterized by a secondary impulse in each beat, following the first as a small wave may a large one. It indicates a relaxed condition of the arteries. The primary beat follows the systolic contraction of the ventricle; the secondary beat occurs after the closing of the aortic valves, and is a transmission of the impulse given to the blood- stream by the contraction of the walls of the aorta, an impulse which, though always present, is imperceptible to the examining finger in the ordinary condition of the circulation. Where the dicrotic beat is strong, it is possible to mistake it for a second true beat; when any doubt exists, the heart-beats should be counted at the same time the pulse is taken. Another variety of pulse, which should be recognized when met, is the water-hammer pulse, also known as Corrigan's pulse. It may be observed in the carotids as a sharp rising and falling of the artery. Under the finger it has the sensation of a sharp, powerful beat with a quick recoil. It is associated with disease of the aortic valves, producing a condition known as aortic regurgita- tion. In persons suffering from severe anemia the pulse may be visible in the capillaries. In order to observe it the mucous membrane of the lip may be pressed with a glass slide until colorless, when the area may be seen under the slide to flush and pale rhythmically. It is also sometimes observed under the finger-nails. The condition is seen, as a rule, only in extreme cases. In some rare conditions the pulse of the right and left wrist on the same individual differ. This points to some obstruction in the course of the circulation of one or other upper extremity; generally it is caused by pressure from an aortic aneurysm. PULSE 167 The Sphygmograph.—This is an instrument for record- ing graphically the different variations of the pulse. It is somewhat compHcated. It consists essentially of a Pulsus durus. Pulsus mollis. mammmm Pulsus dicroticus. Pulsus anacroticus. Fig. 40a.—Sphygmograms of pathologic types of the arterial pulse. (Tracings by Dr. G. Bachmann.) (From DaCosta's ' Physical Diagnosis.") metal plate, fixed by a strap round the wrist over the pulsating artery; to the plate is attached a delicately adjusted needle in such a manner that the pulsations of 168 TEMPERATURE.—PULSE.—RESPIRATION.—CHARTS the artery are transmitted to the needle and traced by the needle on specially prepared black paper as a fine, white, wave-like line, corresponding exactly to the dila- tation and contraction of the walls of the vessel. These traceries are known as sphygmograms, and offer a perfect picture of the pulse-wave. In a normal pulse the secondary impulse, noted above, is shown as a notch in the descend- ing line; where the pulse is dicrotic, the notch becomes a well-marked second wave, often only slightly smaller than the primary wave. Many irregularities, difficult to observe with the examining finger, are clearly shown and easily studied when traced as a sphygmogram (Fig. 40a). RESPIRATION Of equal importance with the observation of the rate of the temperature and the pulse is the observation of the rate and character of respiration; that is to say, the manner in which breathing is performed. The immense importance of breathing is realized on calling to mind that, through the act of respiration, the body is supplied with oxygen, without which life cannot be maintained even for a few moments, and that with the act of respiration the body parts with carbonic acid gas, a poison which, if retained, would be fatal to life. Any interference with the normal respiration is likely, there- fore, to have serious results. Breathing under normal conditions is an involuntary act, accomplished without exertion, sound, or pain, and ac- companied with a rhythmic rising and falling of the chest- walls and the walls of the abdomen, due to the expansion and contraction of the muscles of respiration. In the act of respiration the lungs are passive, their part being to afford an enormous surface, where the fine capillary blood-vessels can ramify, and be brought into direct con- tact with the air of the atmosphere. The membrane of which they are constructed is so delicate that it is easily permeable to oxygen and carbonic acid gas, as are also the walls of the capillary blood-vessels. Air is drawn into the lungs by the mechanical enlargement of the cavity of the chest, just as a pair of bellows is inflated with air by pulling the surfaces apart; when the cavity is made smaller RESPIRATION 169 again, the air is expelled. The muscles of respiration are the intercostal muscles, which alternately elevate and de- press the ribs, and the diaphragm, which forms the floor of the chest cavity. In emergencies they are assisted by the muscles of the abdominal wall and by others. The mechanical act of respiration is controlled by nervous im- pulse, of which the center is situated in the medulla ob- longata, often called, from the important nerve-centers there situated, the vital knot. The nerve-c'enter is stim- ulated by the need of the body for oxygen. Normal respiration demands a proper balance between the amount and quality of the air that reaches the lungs and the amount and quality of the blood circulating in the lungs. The balance may be affected by the changes in the atmosphere, as, for example, when the atmospheric air is deficient in oxygen; by alterations in the condition of the blood or in the circulation, as in anemia or heart disease; by obstructions in the lungs or air-passages, either from foreign bodies or from the inflammatory processes of disease; and by interference with the mechanism of respiration. The latter may be caused by paralysis of the muscles of the chest-wall, by rigidity of the abdominal walls, as in peritonitis, or by the pressure of fluid or a tumor from neighboring structures. In all these con- ditions we get the character and rate of respiration al- tered, and breathing an act attained by effort, sound, and pain or discomfort. At the same time every part of the body will also suffer from the deficiency of oxygen, and the poisonous effects of the carbonic acid gas, which has not been eliminated by contact with the oxygen. The act of respiration is also altered by conditions directly affecting the respiratory centers, such as toxic conditions of the system and the action of certain drugs. The rate of respiration may be determined by counting the number of respirations in the minute. The average normal rate of respiration a minute in the human being is reckoned as follows: 16-18 in the male adult. 18-20 in the female adult. 20-25 in young children. 30-35 in infants. 170 TEMPERATURE.— PULSE.—RESPIRATION.- CHARTS The ratio between respiration and pulse is commonly 1 in 4. In health respiration may be quickened by exer- tion, excitement, emotion, and by sudden chilling of the surface of the body, as in cold bathing. It is slower in repose, during sleep, and from the effects of fatigue. The rate of respiration is increased in all diseases of the lungs and air-passages; usually in feverish conditions, in diseases due to toxins, such as the infectious fevers, uremia, etc.; in organic diseases affecting the circulation, such as heart disease and nephritis; in disorders in which the composition of the blood is altered, such as anemia; and in conditions where obstruction to the mechanism of respiration exists, as mentioned above. Respiration is also quickened by the action of drugs that stimulate the respiratory centers, of which atropin, the alkaloid of belladonna, is the most powerful known. The rate of respiration is decreased in many conditions of injury to and disease of the brain, in most forms of coma, and from the action of those drugs that depress the respiratory centers, such as opium. Very slow respira- tion is the most important symptom in opium-poisoning. Character of Respiration.—The respiration is described as shallow, when the volume of inspired and expired air is less than usual; deep, when it is greater than usual. Shal- low respirations may accompany either rapid or slow res- pirations, though more usually the former. They may be caused by rigidity of the abdomen, as in peritonitis or abdominal distention; by pressure on the diaphragm from fluid, etc., or by a decrease in the available area of lung surface, as from inflammatory processes, consolida- tion, etc. Shallow respirations are also common in con- ditions of profound prostration, where the vital centers are greatly depressed. Deep respirations are characteristic of many diseases of the brain, and especially of those conditions in which, either from disease or injury, there is compression of the brain. Dyspnea means difficult breathing, and is a term used when the act of breathing is accompanied by conscious effort. It is not necessarily associated with pain, though such is frequently the case. Dyspnea occurs whenever RESPIRATION 171 respiration is obstructed by any of the conditions men- tioned above. Where dyspnea is so great that breathing is possible only in an upright position, the term orthopnea, upright breathing, is used to describe the condition. Pain associated with dyspnea is most marked where the act of breathing causes friction between sensitive surfaces, as, for example, in pleurisy, where pain in the side, in- creased by drawing a long breath, is a prominent symptom. The pain is due to the rubbing together of the inflamed surfaces of the pleura, the double covering that envelops each lung. Dyspnea is usually accompanied by sound. In certain diseases the sound is so characteristic as to be diagnostic. Thus we have the crowing inspiration of croup, the harsh or stridulent breathing of diphtheria, the wheezing of bron- chial affections, the grunting expirations of pneumonia; where the obstruction to respiration is great, and where, as in cases of great prostration, the body is not getting the oxygen it needs, the respirations may become irregular and jerky. Where the act of inspiration is accompanied by a loud, snoring noise, the breathing is said to be stertorous. It is noticed in many forms of coma, especially in that of apoplexy, and is caused by the vibrations of the relaxed soft palate. Sighing and yawning in the course of an illness are frequently significant. Sighing is a common symptom in severe hemorrhages, and indicates that the body is not receiving sufficient oxygen; it is often accom- panied by gasping and fighting for air, a condition known as air-hunger. Yawning is a symptom of syncope or faintness when occurring in conditions of shock, collapse, or hemorrhage; it is, on the other hand, considered as a favorable symptom and a sign of returning vigor if noticed during convalescence after a long illness. A type of respiration known as tidal breathing, or Cheyne-Stokes respiration, is sometimes observed in very serious physical conditions. In a typical case the respira- tions begin quietly; each succeeding respiration is a little louder and deeper than the preceding one, until a climax is reached, after which the respirations as gradually sub- side; the wave of breathing is followed by a complete 172 TEMPERATURE.—PULSE.--RESPIRATION". (HARTS pause of several moments' duration, following which the same process is repeated. Such breathing indicates fail- ure of the respiratory centers, but how it is caused is not fully understood. It is always of grave significance, and in the course of acute illness is usually regarded as a sign of approaching death. It must not be confounded with irregular respirations, of varying rate and force, which do not occur rhythmically, and which are not followed by a distinct pause. Mechanism.—Together with the rate and character of respirations the pupil should be taught to observe certain physical conditions which accompany the mechanical act of breathing. This will include observation of the shape of the chest, of the action of the muscles of respiration, and of the positions assumed by the patient. In observing the mechanism of respiration it will be noticed that women have a tendency to use chiefly the chest muscles {thoracic breathing), and men and children chiefly the diaphragm and abdominal muscles {abdominal breathing). The use of deep breathing exercises aims at modifying this tendency. In disease, the area used in the mechanism of breathing may be greatly modified, the greater part of the work being thrown on the unaffected areas; thus, when the action of the abdominal muscles causes pain, as in peritonitis, or their action is impeded, as by pressure from a tumor or the presence of fluid or gas in the abdominal cavity, we get the thoracic muscles only working—a condition spoken of as restricted abdominal breathing. In pleurisy and in diseases causing temporary or permanent consolidation of the lungs the affected side of the chest is noticed to expand less than the sound side. Where the bases of the lungs, for example, are solid, the upper part of the chest will do practically all the work, as in cases of emphysema. The term used for this condition is diminished expansion. In new-born infants it may sometimes be observed that one side of the chest-wall has failed altogether to expand, a serious condition, requiring resort to artificial respira- tion to rectify it. The position of the patient with reference to his breath- ing is frequently significant of disease. In diseases of RESPIRATION 173 the lungs patients have a tendency to lie on the affected side, thus giving the sound lung free play. Where obstruction exists in the air-passages, such as from asthma, patients cannot breathe in the recumbent position, and the same condition is observed in those forms of heart disease associated with venous congestion. Where there is prolonged dyspnea from any cause, the ordinary muscles of respiration become inadequate for the work. To aid in overcoming this obstruction other muscles must be brought into play. The first to be observed will be the sternocleidomastoids, the muscles lying on either side of the throat, which have their origin in the clavicle and sternum and their insertion in the mastoid bone. By their action the upper part of the sternum and clavicle are brought forward and upward, thus aiding in enlarging the thoracic cavity. Next, the tiny muscles of the alae, or wings of the nostril, will be noticed enlarging, to a slight extent, by their dilatation, the openings to the air-passages. When the effort of respiration is very great, the lower end of the sternum may be seen to be sucked in with each inspiration, forming an appreciable hollow in the chest at this point. These symptoms are of serious significance. As a patient gets very weak the action of the sterno- cleidomastoid muscles has a tendency to draw the head backward, throwing the chin forward and upward with each inspiration, and giving to the head a rocking move- ment. This is usually a sign of swiftly approaching death, and is almost invariably present some minutes before death occurs. The rosy color of the skin is dependent upon the oxy- gen taken up by the blood. An examination of the pa- tient's skin will, therefore, show very quickly if respiration is failing to give the blood a sufficient supply of oxygen. Blood deficient in oxygen has a dark bluish hue. This discoloration will first be noticed about the lips; in other words, they become blue or cyanosed. In severe cases the cyanosis will spread to the extremities and be noticed at the tips of the fingers, under the nails, and may finally extend to the whole body. It will readily be seen that a record of the character of 174 TEMPERATURE.—PULSE.—RESPIRATION.—CHARTS the respiration will hardly be complete wit hout an intelli- gent observation of the above conditions. As a record of the pulse and respiration can be achieved with very little, if any, disturbance to the patient, they can be made more frequently than that of the temperature, the taking of which in many instances is fatiguing, and sometimes impracticable. Conditions calling for frequent observations of the pulse and respiration are—during and following the administration of an anesthetic; in cases of shock, collapse, or hemorrhage; during and after a crisis—circumstances in which, it is obvious, the use of the temperature thermometer would be either imprac- ticable or inadvisable. Where a record of the temperature is made, however, the pulse and respiration are recorded at the same time, their relation to each other being of great importance. In counting the rate of respiration in nervous patients it is advisable to do so without their knowledge. In many cases the respirations can be counted by watching the rise and fall of the chest-wall. As it is impossible to main- tain any but the natural rate of breathing for any length of time, a little patience is usually all that is necessary to take the respirations correctly. Where there is any doubt, the respirations should be counted while the patient is asleep. CHARTS Clinical charts are usually found more convenient than written records for following the course of an illness. A picture of the temperature day by day is by this means given at a glance, and if desired, the pulse and respira- tion and other matters, such as weight, amount of urine, etc., can be recorded in the same way. The rulings on the temperature chart correspond exactly to the markings on the clinical thermometer, with a black fine at the 98.5° of the normal tempera- ture; cross rulings divide the chart into spaces, which may be made to signify days or portions of a day, as desired. If several spaces are taken for one day, as in the four- hourly chart, Fig. 41, a well-marked ruled line should CHARTS 175 njbi1 a^TT^ <■ >■• >• '■ '* v•> •• '< /•' • ■»». ««. j^\ •*•"" v « «| ^ 8 n ^* a.2.£/5.2.£./J.2*o££.o £.,£./(>,£ .Sr^ Xs"" tH1* £.£.Mt r <* £_& '". 1 • 104- ' 1° '"■ *♦ —1— :" £5 t~Z fcr £ 2 4 L4 ?»■ -^ \ t l. HS 4 4 _4 h»' ^- - t- A y •*- (-/ " x« 5? ^-^4 * fc-«=^<^ -v -1r~* - V- ; !T. ^4 *—■- - -t- -*==*■ h *4~ 3o 2_z _i 'e "^ ,r -3 - Z £ ™C A -4V S- „i £r - f v, 7 1 • " >*—< -, % * <-* ^ x~-- i ^2 ■ „__ * ^_^2 \/ S*^~^ £ v- ^ " .2 v ^ \ ■' \ i" i _ «,__ _ __ ________________4 . " - *_ s " u ♦ *■ A--«- L.\- - *- = " A *% - \ r — r- -^ ^ * : " * Z ±^*.* ~ \ -. f % _p v—.^ - ;*A ^^-^^ *t_ fc MJfc-S---s-g---iS;-SSas;5-i"i----------s»------s~SSS Fig. 41a.—Four-hourly chart of temperature, pulse, and respira- tion, medical case, showing one week. (Courtesy of Massachusetts General Hospital, Boston, Mass.) •.•::4'l*j, i;i.|r(/if.'/ . | "W*»~J/, 11/ ::« 1 ll\H U n 1 « 1 "7 i t i" i v - !■?,.. / i'4 / -' t ° ! 1 1J \ i ! *" H- ".-"s A'4f:- M ■ - ■■~':-'-:- - i-- '■ ■'■• ........ -1 ;.^x • t £-■ T ^ ■+■*-. . r---,--*■■-P X4 rr_r .....-,..*. 4-1 T: : .; ■ •• t "'■■■ i "j 4_ 1 j4 mU -3 J ll I - r ■■ -, - - r - - - £r 4m t J l£. 4-. -J r + 4, i h4J 4 "L ^ T3~ ZVL-* _,_ : 4| I Ti.r + J - '•*(-/■ r v_» ^ ,'* -= "!r" / ,5 i/ i i » "^ .....r -+ i -l- "i4 H)( . :T . r--,-. r -.--4- ^_ uS ,: / j ,i*. j-^.'V « i l ■ - X ^ 747^4- !. i.,-- • _l J ; F Ti ^'» 1 ■ r ^ = t mCZ^I t .+.!_]_ _i__i_ J ° ; mX c » ■ ._ _ *l ..^1 i ^T 41' " T-___ X. -. - i4_4 n i t r ^ ' n^ -JLE«iB—B_——..— =^.,.-,M —^—.s^.—-^ Fig. 416.—Daily chart, surgical case. (Courtesy of Massachusetts General Hospital, Boston, Mass.) 176 TEMPERATURE.—PULSE.—RESPIRATION.—CHARTS divide the days between the last temperature taken on one date and the first after midnight on the following. A dot is made on the line corresponding to the height of temperature shown by the clinical thermometer, and the dots connected by a line drawn from one to the other. Besides the temperature rulings, there are spaces for the date, the day of disease, and for recording the pulse, respiration, amount of urine, and number of the bowel movements, with a marginal space for the name of the patient and other necessary details. The keeping of a simple clinical chart presents no difficulties, and pupils should be accustomed early to keep them accurately and scrupulously neat. Where the pulse and respiration, either or both, are recorded on the same chart, also by dot and line, it takes some practice to make the charts neat and clear. It is usual, for the sake of clearness, to use different colored inks for the tracings, the scale being drawn on the margin in the same color (Plate III). It is often of value to show discrepancies between the normal ratio of temperature, pulse, and respiration in this manner. A clinical chart is issued with three separate rulings on each sheet, to enable the three records to be kept separately, and yet compared at a glance (Fig. 41, Plates II and IV). These are, on the whole, more easily kept neat and are quite as satisfactory as a clinical record. The ruled chart can, of course, be made to serve as a record of any facts connected with the disease which are capable of being measured; thus, on Plate II and Fig. 41c we have a tracing of the weight; on Plate IV, of the urine and blood-pressure. Special Chart.—Besides the clinical chart, in cases of serious illness it is usual to keep a special written record in which all details of the symptoms and nursing can be noted. Spaces should be ruled for the date, hour, the temperature, pulse, and respiration, the urine and bowel movements, and for the record of nourishment, medicines, and other treatment. A margin is left in which remarks, notes, and descriptions of symptoms, and so forth can be written down. These charts are a very great help in insuring an PLATE II Diyj ol Month Jl SU ) a>i$ it it ^f a1 3o 31 1 | 2 ^ M i b 1 « i ■ till |ill|-3liv|'Sllt.|i? D.y* ol DistiK "\ <«> 11 ,tt >vu n n 3,3 l1 U Ik »i J?iil|»oK.Ui|«4-jM c 42.1 n e 41.1 40.5 40.0 89. i 38.8 M.3 3?. 7 3?. 2 36 6 34.1 35. S 35.0 Sit M' "' " '" ■ "*"'"' " "' "' " ME ME ME "' ME "E ME ME ME Ml 4j ME ME ME ME M, M, ME - " - ~ ^ - ~ - - " M - - -J- S < - Id *»^*- * -J a ss J ^* ■**■ £ *? t h N. S — V / •A *. / >/«-* U n i " I _3 96 f - 95 -^ 94 -g 180 " 170 180 u j A; ; 0. A/^ fl / 130 -^-»« K ^ / ; j I \ M / ^ J / V ^ u . \i »-• • 100 A » 30 / * x \ \ "ic-V 1. i£fl£-n , ' t7 \ J 65 » ._., ^ 60 \ J *s 50 -4 ' • " 0 "i " , p/\ / < /\N% * / ^ »* \ ^ 35 "\? Y »• % *+ ** ^ >,* £ 30 » * • of 25 20 15 ,Df toast ' e 96 9¥ 3Z Zounces Ihoobr-omtn Cocp of tea will? Brown sotV stool containing Sod.SaJicyl .on* cream % 3uqo.r mucus- . 10 10 ounces fitntchsuifih.3r.t1 Oranqt aJbumeir .^porroe jra-fh A1 tropin Su'lbh'qr^i (f£»*fc-fm)1ic ' Puh.d.f^.jr.-H lVilfoo/yc. rtf X li. 9b 76 3i. Co^oa. ~%t^ir Merc urial inunction / to left Jhotj.icLe.r-. Fig. 41d.—Special chart. (Model used at Polyclinic Hospital; Philadelphia.) given in fractional doses. Where the handwriting is very bad, pupils can usually be taught to print. CHAPTER VI OBSERVATION AND EXAMINATION Subjective and Objective Symptoms—General Points to be Ob- served—Physical Examination—Inspection, Palpation, Ausculta- tion, Rales, Murmurs, Percussion—Gynecologic Positions, Dorsal Recumbent, Dorsal or Lithotomy, Knee-chest, Sims', Trendelen- burg—Vaginal Examination—Packing the Vagina—Uterine Exam- ination—Examination of Bladder and Rectum—Examination of Eye, Ear, Nose, and Throat—Observation of the Skin: Abnormal Color; Eruptions; Other Alterations—Examination of Blood: Red Count; White Count; Varieties of White Cells. One of the most important lessons that can be taught a nurse is to use her power of observation. The faculty of accurate observation, with a knowledge of the relative value of the facts observed, and the power of accurately describing the same, is probably of greater assistance in making a successful nurse than any other one thing. In most cases it is largely a matter of training. This must be done in two ways, by cultivation of the practice of observation in the pupil, and by accurate teaching in the matters to be observed and their significance. The clinical examination of patients is at the present day a matter that may involve many complicated details in which the nurse may often be required to assist. In the present chapter we shall go over the principal common methods of clinical examination, with some brief notice of their use and significance. Disease, or departure from health, is perceived, its nature diagnosed, and the necessary treatment determined, by the observation and examination of the person afflicted. Disease is manifested by symptoms and by physical signs. SYMPTOMS . Symptoms are divided into two groups—subjective, those complained of by the patient, and objective, those which may be noted by the observer. 179 180 OBSERVATION AND EXAMINATION Subjective Symptoms.—The most important subjective symptoms are pain, discomfort, sensations, such as nausea or giddiness, defects of hearing and vision, and hallucina- tions or allied mental conditions. To ensure accuracy, the report of the subjective symptoms should be given in the words of the patient, and particularly so in describing pain. The locality of the pain, its character, whether severe or slight, continuous or occurring at intervals; sharp, piercing, dull, aching, or throbbing; whether in- creased by deep breathing or coughing, or mitigated by change of position, and the time, duration, and frequency of the occurrence—are all points important to diagnosis and must be accurately noted. (See also p. 687.) Where the patients are young children, unconscious, delirious, or in conditions of extreme weakness, an account of the subjective symptoms is obviously impossible to obtain. A diagnosis is then obtained by an examination of the objective symptoms and of the physical signs. The objective symptoms include those due to the general condition of the patient and those which are the manifestations of the disease from which he is suffering. The following list suggests the more important symp- toms to be noted and which nurses in their work should train themselves to observe. The apparent bodily strength, as shown in the ability to walk, stand, or sit. The condition of the body, whether emaciated or plump; whether the muscles are flabby or firm. The condition of the skin, whether dry, moist, or clammy; undue redness of any part; the presence and locality of sores, scars, or eruptions. The color of the skin and mucous membrane, especially of the face, whether flushed, pale, cyanosed, or of an ab- normal color. The presence and locality, and, as far as possible, the character of abnormal prominences, swellings, or tumors; dropsy in any part, especially in the feet; enlargement of any joints; spots of abnormal tenderness. The surface warmth of the body, especially of the extremities. SYMPTOMS 181 The temperature of the body, as shown by the clinical thermometer. The character of the pulse and respiration. The mental condition, whether quiet and placid, or restless, excited, talkative, fretful, irrational, or delirious, unduly depressed and melancholy, or unconscious. The facial expression, which is frequently of impor- tance, evincing pain, anxiety, apathy, ecstasy, or other emotions. The odor of the breath: it may be heavy from gastric disturbances, offensive from the presence of decayed teeth, or fetid from disease, such as scurvy; alcohol and a few drugs impart a characteristic odor to the breath which may be of diagnostic importance. The appearance of the abdomen: it may be distended with gas, enlarged by the presence of fluid or tumor, or hollowed out, as in conditions of great emaciation. The appearance of the eyes, whether sunken or unduly prominent; any inflammation or discharge from the lids; unusual contraction, dilatation, or inequality of the pupils. The condition of the nose and the character of any discharge. The condition of the mouth, which is an important indication of many conditions; this will include an exam- ination of the teeth, gums, and tongue. It should be noted whether the teeth are permanent or false, firm or loose, sound or decayed, clean or covered with sordes; whether the gums are normal, or swollen with a tendency to bleed easily. The tongue may be clean or coated; furred in the center or all over; dry, brown, or fissured, as in cases of profound toxemia; covered with patches, as in thrush, or ulcerated, as in stomatitis; or it may have something of the color and appearance of a ripe straw- berry, a condition seen in scarlet fever. The throat should also be examined, especially in young children, who do not complain of their troubles. Any redness or swelling and the character of any patches or the presence of discharge should be noted. The gait of the patient, lameness, inability to place a foot on the ground, inversion or eversion of the foot, 182 OBSERVATION AND EXAMINATION dragging of the limbs, and inability to walk without looking at the feet, are all points of diagnostic value. Certain symptoms are manifestations of certain condi- tions and should be accurately observed. 1. Paralysis in any part of the body, such as the limbs, part of the face, throat, or vocal cords, evinced by an insensibility to touch or an inability to perform their functions (p. 695). 2. Tremor or subsultus: a condition of general trembling, noticed at the onset of delirium tremens, and in some con- ditions of great prostration; irrational movements, such as picking at the bed-clothes {carphology), a symptom noticed in profound prostration, uncontrolled twitchings or movements, such as those seen in chorea. 3. Persistent hiccough {singultus), frequently due to gastric irritation, is also associated with certain brain diseases, and is a serious symptom in conditions of severe toxemia or great exhaustion (p. 701). 4. Involuntary evacuations which may be due to paralysis or imperfection of the sphincter ani, persistent diarrhea, or to the mental condition of the patient. 5. Incontinence of urine, which may be caused by an overdistended bladder, paralysis of the urethra or sphinc- ters, or due to the mental condition of the patient. 6. Vomiting.—The time, frequency, and character of the act of vomiting. The vomitus itself should be inspected minutely, and the first vomitus of any patient should in- variably be saved for examination (pp. 216 and 698). 7. Convulsions.—The time, frequency, and duration of the convulsions, together with the character of the movements, and any physical manifestations which ac- company the attack (p. 663). 8. Unusual cries, such as the sharp, piercing cry heard in meningitis, the characteristic night cry common in hip- joint disease, or the wailing cry of an ill-nourished infant. The above are all conditions that may be noticed by the nurse in her attendance on the patient and on her obser- vation of which the doctor is, to some extent, dependent in making his diagnosis. PHYSICAL SIGNS 183 PHYSICAL SIGNS Besides the subjective and objective symptoms just enumerated, the diagnosis of a disease depends also on an examination of what are known as physical signs. Phy- sical signs are those manifestations of a departure from the normal condition of an organ detected in an examina- tion of the organ by the eye, ear, and touch. The methods employed are known as inspection, palpation, auscultation, and percussion. While these examinations are carried out by the physician, an important part of a nurse's duties consists in preparing patients for such examinations, and in many instances she may be required to help. Inspection, or examination by sight, is an observation of the appearance of that area of the body immediately covering the organ under examination; its object is to detect any departure from the normal size and aspect, and the presence of abnormal swellings, prominences, tumors, discolorations, or malformations. When the organ has a function with manifestations of movement, the observa- tion of such movements is included in the inspection; for example, inspection of the heart will include observation of the position and force of the apex-beat against the chest- wall, and will show whether either position or force is changed by change in the position of the patient; inspec- tion of the lungs will include observation of the move- ments of the chest and abdominal walls during respiration. Palpation is examination by touch, and is performed by laying the open palm and fingers flat on the body over the organ to be examined. To some extent it verifies the examination by inspection. It further detects points of tenderness and soreness, and determines the character and condition of abnormal prominences, swellings, and tumors. For example, palpation will determine whether an enlarged abdomen is due to distention by gas, to the presence of a solid tumor, or to a collection of fluid in the abdominal cavity. A special group of symptoms is also examined by pal- pation. These cause a sensation of tremor or thrill under the examining hand, some of which are normal and others abnormal and diagnostic of disease. Such a 184 OBSERVATION AND EXAMINATION tremor is spoken of as a fremitus, and is frequently likened to the thrill felt when stroking a purring cat. A normal fremitus may be observed by keeping the palm on the chest during the act of speaking, crying, or coughing. This normal fremitus is modified, to a great extent, in disease, and others not normally present exist, A thrill may be felt over the region of the heart in such disorders of the circulation as are caused by valvular heart disease or aneurysm of the aorta. A peculiar vibration, known as a friction fremitus, is observed where two serous surfaces roughened by inflam- mation rub together, as in the case of pericarditis or of pleurisy. The character of the fremitus and the point at which it is most distinctly felt are of diagnostic importance. Auscultation, or examination by the ear, may be carried out by the ear alone held against the surface directly over the organ, or by the stethoscope. All those signs which manifest themselves by sound are examined by ausculta- tion; such are the movements of air in the air-passages, or blood in the blood-vessels, and the grating sound caused by the friction of inflamed surfaces rubbing together. Abnormal sounds are heard in diseases accompanied by alterations in the air-passages or in the blood-stream in the blood-vessels. These are spoken of as new or adven- titious sounds. If connected with the air-passages, they are known as rales; if connected with the blood-vessels, as murmurs. Friction-sounds not being perceptible in health belong also to the class of adventitious sounds. These rdles, murmurs, and friction-sounds are very fre- quently referred to in describing diseases. Their signifi- cance, therefore, should be understood. Rales.—When the air on inspiration or expiration passes through liquid secretions, as in the case of catarrhal or inflamed conditions of the lungs or air-passages, sounds of bubbling and crackling are heard through the chest- walls; these are known as moist rdles, their variety being an important aid to diagnosis. A sound caused by a similar condition is heard in what is commonly known as the death-rattle, where the trachea becomes blocked with PHYSICAL SIGNS 185 mucus through which the air is breathed. The sounds of the rales are qualified by the thickness of the secretions and the size of the tubes over which they are heard. According to the sound, they are spoken of as fine, coarse, crackling, bubbling, or gurgling rales. Where the air passes through a tube of which the diameter is diminished by inflammatory processes, the abnormal sounds thus caused are spoken of as dry rales, and are sibilant or sonorous, according to the pitch. The rales are also grouped under the name of the areas where they occur. Thus we have tracheal rales, bronchial rales, and the vesical rales heard over the air-vesicles; the latter are also frequently called crepitant (crackling) rales, from the characteristic sound they produce. Murmurs are due to changes in the directions of the blood-currents, usually caused either by obstruction of a valve, which impedes the flow of blood, or insufficiency of a valve, which allows the blood to regurgitate into one or other chamber of the heart; they may also be due to the presence of an aneurysm in one of the blood- vessels. They are audible over the area of the heart or over the course of certain blood-vessels, and are likened to the blowing sound made by a pair of bellows. Murmurs may also be due to conditions where the blood itself is seriously altered, as in anemia. These are spoken of as hemic or inorganic murmurs. The peculiar sound of the murmur, the area over which it is heard, and the time of its occurrence, whether during or after dilatation or contraction, are all of diagnostic importance. Friction-sounds heard through the chest-wall are caused by the rubbing together of the surfaces either of the pleura or of the pericardium, when they have been rough- ened by inflammation. Percussion is a second method of examination by the ear. By placing a finger of the left hand directly over the point of examination and striking it lightly with the tips of the first or second fingers of the right hand, notes of varying pitch are produced, according to the density of the underlying structure (Fig. 42). By these means an area 186 OBSERVATION AND EXAMINATION occupied by an organ is mapped out and changes in its structure affecting its density are detected; the resonance of the lung is studied, and its elasticity or resistance deter- mined. The above brief description of the methods of physical examination and the significance of the physical signs so demonstrated arc for the purpose of making more readily understood the characteristic symptoms and manifestation of cer- tain diseases, and the aim and direction of the differ- ent methods of treatment. It is not, obviously, in any sense to be understood as a guide to an examination of a patient, such an ex- amination being purely for the purpose of diagnosis, and not included in the duties of a nurse. Some of the terms, however, are so constantly referred to, both in practice and in all text-books which it may be desirable to consult, that an understanding of their mean- ing and significance is not only convenient, but necessary. When the patient is not confined to bed, it is usually preferred to examine the chest with the patient either standing or sitting upright; in most hospital cases this is, however, out of the question. In examining the chest in front the arms are usually held hanging straight from the shoulder; in examining the side, the hands are crossed above the head; when the back is examined, the arms are crossed in front and the head bent forward. In a young child an excellent method of examining the back of the chest is as follows: The child is taken on the left arm of the nurse, the buttocks supported by the arm, the front of the chest Fig. 42.—Percussion (DaCosta). PHYSICAL SIGNS 187 flat against her breast. The head hangs a little downward over her shoulder, and may be held in place by her left hand. Usually the child feels comfortable and will remain still better in this position than in any other. To examine the front of the chest in a young child the child is held on the back across the knees, the head falling a little backward, and the arms held together above the head. If the arms are to be kept to the side, they may be pinioned in the following way: Fold a hand-towel in half lengthways, and lay it cross- ways under the baby's back. Bring the ends up on either side between the arms and the chest, and tuck them in over the extended arms and under the back. In all physical examinations the points essential for a nurse to consider are the following: The room must be 188 OBSERVATION AND EXAMINATION warm; the light good; the patient comfortable, never unnecessarily exposed, and kept comfortably supported without movement during the examination. During aus- cultation and percussion the room must be absolutely quiet. After the examination the patient should be warmly covered and induced to rest. If exhausted, some nourish- ment is given; in some cases a stimulant is ordered. For Fig. 4-1.—Auscultating the chest, showing the arms fixed by the side inspection it is obviously necessary to remove the garment* For the rest of the examination the covering is usually resumed or replaced by a towel or any covering of smooth material. When the chest is hairy, the nurse may be directed to wet the hair with warm water, as when rubbing against the stethoscope the hairs produce very definite sounds. EXAMINATION OF SPECIAL ORGANS 189 EXAMINATION OF SPECIAL ORGANS In special cases it is necessary to examine, either by inspection or by digital examination, the cavities of the body, the vagina, the uterus, the bladder, or the rectum. When an examination of a special organ is to be made, the patient may be asked to assume certain positions, according to the nature of the examination required. The positions are more especially applicable in gyneco- logic work. The usual positions are known by the follow- ing terms: Horizontal or Dorsal Recumbent Position.—The patient lies on the back, one pillow only under the head. The legs are separated and the knees slightly flexed. The horizontal position is used for the ordinary digital examin- Fig. 45.—Dorsal recumbent posture {American Illustrated Medical Dictionary). ation. The examiner usually stands on the patient's right, in order to use the right hand for examination. Dorsal or Lithotomy Position.—The patient lies on the back, either across the bed, the buttocks resting on the edge of the mattress, or, if on the examining table, with the buttocks brought to the edge of the table. A flat pillow is usually placed below the buttocks, in order to raise the pelvis. The legs are well separated, and the knees acutely flexed. To maintain this position it is necessary to support the feet and keep the knees immov- able. An examination table is usually provided with " crutch and stirrup " for this purpose. The crutch is a rod adjusted to a socket at the lower end of the table (one at either side), to which a stirrup or foot support is attached. The stirrups are made of webbing, and are 190 OBSERVATION AND EXAMINATION hung from the crutch at the height convenient to support the foot. When the patient is in bed, she may be directed to place the heels on the edge of the mattress or on a small table or chair placed conveniently near on either side. The nurse, then, standing by the bed on the patient's U^5k Fig. 46.—Lithotomy position (Ashton). right side, holds the knees apart; the examiner usually sits on a chair exactly opposite the patient. Where it is necessary to control the movements of the patient, two nurses are needed, one on either side; the knee is encircled Fig. 47.—Lithotomy position, with leg-holder applied {American Illustrated Medical Dictionary). in one arm, the foot being held in the other hand. Other means sometimes used are to tie each ankle to the wrist on the same side with a wide piece of bandage; or a long wide bandage may be passed behind the shoulders and round the thigh, just above the knee (Fig. 47). This posi- EXAMINATION OF SPECIAL ORGANS 191 tion is used for examination and operations on the peri- neum, vagina, cervix (the neck of the uterus which hangs free in the upper part of the vagina), and uterine cavity, and for digital examination of such parts of the pelvis as can be felt through the vaginal wall; for examination of the bladder and rectum and for the majority of operations on the bladder and rectum. Knee-chest, or Genupectoral, Position.—In this position the patient kneels on the bed or examining table and bends forward until the chest rests on the bed, the abdomen re- maining unsupported. The head is turned to one side, rest- ing on the cheek, and the arms are extended. A small pil- low is allowed under the chest. The knee-chest position is very common in gynecologic work, not only for purposes of examination, but in order to overcome displacements Fig. 48.—Knee-chest, or genupectoral, posture {American Illustrated Medical Dictionary). and for the introduction of pessaries. Patients usually re- quire to be taught the position, their inclination being to rest the abdomen against the flexed thighs. As the object most frequently is to allow the pelvic organs to fall for- ward, the object is defeated if the abdomen is supported. The knee-chest position is also a common one in making a rectal examination and in giving colonic flushing. The simple purgative enema is often more effectual if given in this position. Sims' Position.—This is so called after a famous gyne- cologist who first employed it. It is also known as the left lateral position. The patient lies on the left side, the cheek resting naturally on the pillow (one small pillow only is allowed), the buttocks brought to the edge of the 192 OBSERVATION AND EXAMINATION bed, so that the body lies diagonally across the bed. She is then directed to place her left arm behind her back; this will turn the body with the right shoulder forward, so that the patient is lying partly on her chest, and the right hip is tilted more forward than the left. Both knees are drawn up at right angles to the body, and the right Fig. 49.—Sims' position, anterior view (American Illustrated Medical Dictionary). knee crossed over the left, so that it rests on the bed. The position is peculiarly favorable for obtaining a clear view of the cervix and dome of the vagina. With the body tilted in this position the abdominal viscera fall away from the pelvis, while the flexion and crossing Fig. 50.—Sims' position, posterior view {American Illustrated Medi- cal Dictionary). forward of the right thigh exposes the orifice of the vagina. The Sims' speculum is passed, and the perineum held back; this exposes the vaginal cavity freely, and admits a certain amount of air, which distends the vagina and thus further facilitates the examination of the cervix and adjacent tissues. EXAMINATION OF SPECIAL ORGANS 193 The Sims position is especially used for inspection and for treatment of minor operations on the cervix and anterior wall of the vagina. With many surgeons it is a favorite position for the repair of vesicovaginal fistula (an artificial opening between the bladder and the vagina). In order further to keep the mouth of the vagina free, the nurse may be directed to elevate and support the right thigh. She may hold it in the required position, or. especially if the examination is a long one, place a double pillow or rolled blanket between the knees. The above is the true Sims position; for a simple digital examination of the cervix, etc., where a picture of the parts is not necessary, many surgeons use a modification of the above, in which the left leg is fully extended; the position is otherwise the same. In this circumstance it is not necessary to expose the patient. For some examina- tions one or two pillows are placed below the left hip, thus raising the pelvis and tilting the right hip further forward: this is known as the elevated Sims position. Trendelenburg position, also named after the gyne- cologist who employed it, is not, properly speaking, an Fig. 51.—Trendelenburg position (Ashton). examining position. It is at the present time the usual position in which abdominal operations on the pelvic organs are performed, and operating tables are usually made so that they can be easily adjusted to the required position. When this is not the case, the patient is placed in the dorsal position, with the knees flexed over the lower 13 194 OBSERVATION AND EXAMINATION edge of the table and the feet comfortably secured to the legs of the table. The head is turned to one side, resting on the cheek; the lower end of the table is then raised to the required angle, bringing the hips high above the shoulders. In this position the abdominal viscera fall toward the floor of the chest and away from the pelvis, leaving the pelvic organs more readily manipulated when the abdomen is opened. If it is necessary to put the patient in the Trendelen- burg position in the ordinary bed, a long-backed chair may be converted into an inclined plane by being turned up- side down and laid with the front edge of the seat and the top of the back resting on the mattress, the chair-legs directed toward the bottom of the bed. The plane so Fig. 52.—Improvised Trendelenburg position (Dickinson). formed is comfortably padded with a pillow or a blanket. The legs are flexed over the bars of the chair, and comfort- ably secured to its legs, the patient lying along the back of the chair. The lower end of the bedstead may then be raised on blocks. In using the Trendelenburg posi- tion for any length of time it is usually considered desirable to change the angle from time to time. In the ordinary operating or examination table the adjustment is made by means of a cog-wheel, with the manipulation of which nurses should be made familiar. More rarely the patient is examined standing. A stool is provided on which one foot is rested, the legs being separated as far as is comfortable. The patient supports herself by grasping the back of a chair (Fig. 53). In all the above conditions no part of the patient is 8275 EXAMINATION OF SPECIAL ORGANS 195 exposed except that to be immediately examined. The night-dress should be rolled out of the way above the waist] and the heavier bed-coverings removed. In the horizontal position the sheet may be left over the patient, the sides and bottom untucked, and no exposure at all is necessary. In hospitals, for the Sims, knee-chest, and dorsal positions special ex- amination sheets are usually pro- vided, large enough to cover the patient, and made with an open- ing which can be adjusted over the area to be examined. Where these are not provided, a couple of sheets or draw-sheets, pinned together at the margin, leaving an opening at a suitable point, are practicable. In any circum- stance two sheets, one above and one below, can, with a little ingenuity, be made to serve. The sheets should not be tucked under the mattress, as altera- tion in the position is thereby impeded. For the dorsal position stockings or leggings should cover the legs, and, if an examination sheet is not used, one sheet should cover the body to the pubes, while the second is placed below the buttocks; the sides are brought up on the outside and tucked round the thighs. If a douche is given in this position, a Kelly pad (p. 548) is placed below the buttocks, the rubber apron directed into a bucket on the floor. In the standing position the skirts are removed and replaced by a sheet pinned round the waist in such a way that the opening is toward the examiner. For a vaginal examination both rectum and bladder should be empty. A table is placed conveniently, provided with the following articles, ready sterilized, and laid on a sterile towel; a second sterile towel covers them until ready to be used: Fig. 53.—Standing posi- tion (Ashton). 196 OBSERVATION AND EXAMINATION One pair of rubber gloves. Sterile lubricant. Sims' speculum. Uterine sound. Uterine forceps or sponge-holder. Applicators. Tube of gauze packing. One package of small gauze sponges. One package containing a small quantity of absorbent cotton. Basin of hot sterile water (100° F.). Small bottles containing any applications desired, such as iodin, etc., may be placed ready on a tray containing also a sterile glass measure into which the small amount necessary can be poured. A basin of antiseptic solution for the hands is also provided in case the technic is accidentally broken. The gloves are for the hands of the examiner. The lubricant provided may be sterile vaselin or an emulsion of Castile soap. Many dispense with the use of lubricants entirely. The Sims' speculum is a half cylinder made of plated metal mounted on a handle. It is used to enlarge the vaginal orifice by retracting the perineum, while its brightly plated surface acts as a reflector, increasing the light for purposes of inspection. It is usually advisable to have an artificial light and a head-mirror (see below) in readiness in case the available light is not sufficient. It is frequently the nurse's duty to hold the speculum in position. She should be careful to hold it immovable, as, if she changes the position, a different part of the vaginal wall will be held back and she may interfere with the object of the examination. Other specula sometimes used are in the form of complete cylinders of varying sizes, the inner surface of which is brightly polished. They may be made of metal, or more generally of glass, the outer surface of which is darkened and the inner surface silvered. If a nurse is directed to lubricate a speculum, she must be careful to lubricate only the outer surface, otherwise the reflecting inner surface is dulled. EXAMINATION OF SPECIAL ORGANS 197 The applicators are "mounted" with small strands of absorbent cotton. To do this a very thin strand, about two inches long and one-half inch wide, is taken between the finger and thumb of the left hand. The applicator is a small, roughened metal rod, mounted on a long handle. It is taken in the right hand, the tip placed between the finger and thumb of the left hand, and, by a quick rotatory movement of the right hand, the cotton is securely wound round the tip of the applicator. A little practice is necessary to perform this deftly. The applicator is then dipped in the required solution. A thick piece of cotton must not be used, other- wise it is apt to become detached and left in the cavity. Applications to the cervix, such as iodin, etc., are thus used directly on one spot without danger of dropping the application on other parts. In order to pack the vagina the uterine forceps or sponge- holders are used. Sponges may be necessary to dry up secretions, small points of bleeding, etc.; the hot water is to warm the instruments before use. The uterine sound is a long probe of polished metal marked off into inches or centimeters; 2\ inches from the tip there is a slight enlargement. The sound is used for measuring the cavity of the uterus, the normal depth of which is 2\ inches. The enlargement at this point shows quickly whether or not the cavity is normal. The nurse's part in such an examination lies entirely with the patient. She may be asked to pour out some application, but must be careful to touch nothing sterile on the table. In some cases the nurse may be required to prepare the cervix dilators. These dilators are small, solid instru- ments, usually either of silver or hard rubber, shaped like a pencil, slightly curved, about 3| inches long, and of varying diameters. Usually a set contains 12; they should be arranged on the table in order of gradation, convenient to the examiner's hand. Silver dilators are sterilized by boiling, and should be warmed before introduction; hard-rubber dilators would lose their shape if boiled, and are usually placed in alcohol (70 per cent.) at least half 198 OBSERVATION AND EXAMINATION an hour before use. A sterile lubricant should be provided, . and the Sims' speculum, with which the vaginal orifice is held open during the dilatation. The patient, for this process, lies either in the lithotomy position or the Sims position; if inspection of the part is also desired, the latter is usually preferred. Bladder Examination.—For examination or treatment of the bladder the patient lies in the lithotomy position. Dilators for the examination of the bladder are straight, hollow, cylindric instruments, of varying diameter, usually of silver, which can be sterilized by boiling. The dilators, arranged according to size, are introduced in turn into the urethra; a sterile lubricant is usually required. The examination is made in a darkened room, with arti- ficial light and head-mirror (see below); the polished inner surface of the dilators acts as a speculum, and helps to illuminate the cavity. A special dilator sometimes used is provided with a small electric bulb at the tip. When it is in place, the electric current is turned on and the in- terior of the bladder illuminated. This dilator is especially useful where it is desired to catheterize the ureters, the vessels which conduct the urine from the kidneys to the bladder. To catheterize the ureters long, fine, filiform catheters are used, which must be carefully sterilized, usually in the autoclave. The patient lies in the lithotomy position; the urethra is well dilated, and the dilator kept in position while the catheters are passed; once the catheters are in position, the dilator is generally removed. As it is usually of the first importance to distinguish between the secre- tions of the two kidneys, one of the catheters should have some distinguishing mark, such as a piece of silk threaded through the open end. A note in writing should be made as to whether the marked catheter is passed into the left or right ureter. A couple of sterile test-tubes, also marked right and left, must be provided to catch the secretion. The open ends of the catheters are introduced into the respective tubes, which are corked with sterile cotton, packed lightly round the catheter. For a rectal examination hollow dilators similar to EXAMINATION OF ORGANS OF SPECIAL SENSE 199 those for a bladder examination, but of a considerably larger size, are used. The patient, as a rule, is in the knee-chest position. Frequently applications are made through the dilators on fissures or ulcers that can be reached through the rectum. An artificial light and head- mirror are practically always necessary. These examinations are always peculiarly trying to the patient, and are necessarily made more so if the nurse fails to have things ready, or to place the patient quickly and comfortably in the desired position. Illumination of Cavities.—In conditions when it is desirable to get a clear picture of the interior of a cavity, such as the vagina, the bladder, the posterior nares, the posterior chamber of the eye, etc., a brighter illumination may be obtained by reflecting an artificial light from a small mirror directly on to the spot. The mirror in general use is most conveniently worn on the forehead of the operator, to which it is attached by a strap and buckle; it is usually known as the head-mirror (Fig. 55, p. 202). With the light in a suitable position an intensely bright light is focused from the mirror on to the area to be examined, and re- flected back from the spot so illuminated. Under suitable circumstances sunlight may be used, but usually an arti- ficial light is more satisfactorily adjusted. When an arti- ficial light is used, the room must be thoroughly darkened; the light is held opposite the operator behind, and somewhat to one side of, the part to be examined, at such an angle that the rays are focused by the mirror and thrown directly on the desired spot. The head-mirror is provided with a minute opening in the center, through which the examina- tion can be made if preferred. EXAMINATION OF ORGANS OF SPECIAL SENSE For the proper examination of the organs of the special senses a darkened room, with artificial light and reflecting mirror, is practically essential. Examination of the Eye.—The eye is examined in order to determine irregularities of vision, such as myopia (near-sightedness), hypermetropia (far-sightedness), or astigmatism (defective refraction), and to ascertain the 200 OBSERVATION AND EXAMINATION condition of those parts of the organ of sight contained in the interior of the eye. This includes the retina, which is the expanded end of the optic nerve, forming a fine net- work round the internal chamber of the eye, and the crystalline lens, which is suspended immediately be- hind the ins. The interior of the eye is examined through the pupil, the opening behind the transparent portion of the conjunctiva, which be- comes smaller when ex- posed to the light, owing to the drawing together of the iris, or curtain of the eye. To overcome this, when careful examination of the interior of the eye is necessary, one or two drops of a solution con- taining a mydriatic are applied between the lids an hour or two previously. A mydriatic is a drug which has the effect of di- lating the pupil by con- tracting and paralyzing certain muscles of the iris. The mydriatic usually em- ployed is atropin (the al- kaloid of belladonna); the usual strength used is either 2 grains or 4 grains to the ounce. Generally, 2 drops are ordered, one under the upper lid and one under the lower. The effect of atropin is slow in passing away; usually the effect lasts the greater part of a week, during which time the eye cannot be used for reading, writing, and similar occupations. Where it is not considered neces- sary to keep the eye at rest for so long a time, homa- Fig. 54.—Loring's ophthalmoscope. EXAMINATION OF ORGANS OF SPECIAL SENSE 201 tropin is used instead. Homatropin is a derivative of atropin, with a milder action and more quickly tran- sitory effect. Some discomfort, usually a dryness of the throat or nose, is sometimes experienced by people as the result of atropin eye drops. This may be dimin- ished by care in not applying more than the required number of drops, and by directing the patient to keep the nose held and the eye closed for a few moments after the application. The tears excited will then flow over the cheek, instead of into the nose by the lacrimal canal, and can be removed with a handkerchief. The patient sits opposite the operator, the light behind his head on the side of the eye to be examined. For accurate examination an instrument known as an ophthalmoscope is used. It consists of a small reflecting mirror with an opening in the middle, through which the examiner looks. The mirror is in an oblong metal plate fitted to a convenient handle; to the plate are attached small lenses of varying refractive power, which can be revolved in front of the small opening in testing the refraction of the eye. A crystal biconvex lens is also constantly used, either in place of a mirror, to illuminate the eye, or in testing the refraction. In many cerebral conditions, and in accidents involving portions of the brain, an examination of the internal cham- ber of the eye is of considerable diagnostic importance. In these conditions the examination is, of course, made with the patient in the recumbent position. Examination of the Ear.—The ear is examined for the purpose of obtaining a picture of the tympanum or drum, the delicate membrane lying between the external audi- tory canal and the chamber of the middle ear, upon the in- tegrity of which we depend for our hearing. Small highly polished specula, usually of silver, in shape like a little funnel are used. The outer ear is drawn slightly upward and backward, in order to straighten the auditory canal; the speculum is placed in the opening, and illuminated with the bright light reflected from the head-mirror. Through the speculum applications can be made to the drum, and operations, such as puncturing the drum, per- ?02 OBSERVATION AND EXAMINATION formed. The patient sits, of course, with the ear opposite the operator. Examination of the Nose.—Similar small specula are also used in examining the nose--either the nostrils (nares) or the posterior nares, the small cavity lying be- tween the nose and the throat. The specula dilate the opening and help to illuminate the cavity. In passing any instrument into the posterior nares the tip of the nose is pushed upward and the instrument passed directly back- ward into the small opening thus exposed. Examination of the Throat.—For an examination of the throat a tongue depressor and applicators of a suitable Fig. 55.—Laryngoscopy, showing the mirror being introduced, and also the relative position of the patient and examiner and the posi- tion of the light (Morrow). size are necessary. The patient sits directly opposite the operator, his back to the light; an artificial light and head-mirror are always advisable. Tongue-depressors are flat instruments, made of metal or glass; any small flat body, such as a paper-knife or the handle of a spoon, serves the purpose. In hospital work small, flat pieces of smooth wood are commonly used, especially in the out- patient department, and can be discarded after use, if EXAMINATION OF ORGANS OF SPECIAL SENSE 203 advisable, without much expense. Clothes-pins divided in half are frequently used as cheap and convenient tongue depressors. Wooden applicators resembling long tooth- picks are generally used, and burnt after use. The applicators are mounted with the strands of absorbent cotton as already described; they may be mounted and put up in packets of a dozen and sterilized like other dressings. A second small mirror mounted on a handle is passed to the back of the throat, in order to obtain a picture of the larynx {laryngoscopy). Fig. 56.—Inflation by Politzer's method (Morrow). For a throat examination a basin, towel, and glass of warm water should be at hand. In sensitive patients reflex vomiting may be excited by the pressure on the tongue or the touch of the applicator. Applicators are also frequently applied to the throat in the form of sprays. The Eustachian catheter is a small, fine, hollow instru- ment, used to dilate the eustachian tube, i. e., the passage leading from the back of the throat to the middle ear, or air-space immediately behind the drum. Generally, it is not lubricated, glycerin having too astringent an effect 204 OBSERVATION AND EXAMINATION upon the mucous membrane, and the taste of oil or soap being objectionable to the patient. It is usually wet with hot water before passing. Politzer's bag is an apparatus frequently used in throat treatment. Its use is to dilate the Eustachian tubes by suddenly forcing through them a volume of air. It is a large rubber ball filled with air, and provided with a short nozzle of bone or hard rubber. The tip of the nozzle is introduced into one nostril; the patient is then directed to swallow a sip of water; as he swallows, the bag is sharply squeezed and the air prevented, by the act of swallowing, from escaping out of the mouth or entering the respiratory passages, is forced through the Eustachian tubes (Fig. 56). OBSERVATION OF THE SKIN Any abnormal appearance of the skin, general or local, is probably of diagnostic value. Pallor.—Abnormal pallor of the skin and mucous mem- brane may be due to deficient circulation from disturbance of the heart's action, as in fainting, to contraction of the superficial blood-vessels, as in exposure to cold, to condi- tions in which the blood is deficient in coloring, as in the various anemias. Cyanosis, or bluenessof the skin and mucous membranes, results when the blood is not sufficiently oxidized. It may be caused by obstruction in the respiratory passages or organs (see Respiration), by conditions causing congestion of the venous circulation, as in valvular heart disease, or from failure of the nerve-centers controlling the respira- tion and the action of the heart, as in conditions of collapse. Cyanosis is relieved in several ways: (1) By the administration of oxygen; (2) indirectly by venesection, which relieves the venous congestion; (3) by the subcu- taneous injection of one to two pints of normal salt solu- tion, which increases the volume of the blood, thereby stimulating the circulation, and through the circulation, the vital centers. Color.—Some diseases are characterized by changes in the color of the skin. In jaundice the tissues are stained yellow, from the presence of bile in the blood. The discolora- OBSERVATION OF THE SKIN 205 tion includes the conjunctiva (the transparent covering of the eye), in which delicate membrane the yellow tinge first appears. Jaundice is a prominent symptom in the acute infectious fever known as yellow fever. Any conditions that may cause obstruction to the bile-ducts may be associ- ated with jaundice, such as catarrhal conditions, inflam- mation or disease of the liver or gall-bladder, obstruction by gall-stones, pressure, as from cancer, etc. Anemia.—Simple anemia is characterized by pallor of the skin and of the mucous membrane, especially noticeable on the lips and the conjunctiva. The grave form of anemia, known as pernicious or malignant anemia, is characterized by a lemon hue of the skin and mucous membranes, the eyes remaining clear. The discoloration is permanent and the disease is usually considered incurable. Chlorosis, or green sickness, is the name given to a form of essential anemia occurring chiefly in girls and young women, in which the skin assumes a greenish hue. The disease yields to treatment, including a nourishing diet, iron, rest, fresh air, and good hygiene. A temporary local bronzing of the skin, occurring as tawny patches, chiefly on the exposed surfaces of the body, is common in pregnancy. Pigmented patches of a deeper shade of bronze on the skin and on the mucous membranes, especially of the mouth, is usually associated with Addison's disease, a fatal affection due to disease of the suprarenal glands. Rashes or cutaneous eruptions are inflammatory condi- tions of the skin from various causes. They may be due to the action of toxins, to the use of certain drugs, to local irritations or inflammations, to animal or vegetable parasites, or to subcutaneous hemorrhages. Rashes may be diffuse or circumscribed, and present varied character- istic appearances, to describe which the following terms are used: Erythema.—An erythematous rash gives the skin a bright red appearance, like a diffuse blush. In some in- stances, on close examination, the rash appears to be formed of minute scarlet points in close proximity. Ery- thematous rashes of this variety are known as punctiform. 206 OBSERVATION AND EXAMINATION They are characteristic of scarlet fever, erysipelas, (icrman measles, and many accidental rashes. Macule.—A macule appears as a spot not raised above the surface of the skin. A rash occurring in unelevated spots, either general or in isolated parts of the body, is described as macular. In inflammatory conditions the spots are red; in other conditions they may be brown (freckles or lentigo), yellowish, or white. Papule.—A small solid spot elevated above the surface of the skin, usually pink or red in color, is known as a papule. Papules may occur in isolated areas, as in the typhoid rash, or distributed generally all over the body, as in the rashes of measles, small-pox, etc. In many in- stances papules become vesicular or pustular. Slightly convex papules are described as lenticular, from their resemblance to the form of a lens (example, the typhoid spot). (See also p. 713, Rashes of Eruptive Fevers.) Tubercle.—A solid elevation or patch, larger than a papule, is described as a tubercle or nodule. Characteristic tubercles are found in syphilis, barber's itch, lupus, etc. Tubercles vary in size from a " split-pea to a hazel-nut " (Gould). A vesicle is a blister. An eruption occurring in small blisters containing clear fluid (serum) is described as vesicular. Commonly, the vesicle begins as a papule. The larger vesicles are described as blebs. Pustule.—Vesicles containing pus are known as pustules. They usually occur first as papules or simple vesicles; the clear serum changes to a milky exudate, formed of serum and white corpuscles, which may shortly become true pus. Small-pox is characterized by a pustular rash. The vesicles in chicken-pox, more rarely the papules of measles, may also become pustular, especially if infected by scratching. Wheals or Pomphi.—A wheal resembles a papule, but is evanescent and characterized by excessive itching. They may be red, or show a white papule on a reddened skin. A rash consisting of crops of wheals is characteristic of urticaria or nettlerash; wheals are also produced by the bites of insects. OBSERVATION OF THE SKIN 207, Petechia.—Petechia? are small purple points occurring under the skin, the results of minute hemorrhages. The rash is often described as a hemorrhagic rash. Such rashes are characteristic of purpura, typhus fever, cerebro- spinal meningitis, and may also occur in severe forms of scurvy and the malignant varieties of scarlet fever, measles, and small-pox. A purplish discoloration of the skin in larger patches, caused by profuse subcutaneous hemorrhage, is known as ecchymosis (p. 599). Scales.—A scaly or squamous eruption is due to the separation of the upper layers of the epithelium. Many forms of skin disease are characterized by the formation of scales; the formation, character, and distribution of the scales determine the diagnosis. Commonly, the scal- ing is associated with some inflammatory condition of the skin. The presence of flaky scales on the body may be due to desquamation following one of the eruptive fevers, especially scarlet fever. In certain conditions the skin has a swollen appear- ance. This may be local, occurring in strictly circum- scribed areas, or extensive, involving a large portion of the body, or generally distributed over all the body. Such swellings are described in the following terms: Induration.—The tissues feel hard, solid, and resistant. Separate indurated swellings are commonly due to exuda- tion from inflammatory processes. The swelling may become softer and gradually disappear as the inflammatory processes are absorbed, a process known as resolution; or suppuration may occur, and we speak of the mass breaking down. General induration of the skin occurs typically in the disease known as myxedema. The appearance generally suggests dropsy, but the skin feels solid or resistant, and does not pit on pressure. Brawny.—Extensive local indurations involving deeper tissues are spoken of as brawny. Brawny swellings are frequently due to cellulitis. A brawny condition of the extremities involving the muscles is common in scurvy. Edema or Dropsy.—An edematous swelling is due to an 208 OBSERVATION AND EXAMINATION accumulation of lymph fluid derived from the blood-stream in the cellular tissues (p. 697). A swelling due to edema may be readily indented by pressure, the indentations remaining after the pressure is removed. The skin is said to pit on pressure. Edema is a characteristic symptom in valvular heart disease, acute nephritis, and anemia. In the rare condition known as cutaneous emphysema, air is present in the cellular tissues. The skin will pit on pressure, but the indentation disappears as soon as pressure is removed. On pressure, a crackling noise is heard over the area; the condition is due to an escape of air or gas into the tissues caused by the rupture of such an organ as the lungs or stomach, etc. The rupture may result from a wound or from disease associated with ulcera- tion. Hypertrophy and Atrophy.—Changes in the structure of an organ due to disease are called morbid changes. Enlargement of any organ or tissue due to morbid changes is called hypertrophy. In some conditions we may have extensive areas hypertrophied. The immense swelling of the skin and cellular tissues of the lower extrem- ities in elephantiasis is an example of hypertrophy. A wasting of any tissue or organ resulting in a lessening of the size is described as atrophy. This may infect an entire limb, as in some forms of paralysis, where the proc- esses of nutrition are less active than in other parts of the body, with the result that the limb appears shrunken and withered. EXAMINATION OF THE BLOOD The examination of a patient includes the examination of the excreta, vomitus, and sputum (see following chap- ter), and, usually, the microscopic examination of any abnormal discharge. This latter is accomplished by taking a culture (p. 504). Under all circumstances, at the present day, it is also the custom to examine a specimen of the blood of the patient, its condition being very frequently of diagnostic importance. In many conditions and in diseases affecting EXAMINATION OF THE BLOOD 209 vitality the composition of the blood is altered. It may be altered in relation to the proportion of fluids and solids, or in the proportion of the different solids to each other; it may also contain extraneous substances, such as urea, bile, the bacteria of disease, or certain parasites. The methods' employed for examining the blood are the blood-count, the blood-smear, and in special cases the bloodfculture. The blood-count is used for the enumeration of the corpuscles. 0100mm 4i0 or 2 decimeters, 5 centimeters, and 7 millimeters; or, more simply, 257 millimeters. The measure most constantly met with is the centimeter, which takes the place of the inch in the yard measure, and measures, approximately, f inch. For the multipli- cation of the meter the Greek prefixes deka- (10), hekto- (100), and kilo- (1000) are placed before the word meter. A kilometer thus is a measure of 1000 meters. The divisions of the meter most frequently used com- pare approximately with ordinary lineal measure, as follows: 1 millimeter = ^V inch. 1 centimeter = $• inch. 1 decimeter = 4 inches. 1 meter = 39.37 inches. 1 kilometer = 3280 feet 7 inches, or about J mile. The same prefixes, deci-, centi-, and milli-, for the divis- ions, and deka-, hekto-, and kilo-, for the multiplications, are used before the unit in the measures of weight, capacity, and volume, based on the meter. The measure of capacity is derived from the cube of the meter. A cube is a body measuring exactly the same in its three dimensions of length, breadth, and height. For example, while the term 1 meter signifies a line 1 meter in length, 1 cubic meter represents a body, or a space, which measures 1 meter in length, breadth, and height. 298 MEDICINES Where the cube is intended, the word cubic is placed before the prefixes of multiplication or division; thus, cubic millimeter, cubic centimeter, etc. The Measure of Volume.—The name liter is given to the unit of the measure of volume; it corresponds approx- imately to the quart, or two pints. The liter represents the capacity of a cube measuring 1 decimeter (one-tenth of a meter) in each of its three dimensions, that is, one cubic decimeter (approximately, 4 cubic inches), by which term it might equally well have been known. Using the same prefixes that are used in the multiplication and divisions of the meter, we have the deciliter, centiliter, and milliliter, the dekaliter, hectoliter, and kiloliter. The measure of capacity is equally the measure of volume, and is used in measuring fluids, the liter rep- resenting the volume of water required to fill a cube of that capacity. For these measurements water is taken at its greatest density, which is 4° C. From its size, however, the liter is an inconvenient standard where small amounts and their fractions have to be reckoned. It would obviously be impractical to describe the minim or the dram as fractional parts of a quart. To overcome this disadvantage, in place of the subdivisions of the liter we use the cube of the centimeter, which is equal to one milliliter. This represents the volume of water at 4° C. required to fill a cube measuring 1 centimeter (f inch) in each of its three dimensions. This measure is the ordinary medicinal unit, and is used entirely in place of the subdivisions of the liter. Thus, instead of one deciliter, we say 100 cubic centimeters. A liter also is frequently described as 1000 cubic centimeters. The apothecaries' fluid measures are expressed in cubic centimeters, as follows: Approximately. Accurately. ........ 0.06 c.c. 1 c c. 0.92 c.c. 4 c.c. 3.75 c.c. 30 c.c. 29.57 c.c. 500 c.c. 473.11 c.c. 1000 c.c. or 1 liter 950.22 c.c. i immm = 15 minims = 1 fluidram = 1 fluidounce = 1 pint = 1 auart = THE METRIC SYSTEM 299 Metric Weights.—The unit of weight is the weight of one cubic centimeter of water at its greatest density (4° C). To this unit the name gram has been given. Thus, one cubic centimeter of water by measure equals one gram of water by weight. The multiplications and divisions of the gram are also expressed by the prefixes mentioned above, i. e., the deci- gram, centigram, and milligram, the dekagram, hektogram, and kilogram. The metric measure of weight corresponds to the other measures of weight as follows: Apothecaries' Measure. Approximately. Accurately. 1 grain = 65 milligrams 0.065 gm. 15 grains = 1 gram 0.972 gm. 1 dram = 4 grams 3.900 gm. 4 drams or § an ounce = 15 grams 15.500 gm. 1 ounce = 30 grams 31.100 gm. 12 ounces or 1 pound = 400 grams 373.230 gm. Avoirdupois. 1 ounce = 30 grams 28.35 gm. 1 pound = 450 grams 453.60 gm. 2 pounds 2 ounces = .......... 1000.00 gm. or 1 kilogram. Arabic numerals are used instead of the Latin ones, and the measure, represented either by its initial letter or an abbreviation, is placed after the number: thus, 15 gm., 200 c.c; in writing prescriptions the former is usually omitted, gm. being understood. Thus, a dose of a drug may be written simply 0.65, signifying 0.65 gram. The Common Metric Measures.—The measures of the metric system in most common use and their signs are as follows: The meter........................M. Centimeter.......................cm. Millimeter........................mm. Cubic centimeter..................c.c. Liter.............................L. Gram............................gm. Kilogram.........................K. Approximate Values of Metric Measures.—As a rough estimate in measuring and weighing drugs the following 300 Medicines approximate values of the measures in most common use are generally accepted: 500 c.c. for 1 pint (American). 500 gm. for 1 pound (avoirdupois). 30 c.c. for 1 fluidounce. 30 gm. for 1 ounce by weight. 4 c.c. for 1 fluidram. 4 gm. for 1 dram by weight. 1 c.c. for 15 minims. 1 gm. for 15 grains. Changing Apothecaries' to Metric.—Frequently it may be of use to express a dose measured by apothecaries' measure by the metric system. To do so, the simplest method is to reduce the dose to minims or grains and divide by 15, the approximate number of minims or grains in the cubic centimeter or gram respectively. If the bulk is large, it may, instead, be reckoned in drams and divided by 4, the number of cubic centimeters or grams in a dram. To express portions of a grain in grams two methods can be used. It will be remembered that the grain is equal to 0.065 gm., or 65 milligrams. Half a grain, therefore, represents 33 milligrams (0.033 gm.); \ grain, 16 milligrams (0.016); \, 20 milligrams (0.02), and so forth. A second and more convenient working method is to express the fraction as a decimal, and, as in other doses, to divide by 15. For example, f expressed in decimal fractions is 0.37, which, divided by 15, is 0.025. A dose of f grain is, therefore, represented by the metric system as 0.025 gram, or 25 milligrams. In some tables, comparing doses by vulgar fractions with fractional doses by metric measure, the calculation is made with 15| instead of with 15. The difference of the dose is so extremely small that the more convenient 15 is generally allowed as sufficiently accurate. NAMES OF PREPARATIONS The tables and measures having been mastered, the different forms in which drugs are made up should next be studied. The actual preparation should be used, with which the pupils should be made familiar by observ- ation, smell, and, where practical, taste. At the same time names of preparations 301 a simple general classification of the drugs used into the animal, vegetable, or mineral kingdoms can be made: q 3 *JH p B a P-3 & ^. 3 B M W 5 3 e T3 P t- 09 3 c B W B •o H d H o o> o 2^2 3 S- 8» n P ^ m". 3 {► • & o o a n rr ro B i-i B p o P 3 ^-s t» a- a ►rjGG P& £p- 3 CD £.* P p H 2 M d o B. h-« el- m 7S >-■ <-r rt- ffi era 8? p ► H O g B cd S0 P^.3 85"I £g £,*-» ™ era o S.cd co p b-o P- «,"§»!! P p C CD p o (t m <+"■ 2-5:2, * 5 p -^^ i-i. hj _ CD o -^£§ <*- r"P CL CD ff. m.O^ co re"^^ &-00 B3 „.«,B era ao p era ^ p. CO CD O >o cB O &L P CD ^ P HO o § p P* P 13 co B CD 2 3 P P S..CD i-l B2 cs *"* <5f pr-.o 3 era era p B-3" era >-*i "5* si en « co b O P p cd g.8 b*?T B* B O co ^ p^5 Btp ^ CD CD g-Q 2.S-^M P g S 3 ^^o O ^ ^ CD <^ O p giSsS Bt p &p p- 8"^^ p B 8,5-p < V rt-P^3 CD O B* i i i. onate, 40 gr. Blue packet j Rochelle sa^8j [ 2 dr. White packet, tartaric acid, 25 gr. Pil. j-i] Pil. j-iij Pil. j-ij Pil. j-ij Pil. j-ij nRJ-ij, diluted, 3ij-5j 5j-5i 3ij-iv The packets are dis- solved sepa- rately, then poured to- gether, and taken effer- vescing. As an emetic, gr. ss. gr. x = i of morphin. Trjjv-3ss Antimony and potassium tar- trate. Morphin sulphate, 1 grain to 1 dram with camphor, lic- orice, and carbonate of lime. Contains tartar emetic, 2 grains to the ounce. For External Use Sulphate of copper (solid). Lime-water and olive oil, equal parts of each. Solution of sodium hypochlorite. Distin- guished from Labarraque's solution by being free from any trace of caustic soda. Compound tincture of benzoin. Solution of the acetate of lead. Liquor sodse chlorinatse, sodium carbonate and chlorinated lime. Nitrate of silver stick. Solution of subsulphate of iron. Carbolic acid. Calomel, 1 dram, to lime-water, 1 pint. Bichlorid of mercury (corrosive sublimate), \ dram, to lime-water, 1 pint. Sulphate of zinc, 2 grains, to water, 1 ounce, colored with tincture of lavender. ADMINISTRATION OF DRUGS 313 ADMINISTRATION OF DRUGS Drugs may be administered for either their general action on the system or for a local action on one part of the system. Commonly, a drug taken into the system acts in two ways, direct or near, and indirect or remote. Drugs are absorbed into the system through the fol- lowing channels: 1. The alimentary canal {the mouth and rectum). 2. The respiratory system {inhalation). 3. The lymphatic system {hypodermic injection). 4. The arterial system {intravenous injection). 5. The surface of the skin (inunction and fumigation). Drugs are also applied externally for their local effect, as anodynes, counterirritants, etc. (See Local Applica- tion, Chap. XI.) Administration by mouth is the common method, and is that understood when the dose of a drug is stated without qualification. Medicines, except oily preparations, are diluted with water unless ordered to the contrary. Sufficient water to make the medicine palatable and no more is the usual indication. Minerals and other drugs irritating to the tissues should be well diluted, especially the preparations of iron, arsenic, and the dilute acids. Pills, tabloids, and capsules should be swallowed with water to help in dissolving them. If not perfectly fresh, pills and tabloids are better crushed and mixed with water before administering. Powders should be dis- solved in water before giving. The few official prepara- tions that are insoluble in water may be floated on the top of a spoonful of water, or taken directly on the tongue and swallowed with water. Unpalatable powders may be mixed with syrup, jams, or honey. Salts of mineral waters are taken well diluted, and are more efficacious if taken in warm water. An exception, however, is made in administering salts by the Matthew Hay method to 314 MEDICINES dispel dropsy. Salts are then given in concentrated doses. To make an oil palatable it may be given with orange wine, sherry, or brandy, or the oil may be shaken into an emulsion with double the quantity of hot milk or black coffee. To suck a slice of lemon before and after a dose of castor oil will generally take away the taste. A piece of ice sucked just before taking a dose will minimize a dis- agreeable flavor. Certain drugs are liable to discolor or otherwise injure the enamel of the teeth, and should be invariably taken through a glass drinking tube. The special drugs to be guarded against are iron in all fluid forms, the iodids, and the dilute acids. The ward medicine chest contains glass measures, graduated by drams to 2 ounces, minim measures for doses under one dram, pipets for measuring doses ordered by drops, or guttce, and not by minims, and glass tubes through which such drugs, etc., that discolor or corrode the teeth should be taken. Separate glasses should be kept for oily mixtures. The time-honored rule of reading the label on a bottle three times should be practised until it becomes a habit. The rule is to read the label on taking the bottle from its place, before pouring the medicine, and again on replac- ing the bottle. In pouring, the bottles should be held with the label uppermost to avoid soiling the label with drippings. In measuring, the graduate is held so that the eye is on a level with the line marking the quantity. In ward nursing care is necessary to prevent a dose being given to the wrong patient. Most hospitals have some rule or method to lessen the risk of such occur- rences. The colored card system is probably the most widely used. Different colors denote the different hours at which medicines are to be given, thus: Red, four-hourly, red with some additional mark, such as a corner cut off, two- hourly; blue, six-hourly, and blue with a corner off, three-hourly; yellow before food, orange after food, green ADMINISTRATION OF DRUGS 315 three times a day, and plain white cards for special orders. On the card is written the patient's name, the hour, the medicine, and dose, thus: Ward A. 12. 4. 8. John Smith. Tinct. digitalis, 10 minims in water. The cards are written out by the head nurse from the order-book or head-board, and are kept in separate packets, according to color, in the medicine closet. At the hour the nurse places the cards in a row in front of her, measures out each medicine, and covers the glass with the card, which is not removed until the medicine reaches the patient. The packet of cards is then placed on the head nurse's table, as an indication that the medicines have been given. The head nurse should keep a memorandum of the number there should be in each packet, so that she can tell at once if any have been forgotten. When a medicine is discontinued, the head nurse tears up the card. This system also saves the daily writing out of long lists of medicines to be given, a considerable item in a large ward. It is important that medicines should be given at the hour at which they are ordered. If a dose for any reason is omitted, a note in writing should be made of the fact, stating the reason. When a dose has been omitted, the omission cannot be rectified by giving a larger dose at the next time. By Rectum.—Administration by rectum is employed when, for general or local causes, feeding by the stomach is not possible: for example, in persistent vomiting, gastric ulcer, stricture of the esophagus, in some operations on 316 MEDICINES the mouth or on parts of the alimentary canal, and occa- sionally in conditions of coma and delirium. Drugs are also given by rectum to apply local remedies or to relieve local conditions, such as constipation, tympanites, or diarrhea. The absorptive power of the rectum is less than that of the stomach; in consequence, the dose by rectum is usually twice that given by mouth, unless the drug is ex- ceptionally powerful. Drugs are given by rectum, by enema, by douche, or by suppository, the patient lying with the legs flexed either in the dorsal position or on the left side. (See Enemata.) HYPODERMIC INJECTION Drugs are given by hypodermic injection when imme- diate action is required, or in place of rectal administra- tion, when giving by mouth is impracticable for the reasons just stated. The drug is taken without alteration di- rectly into the circulation by the lymphatic vessels: for this reason the dose is usually half the quantity given by mouth. Concentrated solutions of the active principle of a drug are used for hypodermic injection. For this purpose the drug is usually put up in the form of small tabloids, readily dissolved in a few minims of water. Stimulants, such as brandy and ether, are given by hypodermic undiluted, and camphor in two or three drops of sweet oil. Hypodermic injections are given in two ways, super- ficially, i. e., directly under the skin, or deep, into the mus- cular tissue. The rule used to stand that drugs irritating to the tissues were given deep into a muscle, and those without irritating properties, by the superficial method. At the present day the deep method is in favor for all drugs with the exception, perhaps, of morphin, atropin, and strychnin, which, for convenience sake, are frequently given in the fleshy part of the upper arm. Drugs in com- mon use that are specially irritating to the tissues are ergotin, digitalin, mercury, arsenic, and camphor. Certain drugs are administered by hypodermic injec- tion to act as local anesthetics during operations or painful HYPODERMIC INJECTION 317 surgical procedures. At the present day novocain is the drug generally employed for this purpose. It is a syn- thetic preparation, not related to cocain, but so called on account of the similarity of its action. It is preferred as less toxic than cocain or other substitutes. Though a prompt and powerful local anesthetic, the effect passes quickly. To rectify this drawback adrenalin (4 drops to 60 c.c. of novocain) may be added immediately before the injection is given; this is equivalent to 1 in 40,000 adrenalin. Novocain is sterilized by boiling five minutes, adrenalin by boiling one minute. The preparation may be obtained in tablets containing novocain .05 grams and suprarenin .00083 grams. Two tablets dissolved in 2 c.c. of distilled water give a 5 per cent, solution. The strength used is 1, \, and \ per cent.; for the average operation about 100 c.c. is re- quired. A special hypodermic syringe of a large size is used; small quantities of the drug are distributed under the skin all over the area to be anesthetized. Novocain may also be used as a general anesthetic in spinal anes- thesia, in which case very small concentrated doses are given. (See p. 330.) Other drugs used as local anesthetics are cocain, eucain, and a preparation of cocain containing morphin, known as Schleich's solution. For these drugs a long hypodermic needle is chosen, and introduced immediately under the skin or mucous membrane, below the line of the proposed incision; the needle is withdrawn a little at a time, and a few drops of the solution injected at each stop. The injec- tion should be completed five minutes before the opera- tion. Cocain is used for this purpose in the strength of 0.5 to 1 per cent, in sterile .distilled water. From 1 to 2 grains is the usual dose. Schleich's solution, of which there are three formulas, is given in a larger quantity of fluid, suffi- cient to produce edema of the part. Drugs for Hypodermic Injections.—The following is a table of the drugs most commonly given by hypodermic: Drug. Avebage Dose. Derivation. Chief Effect of the Dbcg. Morphin sulphate. Atropin sulphate. Apomorphin hydrochlorid. Strychnin sulphate. Nitroglycerin. Cocain hydrochlorid. Novocain. Pilocarpin hydrochlorid Hyoscin hydrobromid. Brandy. Ether. Oil of camphor. gr. TW gr. r.\ o-s'ff gr. TV, repeated in ten minutes if not effective. gr- sWV gr- 2ff?r~T5ff gr- 4-i 5 iij of | to | per cent, solution. gr. i-i gr. t&b-i& TTJJX-XXX ItJJX-XXX npij-vj Alkaloid of opium. Alkaloid of belladonna. Prepared from morphin by the action of hydro-chloric acid. Alkaloid of nux vomica. Anodyne and hypnotic. Powerful stimulant, especially to the respiratory centers. Powerful emetic, used when poisons have been swallowed, provided the stomach has not been injured. Cardiac respiratory and nerve stimu-lant. Cardiac stimulant, lowering blood-pressure by dilating the arteries. Cardiac stimulant, more frequently used in less concentrated form to induce local anesthesia. Local anesthetic. Powerful diaphoretic. Cardiac and respiratory stimulant, powerful hypnotic. General stimulant. General stimulant. Stimulant, especially of the nervous system. 1 Alkaloid of coca. Synthetic preparation. Alkaloid of jaborandi. Alkaloid of hyoscyamus. HYPODERMIC INJECTION 319 Antitoxin Serums.—(See Chapter XIV.) Hypodermoclysis.—(8ee Chapter XIV.) Lumbar Injections—{See Chapter XIV.) Intravenous Injections.—(See Chapter XIV.) On the continent of Europe it is quite customary to give almost all drugs, including even irritants, such as iron, arsenic, and digitalis, by hypodermic or " piqure," in pref- erence to by mouth. The drugs are put up each separate dose in a tiny glass vial, hermetically sealed, and opened by breaking off the slender neck: the needle is attached directly to the neck by a small piece of rubber tubing. There are two preparations of digitalis in use for hypo- dermic injection—an American preparation, digitaZi'we, of which the dose is -^ to -^ grain, and a German prepara- tion, digital, of which the dose is ^ to £ grain. Since Fig. 129.—Hypodermic tray. the difference of the dose is so great, it is highly important to be certain which preparation is being used. To give a hypodermic injection it is necessary to prick the surface of the skin, thus opening what may prove a channel of infection if proper precautions are not ob- served. The hands of the operator and the area to be pricked must be surgically clean, the syringe, needle, and injection sterile (Chap. XIV). At the same time it is important that the technic employed should be simple and take up no unnecessary time. A small tray arranged with all necessary articles for the operation should form part of the equipment of the medicine cupboard. This consists of an alcohol lamp, a spoon, the syringe, a bottle of alcohol, a small covered jar for sterile gauze sponges, 320 MEDICINES another for needles, a small glass or gallipot, matches, the tabloids of the drugs used in small stoppered bottles or glass tubes. The needles may be kept in shot, emery powder, or between layers of gauze, and should invariably be kept threaded with wire when not in use, the wire coming well beyond the point. If the syringe is entirely of glass, with solid glass piston, it is sterilized by boiling. Fig. 130.—Ordinary glass and metal hypodermic syringe (Morrow). The syringe in general use has rubber washers, which are injured by boiling; it is best prepared by soaking in alcohol before use. Proceed as follows: 1. Fill the syringe with alcohol; pour some into the gallipot, and leave the syringe to soak for a few minutes. 2. Wash your hands. 3. Boil the needle over the alcohol lamp in the spoon without the wire. Fig. 131.—Method of giving a hypodermic injection (Thornton). 4. Empty the syringe and draw up about five minims of the boiled water. 5. Unscrew the top and shake in from the vial a tabloid of the required dose; it will dissolve readily. A drug should never be boiled. 6. Take the needle with a sterile gauze sponge and join to the syringe. Keep the sponge round the needle until actually to be used. INHALATION—ANESTHESIA 321 7. Hold the syringe upright, and press the piston gently until a drop appears at the point. This is to expel the air. 8. Soak a gauze sponge in alcohol, carry it and the syringe to the patient. The alcohol sponge is to cleanse the site of the puncture. It should be rubbed briskly over the surface until the skin is well reddened; this removes superficial grease and epithelium from the area, and the increased blood-supply brought to the surface promotes quick absorption of the drug. In giving a hypodermic superficially, the usual site is the fleshy part of the upper arm. A piece of flesh is pinched between the finger and thumb and the needle introduced in a slanting direction. In giving the injec- tion deep, the muscles of the buttock or the thigh are generally chosen. The skin is stretched tightly over the part and the needle plunged straight into the tissues. Care must be taken that the puncture is not made over a superficial vein or too near a bone, or the periosteum may be injured. The needle is inserted nearly to its full length and then withdrawn slightly while the injection is made. The injection is given gently. As the needle is withdrawn the gauze sponge is pressed over the puncture and held in place a few moments. A few moments' light massage round {not over) the site of puncture will hasten the absorption of the drug. Care must be taken to use a sharp needle: a blunt one causes unnecessary pain. Careless technic may result in the infection of the part and the formation of an abscess at the site of the puncture. INHALATION—ANESTHESIA Volatile drugs may be administered by inhalation, either for general or for local effects. The general systemic effects obtained by inhalation are: 1. General anesthesia. 2. Stimulation of the general circulation. Anesthesia.—The administration of drugs for the pur- pose of general anesthesia can be taught only by many 21 322 MEDICINES careful demonstrations from an expert anesthetist, fol- lowed by closely supervised practice. Wherever practi- cal it should be taught, as emergencies arise, both in private nursing and in the smaller hospitals, where a nurse may be required to act as anesthetist. Moreover, at the present day, both in hospital work and in private practice, nurses are proving themselves exceedingly reliable as anesthetists, and several of the leading hospitals have nurses in these positions, with very satisfactory results. The anesthetics in most frequent use are nitrous oxid gas, chloroform, and ether, and derivatives from ether, such as ethyl chlorid, ethyl bromid, and such patent preparations as antidolorin, etc. Nitrous oxid gas is used where very short anesthesia is necessary, as in dentistry, opening an abscess, etc. The Fig. 132.—Esmarch chloroform-inhaler: a. Stockinet cover, to be held tense by b, wire frame; c, dropping-bottle (De Nancrede). mouth and nose are covered with a rubber mask con- nected by a tube with a tank containing the gas; the gas is inhaled directly from the tank. Consciousness is lost in less than three minutes, and recovered as quickly when the gas is removed. There are usually no after-effects, as in other forms of anesthesia. Gas and Oxygen.—By means of a special apparatus, nitrous oxid gas in conjunction with oxygen can be used for prolonged periods, two hours or more. This means of anesthesia is favored for emergency operations, where the patient cannot be thoroughly prepared, and in conditions INHALATION—ANESTHESIA 323 where ether is contra-indicated. Gas is not so irritating as ether, but is more depressing and relaxation is not so complete. Where complete relaxation is needed for a short time ether can be substituted and replaced by the gas and oxygen as soon as the necessity is passed. Fig. 132a.—Teter nitrous oxid gas and oxygen apparatus. Several patent apparatus are on the market, such as the Teter, the Ohio monovalve, and the S. S. White (Phila- delphia). Full directions are sent with either machine. Chloroform.—Although not so widely used as ether, chloroform is preferred in some conditions. It is pleasanter to take than ether, recovery is quicker, and the after- effects are less disagreeable. It is not considered so safe as ether on account of its depressant effect on the heart; on the other hand, it is less irritating to the respiratory organs and to the kidneys. It is largely used in obstetrics, 324 MEDICINES a very little chloroform producing insensibility to pain without the muscular relaxation of complete anesthesia, which would delay labor. Chloroform is given on a special " mask," a convex wire frame, a convenient size for fitting over the mouth and nose, over which a piece of flannel is stretched (Fig. 132). The mask is held in front of the mouth and nose, and the chloroform dropped from the drop bottle. The nose and lips are smeared with cold cream or vaselin, to prevent blistering if the chloroform should accidentally come in contact with the skin. Fig. 133.—The Clover ether inhaler (Morrow). Accidental death occurring during chloroform anesthesia is due to paralysis of the heart; the pulse, therefore, must be closely watched. Ether.—Ether is the anesthetic chiefly used in America in surgery. It is unpleasant to take, and comparatively slow in its action; for this reason nitrous oxid gas is often given as a preliminary. It is safer than chloroform, as it acts as a stimulant to the heart and respiration. The after-effects are unpleasant, though considerably less so when the ether is skilfully given. The common effects are nausea, vomiting, violent "swimming" headache, and constipation. Ether is administered by the closed or the open method. . INHALATION—ANESTHESIA 325 Closed Method.—For the closed method a special appa- ratus, known as the Clover inhaler, is generally used (Fig. /8 Fig. 134.—Ether cone: a, Cardboard; b, towel with cardboard rolled inside from points 1 to 2; c, long end of towel drawn through the cone; d, cone complete, with gauze sponge pinned in (Massachu- setts General Hospital). 133). The ether is contained in a reservoir (a) connected with a large rubber bag (6), from which a tube leads to a 326 MEDICINES rubber face-piece (c). The face-piece is fitted closely over the mouth and the nose, the patient breathing thus directly from the rubber bag. Fresh air is admitted now and then by removing the face-piece. The open method of giving ether is to drop the ether on a folded towel, holding it at a short distance from the patient's face. This method is very slow and wastes much of the ether. The semi-open method, although slower than the closed, is considered safer, and generally preferred. The ether is dropped on a piece of gauze placed at the apex of an open cone, the base of which is held down over the patient's nose and mouth. Various cones are used for this method; one of the simplest (Fig. 134) is made as follows: Take a piece of cardboard 18 inches long by 5£ inches wide. Fold like a cuff, overlapping 6 inches, and shape one margin with a pair of scissors to fit over the chin and nose; the folded cuff is 12£ inches round. Place the folded card- board on a dressing towel, so that on one side of the cuff there are three or four inches of towel, and, on the other, half of the width of the towel. Roll up tightly. Turn the narrow margin of the towel inside the edge of the cuff. Push the wide margin of the towel through the cuff, and turn down over the outside. Make the edge of .the towel into a firm little roll; this makes a convenient grip to hold the cone in place. Lay a large gauze sponge inside the cuff at the straight edge, and fasten in place with a safety-pin. The cone is held down firmly over the nose and mouth, fitting closely round the chin; the ether is dropped on the gauze sponge. Intratracheal Etherization.—In operations on the jaw, mouth, and other parts of the face ether is most con- veniently administered by the intratracheal method. In the methods of etherization, just described, the ether vapor is inhaled through the air-passages as in the ordinary act of breathing. By the intratracheal method the vapor is forced into the lungs through the trachea by insufflation or positive pressure. A special apparatus for intratracheal INHALATION—ANESTHESIA 327 etherization is patented by Dr. Samuel Robinson, and other models and modifications are in use. These various apparatus appear somewhat complicated, but they consist of three essential features whose uses are readily ap- preciated. 1. The ether tank, a glass vessel containing a small quantity of ether, which is placed in a second vessel containing hot water, acting as a water-bath, by which the ether is kept at a tem- perature of about 60° C. In the S. Robinson apparatus the water-bath stands on a flat electric stove regulated to maintain the required temperature. 2. The insufflation appa- ratus, by which the ether vapor, combined with a per- centage of oxygen, is blown into the trachea. This is at- tached to the ether tank and consists of a pair of bellows worked by the foot; in the Samuel Robinson apparatus the bellows are replaced by a small electric motor. 3. A rubber tube from the ether tank, to which is at- tached a glass nozzle if the ether is to be given through the mouth, or a rubber nasal tube if it is to be given through the nose. This takes the place of the usual ether mask. During intratracheal etherization the pharynx is packed with wet gauze. This ensures that the ether vapor enters the trachea and considerably lessens the gastric irritation common to etherization. Fig. 134a— Dr. Samuel Rob- inson's apparatus for thoracic surgery under intratracheal in- sufflation or positive pressure. 328 MEDICINES In giving ether in this way it is necessary that the vapor should be warmed, as it is blown directly into the lungs without passing through the nasal passage, where the air to be breathed is warmed on its way to the trachea. By this means the risk of pneumonia is lessened; it is also found that when warmed a smaller quantity of ether is required to produce the effect. Stages of Ether Anesthesia.—In administering ether three stages are noticed: First: Primary Anesthesia.—The patient is semicon- scious, the muscles are not relaxed, the face is flushed, the pulse quick, but regular, the pupils dilated, but react to light (the last condition may be absent if morphin has been given). Following this stage is an intermediate stage, in which the patient is highly excited, frequently violent, and extremely difficult to restrain. Second: Surgical Anesthesia.—The patient is profoundly unconscious, the muscles are quite relaxed, though never absolutely (for example, some spasm is present in the perineal muscles), the pulse is quick and regular, but less quick than in the primary stage, the respirations are slow, deep, and regular, the pupils are contracted, but still react. It is during this stage that surgical operations are performed. In certain conditions, as in operations on the perineum, it may be necessary to push the anesthetic further, but, speaking generally, the patient is not allowed to go beyond this stage. It is important to bear in mind that in giving ether the quality of the breathing is the most reliable guide to the patient's condition: as long as the respirations are slow, deep, and regular, the danger stage has not been reached. Third: Profound Anesthesia.—This stage is fatal if continued; the muscles are absolutely relaxed, respira- tions are rapid and become quickly shallow, the pulse is rapid and may be irregular, the skin pale and clammy, the pupils again dilate and do not react. In a fatal case the breathing stops before the pulse. Hemorrhage oc- curs from the absolute relaxation of the muscular walls of the blood-vessels. If this stage has been accidentally reached, the ether must be instantly removed, and means INHALATION—ANESTHESIA 329 taken to restore the patient. The usual means are arti- ficial respiration, fresh air or oxygen, and stimulants by hypodermic injection, especially atropin (y^g- to ^ grain), which is the most powerful respiratory stimulant known. An accident that may occur in administering a general anesthetic is to allow the tongue to fall back over the glottis and thus cutting off the supply of air. To prevent this the head is kept to one side and the jaw held forward. A pair of forceps should always be at hand to pull the tongue outside the mouth if such an accident happens. Examination Before Anesthetizing.—Before an anes- thetic is given, there is always a preliminary examination of the heart, the lungs, and the kidneys (the latter by examination of the urine). Ether is a local irritant: it produces little effect on healthy tissue, but is excessively irritating to diseased organs. For this reason ether as an anesthetic is contraindicated when either kidneys or lungs are unhealthy, and chloroform is frequently given instead. Chloroform is depressing to the heart; it is, therefore, contraindicated when there is any weakness of that organ. If chloroform is pushed to a fatal conclusion, the pulse fails before the respirations. Preparations derived from ether, such as ethyl chlorid or ethyl bromid, are also much in use as anesthetics for minor operations, where muscular relaxation is not neces- sary, in place of nitrous oxid gas, and may also be preferred to chloroform in obstetric work. They are given by the open method, on a piece of folded gauze or a towel. Local Anesthesia.—In cases where pain is slight or of momentary duration, local anesthesia is used instead of gen- eral anesthesia, and may, conveniently, be considered here. The operation may be conducted with the part im- mersed in water as hot as can be borne; this is, ob- viously, only practical in a limited way, as in minor operations on a hand or foot. More commonly the local site is superficially frozen by some such substance as ether. Ethyl chlorid and similar preparations are put up in sealed glass tubes, fitted with a special metal cap held by a spring over a very fine opening. On inverting the tube and opening the cap, a fine jet of the preparation is 330 MEDICINES thrown on to the skin. The part is anesthetized when the skin is whitened. Local Anesthesia by Novocain, Cocain, Etc.—(See p. 320) Spinal Anesthesia.—General anesthesia may also be produced by injecting the spinal fluid with one of the drugs having a "local" anesthetic property. Usually novocain is used, a small dose in a strong solution (generally 2 c.c. of a 5 per cent, solution). Sensation is lost, but the patient retains his consciousness completely. Under spinal anes- thesia quite extensive operations are performed, but the method is not in general use. (See Lumbar Puncture, page 512.) Inhalation for Stimulation.—For purposes of general stimulation some drugs are also administered by inhala- tion. The fumes of ammonia may be inhaled through the nose, causing direct stimulation of the nerve-centers that govern the act of respiration and the action of the heart; they afford relief in syncope and some forms of headache. The ordinary smelling-salts are prepared from ammonia, rock-salt crystals, and some aromatic perfume. Any pungent odor, such as that of burnt feathers, may produce the same effect. Inhalation of the vapor of amyl nitrite causes prompt dilatation of the arteries, thus lowering the blood-pressure and relieving distressed cardiac conditions. It is the common remedy in attacks of cardiac asthma or of angina pectoris. The best preparations are the nitrite of amyl pedes: small sealed glass capsules containing 3 minims of the drug. The capsule is broken in a fold of gauze or a handkerchief, and held to the nostrils. If placed thus in a tumbler, and the tumbler held over the mouth and nose, none of the fumes are lost. Inhalations are largely used for local action on some part of the respiratory system. The drugs are used dry, as smoke, or given in steam. To relieve asthma various patent apparatus are sold, containing either stramonium or potassium nitrate (salt- peter), in convenient form for vaporizing. An economic preparation of saltpeter for inhalation is made as follows: A saturated solution of the drug is INHALATION—ANESTHESIA 331 made in boiling water, and a sheet of white blotting- paper placed to soak in the solution. When thoroughly saturated, the blotting-paper is hung up to dry and then cut into convenient strips. A strip at a time, placed on a plate and set alight, will smolder slowly, giving off the fumes of saltpeter, soothing the irritated tissue of the trachea, and thus relieving the spasmodic respirations. The fumes may be directed toward the patient's face by means of a cone improvised from a piece of stiff paper. The leaves of stramonium can be burnt in the same way. Fig. 135.—Croup kettle (J. P. C. Griffith). Steam inhalations are used to relieve spasmodic breath- ing, to disinfect bronchial secretions, and to stimulate ex- pectoration. Plain boiling water may be used, or the water may contain some drug with one or other of these properties. Special closed kettles are sold for the purpose, fitted with a long straight spout and a small opening for filling. The steam is under low pressure, and is emitted from the spout in a steady stream. They can be heated over an alcohol lamp or gas-stove, and kept at steaming-point for hours, thus carrying on the treatment without inter- 332 MEDICINES mission. In place of adding the drug to the boiling water, a small sea-sponge may be kept soaked with the drug and secured at the mouth of the spout. The drugs most frequently used in this way are benzoin, eucalyptus, and creosote. In giving an inhalation in this manner, the bed must be carefully screened, and the spout of the kettle Fig. 136.—A movable croup tent made of gas-piping and dimity curtains. The frame is quite separate from the bed, which it en- tirely surrounds. A canopy curtain also covers the top when neces- sary. By substituting black curtains, a dark cabinet (for eye cases, etc.) is contrived (Polyclinic Hospital, Philadelphia). directed inside the screen. In hospital wards some ade- quate means of screening is always at hand. Rods of gas-piping screwed to the four posts and connected by cross rods at the top make a satisfactory frame on which cotton curtains can be hung, one across the entire top, forming a canopy. The kettle stands outside. The spout enters the curtained space at the side of the bed, and is directed toward the patient's face. INUNCTION 333 Such a screen can be improvised from a clothes-horse, over which sheets are securely pinned. The upper half of the bed is sufficient to inclose. The sheet forming the canopy is made to hang down in front, about half way to the mattress, and being pinned to the screen on either side, a screened space sufficient for practical purposes is formed. Where continuous treatment is not necessary, the in- halation may be given conveniently from a pitcher or with one or other of the patent inhalers. A small pitcher, well warmed, is half filled with boiling water, and the drug added. A towel is then folded round the top, leaving an opening which is placed over the mouth and nose, and the patient breathes in the steam. The principle of any patent inhaler is the same: the pitcher is merely made in a convenient shape and fitted with a mouth-piece. Special inhalations for the throat are frequently ordered merely warm, and in others the vapor is produced by chemical reaction, and should not be heated at all. When the drug is required for local application to the throat or the posterior nares, the throat spray is often preferred to the inhaler, in order to apply the remedy with- out the relaxation of the parts caused by the steam. In spraying the posterior nares, the tip of the nose is pushed upward, and the spray directed straight backward, not up the nose, as is generally attempted. INUNCTION Drugs are absorbed through the surface of the skin by inunction only in a limited way. The drug may be blended with an oil or an ointment and rubbed over the surface until it is absorbed. Cod-liver oil or olive oil is used as an inunction for marasmic infants or delicate children. The oil should be warmed and the abdomen washed previously with hot soap and water and dried. The oil is rubbed into the abdominal wall by the palm of the hand, using a circular movement. Mercury is very commonly given to syphilitic patients by inunction. One-half to one dram of mercurial 334 MEDICINES ointment is given at a time. As the mercury irritates the skin, it should not be rubbed into the same spot on consecutive days. The usual sites for mercurial inunction are as follows: Right axilla, left axilla, space in front of the right elbow, space in front of left elbow, inner surface of the right thigh, inner surface of left thigh. In carrying out the treatment these spaces are used in rotation on successive days; a day is then allowed to elapse, and the cycle begun again in the same order. In rubbing, the bare hand should not be used, or the operator may absorb the drug. A smooth glass stopper from a wide-mouthed bottle makes a convenient rubber. Mercurial inunction is usually given in connection with a course of sweat-baths. It should be given after the bath when the pores are open. Fumigation is more rarely used. The patient is> ar- ranged as for a vapor-bath (see Baths); over the lamp, instead of the kettle of water, is placed a metal plate con- taining the drug to be vaporized. Mercury is the principal drug administered in this manner, but, generally speaking, inunction is preferred. CHAPTER X POISONS AND THEIR ANTIDOTES A poison is described as a substance " which, if taken into the system, produces disease or death." The large majority of medicines, if taken in excessive doses, act as poisons. It seems, therefore, essential that nurses should, in administering medicines, be familiar with the symptoms that denote overdosage. Symptoms of poisoning may arise from the actual accumulation of an excessive quantity of a drug in the system, especially in patients suffering from dropsy (see p. 698) or from the drug having been pushed until what is known as the "physiological limit," or the limit of the normal toleration of the drug is reached. On the first appearance of any such symptom the drug is withheld; frequently no other treatment is necessary, but in some conditions, such as digitalis poisoning, the physical symptoms are severe and require careful treat- ment. Differing from the above are the cases in which the poisoning is caused by an overdose of a powerful drug, either through carelessness or from suicidal intent. The condition is one of acute poisoning, and calls for prompt treatment. In the treatment of poisoning three steps are to be observed: (1) Get rid of the poison. (2) Administer the antidote. (3) Treat the physical symptoms. If the poison has been taken by mouth, the first step is to empty the stomach, either by lavage or by the admin- istration of an emetic, following which the antidote is given. A chemical antidote is a substance, frequently a drug, that acts directly on the poison in the stomach and renders it 335 336 POISONS AND THEIR ANTIDOTES inert. It has no effect on any part of the poison already absorbed into the system. A physiologic antidote is a drug or substance that coun- teracts the effects of the poison on the general system. For example, in poisoning by opium, either permangan- ate of potash or tannic acid is given as the chemical anti- dote. It converts the opium actually in the stomach into an inert and harmless mass. Atropin in its physical effects is the direct antagonist to opium. Opium depresses the respiratory centers, atropin is a powerful respiratory stimulant; opium increases perspiration by checking other secretions, atropin checks perspiration and stimu- lates the secretion of urine; the effect of opium on the nervous system is shown in pinpoint pupils, of atropin, in widely dilated pupils. In cases of poisoning by opium, atropin, therefore, is given as the physiologic antidote. A physiologic antidote must always be administered with caution, or one poison may be substituted for an- other. Lavage may be given with plain warm water, but more commonly the chemical antidote is used as a lavage, about half a pint being left in the stomach after any repetition of the process. In some cases it is necessary to repeat the lavage at intervals of twenty to thirty minutes. Once the chemical antidote is considered to have produced its effect, the stomach is usually washed out with plain warm water. The reason for this is that the inert mass formed by the poison, combined with the antidote, may, by the action of the digestive secretion, become dissolved, and the poison once more be set free. Emetics.—Warm soapy water, salt and warm water (2 drams to 1 pint), or mustard and warm water (2 drams to 1 pint) are domestic emetics commonly ob- tainable. One or two glassfuls are usually effectual. If mustard is used, it should be followed by plain water, to prevent irritation to the lining of the stomach. Other safe emetics, generally at hand in hospital work, are as follows: Sulphate of zinc, 15 grains in a tumbler of warm water, repeated, if necessary, in fifteen minutes. EMETICS 337 Carbonate of ammonia, 30 grains in a tumbler of warm water or milk, repeated, if necessary, in fifteen minutes. Ipecacuanha wine, 4 drams to 1 ounce, every quarter of an hour until the result is obtained. Apomorphin is a powerful emetic, used when prompt emesis is necessary or where the patient is unable to swal- low. It is given as a hypodermic injection, in doses of TV grain. It is usually effective in about five minutes. If no result is shown in ten minutes, the dose is repeated— generally the second dose is effectual. Where the nature of the poison is known, the treatment of the condition is simple. In many cases the patient is not seen until unconscious, and no history is obtainable. The objective symptoms are then of the first importance in determining the diagnosis. The following points should be noted: The physical condition, whether stimu- lated or depressed; the presence of pain, vomiting, and the appearance and smell of the vomitus; nervous symp- toms, such as sleep, unconsciousness, delirium, or convul- sions; the smell of the breath; contraction or dilatation of the pupils; marks of burns about the lips and mouth. In carrying out the treatment care must be taken never to exhaust the patient. In cases where collapse has al- ready occurred, or where the poison used has a depressing action on the heart (aconite, digitalis, etc.), lavage is used in preference to emetics, and the patient should be kept lying down during the process, with the head low. It must be borne in mind that most poisons are elimin- ated by the intestines and the kidneys, and both should be kept active. If urine is suppressed, the catheter should be passed, as there is some possibility of the poison ex- creted by the kidney being reabsorbed from the bladder. In all cases of poisoning it should be a rule that all the urine passed should be saved for examination and carefully measured. The vomitus also should be kept, as an aid to diagnosis. Poisons may be considered in three groups: Corrosive.—Those that corrode or destroy the tissues with which they come in contact. 22 338 POISONS AND THEIR ANTIDOTES Irritants.—Those that irritate the tissues. Taken in large quantities or in concentrated form, the irritants will act as corrosives on the tissues. Functional Poisons.—Those that act on one or other of the organs, interfering with their function, and causing direct and indirect physiologic symptoms. CORROSIVE POISONS The common corrosive poisons are the acids—acetic, carbolic, citric, hydrochloric (muriatic), hydrocyanic (prussic), nitric, oxalic, sulphuric (vitriol), tartaric—and the alkalis—ammonia, lime, caustic potash, carbonate of soda (washing-soda), and nitrate of potash (saltpeter). Many of the above are given in small, highly diluted doses, as medicines, chiefly tonic in their action. Symptoms.—The general symptoms of poisoning by corrosives are: Corrosion of the mucous membrane lining the mouth, esophagus, and stomach, evinced by whitening and burns about the lips and mouth, the injury frequently being so severe as completely to destroy the membranes; acute pain in mouth and abdomen; vomiting, usually of mucus and blood, and acid or alkaline in reac- tion, according to the nature of the poison; bloody stools; frequently bloody frothing at the mouth; giddiness; rapid collapse; coma, or sudden failure from paralysis of the heart. Convulsions may occur. Perforation of the stomach or intestines is not uncommon. Poisoning by corrosives is the most fatal form of poison- ing. In severe cases (nitric acid, sulphuric acid, or strong alkalis) death occurs rapidly from shock and the local effect of the corrosive. Partial recovery may take place, and the patient die eventually either from the local or physiologic effects of the poison. If recovery takes place, scarring of the tissues is a common cause of stricture of the esophagus. Death may also result from starvation caused by injury to so large a surface of the alimentary canal. A routine treatment is common to all forms of corrosive poisomng. CORROSIVE POISONS 339 Emetics are rarely used, the violent muscular con- traction caused by emesis tending to injure the tissues further. Lavage is given promptly, where possible {i. e., unless the local injury is too severe), and should contain the anti- dote. The natural antidote to an acid is an alkali. In poison- ing by the acids the alkalis—lime, chalk, magnesia (sul- phate), or soda (sulphate)—are given as a lavage or as drinks stirred up in milk. Warm soapy water is a con- venient alkaline lavage. The natural antidote to an alkali is an acid. Vinegar and water is used as a lavage, and the dilute acids, vinegar, or lemon-juice in water, are given by mouth. The antidote is followed by oil (exception, carbolic-acid poisoning), milk, the white of eggs, and bland drinks, such as flaxseed tea or barley-water. External heat is applied, and stimulants given by hypo- dermic. Morphin is usually necessary to allay the pain. Convalescence is slow. The diet should consist of milk, egg-albumen, and bland drinks. The kidneys are usually in an irritated condition, and the urine should be measured and examined. Strychnin and other cardiac stimulants are given by hypodermic. Certain special points should be carefully remembered. In poisoning by carbolic acid, the antidote, alcohol, is given freely as a lavage and by mouth. Neither oils nor glycerin can be given, as they dissolve the acid and promote its absorption. In poisoning by oxalic acid (usually taken by mistake for Epsom salts) either lime or chalk of the alkalis should be used, the union of some of the others forming poisonous compounds. * Of the acids, sulphuric acid and nitric acid have the most violent corrosive action on the tissues, in concentrated form completely destroying the membranes. The symp- toms are violent, the collapse profound and rapid. Per- foration frequently results. The vomitus is stained char- acteristically tarry from sulphuric acid, and yellow from nitric acid. THE MORE p Poison. Physical Symptoms. Acids: Hydrochloric. Burns about the lips and Nitric. mouth; acute pain from Phosphoric. mouth to stomach; dysp- Sulphuric. nea; collapse rapid and frequently fatal; sometimes hematemesis and purging, with bloody stools. Death may occur suddenly from perforation or hemorrhage, as well as from the physical effects of the drug. Acetic. Same as above. Oxalic. Tartaric. CarboUc. Same as above, together with scanty, dark-colored urine, contracted pupils, collapse very rapid. Hydrocyanic. Usually almost instant death. Alkalis: Ammonia. The same physical symp- Caustic potash. toms. The injuries to the Caustic soda. tissues are still more severe. Lime. Nitrate of potash. VION CORROSIVE POISONS Chemical Antidotes. An alkali—lime-water, soda, chalk, whitewash, soapy water—by mouth, or by lavage if unconscious. Treatment and Physiologic Antidotes. "1 Lime or chalk in water or milk by lavage. Alcohol (whisky, etc.) by lavage and by mouth. Lime-water. Alkaline lavage if time per- mits; emetic of soapy water Lemon-juice, vinegar, and other vegetable acids in water, by mouth or lavage. Recumbent position, with the head low; external warmth; fresh air; cardiac stimulants by hypodermic, oil, milk, and egg-albumen by mouth; morphin by hy- podermic for pain. Same as above Same as above. No oils. Barley-water and gruels. Artificial respiration: al- ternate affusion of cold and hot water to face and spine; external heat; stimulants (atropin) by hypodermic and inhalation. Treatment as in poisoning by acids. In ammonia poison- ing, especially, fresh, cold air should be allowed plentifully. o IRRITANT POISONS 341 In poisoning by hydrocyanic acid death usually occurs too rapidly for treatment. Collapse is sudden. There may be convulsive movements of the toes and fingers, or complete muscular relaxation. The eyes are usually prominent and the pupils dilated. If there is time, the treatment consists in artificial respiration, cold and hot water dashed alternately on the spine and in the face, external heat, and stimulants by hypodermic. IRRITANT POISONS The larger proportion of the irritant poisons are the metals, such as alum, antimony, arsenic, copper, lead, mercury, silver nitrate, and zinc. Other irritants are iodin, cantharides, phosphorus, and turpentine. The fumes of certain gases are also considered as irritant poisons. A certain similarity may be noticed in the physical symp- toms following poisoning by the metals and other irritants. The physiologic dose is characterized by digestive dis- turbance, diarrhea with cramping pains, salivation, fre- quently coryza, and, in the case of the metals, by a metallic taste in the mouth. Poisonous doses cause acute burning pain at the epi- gastrium, colic, vomiting, and purging, with watery stools. The vomitus and the stools may contain blood. Prostra- tion is marked, and severe cases frequently end in fatal collapse. Nervous symptoms are common, such as muscular cramps, especially in the legs, convulsions, or some form of paralysis. The kidneys are irritated, the urine scanty, albuminous, or bloody, and frequently suppressed. The chronic form of poisoning is associated with anemia, emaciation, muscular weakness, local paralysis, and di- gestive disturbances. Acute Poisoning.—In the treatment of acute poison- ing the stomach is emptied either by emetics or by lavage. The chemical antidote is usually some soluble sulphate or egg-albumen. It should be administered promptly, and usually in repeated doses. For the reasons already stated, 342 POISONS AND THEIR ANTIDOTES a lavage of plain water should follow the administration of the chemical antidote once the effect of the antidote is established. The further treatment common to all cases of acute poisoning by the irritants consists in hot applications to the abdomen, stimulants administered by hypodermic injection, and external heat. The recumbent position is enforced, and, where the heart is much depressed, as shown by a small, feeble, irregular pulse, the bottom of the bed should be elevated and the head kept low. Opium is frequentty necessary to relieve the acute pain, and is ordered in extreme cases; it is, however, avoided, if pos- sible, on account of its constipating properties, which hinders the prompt elimination of the poison. Opium is not, as a rule, given where the poison causes marked symp- toms of congestion of the kidneys. Castor oil is commonly given to hasten the elimination of the poison. Egg- albumen, milk, and bland drinks are given, as in the treat- ment of corrosive poisoning. Oil may also be given for its soothing effect on the tissues, except in poisoning from cantharides or phosphorus. As with carbolic acid, oil dissolves these substances and makes them more readily absorbable. As many of the irritant poisons are in common use as medicines, nurses should be familiar with the symptoms of intoleration, as well as with the symptoms and treatment of poisonous doses. For convenience, the two are de- scribed together. Convalescence from the acute poisoning is always very slow, and death may occur after the lapse of several days. Prolonged rest in bed cardiac stimulants, and soft diet until the tissues are quite healed, are the common lines of treatment. If the kidneys are affected, no nitrogenous foods are given until the urine is normal. In these cases the urine must be measured and examined daily. Sequelae, such as nephritis, local paralysis, pronounced anemia, and other physical manifestations, such as jaun- dice (in phosphorus-poisoning), may follow poisoning by one or other of the irritant poisons. Poison. Alum. Antimony. Arsenic. Pkeparations and Average Dose. External use. Tartar emetic, & grain; wine of antimony, 5 to 30 minims. Tartar emetic is also an ingre- dient in com- pound syrup of squills (} grain in 1 ounce). Fowler'ssolution, 1 to 10 minims; arsenous acid, ^grain. Taken with suicidal intent in Paris- green or rat's- bane. Physical Symptoms. Intolerance. Soft pulse, general depression, muscu- lar relaxation, vom- iting, profuse per- spiration. Puffiness and itching of the eyelids on awakening; nausea; metallic taste; colic, diarrhea. Chronic poisoning (from fumes, etc.), anemia; gastric disturb- ances; debility; neuritis. Acute Poisoning. Usual symptoms of irritant poisoning (see Arsenic). Usual symptoms. Special symptoms, profound and rapid collapse, muscular cramps. Acute burning pain in epigastrium; violent vomiting; purging, with watery, frequently bloody, stools; thirst; colic ; urine scanty, containing albumin or blood, and sometimes sup- pressed ; collapse frequently fatal. Sometimes complete unconsciousness, convulsions, and rapid death. Chemical Antidote. Carbonate of ammo- nia as emetic; lav- age of sulphate of magnesia. Tannic acid given by lavage (10 grains to 1 pint). Strong tea. Sesquioxid of iron, one tablespoon in milk or water, at repeated intervals of about ten min- utes. (To prepare the above, combine tincture of the chlo- rid of iron with half a pint of ammonia water until no more precipitate forms; turn the precipitate on to a piece of gauze, and wash under cold water to remove the am- monia ; the antidote is then ready for use. It cannot be relied upon if the arsenic has been taken in a solid form (i. e., rat's-bane). Treatment, Including Physiologic Antidote. Usual treatment of irri- t a n t poisoning (see Arsenic). Usual treatment. Special treatment, no emetic; alcohol in full doses; the head kept low on account of the cardiac depres sion; opium generallyneces- sary. Emetic. Lavage of plain water after the antidote has been given; recumbent position; stimulants by hypodermic (atro- Ein, etc.); external eat; hot applications to abdomen; bland drinks (milk, flaxseed tea, barley-water) and egg-albumen; opium to relieve pain ; castor oil to eliminate the poison. Chronic poisoning treated with removal of the cause, good hygiene, nourishing food, and, usually, iron. Poison. Cantharides. Copper. Iodid of pot- ash (KI). Iodin. Preparations and Average Dose. External use. Blue-stone, ex- ternal use. Sul- phate of copper, i to } grain, or as emetic, 3 to 6 grains. 5 grains to 1 dram, well diluted in milk, or with aromatic spirits of ammonia. Tincture of iodin. External use. Intolerance. Chronic, from fumes, etc., in some facto- ries ; debility, gas- tric disturbances, jaundice. Puffy eyelids, coryza, malaise, rise of temperature, saliva- tion, sore throat, difficulty in swal- lowing, gastric dis- turbances, acne rash. Symptoms. Chemical Antidote. 1 Treatment,Including Physiologic Antidote. Acute Poisoning. Absorbed from No chemical antidote. Taken internally, usual blister: headache, treatment. iVo oils ; as nausea, rise of tem- in carbolic poisoning perature, conges- they aid in the absorp- tion of the kidneys, tion of the drug; opium albuminuria, hema- also avoided on ac- turia. Taken in- count of the kidney ternally, usual condition. Magne- symptoms. Special sium sulphate as aperi- symptoms, muscular ent. Hot baths and cramps, salivation, packs. If from ab- congestion of t h e sorption, the blister is kidneys, sometimes removed and the part convulsions. ( washed with soap and water. Usual symptoms. Potassium ferrocya- Usual treatment. Special symptoms, nid, if it can be metallic taste, fre- obtained at once. quently jaundice, Egg-albumen, flour- coma. water. Antidote followed by lavage of plain water. Intolerance, withdrawal of drug, mouth-wash and gargle of chlorate of potash; digestive disturbances treated with diet and purga- tives. Usual symptoms. Starch, as starch- Usual treatment. Special symptoms, water, or flour- vomitus stained yel- water, followed by low, or bluish if plain lavage. starchy food has been taken. | Lead ana opium pill. Lotion for external use. Calomel, ^ to 5 grains. Blue- mass, 3 to 5 grains. Gray powder, 2 to 5 grains. Bichlo- rid of mercury, Ato A grain. Iodid of mer- cury, solution of bichlorid of mercury, 1:1000 to 1: 10,000 for external use. Dilute phospho- ric acid, 10 to 20 minims. Syrup of hypophos- phites, 1 to 2 drams. Acute poisoning, usu- ally from suck- ing matches or from vermin pastes contain- ing phosphorus. Usually chronic, from working with lead, known as painter's colic. Also from adulterated food, or water contaminated by lead pipes. Most prominent symp- toms are anemia, colic, muscular weakness, wrist- drop, and a blue line around the gums. Metallic taste, saliva- tion, tender gums, sore throat, gastric disturbances; later, vomiting and purging, rise of temperature,spongy gums, loose teeth, ulceration of mouth, anemia, and ne- phritis. Depression, increase of urine and per- spiration. Chronic (as in match facto- ries) may result in necrosis of bones, especially of the jaw, and changes of tissues in various organs. Usual symptoms. Usual symptoms. Special symptoms, metallic taste, white appearance of mu- cous membranes, congestion of the kidneys, frequently suppression of the urine. Usual symptoms. Special symptoms, vomitus with odor of garlic; excreta and vomitus lumin- ous at first, later coffee-ground vomit from altered blood. Jaundice occurs from about the third day. Death may result sud- denly or after several days, occa- sionally after two or three weeks. Sulphate of magnesia as lavage or emetic. Egg-albumen, fol- lowed by lavage of plain water. Where the quantity taken is known, one egg is given for every four grains of the poison. Crude French tur- pentine or old oil of turpentine, given i n tablespoonful doses every ten or fifteen minutes, fol- lowed by lavage. Sulphate of copper, 3 grains every five minutes, as emetic; after emesis, every twenty minutes, as long as necessary, in half-grain doses. Usual treatment. Chronic form : free purging, usually with sulphate of magnesia; liberal diet, including eggs, milk, and lemon- j u "i c e. Potassium Iodid is usually given to hasten elimination. Usual treatment. Special treatment, apo- morphin as emetic. Lavage or emetic re- peated frequently after administering the antidote. Castor oil. Opium may be neces- sary. Potassium iodid frequently given in after-treatment. Milk and egg-albumen the only diet until the urine is normal. Usual treatment. Re- peated lavage. No oils; as in carbolic and can- tharides poisoning they promote the ab- sorption of the poison. Poison. Silver nitrate. Turpentine. Zinc. Gases: Carbonic acid. Charcoal. Chlorin. Illuminating. Chloroform. Ether. Nitrous oxid. Preparations and Average Dose. i to i grain in pill form. Silver stick, solution of silver nitrate, external use. Oil or spirits, 5 to 30 minims in capsuleoronsu- gar. More com- monly for exter- nal use in stupes or liniments. Principally for external use, as ointment, powder, or lo- tion. Zinc sul- phate, A to J grain; asemetic, 15 to 20 grains. [Exposure to I fumes. Bv inhalation. Intolerance. Gastric disturbances, irritation of kid- neys, irregular heart's action. Taken internally for length of time, ni- trate of silver gives to the subcutaneous tissue a permanent bluish discoloration. Chronic form, from factories, etc., re- sembling chronic lead-poisoning. Symptoms. Acute Poisoning. Usual symptoms. Usual symptoms. Special symptoms, congestion of the kidneys, imparts odor of violets to the urine. Death is not common. Usual symptoms. Special symptom, violent vomiting. Asphyxia. Asphyxia. General anesthesia. Fatal accidents in admin- istering chloroform are usually due to paralysis of heart; in ether, to paralysis of the respiration. Chemical Antidote. Common salt as emetic or lavage (2 drams to the pint). No chemical antidote. Tannic acid, strong tea, carbonate of soda, lime-water, or soapy water as lav- age. Oxygen. Treatment, Including Physiologic Antidote. Usual treatment. Usual treatment. Special treatment, prompt and repeated lavage of plain water. Hot baths and packs, etc., to relieve the kidney condition. Usual treatment. Vomiting should not be checked. Removal from the fumes. Fresh air, arti- ficial respiration, stim- ulants by hypodermic. Hot coffee enema. As above. The tongue pulled well forward, the head low. Cold affusions to face and chest. Battery, atro- Ein, strychnin by ypodermic, amyl ni- trite by inhalation. 00 03 THE FUNCTIONAL POISONS 347 The chronic forms of poisoning (arsenic, lead, cop- per, etc.) are treated by withdrawal of the cause, good hygiene, rest, and nourishing diet. Local paralysis is treated with massage, and, usually, the alkaline tonics are prescribed. THE FUNCTIONAL POISONS The large majority of the functional poisons belong to the vegetable kingdom. All of them are in constant use as medicines; the early recognition of the full physiologic effect of each drug is of importance. The treatment of the toxic condition is governed by the effect produced by the drug. Lavage or emetics are employed to empty the stomach. In a number of cases, especially in poisoning by the vege- table alkaloids, tannic acid is the chemical antidote (10 grains to 1 pint). It is given as a lavage, repeated from time to time, some of the solution being left in the stomach after each lavage, and a final lavage of plain water; or it may be given by mouth in repeated doses, a glassful at a time every ten minutes, followed finally by lavage of plain water. Tannic acid may also be given in the form of very strong tea. Permanganate of potash is also a common antidote, especially for the vegetable alkaloids, and is used in the same manner as tannic acid. Sufficient of the crystals to color the water dark pink is the usual strength. The alkaloids of many of these drugs are commonly given by hypodermic, and it is obviously futile to empty the stomach. Reliance must then be placed on counter- acting the physical symptoms. An exception is met with in some drugs which are actually excreted in the stomach, of which opium is an important example. The same is true in cases where the toxic condition is due to an accumu- lation of the drug in the system, as already explained, the individual dose being harmless. In many cases also by the time the effects of poisoning are manifested little of the poison remains in the stomach, and to administer emetics or lavage is merely unnecessarily exhausting. These drugs are excreted in the urine and by the bowels. 348 POISONS AND THEIR ANTIDOTES Elimination is hastened, therefore, by keeping the kidneys and the bowels active. Urine should not be allowed to accumulate in the bladder or the drug may be reabsorbed from the urine. If the urine is not passed voluntarily, the catheter should be used. The urine should in all cases be saved for examination. Many of the functional poisons have an intensely depressing effect on the heart; for example, aconite, digitalis. In the treatment of these cases a small exer- tion on the part of the patient may cause a fatal syncope. Where possible {i. e., unless there is the condition of orthop- nea), the recumbent position must be enforced and the head kept low. Emetics must be avoided, and lavage given with caution. If emesis occurs, the vomitus should be received on a towel without the head being raised. In the treatment of all poisons, and especially of poisons belonging to this class, the strength of the patient must be carefully husbanded. Besides the recumbent position and external warmth, the treatment commonly comprises the giving of a cardiac stimulant by hypodermic or rectum, and infusion of normal salt solution. On account of the importance of these drugs as medicines and their very varied effects, the symptoms and treatment of overdose and poisoning is given at greater length. Aconite.—Action.—Depressant, lowering the rate and volume of the pulse; sedative, diuretic, diaphoretic, antipyretic. Preparations.—Tincture of aconite (1 to 4 minims); aconitum (ifo to sV grain). Physiologic Dose.—Pulse small, soft, slow; respiration slow, deep; vertigo, weakness; sensation of tingling on the tongue. Treatment.—Withdrawal of drug; the recumbent position; no sudden movements; cardiac stimulants. Poisonous Dose.—Tingling sensation; pulse very slow and irreg- ular (30 to 40); respiration slow and irregular; temperature sub- normal; muscular weakness, profound depression, sweating; fre- quently vomiting; dilated pupils; finally, collapse. Treatment.—Lavage with tannic acid; external heat; the recum- bent position with the head low; stimulants, especially atropin, on account of its prompt action; infusion of normal salt solution. Artificial respiration may be necessary. The greatest care must be taken not to exhaust the patient or in any way tax the depressed heart. After-treatment.—Rest in bed until the pulse is normal. Digitalis and alcoholic stimulants are usually ordered. Alcohol.—Intoxication by alcohol in any form produces exal- THE FUNCTIONAL POISONS 349 tation, staggering gait, deep sleep with stertorous breathing, acute gastritis, and, finally, profound depression. Treatment.—Emetics or lavage. Gastric symptoms treated by diet and purgatives. Death may occur from paralysis of the heart, and has been known to take place several days after recovery has apparently been assured. Antipyrin.—Actam.—Reduces temperature, relieves mild nervous conditions, such as migraine, sleeplessness, etc. Preparation.—Powder (5 to 15 grains). Physiologic Dose.—In full or too frequent doses produces marked depression, with syncope, cyanosis, feeble, irregular pulse, rapid respiration, and collapse. A skin eruption often resembling the rash of measles is common. Acetanilid (antifebrin) and preparations containing acetanilid— antikamnia, antinervine, etc.—and phenacetin produce effects similar to antipyrin. Treatment.—Recumbent position, external heat, stimulants, hot coffee, rest in bed until the pulse is normal. In large amounts taken accidentally antipyrin and its derivatives are corrosive poisons. Belladonna.—Action.—Deliriant, respiratory and cardiac stimu- lant; antispasmodic; anodyne; checks all secretion except urine; dilates the pupils. Preparations.—Tincture of belladonna (10 to 30 minims); atropin sulphate (^s to y5 grain). Atropin and its derivative, homatropin, are used as mydriatics. Physiologic Dose.—-Dryness of the nose and throat, pulse rapid and full, excitement, dilated pupils, rise of temperature, saliva and sweat checked, thirst, skin rash suggesting scarlatina. Treatment.—Withdrawal of the drug; water freely; cold sponging or packs; sedatives, such as the bromids, may be necessary. Poisonous Dose.—All the above symptoms intensified. Wild and noisy delirium. In fatal cases convulsions, paralysis, and coma. Treatment,—Lavage with the chemical antidote, tannic acid. Cold sponging or packs, ice-bag to head. In collapse, coffee and brandy enema, external heat, normal salt infusion. Morphin, the physiologic antidote, may be given by hypodermic. Pilocarpin may be ordered to induce sweating, and, more rarely, physostigma, or its alkaloid, eserin, is given. If morphin is not used, the bromids are generally given. Chloral.—Action.—Narcotic; antispasmodic; depressant. Preparations.—Chloral hydrate (10 to 20 grains); chloralamid (15 to 30 grains). Physiologic Dose.—Sleep, syncope, cyanosis, irregular pulse. Chloral should always be given with caution. An ordinary dose has been known to cause death from paralysis of the heart. Treatment.—Fresh air, rousing, stimulants, friction of extremities, external heat. Poisonous Dose.—Profound sleep, passing into coma; pulse at first slow, feeble, and irregular, later rapid and thready; respiration slow and shallow; subnormal temperature; syncope; cyanosis; clammy skin; pupils first contracted, then widely dilated. Death occurs from paralysis of the heart. Treatment.—Lavage with strong coffee or tea; fresh air; rousing; recumbent position, with the head low; external heat; stimulants, especially atropin or strychnin, by hypodermic; hot coffee and 350 POISONS AND THEIR ANTIDOTES alcoholic stimulants by mouth or enema; amyl nitrite by inhalation, oxygen; the electric battery; artificial respiration. The patient must be spared all exertion. Cocain Hydrochlorid (Alkaloid of Coca).—Action.—Stimulant, deliriant. Chiefly used as a local anesthetic by hypodermic injec- tion. Acts also as a mydriatic. Preparation.—In solution, 2, 4, etc., per cent. As a stimulant, £ to £ grain. Poisonous Dose.—Excitement, incoherence, nausea, vomiting; later, marked depression, with small, rapid pulse, slow respiration, cyanosis, dilated pupils, and syncope or collapse. Treatment.—Lavage of plain water (if taken by mouth). In collapse, recumbent position, external heat, alcoholic stimulants, coffee enema, amyl nitrite inhalations, artificial respiration, saline infusion. The physiologic antidote is opium, given as morphin sulphate by hypodermic injection. Cocain is also a drug which induces a habit. Digitalis.—Action.—Cardiac stimulant and tonic; diuretic. Preparations.—Tincture of digitalis (5 to 20 minims); infusion, (1 to 4 drams); digitalin {fa grain). Physiologic Dose.—Headache, nausea, vomiting, diarrhpa, dis- turbances of vision, slow, full pulse, becoming rapid on slight ex- ertion. Treatment.—Withdrawal of drug, recumbent position, alcoholic stimulants, or strychnin. Poisonous Dose.—The above symptoms intensified. Small, ir- regular pulse, with " wild " heart, protruding eyes, with blue tinge to the whites, marked prostration, and collapse. Treatment.—If a poisonous dose has been taken (rare), prompt lavage with tannic acid. The recumbent position absolutely (except in orthopnea), external heat, stimulants, especially alcohol and strychnin. All exertion must be avoided until the pulse is restored. Hyoscyamus resembles belladonna in its action and toxic effects. The treatment of poisoning by hyoscyamus or its preparations is the same as in belladonna-poisoning (see Belladonna). Mushroom-poisoning has marked depressing action on the sys- tem, causing collapse, cyanosis, and syncope, with small, feeble pulse and shallow respiration; vomiting and purging may be present. Treatment.—Lavage with tannic acid; hot strong tea; external heat. Alcoholic stimulants, coffee and brandy enema, saline infusions. Physiologic antidote is atropin, -^ to ^ grain. Opium.—Many alkaloids, of which the principal are morphin, codein, and heroin. Morphin only has narcotic action. Principal Preparations.—Tincture of opium, 20 to 30 minims; camphorated tincture of opium or paregoric, 1 to 4 drams (contains opium, 2 grains in each ounce); morphin sulphate, TV to £ grain; Dover's powder (contains opium, 1 grain in every 10 grains), 5 to 10 grains. In acute opium-poisoning there are three stages, with character- istic symptoms. First stage: happy, sleepy, painless state, passing into sleep. Second stage: sleep from which the victim can be roused. Slow respirations; pulse slow and full; skin flushed and dry; contracted pupils; retention of urine. THE FUNCTIONAL POISONS 351 • Third stage: profound sleep, passing into coma; respiration very slow and shallow, toward the end, two to four a minute; rapid pulse, generally thready, cyanosis; clammy sweat; pin-point pupils; just before death the pupils dilate widely. The most important symptom to watch in opium-poisoning (and all narcotic poisoning) is the rate of the respiration. Where the rate does not sink below 10 to 12, the chances of recovery are good, and any improvement in the rate of respiration is always a favorable symptom. In administering opium in any form nurses should be taught to report at once any drop in the rate of respiration. Treatment.—Chemical antidotes, permanganate of potash or tannic acid, given as lavage or in a weak solution by mouth. The treatment aims at stimulating the respiratory and cardiac centers, and the urgency of the treatment is guided by the condition of the respiration and pulse. If both are good, the patient is allowed to sleep off the effects of the poison. Commonly, drastic treatment is necessary. The patient is kept awake by constant movement, cold water dashed in the face and over the spine, black coffee by enema and mouth; fresh air is supplied freely; artificial respiration and electricity may be necessary. Atropin is the physiologic anti- dote, and is given by hypodermic in doses larger than the average; alcoholic stimulants and strychnin may also be used. If the urine is not voided, the bladder must be emptied to prevent reabsorption of the drug from the bladder. From the first and second stages recovery is usual, the third stage once reached is generally fatal. Stramonium.—Alkaloid, daturin. In its action and toxic effects resembles belladonna. The treatment of the poisoning is the same as in belladonna (see Belladonna). Strychnin.—Alkaloid, strychnin sulphate. Action.—General nerve stimulant and tonic acting on all the im- portant nerve-centers. Preparations.—Tincturenuxvomica (about 2 percent, strychnin), 5 to 20 minims; strychnin sulphate, -fa to ^ grain. Physiologic Dose.—Given over lengthened periods or in too full or too frequent doses, strychnin produces excitement, overstimula- tion of the special senses, especially hearing, cardiac disturbance, and muscular twitchings beginning at the fingers and toes. Treatment.—Withdrawal of the drug, rest (in bed if the symptoms are severe), freedom from strain and excitement; the bromids are given and pushed until the full effect is obtained. Poisonous Dose.—In poisonous quantities, usually taken with suicidal intent, strychnin produces typical convulsions resembling those of tetanus or lock-jaw, with certain marked differences. (See p. 669.) The convulsion begins at the extremities and quickly in- volves the whole frame; the jaws are the last to be affected; between the convulsions the muscles are completely relaxed; the eyes remain open and staring; the mouth has a horrible grin; consciousness is maintained to the end. Treatment.—Prompt lavage with the chemical antidote, tannic acid, or emetic followed by tannic acid or animal charcoal; inhalation of chloroform during convulsions; chloral and bromid in full doses by enema or stomach. The bladder must be emptied—by catheter, if necessary. Absolute quiet is imperative, a slight sound causing a fresh convulsion; in collapse, external heat, saline infusion, and alco- holic stimulants are given. ' 352 POISONS AND THEIR ANTIDOTES Veratrum Viride.—Action.—Cardiac depressant, reduces pulsu both in strength and frequency. Preparations.—Tincture of veratrum viride, 2 to 10 minims. Frequently ordered 2 minims every hour until the desired effect is produced. Poisonous Dose.—Complete prostration, nausea, and violent vomiting. The pulse is first abnormally slow and soft, later small, rapid, and thready. As emesis is at once produced, poisoning by veratrum is rarely fatal. Treatment.—The recumbent position absolutely, with the" head low; lavage of plain water; stimulants by hypodermic; hot coffee enema; saline infusion; external heat; friction to the extremities. Some drugs which have not a toxic effect produce char- acteristic groups of symptoms if taken for lengthened periods or in full doses. The most important are as follows: Bromids.—Action.—Sedative. Preparation.—In combination with the alkalis, potassium, sodium, etc., 10 to 30 grains, A group of symptoms known as bromism. Mental and physical inertia, apathy, dulness, fetor of breath, gastric disturbance, and acne rash. On withdrawal of the drug the symptoms usually disappear. Arsenic is sometimes given to correct the skin condition. Quinin.—Action.—Tonic, antipyretic, specific in malaria. Preparations.—Quinin sulphate (2 to 10 grains), and in combina- tion with other drugs. Full doses of quinin cause a sensation of ringing in the ears and deafness; skin eruptions frequently follow, either resembling urticaria or the rash of scarlet fever. The condition is called cinchonism. Usually the drug is withdrawn and no further treatment is neces- sary. An idiosyncrasy against quinin is not uncommon. In persons with this characteristic or after an abnormally large dose, quinin may cause syncope and prostration. Treatment.—The recumbent position; fresh air; alcoholic stimu- lants; strong coffee; external heat. Salicylic Acid.—Action.—Antipyretic, specific in rheumatism. Preparations.—Salicylic acid (5 to 20 grains); sodium salicylate (5 to 20 grains). Full doses produce a group of symptoms known as salicism, characterized by buzzing and roaring in the ears, deafness, headache, sense of great depression, and physical weakness. Some albuminuria is usually present. A rash, usually resembling urticaria, is not uncommon. Treatment.—The drug is withdrawn. Rest and the moderate use of alcoholic stimulants may be necessary. In some rare instances marked dyspnea and delirium follow overdosing by the salicylates. Snake-bite.—The poison from a snake-bite has a rapidly depress- ing action on the vital centers. Free stimulation with alcohol or strychnin should be given promptly, external heat should be applied, and the recumbent position inforced. Cupping over the wound is sometimes recommended, or means to encourage bleeding. Recov- ery from snake-bite is not uncommon. CHAPTER XI ELEMENTARY BACTERIOLOGY AND THEORIES OF IMMUNITY Classification of Bacteria, Morphology, Parasites—Examination of Bacteria—Microscope, Smear, Staining, to Stain Tubercle Bacil- lus, the Hanging Drop, Widal Reaction—Cultivation of Bacteria, Plating, Culture-media, to Take a Culture—Invasion of the System by Bacteria—Varieties of Toxins—Koch's Postulates—Pathogenic Organisms Already Discovered—Air-borne Infections, Droplet Infection, Water-borne Infection, Infection through the Broken Surface, by Inoculation, Transmitted by Insects—Prophylaxis of Infectious Diseases—Immunity—Natural, Acquired, Active, Pas- sive—Vaccination, Inoculation, Antitoxins—Theories of Immunity— The Feeding Cell, Side-chain Theory, Opsonic Theory—Incubation —Protection Against Contagion in Special Infections. CLASSIFICATION So large a portion of our work is the practical outcome of modern research in bacteriologic laboratories, so greatly is it influenced by the theories and deductions of modern scientists, that some accurate, if elementary, knowledge of the more prominent facts of bacteriology should be available to the pupil nurse from the earliest days of her training. Bacteriology, or the study of micro-organisms, belongs to modern times, and especially to later years, where three important factors have made possible an accurate study of the Jife-history of these minute bodies not possible be- fore. These three factors are: first, the perfection of the microscope; second, the discovery of a method of isolating the individual organism in "pure culture") and, third, the discovery of a means of differentiating micro-organisms by staining them with anilin dyes. Bacteria are unicellular micro-organisms of vegetable origin. Their structure is of the simplest, consisting of protoplasm surrounded by a cell-wall and devoid of nucleus. In common with other similar micro-organisms, 23 * 353 354 ELEMENTARY BACTERIOLOGY AND IMMUNITY they are also known as germs or microbes. They resemble the lowest form of vegetable life—the fungi. Fungi differ from ordinary plant life in their method of development, in the food which they require, the condi- tions in which they flourish, and in the fact that they possess no chlorophyl. Chlorophyl is the green coloring- matter of plants which is essential to their growth. It makes possible in the plants the process of chemical change (accomplished in our bodies by the processes of digestion and assimilation), by which the plant, under suitable con- ditions of sunshine and moisture, can take up carbon dioxid from the atmosphere, and convert it into the essen- tial elements of plant structure. Fungi, which have no chlorophyl, cannot live on air and water only, but require to be fed also with organic matter. Some feed on vege- table organic matter and some on animal; some varieties require the organic matter to be living; others feed only on dead matter. , According to their method of development, these vege- table micro-organisms are divided into groups: 1. Bacteria, or schizomycetes, which multiply by fission, a simple division of the parent cell into two. The large majority of disease-producing germs belong to this group. 2. Molds or Hyphomycetes.—These multiply by sporu- lation, a process somewhat similar to seeding, and grow as a network of fine filaments from which other threads project, bearing the spores. 3. Yeasts or Saccharomycetes.—These multiply by budding, the protrusion of a new cell from the parent cell. To the activity of the yeasts are due the familiar phenom- ena of fermentation, causing milk to sour, bread to rise, the conversion of sugar into alcohol, etc. Few of the molds or yeasts are disease-producing. Thrush, and some varieties of skin disease, such as favus, are caused by organisms belonging partly to the mold and partly to the yeast families. In very rare conditions mold fungi are found in the lung. Protozoa.—This is another variety of micro-organism, not of vegetable but of animal origin, and belonging BACTERIA 355 to the lowest known form of animal life. Malaria, syphilis, certain forms of dysentery, are among the dis- eases due to protozoa. Micro-organisms that produce disease are classed as pathogenic; those that do not produce disease, as non- pathogenic. To the activity of the non-pathogenic or- ganisms we owe many of the beneficent acts of nature. One of their functions is the breaking up of complex organ- isms into simple compounds—the process we know as decay. Thus, dead organic matter, whether vegetable or animal, is converted into gases and water, which can be used as food by plant life, the plants again, in their turn, forming food for animal life. BACTERIA Investigation proves that bacteria exist wherever animal or vegetable life has existed. They are found in the air, in water, and in the soil, particularly where the soil has been tilled, and may be present on any tangible object. Bacteria are constantly present in some parts of the body, especially the mouth, the different parts of the alimentary tract, and the skin. They are not, it is be- lieved, present, in a normal condition, in the internal organs. In order to grow, bacteria require food, moisture, and warmth. Some require oxygen as supplied by the air of the atmosphere in order to develop; others will only flourish where the air is excluded. Bacteria that require air are called aerobic; those that require absence of air, anaerobic; bacteria to the development of which one condi- tion or the other is essential are spoken of as obligate or strict; those that flourish in either condition as facultative. The food of bacteria consists of organic compounds, either vegetable or animal. Bacteria that feed on living tissue are known as parasites; those that feed on dead organic matter, as saprophytes. In feeding, the bacterial cell has the power of selection, by which it attracts those organic cells necessary for its development and repels those that destroy it. The attraction of one cell for an- 356 ELEMENTARY BACTERIOLOGY AND IMMUNITY other is called positive chemotaxis; the reverse, negative chemotaxis. The temperature most favorable for the growth of bacteria is the temperature of the living body; for some the temperature of the human body is most favorable, others develop in the bodies of cold-blooded animals. Since the body furnishes the right temperature, organic food, moisture, and absence of light, it forms an ideal soil for the development of bacteria. K -i ■ S=i i!ft ^ '«|i ^ Fig. 137.—Various forms of bacteria: 1 and 2, Round and oval micrococci; 3, diplococci; 4, tetracocci or tetrads; 5, streptococci; 6, bacilli; 7, bacilli in chains, the lower showing spore-formation; 8, bacilli showing spores, forming drumsticks and Clostridia; 9 and 10, spirilla; 11, spirochsetse (McFarland). Classification by Characteristics.—Certain bacteria, by their activity, produce characteristic phenomena, and are classified according to these characteristics: Chromogenic, those that produce color. Aerogenic, those that produce gas. Photogenic, those that produce phosphorescence. Zymogenic, those that cause fermentation. *i» &9»39 Qcr Fig. 138.—Diagram illustrating the morphology of cocci: a, Coccus or micrococcus; b, diplococcus; c, d, streptococci; e, f, tetragenococci or merismopedia; g, h, modes of division of cocci; i, sarcinae; j, coccus with flagella; k, staphylococci (McFarland). Some organisms form acids, such as lactic acid, butyric acid, etc., and others, alkalis, of which the principal is ammonia. This is often an important aid in differentiat- BACTERIA 357 ing between bacteria that otherwise closely resemble each other. That part of bacteriology which treats of the shape and structure of bacteria is called morphology. Fig. 139.—Various forms of micro-organisms: 1, Streptococci; 2, staphylococci; 3. diplococci; 4, tetracocci; 5, spirilla; 6, bacilli; 7, bacilli with spores (Paul). Classification by Shape.—According to their shape, bac- teria {schizomycetes) are divided into three principal groups: 358 ELEMENTARY BACTERIOLOGY AND IMMUNITY 1. The spherical or coccus (called also micrococcus). 2. The rod-shaped or bacillus. 3. The curved or spiral or spirillum. Cocci.—The cocci may be round or oval. In their development the different varieties form characteristic groupings, according to which they are classified: Monococci, occurring singly. Diplococci, occurring in pairs. Tetrads, occurring in groups of four. Sarcince, occurring in cubes. Staphylococci, occurring in clusters that resemble a bunch of grapes. Streptococci, occurring in chains. Bacilli.—The different bacilli vary considerably in appearance, but all retain more or less their rod-like shape; ® <■ 2) O O o C£=> g=3 a b c d e f Fig. 140.—Diagram illustrating sporulation: a, Bacillus inclosing a small oval spore; 6, drumstick-bacillus, with terminal spore; c, Clostridium, with central spore; d, free spores; e and/, bacilli escap- ing from spores (McFarland). that is to say, they are always longer than they are broad. Some are straight, others distinctly oval; in some the ends are square, in others, round; some are short and others long. Bacilli occur as separate bodies, or grouped end to end in chains or threads. In the latter, light transverse markings may be seen, marking the outline of the in- dividual cells. The shape of a bacillus is sometimes altered by the presence of what is known as a spore (see below). Where a spore forms, the bacillus bulges slightly. Thus, if a spore forms in the center, it gives to the bacillus a spindle shape, tapering at either end; a spore forming at one end gives to the bacillus the shape of a drumstick. Unlike the cocci, bacilli are not usually subdivided accord- ing to their form or groupings. Many are named after the scientist who first described them, as the Klebs-Loffler bacil- lus; others are named from the disease of which the variety BACTERIA 359 is the cause, as the tubercle bacillus, the typhoid bacillus; and others again from the substance in which they flourish, as the hay bacillus, the potato bacillus. Spirilla.—Spirilla may be formed of one single curve, known as comma, or of many curves, like a cork-screw; the latter are frequently called spirochcetoe. Spirilla forming simple, wave-like lines are also called vibrios. Some bacteria possess the power of motility. The micro-organism is provided with minute, whip-like proc- esses, known as flagellar, by the vibration of which it can move about in a fluid medium, and apparently steer itself. There may be only one flagellum, giving to the cell the appearance of a tadpole, in which case the organism is said to be monotrichous, or they may be distributed like a fringe, either all round the cell or in groups, in which case the organism is peritrichous. Micrococci are not, as a rule, motile; many bacilli and the majority of the spirilla have this property. Under certain conditions the power of motility is lost, a fact that has its weight in cer- tain methods of diagnosis. (See Widal Reaction.) This power of motility is an independent and characteristic property of the cell, quite different from certain oscillat- ing movements, which they show in common with other minute particles of matter when floating in a fluid medium. Reproduction.—All bacteria, as has been said, multiply by fission, a simple division into two of the parent cell- Multiplication by fission is termed vegetative reproduction. This division takes place with great rapidity—sometimes in as short a time as twenty minutes. As is seen, espe- cially in studying the micrococci, in dividing, bacteria show a tendency to form characteristic groupings and to adhere in pairs, fours, or eights, or in the form of clusters, chains, or threads. In certain of the bacilli a second method of reproduc- tion sometimes occurs. In the bacillus a peculiar bright, light spot is observed, generally, but not invariably, about the center. This is the spore; it bears to the bacillus the relation a seed has to a plant, and will, in favorable conditions, germinate and develop into an ordinary bacil- lus, and proceed to multiply by fission in the usual way, 360 ELEMENTARY BACTERIOLOGY AND IMMUNITY Spores are very much more difficult to destroy than the ordinary bacteria, owing to the highly resistant capsule in which they are inclosed. Means for disinfection and sterilization which destroy all other forms of bacteria arc ineffectual with spores. The recognition of spore forma- tion in certain bacteria is, therefore, extremely important. Fortunately, in few of the known pathogenic bacteria does spore formation occur. Three known to possess this property are the anthrax, the tetanus bacillus, and the bacillus aerogenes capsulatus or gas bacillus. PROTOZOA The protozoa, being animal micro-organisms and not of vegetable origin, reproduce in a totally different manner. They resemble a very elementary form of animal life, found in swamps and stagnant water. Recent research has brought to light a curious fact in the life-history of many of the pathogenic protozoa which has revolutionized the methods of prevention of the diseases caused by these organisms. Part of the development of the protozoa takes place in man and part in the body of an insect, called in this respect the host. The parasite is sucked from the blood of man by the bite of the insect, and in the body of the insect only undergoes sex development, without which it remains sterile, and gradually disinte- grates. The infection, it is considered, is transmitted only through the bite of the host. Transmission by Mosquitos.—A species of mosquito, a variety of the anopheles, acts as the intermediary host to the malarial parasite (plasmodium or hematozobn malarice), and the disease is transmitted by its bite. A second mos- quito, cedes calopus, formerly classed as the stegomyia, is considered in the same way to transmit the infection of yellow fever, and investigation at the present day points to the tsetse-fly as the carrier of the tropical disease known as sleeping-sickness. Bubonic plague is due to transfer of infection by fleas, and typhus fever is carried by body lice. Certain flies and cattle-tick are similarly the source of certain diseases affecting animals. Size.—The microscopic minuteness of the above or- CESTODES—NEMATODES 361 ganisms is difficult to realize. To measure them, a special measure, the micromillimeter, or micron, is used, the sym- bol of which is the Greek letter /jl. One micron equals the thousandth part of a millimeter, or 2^ooo Var^ °f an inch. Thus, if a bacillus measures in length one micron, 25,000, placed end to end, will measure only one inch. Some bacilli measure less than one micron. CESTODES—NEMATODES Other parasites which infest the human body are not protozoa, but may be briefly mentioned. Such are the cestodes, or tapeworms, and the nematodes, or round- worms, which gain entrance to the body through food or drinking-water containing the larvae of these parasites. For the development of many of them an intermediary host is necessary, such as the hog, the ox, or fish. By these animals the eggs are ingested and the flesh becomes gradually infiltrated with the larvae (measly meat). The larvae consumed by man in such meat lodge in the in- testine, and there develop into the different varieties of tapeworm. Another cestode has as its host the dog. The eggs gain entrance in drinking-water or on cress or other plants grown in the water and eaten raw, and de- velop in man, usually in the liver, where they grow and form numerous cysts, varying in size from a pin's head to a pigeon's egg (hydatid cysts). Hookworm.—Among the nematodes are two important worms that cause serious illness when developed in man. One, the hookworm {Ankylostomum duodenale), develops in the small intestine. It is a small worm, about half an inch in length, with a hook-like head, by which it attaches itself to the walls of the small intestine. It causes an intense, persistent anemia, from which recovery is possible only if the worm can be expelled. The Filaria sanguinis hominis is another which develops in the lymphatics. The embryos are found in the blood, it is said, only at night or during the hours of sleep. In time the worms cause occlusion of the lymphatics, and are the origin of a group of diseases arising from this condi- tion, of which elephantiasis is one. 362 ELEMENTARY BACTERIOLOGY AND IMMUNITY Both these worms are taken into the system in drinking- water. It is considered that the embryo of the filaria sanguinis hominis is taken from man to the water by the mosquito, another instance of an insect as a medium of infection. Pin-worm.—Other varieties of nematodes are the pin- worm, common in children, the earth-worm, and the small worm peculiar to the hog, and found in " measly pork," which causes trichiniasis when developed in man. EXAMINATION OF BACTERIA Micro-organisms are examined under the microscope, both in a stained or an unstained condition (see below), and either alive or dead. The Microscope.—The principal parts of the microscope are as follows (Fig. 141): Eye-piece, or ocular. Draw-tube. Tube. Objectives with nose-piece. Stage. Substage. The coarse adjustment. The fine adjustment. Adjustment of substage. The reflector. The iris diaphragm. The base. The base supports a short pillar, to which the micro- scope proper is attached. The ocular and the objective are both fitted with lenses, thus forming a compound microscope; a single magnifying lens is known as a simple microscope. Usually there are three objectives of different magnifying power, used at different distances from the object under examination. They are frequently named according to the focal distance. Thus, a ^-inch objective is one focused half an inch above the object to be examined; the measurement has no refer- ence to the size of the objective. The terms high power and low power are employed to EXAMINATION OF BACTERIA 363 denote the magnification, which depends both on the ocular and the objective. The stage has an opening in the middle for the admis- sion of light, directly over which is placed the specimen for examination on a glass slide. Below the stage is the iris diaphragm, a circular shutter, by opening and closing which the area of light may be enlarged or decreased. Where an intense il- lumination is desired, an arrangement of lenses known as the Abbe con- denser is attached below the stage opening. The condenser focuses the light from the reflector, and throws an intense light on a small area. It is specially required when specimens are ex- amined under the oil- immersion lens. The oil-immersion lens is used where a very high power of magnification is desired. The lower surface of a high-power objective (TV) is im- mersed in a drop of cedar-wood oil placed on the cover-glass, be- low which is the object for examination. A layer of oil is then formed between the objective and the object. The oil prevents the dispersion of light, thus increasing the magnifying power of the microscope. Fig. 141.—The microscope: 1, Eye- piece; 2, draw-tube; £3, main tube; 4, nose-piece with objectives attached; 5, objective in position; 6, stage; 7, substage; 8, adjustment of sub- stage; 9, reflector; 10, coarse adjust- ment; 11, fine adjustment. 364 ELEMENTARY BACTERIOLOGY AND IMMUNITY The object for examination in position, the objective is lowered close to the object, without touching it, by the coarse adjustment, and finally focused by the fine adjust- ment. Before being shown specimens under the microscope, pupils should be carefully taught the simple manipulation of the different parts of a microscope and the purpose of each. Every part of a microscope is an expensive item, and more or less easily destroyed by careless handling, objectives in particular being readily spoilt by scratching. Examining Bacteria.—For examining bacteria when alive, what is known as the hanging drop is used; for dead bacteria, the smear. PREPARATION OF SPECIMENS FOR EXAMINATION Smears.—In lifting the material for examination a fine platinum wire is used, mounted on a glass rod or on a special metal holder. The wire may be straight, or, more frequently, the end is twisted into a small loop. The wire is sterilized by being brought to a red heat over a clean flame (alcohol lamp or Bunsen burner), and must then be allowed to cool before using. After use the wire must again be sterilized in the same manner, in order completely to destroy any organic substances still adher- ing. The specimen for examination is spread in a thin smear, in the center of a glass slide, a thin piece of clear glass about three inches long and one inch wide. The glass must be absolutely clean and free from scratches. If the specimen is thick and tenacious, it may be diluted by placing first a drop of distilled water on the slide. The smear is exposed to the air for a few moments to allow it to dry; it is then "fixed," usually by passing the slide three times slowly through a clean flame. The smear is then ready for staining. The smear may also be made on a cover-glass, but this method is more difficult and less practical than the use of the slide. Staining.—Weigert and Ehrlich, two German scientists, introduced, about 1877, a method by which micro-organ- isms in prepared specimens can be stained or colored, with- PREPARATION OF SPECIMENS FOR EXAMINATION 365 out, at the same time, coloring the medium in which the bacteria are found. Certain colors derived from coal-tar products, and known loosely as anilin dyes, have, they demonstrated, an affinity for bacteria and for the nuclei of tissues. Bacteria stained by their dyes stand out clearly from the background, and are much more readily examined than are the transparent, colorless, ill-defined bodies they appear under the microscope in an unstained condition. Other anilin dyes, again, have no affinity for bacteria, but stain tissue diffusely, and serve, therefore, as contrast stains. The anilin dyes in use in bacteriology are classified as—(a) acid and (6) basic stains. The basic stains are used to stain bacteria and the nuclei of tissue; the most commonly used are fuchsin, gentian-violet, and methylene-blue. The acid stains are used chiefly to stain tissue-cells and as contrast stains; the principal are eosin and picric acid. There are numerous methods of staining specimens. The following is one of the simplest: 1. Fill a small shallow dish with a weak solution of one of the basic dyes in distilled water. 2. Immerse the slide on which the smear has been made as above for thirty seconds. 3. Remove and wash thoroughly in distilled water, or, place a few drops of the stain directly on the smear; after thirty seconds to two minutes, wash. The speci- men may now be examined under the microscope or it may be mounted permanently. To mount a specimen, a drop of Canada balsam is allowed to fall in the center of the smear; a cover-glass is then placed over the smear on the slide, and the two are gently pressed together. Precautions.—In teaching pupil nurses a simple proc- ess of staining, the need for care in handling the speci- mens must be constantly emphasized. The cover- glasses and slides must be handled throughout with forceps; the loop must be sterilized by bringing to red heat immediately after use and before being laid down; the hands should be washed and disinfected when the process is over, in case, through inexperienced handling, any bacteria should accidentally adhere to the hands. 366 ELEMENTARY BACTERIOLOGY AND IMMUNITY No one should touch a specimen in preparation, however carefully, if there is the smallest scratch or abrasion un- covered on the hands. Many differential methods of staining are also used, the most important of which are Gram's method and the Ziehl-Neelson method of staining acid-fast bacteria, such as the tubercle and leprosy bacilli. Ziehl-Neelson stain for acid-fast bacilli. Required: Carbol-fuchsin solution: Basic fuchsin............................ 1 gm. Carbolic acid, pure....................... 5 c.c. Alcohol................................. 10 c.c. Water.................................. 100 c.c. Nitric acid, 30 per cent., or sulphuric acid, 15 per cent., or acid alcohol (2 per cent, hydrochloric acid in 95 per cent, alcohol). Loffler's methylene blue: Saturated alcoholic solution of methylene-blue 30 c.c. Caustic potash (0.01 per cent, solution)..... 100 c.c. The smear being made as described: 1. Cover with the carbol fuchsin solution. 2. Hold the slide over a flame for a few minutes at such a distance that steam is formed. 3. Decolorize with either the nitric or sulphuric acid. 4. Wash in water. 5. Counterstain with methylene-blue. 6. Wash in water, dry, and mount in Canada balsam. The tubercle bacilli will appear as "red rods in a blue field." The method of thus demonstrating tubercle bacilli (Plate V) rests on the principle that "after adding to solutions of anilin dyes certain substances, such as car- bolic acid, . . . the tuberculosis bacillus is stained with great intensity and gives up its stain with difficulty. Solutions of acids will remove the stain from all parts of the preparation except from the tuberculosis bacilli, which retain the dye. having once acquired it" ("Manual of Bacteriology,'' H. U. Williams). PLATE V rffli Tubercle bacilli in urinary sediment; X 800 (Ogden). PREPARATION OF SPECIMENS FOR EXAMINATION 367 Gram's Stain.—To 10 c.c. of distilled water in a test- tube add anilin oil to make a dilution of about 1 : 20. Shake thoroughly and filter. Add saturated alcoholic solution of gentian violet until the mixture is no longer transparent and a metallic film appears on the surface. 1. Cover the smear on the slide with this solution for three minutes. 2. Wash with water. 3. Cover with Gram's iodin solution three minutes. Gram's iodin solution: Iodin.................................. 1 gm. Potassium iodid........................ 2 gm. Distilled water......................... 300 c.c. 4. Decolorize with 95 per cent, alcohol until no more of the stain can be washed out. 5. Wash with water. 6. Counterstain with dilute carbol-fuchsin or Bismarck brown. Gram-positive bacteria are those which retain the gentian violet. Gram-negative bacteria are those that lose the gentian violet and take the counterstain. The Hanging Drop.—When it is desirable to examine living bacteria, a special slide is used which has a small cell or depression in the center, ground out of the thick- ness of the glass. For such an examination the bacteria must be in a fluid medium. If the medium is solid, the cul- ture is suspended in a drop of bouillon or sterile distilled water. The drop for examination is placed on a cover- glass, which is then laid, drop side downward, exactly over the small concavity, thus forming a tiny sealed chamber. V'aselin smeared on the slide round the edge of the de- pression serves to keep the cover-glass in place and to exclude air. In this hanging drop, as it is called, the movements of bacteria, their development and multipli- cation, can be observed under the microscope. One of the important phenomena studied by the hang- ing drop is the so-called Widal or serum reaction of the typhoid bacillus (p. 384). 368 ELEMENTARY BACTERIOLOGY AND IMMUNITY ^^^-\ Mf \ if G J «=^= v_y ^^^=S8BaBBB Fig. 142.—The " hanging drop" seen from above and in profile (McFarland). Fig. 143.—Application of the serum-reaction to typhoid bacilli: A shows the distribution of the bacilli before the reaction; B shows clumping of the motionless bacilli after mixture with the serum of a case of typhoid fever (Williams). (Diagrammatic.) CULTURE OF BACTERIA In order to study bacteria, it was found necessary to separate the different varieties, not only from each other, but from all other organic matter (matter, that is, of cell construction), and to cultivate them artificially by placing them In media that furnish the proper conditions for their development. Culture-media.—The first culture-media were fluids, broths made from meat or vegetables, and contained in glass flasks. As media they were, however, imperfect; CULTURE OF BACTERIA 369 all forms of microscopic life spread quickly through the fluid and were difficult to isolate or differentiate. By boiling the broths before introducing the material under examination a good deal of micro-organismic life was elim- inated, and examination was further facilitated by dilu- tion through several flasks of carefully prepared and sterilized bouillon. Thus the material from which the bacteria were to be cultivated would be stirred into one flask, a small amount would then be taken from the first flask and introduced into a second, and the process re- peated through several others. The highly diluted specimen thus obtained was, when developed, much easier to examine than one crowded with micro-organisms. Still the method was baffling and imperfect. In 1881 Koch, a German scientist, and, after Louis Pasteur, probably the most universally famous of bac- Fig. 144.—Petri dish for making plate cultures (McFarland). teriologists, introduced the method known as plating and the employment of solid culture-media, which he obtained by mixing the bouillon with gelatin. Koch had observed that micro-organisms growing on solid bodies, such as the potato, grew in separate colonies, and did not become confluent, as when developed in fluid media. In plating, three tubes of gelatin-bouillon or agar are used, at a tem- perature which will keep the medium liquid. The infected matter is introduced into the first tube on a sterile loop. Three loopfuls are then taken from the first tube and mixed with the second, and three again from the second to the third. Each tubeful is then poured into a separate flat glass dish, called a Petri dish, and covered with a closely fitted glass cover. On cooling, the medium solid- ifies and serves to keep the bacteria stationary and sepa- rate from one another. As the bacteria develop, which 24 370 ELEMENTARY BACTERIOLOGY AND IMMUNITY they do in from one to two days, each organism develops its own species in an area more or less isolated, forming what is known as a colony. In the third and most highly diluted specimen the colonies are fewer and more isolated than in the other two. A culture obtained in this way is known as a pure culture, of which the definition is that it is "one variety of one organism." A pure culture may also be obtained by means of streaked plates. In this method the melted medium Fig. 145.—Instruments for making a culture: 1, Alcohol lamp; 2, thumb forceps; 3, sterile swabs; 4, culture-tubes; 5, platinum needle (Morrow). (agar) is poured into a sterile Petri dish and allowed to harden. The material to be examined is then streaked over the surface of the medium by means of a sterile platinum wire or a bent glass rod. Two or more plates are inoculated without sterilizing the wire. Single colonies will develop as on the poured plates. The advantage gained in examining bacteria developed by the plating method is obvious: its introduction gave an immense impetus to the study of bacteria, and especi- ally to the discovery of the specific organisms which now CULTURE OF BACTERIA 371 were quickly coming to be recognized as the cause of different diseases. Simple and practical though these modifications of existing methods by Koch appear, they are considered by bacteriologists to have had such im- portant results that Koch is usually considered, by this invention, to have made the most important of any one contribution to bacteriologic research. At the present day a variety of culture-media is used in the development of bacteria. Nutrient bouillon is the Fig. 146.—Showing the method of taking a culture from the pharynx (Morrow). most commonly used, either by itself or as a basis for other culture-media. It is made of freshly expressed beef- juice or of beef-extract, to either of which are added pep- tone, common salt, and a proportion of water adjusted to a neutral reaction and sterilized. For the solid media the same bouillon is used, with the addition of gelatin or agar-agar. The latter is a jelly-like sea-weed obtained from Japan. It is valuable in laboratory work, as it 372 ELEMENTARY BACTERIOLOGY AND IMMUNITY liquefies at a higher temperature than ordinary gelatin. Slices of raw potato are also used as solid culture-media. Milk, to which a small proportion of litmus is added, and blood-serum are other culture-media in frequent use. "Loffler's blood-serum" is made of three parts blood- serum and one of a bouillon containing 1 per cent, glucose. It is the culture-medium usually employed to develop the diphtheria bacillus. Blood-agar is made by adding a small amount of sterile blood to plain agar. This is used for the cultivation of organisms that do not grow readily on plain media, for example, the streptococcus, influenza bacillus, pneu- mococcus. Various sugar media (glucose, lactose, saccharose, and inulin) are made by adding 1 per cent, of the sugar to the plain agar or bouillon. These media are used for the production of acid and gas by bacteria. Many modifications of the above are used. All require the most careful preparation and sterilization in order to prevent the possibility of bacterial contamination. In their preparation the possibility of spore contamination must be borne in mind, since if these resistant bodies should develop, the media would be spoiled. To prevent this risk in the preparation of culture-media, sterilization is usually done by the fractional method (p. 428). Taking a Culture.—It is frequently a nurse's duty to " take a culture," as, for example, from a patch on the throat or the discharging surface of a wound. For the process, the following are required: A loop, or tooth-pick applicator mounted in cotton. An alcohol lamp. Two test-tubes containing the media desired. The test-tubes are stoppered with sterile cotton. The loop must be sterilized as described and cooled before using; if an applicator is used, it must, of course, be strictly sterile. Taking the greatest care to come in contact with no other object, the loop or applicator is gently touched to the infected spot and lightly moved over the surface; the tube containing the medium is then opened, and the ma- \ INFECTION 373 terial introduced. If a fluid culture-medium is used, the instrument is stirred into the fluid. When the medium is solid, about a third of the tube is filled in such a manner as to form a long, slanting surface; over this surface the instrument is lightly zigzagged from the bottom up, tak- ing care not to break the surface. The cotton stopper, which must be held in the fingers and kept from touching any object, is then set alight at the alcohol flame, allowed to blaze a moment, and replaced. The loop is sterilized Fig. 147.—The method of making a smear culture (Morrow). by reheating; a wooden applicator should be burned at once. INFECTION Pathogenic bacteria gain entrance to the body through the lungs, the alimentary system-, the genito-urinary tract, or the broken surface of the skin or mucous membrane. When they gain entrance to the body in sufficient strength to overcome the natural resistance of the body cells symptoms of disease result, and we say that infection has taken place. Infection may be local, as in an abscess or infected wound, or systemic, as in any of the so-called infectious diseases. 374 ELEMENTARY BACTERIOLOGY AND IMMUNITY The bacteria themselves do not attack and destroy the tissues, but, as a result of their activity, they elaborate1 certain poisonous substances loosely classed as toxins. The production of these toxins is similar to the produc- tion of ferments in such familiar processes as the souring of milk, the fermentation of sugar, etc. Bacterial toxins are of two kinds: 1. Exotoxins, or extracellular toxins, are poisonous sub- stances produced and excreted by bacteria both in living tissues and in artificial culture-media. By the process of immunization an antitoxin can be produced against an exotoxin. 2. Endotoxins, or intracellular toxins, are not excreted by the bacteria, but are held within the bacterial cell and can be separated only by the breaking up of the cell body. Satisfactory antitoxins for endotoxins are not readily produced. Ptomain.—An alkaloid substance produced by the action of bacteria on dead organic material, such as oysters, canned meats, milk, etc. Ptomains arcs usually elaborated during putrefaction, and are, in consequence, sometimes known as putrefactive alkaloids. Contagious Diseases.—All diseases which are the result of bacterial invasion are, strictly speaking, infectious; that is, the specific disease does not develop unless the human being is actually infected with the specific germ causing this one disease. By the laity the term is gener- ally loosely used to describe only such diseases as are communicable by either direct or indirect contact from man to man, which is misleading. The correct term for such diseases is contagious. While all contagious diseases are infectious, many infectious diseases are contagious only to a limited extent, as, for example, pneumonia, and others not at all, as, for example, rheumatic fever. Still another variety we have seen requires the interven- tion of an intermediary host to be conveyed from man to man. Besides the general effects produced on the system, bacteria, as a rule, have an affinity for special organs or parts of an organ, in which they produce lesions charac- INFECTION 375 teristic of the disease. Thus, in typhoid fever, we find certain glands in the lower intestine extensively ulcerated; in diphtheria, a characteristic membrane is observed, usually on the mucous membrane of the nose and throat; other infections are characterized by skin eruptions or rashes. The toxin produced by the tetanus bacillus acts on the nervous system, producing violent muscular con- tractions and profound prostration. Some bacteria, such as the tubercle bacillus, attack now one group of body-cells, now another, producing in the proc- ess different groups of symptoms. Thus, when the germ attacks the coverings of the brain, we have tubercular meningitis with cerebral disturbances as the prominent symptom. If the same germ, however, attacks the lungs, we have pronounced pulmonary symptoms, while the brain may remain clear and undisturbed. That certain diseases were from the earliest times recog- nized as contagious we know from writings that have come to us from the ancients. They also recognized that the spread of such infections was to some extent controlled by isolation and by purification of the effects and dwell- ings of the victims by fire and by cleansing with water. In such an ancient writing as the Odyssey we find reference also to the use of the fumes of sulphur for such purpose. The discovery of the specific organisms that produce disease, with the manner of their invasion of the human structure, and the channels through • which the invasion is effected, are the result of research covering but little more than the last half century. Of the many brilliant men to whom we are indebted for the numerous discoveries in the field of bacteriology, none is so famous as Louis Pasteur. Louis Pasteur, a Frenchman, born in 1822, from about the year 1862 until his death in 1895 devoted his time, his money, and wonderfully brilliant intellect to bacterial research, especially in reference to the nature, course, and prevention of infectious diseases. His name is universally known as the originator of the method of curing rabies by inoculation. In the scientific world 376 ELEMENTARY BACTERIOLOGY AND IMMUNITY Louis Pasteur is regarded, on account of the methods of observation he originated, his experiments, and the deductions and teaching he based upon the results ob- tained, as the father of all discoveries in the field of bacteriology; he is also the founder of the first school on the subject. Theory of Antisepsis.—The discoveries of Pasteur and his school, especially on the nature and causes of fermenta- tion and putrefaction, were followed with absorbing in- terest by the medical scientific world, but probably with but a faint conception of the enormous benefit to human and animal life which was to be the practical outcome of their work. In 1867 an English surgeon, Joseph Lister, then attached to Edinburgh University, and later to King's College Hospital, London, applying the teaching of Louis Pasteur to practical medicine, propounded the theory that suppuration in wounds was a process closely allied to fermentation, and similarly the result of the activity of micro-organisms which have gained access to the living tissues. If, therefore, he deduced, a wound could be protected from the invasion of bacteria (or infec- tion), suppuration would not occur. From the basis of this deduction has been built up the entire fabric of modern antiseptic and aseptic methods in surgery, which have opened out to the surgeon the immense field of enter- prise impossible before. A few years later (1872) a German scientist, Klebs, pointed out a similar origin as the cause of general sepsis, or blood-poisoning (which, up to this time, was constantly present in surgical wards), and a similar possibility of its prevention. Koch's Postulates.—In the earlier years, as has been already noted, the imperfection of the means and methods of examination stood in the way of the discovery, differ- entiation, and classification of the various organisms. After the introduction of the methods of plating and stain- ing already described, and with the improvements of the microscopic lenses, research began to make rapid strides, and many of the specific organisms of special diseases were discovered. In order that a specific organism should be recognized as the sole origin of a disease, Koch, the German scientist already mentioned, formulated certain 1^ Diseases. Germ. Anthrax......... Bacillus of anthrax Relapsing fever..... Amebic dysentery.. . Malaria........... Spirochaeta obermeieri Ameba of dysentery Plasmodium malaria? Typhoid.......... Tvphoid bacillus . f Pneumoma.......< Tuberculosis....... Glanders.......... Erysipelas......... Cholera........... Diphtheria......... Tetanus........... Diplococcus lanceolatus, Frankel's pneumococcus Tubercle bacillus Bacillus mallei Streptococcus of erysipelas Spirillum cholera? or comma bacillus Klebs-Loffler bacillus Tetanus bacillus Malta fever........ Chancroid......... Bubonic plague..... Cerebrospinal menin-gitis ............ Dysentery......... Sleeping sickness.... Syphihs........... Yaws (frambesia). .. Micrococcus melitensis Ducrey's bacillus Bacillus pestis Diplococcus intracellularis meningit-idis Shiga's bacillus Trypanosoma gambiense, Dutton Treponema pallidum Treponema pertenue Discoverer. Nationality. Date. f Pollender German 1849 j Rayer French 1850 1, Davaine French 1850 Obermeier German 1873 Losch German 1875 Laveran French 1880 Eberth and Koch German 1880 > Frankel Koch German 1880 German 1882 Loffler and Schutz German 1882 Fehleiser German 1883 Koch German 1884 Klebs and Loffler German 1884 Nicolaier German 1884 Bruce English 1887 Ducrev French 1889 f Yersin ' 1 working inde-\ Kitasato / pendentlv French 1894 Japanese 1894 1 Weichselbaum German 1887 \ Jaeger (confirmed) German 1895 Shiga Japanese 1898 Dutton English 1902 Hoffman and Schaudinn German 1905 Castellani Italian 1906 CD s o •l£ © 3 is 378 ELEMENTARY BACTERIOLOGY AND IMMUNITY 1. The organism must be present in the tissues in every case of the disease, and in no other, and it must be found in sufficient numbers to explain the lesions of the disease. 2. The organism taken from such a case must be de- veloped in "pure culture." , 3. The organism developed in pure culture must, when inoculated in a healthy animal, produce the same^ disease. 4. The same organism must be recovered from the animal so inoculated in which the disease has been repro- duced. Bacteria which have fulfiled these conditions are con- sidered as the origin of the special disease in which they are found. At the present time, however, immunological reaction can afford proof of the specificity of a certain organism to a certain disease even though all of Koch's laws have not been complied with. The organisms shown on p. 377 have been proved to comply with Koch's postu- lates. Another group of diseases are shown to be always as- sociated with a specific organism which is considered to cause the disease; these organisms fail, however, to com- ply with Koch's postulates. Such are: Actinomycosis, 11 elapsing fever, Gonorrhea, Whooping-cough, Leprosy, Yaws. Rabies, and many tropical diseases. In many cases the bacteria fail to develop in the body of an animal. In several other diseases, presumably due to micro- organic invasion and classed as infectious, the specific bacteria have not yet been isolated. Such are: Chicken-pox, Mumps, Epidemic poliomyelitis, Scarlet fever, German measles, Smallpox, Influenza, Typhus fever, Measles, Yellow fever. The majority of these diseases are actively contagious. Many theories are advanced to explain why the bac- teria of these diseases have so far baffled research. It is A DESCRIPTION OF COMMON PATHOGENIC BACTERIA 379 suggested that the methods and means are yet imperfect, that the organisms may be too minute to be detected, even by the powerful lenses of the present day, or that the usual processes of culture, staining, etc., may actually destroy or render them invisible; others advance that the organisms may actually be dissolved by the products of their own activity. A DESCRIPTION OF THE MORE COMMON PATHOGENIC BACTERIA Cocci Staphylococci are small Gram-positive, aerobic cocci that occur usually in irregular masses. They grow readily on all ordinary culture-media, producing a heavy and shiny growth. The pathogenic staphylococci are of three varieties: 1. Staphylococcus {pyogenes) aureus—most frequently found in acute suppurative conditions, such as abscesses, boils, and carbuncles. It is characterized by the golden yellow pigment produced by its growth on culture-media and is the most virulent of the three varieties. 2. Staphylococcus (pyogenes) albus — morphologically identical with staphylococus aureus, but produces no pig- ment. Cultures on agar have a milk-white color. One variety of the albus, the staphylococcus epidermidas albus, is constantly found in the epidermis. Usually innocuous, it may be the cause of suppuration in certain conditions, especially, it is said, when the tissues are irritated by the presence of a foreign body, such as stitches, necrosed tissue, etc. 3. Staphylococcus {pyogenes) citreus is characterized by the lemon-yellow pigment it produces. It is occasionally found in acute abscesses with other pyogenic cocci. Streptococci are Gram-positive, aerobic, chain-forming cocci. They do not grow readily on ordinary culture- media, blood-serum or blood-agar being the most favor- able solid media and ascites or serum bouillon the best fluid media for their cultivation. Pathogenic streptococci are subdivided as: 380 ELEMENTARY BACTERIOLOGY AND IMMUNITY 1. Hemolytic—those which produce hemolysis of blood- cells and a clear zone around each colony on blood-agar. This is the most virulent type and includes the strepto- coccus pyogenes, responsible for acute abscesses, septi- cemia, puerperal fever, sore throat, and acute inflamma- tory conditions of the serous membranes, such as peri- tonitis, pericarditis, etc. The streptococcus of erysipelas also belongs to the hemolytic streptococci. 2. Non-hemolytic—those which produce no hemolysis of blood-cells and no clear zone around the colonies on blood-agar. This type is not so highly virulent as the hemolytic type, but may produce chronic inflammations. Diplococci.—Of these there are several pathogenic forms: 1. Pneumococcus {Diplococcus pneumonia?).—Oval or lancet-shaped coccus, usually in pairs, occasionally in short chains, Gram-positive, non-motile, and surrounded by a capsule when found in blood, sputum, or body fluids. Capsule formation is lost on artificial media. The pneumococcus does not grow well on ordinary media, blood-serum or ascites broth or blood agar being the best media for its growth. Diseases caused by the pneumococcus are lobar- and bronchopneumonia, pleurisy, empyema, otitis media, meningitis, endocarditis, arthritis, tonsillitis, and con- junctivitis. Pneumococci are divided into four types. Speeific sera are produced for Types I, II, and III. All not classed as such are Type IV. In order to determine the type a portion of the sputum containing pneumococci is injected into the peritoneal cavity of a white mouse. The pneu- mococci multiply rapidly; other organisms die. Within six or eight hours the mouse becomes sick and usually dies. If it does not die it is killed and autopsied. The peritoneal exudate is washed out with sterile salt solution and centrifuged to throw down the bacteria. The bacterial sediment is then suspended in salt solution, portions of it placed in small tubes mixed with equal amounts of Type I, II, and III sera respectively. Agglutination or clumping of the organisms is produced by the specific A DESCRIPTION OF COMMON PATHOGENIC BACTERIA 381 serum for their type. For example, if agglutination occurs with Type I serum and not with the other sera, the organism belongs to Type I. Type sera are used in the treatment of pneumonia. 2. Gonococcus (Micrococcus gonorrheal).—A Gram-nega- tive diplococcus with a characteristic coffee-bean shape, the flattened surfaces facing one another. It does not grow on plain media—blood, ascites, or hydrocele agar being required for its cultivation. The organism is frequently spoken of as Neisser's organism because it was discovered by Neisser. It is the cause of gonorrhea and gonorrheal ophthalmia and is found in the urethral and vaginal discharges and in pus from the infected eye. During the acute stage of the dis- ease when the discharge is purulent the organisms are found almost entirely in the pus-cells. Another method of diagnosis is by the complement- fixation test. This is of more value in chronic infections than in acute cases. Gonorrheal ophthalmia is a frequent accidental infection at birth and is often the cause of blindness in infants. 3. Meningococcus (Diplococcus intracellularis menin- gitidis).—A Gram-negative coccus, usually found in pairs and closely resembling the gonococcus. The organism does not grow on ordinary media, blood-serum or ascites or blood-agar being the best media for its growth. The meningococcus is the most frequent cause of purulent meningitis (rare cases are caused by pneumococci, streptococci, and the tubercle and influenza bacilli). It is frequently found in the nasal cavities and from there finds its way to the meninges. It can be found in the spinal fluid of such cases, both within and without the cells of the fluid. If the organisms are intracellular the prognosis is better. An antimeningococcus serum has been produced by immunizing horses with meningococci. In the treatment of meningitis the serum is injected intraspinally. Under this treatment the mortality has been reduced to about 25 per cent, as compared with a mortahty of 50 to 80 per cent, without serum treatment. 382 ELEMENTARY BACTERIOLOGY AND IMMUNITY Micrococcus catarrhalis is a Gram-negative diplococcus found in the mucous membranes of the respiratory tract. At times it may cause inflammation of the membranes and pneumonia. The organisms resemble meningococci and are sometimes confused with them. In this case cultural and serological tests must be made. Micrococcus catarrhalis grows readily on plain agar. Bacilli Anthrax Bacillus {Bacillus anthracis).—A long, slender bacillus, Gram-positive and non-motile. It grows readily on ordinary culture-media and is characterized by the formation of spores which are extremely resistant to heat and disinfectants. The organism can usually be found in a direct smear from the lesion, where it appears as a single encapsulated bacillus. In culture it produces long, fine chains or filaments composed of a number of organ- isms placed end to end. The anthrax bacillus is the cause of anthrax, a disease prevalent among animals, especially sheep and cattle, and also occurring in man as a result of infection through the skin, alimentary canal, or lungs. It is found among persons who work with leather, hair, or wool, and the most common form, malignant pustule, is produced by infection through an abrasion of the skin on the face, neck, or arms. Diphtheria bacillus {Bacillus diphtherial) is commonly known as the Klebs-Loffler bacillus. The organisms vary greatly in size and shape, grow singly or in pairs, and usually appear at angles to one another. The rods are sometimes straight, sometimes curved, and may con- tain one or more refractile bodies called granules. They are stained best by Loffler's methylene-blue, which stains the granules more deeply than the rest of the organism. Loffler's blood-serum is the best medium for the cultiva- tion of diphtheria bacilli. Some types of diphtheria bacilli are virulent, some non- virulent. The test for virulence is made by inoculating a 200-gram guinea-pig subcutaneously with a portion A DESCRIPTION OF COMMON PATHOGENIC BACTERIA 383 of a twenty-four-hour pure culture. If the culture is virulent the pig dies within twenty-four to seventy-two hours or shows signs of toxemia or paralysis. On autopsy a hemorrhagic edema is seen at the point of inoculation and the adrenal glands are congested. Vincent's bacillus {Bacillus fusiformis) together with spirochetes is the cause of Vincent's angina, a pseudo- membranous condition of the throat sometimes confused with diphtheria. The organism is detected in direct smears from the throat, stained with dilute carbol-fuchsin. It appears as a large crescent or "banana-shaped" organ- ism, pointed at each end, and containing one or more heavily stained granules. The spirochetes associated with Vincent's bacillus are very fine, thread-like organisms usually showing a number of spirals. The Colon Typhoid Group of Bacilli.—Among the most important members of this group are: The typhoid bacillus {B. typhosus). The colon bacillus (B. coli). The dysentery bacillus {B. dysentence). The paratyphoid bacilli A and B {B. paratyphosus A and B). The chief characteristics common to all are: (1) Similar morphology—short, plump, non-spore-bearing bacilli; (2) Gram-negative staining reaction; (3) similar growth on agar and gelatin; (4) non-liquefaction of gelatin. The colon bacillus is a normal inhabitant of the intestines, but may at times become pathogenic by infecting the gall-bladder or urinary tract or by producing peritonitis in typhoid fever. It is of interest also because it is an index of fecal pollution, a very important factor in the examination of water. The colon bacillus differs from the typhoid bacillus in that it produces acid and gas in glucose media, forms red colonies on Endo medium, and gives a negative Widal reaction with typhoid serum. The typhoid bacillus does not produce acid and gas in glucose media; it forms colorless colonies on Endo medium and gives a positive Widal reaction. The Widal reaction is used in the diagnosis of typhoid 384 ELEMENTARY BACTERIOLOGY AND IMMUNITY fever and is due to the presence of antibodies or agglutinins in the blood of a patient having typhoid fever. These agglutinins have the ability to agglutinate typhoid bacilli or cause them to form in clumps. Technic of the Widal Reaction.—A small amount of blood is obtained by pricking the finger or ear of the patient and collecting a few drops of blood in a small tube. The clot is broken up and centrifuged and the serum separated and diluted 1 to 10, 1 to 20, and 1 to 40 with salt solution. Hanging-drop preparations (p. 367) are made with each of these dilutions, one loopful of diluted serum being mixed with one loopful of an eighteen- hour broth culture of the typhoid bacillus. This gives final dilutions of 1 to 20, 1 to 40, and 1 to 80. A culture control is also set up with one loopful of the broth culture and one loopful of salt solution. Prepara- tions are allowed to stand at room temperature for one hour, then examined microscopically. Loss of motility and clumping of the bacilli in the lowest or in all of the dilutions, with no loss of motility or agglutination in the culture control, constitutes a positive reaction. The serum of a patient does not give a positive reaction until a week or more after the onset of the disease, but retains it for a year or more after recovery. Persons who have received typhoid vaccine also give a positive Widal reaction. Influenza Bacillus (Bacillus influenzae; Pfeiffer's bacil- lus), a very small, thick, Gram-negative, and non-spore- bearing bacillus which occurs singly or in pairs. It does not grow on ordinary culture-media, but requires a medium containing hemoglobin. Blood-agar is the best medium for its cultivation.. While it has been proved that the influenza bacillus is definitely pathogenic, its specificity in epidemic influenza has never been proved and it may be only a secondary invader. Bacillus pyocyaneus—a small, slender bacillus, Gram- negative, and occurring frequently in pairs or in chains of four or six. It grows well on all ordinary culture-media and is characterized by the formation of a green color A DESCRIPTION OF COMMON PATHOGENIC BACTERIA 385 in the medium. The blue and green coloration often noticed in pus is due to this organism, which is ordinarily non-pathogenic, but in cases of debility may become a source of infection. Tubercle Bacillus {Bacillus tuberculosis), a small, slender, non-motile rod, sometimes curved and sometimes having a beaded appearance. It is an acid-fast organism and does not grow on ordinary culture-media. Coagu- lated serum or egg-media, glycerin-agar, and potato may be used for its cultivation. The organisms can be found in the sputum from pul- monary tuberculosis, in urine and feces, in many of the internal organs and glands, in the joints, bones, mucous membranes and skin, and in the spinal fluid from tuber- cular meningitis. In cases where the tubercle bacilli cannot be detected by microscopic examination a small amount of the suspected material may be injected sub- cutaneously into a guinea-pig in the region of the inguinal gland. After about four weeks the pig is killed and autopsied. Even a very small number of tubercle bacilli will produce tuberculosis. On autopsy the animal shows marked swelling of the inguinal gland and tubercles on many of the internal organs, especially the liver and spleen. The bacilli may be recovered from the tubercles. Leprosy Bacillus {Bacillus leprce), an acid-fast bacillus resembling the tubercle bacillus. It has never been definitely proved that the organism can be cultivated on artificial media and the disease has never been produced experimentally in animals. The bacilli can be demon- strated in tissues (skin, internal organs, and nerves) and in the secretions of the mucous membranes of the mouth and nose, as well as in direct smears from the lesions. Tetanus Bacillus (Bacillus tetani), a slender, motile, Gram-positive bacillus with rounded ends. Spores are formed in the bacillus which develop at one end of the organism and distend it, giving the characteristic "tack" or "drum-stick" appearance. The organism can be culti- vated on ordinary media if grown anaerobically. Tetanus is caused by the entrance of the bacillus into a wound or through an abrasion of the skin. A toxin is 25 386 ELEMENTARY BACTERIOLOGY AND IMMUNITY produced which attacks the central nervous system, thus causing the spasmodic contractions of the muscles and the paralysis, which are characteristic of the disease. Spirilla Cholera spirillum {cholera vibrio, "comma bacillus")—a curved rod with rounded ends. The curvature may be very slight, like that of a comma, or distinctly marked. The organism is Gram-negative and can be grown readily on all ordinary culture-media. It is found only in the intestines in cases of Asiatic cholera, where the symptoms of the disease are produced by a toxin which is released by the breaking down of old organisms. Pathogenic Protozoa The most important of the pathogenic protozoa are the trypanosome of sleeping sickness, the spirochetes of syphilis and yaws, and the Plasmodium or hemameba of malaria. These organisms belong to the animal kingdom and are more complex in structure than the bacteria. The trypanosome of sleeping sickness {Trypanosoma gambiense) is a long spirally twisted organism along one side of which is attached an undulating membrane with a cord-like edge that is continued forward as a free flagel- lum. It is actively motile and may be seen moving among the corpuscles in a fresh drop of blood from the patient. The spirochete of syphilis {Spirocheta pallida or Tre- ponema pallidum)—a delicate, thread-like organism, hav- ing from three to twenty spirals. It is flexible and actively motile. It does not stain well with bacterial stains, special staining methods being required. When alive it cannot be seen readily with the ordinary microscope, but must be studied by means of a special microscope with a dark-field illumination. The malarial parasite {Plasmodium or Hemameba malarice) on account of its complex life-cycle may show a number of different forms, the most common form, however, being the ring body. In a stained preparation MODES OF TRANSMISSION 387 the parasite may be seen lying on a red blood-corpuscle. When properly stained it appears as a disk consisting of a central, unstained area with a blue periphery, at one side of which is a rounded, compact, red mass, which gives the parasite the form of a signet ring. MODES OF TRANSMISSION The germs of disease are conveyed to man, in the large majority of cases, by the air, or, more correctly, the dust- particles in the air, and by water or food contaminated by impure water. Other methods are by direct inocula- tion and by the bite of an insect acting as host to the germ. Air-borne Diseases.—Diseases carried by floating dust are classed as air-borne. The majority invade the res- piratory tract. In this class are all actively contagious diseases: Cerebrospinal meningitis. Chicken-pox. Diphtheria. Epidemic pneumonia. Influenza. German measles. Measles. Mumps. Scarlet fever. Smallpox. Tuberculosis. The germ-laden dust-particles may float in the air or may settle on solid articles in the vicinity of the patient, which may then become media of infection. Substances which absorb contagion in this way or by direct handling by the patients are called fomites. In the more virulent infections, especially smallpox and scarlet fever, the germs are retained by the fomites for practically in- definite periods. Articles actually handled by the patients, such as toys, books, and work, are impossible to disin- fect with any certainty, and should be destroyed after convalescence or given for the use of patients suffer- ing from the same disease in hospitals devoted to this purpose. 388 ELEMENTARY BACTERIOLOGY AND IMMUNITY The germs may escape into the air in several ways. The special germs causing the disease, it must be remem- bered, are always present in the greatest number in the lesions of the disease. 1. When lesions are present in any part of the respira- tory tract, the mouth, throat, nose, or lungs, the germs are actually breathed into the air and adhere readily to floating dust. In such acts as sneezing, coughing, speak- ing, and even breathing, under some circumstances, the germ may be transmitted in minute drops of moisture which remains suspended in the air for considerable periods. Infection by this means is known as droplet infection. In the diseases above mentioned many are characterized by lesions in the throat or air-passages. In those without this special characterization, especially typhus fever, meningitis, and smallpox, the germ seems also to be present in the breath. 2. In those infectious diseases characterized by a rash and followed by desquamation, the germs are contained in the shed particles of epithelium. Minute particles remain floating as dust in the air or settle on objects in the vicinity, which then become sources of contagion. 3. Where the lesions of the disease are associated with abnormal secretions, countless numbers of the germs will be found present in the discharges, sputum, etc. As long as the bacteria remain enmeshed in the moist substance they are not in a position to do harm, and may readily be destroyed (see Disinfection). If, however, through lack of cleanliness> the discharges are allowed to dry, as, for example, the sputum in public streets, or on the hands, sputum-cups, or clothing of patients or attendants, the germs are set free and carried by floating dust. Water-borne Diseases.—A more limited number of infectious diseases are communicated through drinking- water, contaminated by the specific bacteria of the disease, and are classed as water-borne diseases. They invade the system through the alimentary tract. Such are: Cholera. Diarrhea (certain forms). Dysentery. Typhoid fever. MODES OF TRANSMISSION 389 Food may also be contaminated with the bacteria of any of these diseases by such means as washing vegetables consumed in a raw condition with contaminated water, by using such water for the cleansing of vessels, especially those for containing milk, or by diluting milk with con- taminated water. Food may also be infected directly from the hands of patients or their attendants if these are not kept scrupulously clean, and the bacteria prob- ably taken into the system in this way. Infection has also been conveyed by oysters that have been fed on a contaminated water supply. (Flies, p. 391.) Water-borne diseases may also in certain conditions be air-borne. The lesions in this class of infections are in the ali- mentary tract, consequently the evacuations are loaded with the bacteria. If the evacuations are left exposed and not immediately disinfected, the bacteria readily escape into the surrounding air and may be conveyed on floating dust. The smallest stain of feces on linen 01 vessel should be regarded as an active colony of bacteria and rigorously disinfected. Some air-borne diseases may also be made water-borne by direct contagion. In this way scarlet fever and diph- theria have frequently been spread from a milk supply where the milk has been left exposed in the vicinity of such cases. Milk, it will be remembered, is one of the media in which bacteria readily grow. Tuberculosis is conveyed in the milk or flesh of cattle with the animal variety of this disease. While the bovine type of tubercle bacillus infects human beings with diffi- culty, a number of cases on record have proved beyond question that there is danger, especially to children, when they are exposed to this source of infection. A group of infections associated with surgical condi- tions are also air-borne, but invade the system through the broken surface of the skin or mucous membrane- Such are: Erysipelas, Puerperal fever. Septicemia. Pyemia. 390 ELEMENTARY BACTERIOLOGY AND IMMUNITY All forms of septic infection, either general or local. Instances also occur where the germs of scarlet fever, diphtheria, or smallpox apparently invade the system through the broken surface. This is demonstrated in the peculiar susceptibility of patients during the puerperium to these infections, and a disposition on the part of patients who have undergone recent operation to develop a mild form of scarlet fever. The diphtheria germ has also been known to attack the broken surface, developing the char- acteristic membrane on the surfaces of wounds, and giving rise, at the same time, to the physical symptoms that accompany an attack of diphtheria. Infection by Inoculation.—Besides the air-borne dis- eases which invade the system through an accidental break in the continuity of the surface of the body at some point, others require that the virus containing the germ should be directly inoculated below the surface, as the snake, by its bite, introduces its venom into the blood. The principal diseases of man so communicated are: Cowpox, or vaccine. Glanders. Gonorrhea. Leprosy. Ophthalmia. Rabies. Syphihs. Tetanus. The germ of tetanus develops in the absence of air; it finds a favorable condition for development in the deep wounds caused by puncture or by gunshot accidents; it is especially to be guarded against in wounds that are contaminated by the soil, since the tetanus germ is found in the soil. Rabies is introduced by the bite of an infected animal; syphilis, by the virus coming in direct contact with an abrased surface; ophthalmia, in like manner, through an abrasion of the conjunctiva; leprosy, glanders, and cow- pox, the two latter diseases transmitted to man from cattle, are usually conveyed through abrasions on the hands. It is considered probable that bubonic plague also PROPHYLAXIS OF THE INFECTIOUS DISEASES 391 invades the system by inoculation, as well as by the respiratory and alimentary tracts. Tuberculosis, though most commonly conveyed by the air, either through floating dust or by droplet infection, may also be transmitted by inoculation. This is especially true of tuberculosis attacking the skin, as in lupus, and should be borne in mind in working with laboratory specimens. As has already been noted, certain diseases are trans- mitted from man to man through the bite of an insect acting as intermediary host. Such are malaria, by the anopheles mosquito; yellow fever, by the aedes calopus; sleeping sickness, by the tsetse fly; and typhus fever, by the body louse. Recent investigation seems to show that bubonic plague is frequently transmitted by the bite of fleas infesting rats which are infected with the plague bacillus. Relapsing fever, a disease fast disappearing under im- proved hygienic conditions, is also considered to be prob- ably conveyed by the bite of an insect, and the same may be true of other infections which are spread by filth and overcrowding, such as typhus fever or jail fever. That domestic insects, flies, bedbugs, etc., may be carriers of disease is an accepted fact, and all methods of prophy- laxis and disinfection include the rigorous extermination of these pests. Flies we can readily realize may be the means of infecting milk and other foods. We know how quickly they are attracted to organic matter. If, through lack of cleanliness, flies are allowed to alight on particles of feces, sputum, soiled dressings, and similar sources of infection, germs may adhere to the legs and bodies of these insects and be conveyed to food left exposed; in addition, fly spots are made by the excreta and the vomitus of these insects. The water-borne diseases, especially ty- phoid fever, are particularly apt to be spread in this way. PROPHYLAXIS OF THE INFECTIOUS DISEASES Modern prophylaxis, or the prevention of infectious diseases, rests on a recognition of the sources of infection, and on the use of hygienic and scientific methods for the control of the media by which infection is spread. 392 ELEMENTARY BACTERIOLOGY AND IMMUNITY The most powerful enemies of the air-borne infections are fresh air and sunlight. The air of a sick-room, if well diluted with constantly changing fresh air, will ob- viously contain much fewer germs than if the room is kept closed and only " aired" at stated intervals. Direct sunlight is a natural germicide, and should have access to every corner of a sick-room. The walls, floors, and furniture of a room constantly used as a sick-room should be chosen with hard, non-absorbent surfaces and kept scrupulously free from dust; draperies, rugs, and up- holstered furniture should be banished or be entirely of washable materials, as should also be the clothing of those in attendance on the sick. The air of the sick-room should be kept free from contamination from such sources as uncovered sputum-cups, soiled surgical dressings, or bed- pans not instantly removed. The prophylaxis of the water-borne infections bears chiefly on the insistence of a pure water supply and the scrupulous disinfection of all excreta in these cases. (See Disinfection, p. 442.) If there is any doubt on the subject of the water-supply, it must be an absolute rule that only boiled water is used for drinking, for washing vegetables, and for cleansing the vessels used for cooking and in the serving of the meals. The water-supply of districts may be contaminated from infected excreta thrown without thorough disinfection down the soil-pipes, or from excreta deposited on the surface soil or carried to cess-pools in the vicinity of natural wells. Standing water, such as the water of wells, if once contaminated, always remains so, and the well must, therefore, be closed. Food must obviously be screened from flies, and never exposed in the neighborhood of lavatories; milk and butter should be especially kept in closed cans or chests. The strictest care must be taken in the immediate cleansing of the hands after doing any service about the patient, and especially in regard to the removal and disinfection of the excreta. The vessels used should be closely covered for removal from the bedside, and the smallest stain of fecal matter on the linen disinfected at once. Domestic insects, flies, mosquitoes (page 395), and PROPHYLAXIS OF THE INFECTIOUS DISEASES 393 bedbugs should be literally exterminated as far as such means can be controlled by the hospital authorities. Adequate screening will rid a building of the menace of flies, but there are many conditions in which patients are not nursed in buildings, as in tuberculosis open-air camps and, notably, in the huge hospital camps of the late war. It is stated on reliable authority, as a remarkable triumph of modern hygienic methods, that a fly was practically unknown in the huge army medical camp at Etable, a camp where every unit took care of one thousand sick and wounded. This was accomplished chiefly by having nothing exposed that would attract flies. Excreta, gar- bage, grease, and all manner of refuse was promptly col- lected and destroyed by burning; grease from sinks and hoppers was collected systematically twice a day; slops and soapy water instead of being emptied on the ground were emptied into pits containing coke on large perforated trays; these acted as a filter, by means of which grease and other debris were caught and could be destroyed by burning, and the soil was thus prevented from becoming clogged and sour. The trays and pits were painted with crude petroleum as a further prevention of flies. The superintendence of these details was one of the most important duties of the sanitary officer and his subordi- nates, and to their care is largely due the fact that for the first time in history a camp of wounded soldiers has been as sanitary and as free from epidemic disease as the best equipped hospitals in our cities. In those air-borne diseases which invade the system through the broken surface (see above), protection lies in never exposing a wound where there is any possibility of these germs being present in the air. Such cases may be nursed without risk of contagion in a medical ward, but are a fertile source of infection in a surgical ward, where wounds are exposed for dressing or treatment. The spread of infection where inoculation is the means of transmission should be easy to control; nevertheless, the sources of infection require to be recognized. Rabies is transmitted only by the bite of a rabid animal (unless one excepts accidental inoculation in laboratory work). 394 ELEMENTARY BACTERIOLOGY AND IMMUNITY The germ of tetanus is found in the soil, especially in soil contaminated by the excreta of herbivorous animals, such as may be found round farms and stables. The germ is usually introduced at the time of injury, but wounds previously clean may absorb the tetanus germ if exposed to dirt in which the germ is present. The virus of syphilis is contained in any of the discharges of a syphilitic patient. Discharges from the genito-urinary tract or the nose, and ulcers with a discharging surface, are common manifestations of venereal disease. An abra- sion on the hands of doctor or nurse carelessly brought in contact with such discharges may readily be the means of infecting the system with this most virulent disease. Closets and vessels used by patients with gonorrheal dis- charge are a source of infection unless rigorously disin- fected. The virus may also be transmitted to a third person by the hands of the attendant or by instruments, especially catheters, laboratory vessels, or linen, which have been used for a syphilitic patient and imperfectly disinfected. Ophthalmia is communicated in a somewhat similar way. The discharge, in this instance, must come in contact with the conjunctiva. The eyelids may be rubbed with fingers contaminated with the discharge either directly or indirectly from handling infected instru- ments, towels, etc. A common channel for the spread of ophthalmia, especially in children's wards, is the apron- bibs of nurses who thoughtlessly take a baby with oph- thalmia on the arm. The next baby taken in the same position runs a grave risk of infection. The infection of wounds with pus-producing organisms (usually a variety of staphylococcus) is also to a large extent a process of inoculation. The channel is most commonly the hands of the operator or dresser, and, less frequently, the instruments, lotions, dressings, ligatures, etc., used. (See Surgical Technic, Chap. XIV.) A local abscess following the administration of a hypodermic injection, and an infected finger from contact of an un- noticed scratch with an infectious discharge, are direct examples of pus infection by inoculation. It must also be remembered that germs not usually PROPHYLAXIS OF THE INFECTIOUS DISEASES 395 transmitted by inoculation may also be introduced into the system in this way. Thus, a hypodermic needle, used, for example, on a diphtheria case and imperfectly steril- ized, may inoculate with"the diphtheria bacillus a second person not otherwise exposed to the contagion. When we realize that in common with all other known forms of life a germ can only spring from a similar germ already existing, we can understand the immense import- ance of intelligent prophylaxis. A case of scarlet fever, for example, can no more occur independently than a field of wheat can be grown without seed. Infectious illnesses are already more under control than has ever been possible before, and pure air, sunlight, and pure water are regarded not as luxuries, but as necessary to all if the health of the community is to be maintained. In the transmission of infections through an intermediary host prophylaxis lies in the protection of man from the bite of the insect and in the extermination of the insect. The special insects at the present day known to be trans- mitters of the specific diseases are peculiar to certain dis- tricts. Persons who show a special liability to malaria should avoid the districts where the anopheles mosquito is known to exist. The dwellings in these localities should be carefully screened, and vigilance exerted that each insect that may gain admission is promptly destroyed. Persons should remain indoors during the feeding times of the mosquito, especially evening and early morning. When a person has become infected, he must be carefully protected from being bitten, since it is only from his blood that the mosquito in its turn becomes infected. In cases of yellow fever the patient is at once isolated in a fly-screened tent, a precaution which, as soon as adopted, reduces enormously the number of patients in an epidemic of this disease. The insects are exterminated by destroy- ing their breeding-grounds; in the case of the malarial mosquito the breeding-ground is the stagnant water of swamps, woodland pools, etc., or, in inhabited districts, the barrels and cisterns in which water is collected. Thorough drainage in many districts, such as the fen coun- tries of England, has been followed by total extermination 396 ELEMENTARY BACTERIOLOGY AND IMMUNITY of the mosquito and complete disappearance of the disease. Pools and small areas of stagnant water are in other parts covered with coal-oil and thus made impossible as breed- ing-grounds. Wells, water-barrels, drinking-troughs, reser- voirs, and all vessels containing standing water must be kept closely covered or in carefully screened inclosures. IMMUNITY All persons exposed to infection do not necessarily succumb to disease. This is due to two conditions— first, the natural resistance of the body; and, second, a condition of immunity, either natural or acquired. It is considered that the chief elements of resistance to bacterial invasion are found in the blood: in those white corpuscles, or phagocytes, whose function it is to seize and destroy foreign bodies gaining access to the body, and in the blood-serum, which is also held to have bactericidal properties. Bacteria are also eliminated in the natural excreta of the body, especially in the evacuations of the bowel. A further protection is given to the body, it is considered, in the natural secretions which cleanse the sur- face and the external cavities of the body, ridding them, to some extent, of invading bacteria, and which, if not ac- tively germicidal, form media in which bacteria do not readily develop; such are the sweat, the tears, the saliva, and the mucous membrane secretions. The hydrochloric acid contained in the gastric juice is also held to have germicidal properties toward the bacteria of the water- borne diseases. Certain conditions weaken the natural resistance of the body and leave it a prey to infection. Such are unhygienic conditions, overwork, overstrain mental or physical, alcoholism, starving, exposure, debilitating or chronic diseases, such as kidney disease, diabetes, etc., local injuries, serious accidents, and other conditions that impair the general health. In surgical work sound tissue is held to show consider- ably more resistance to bacterial invasion than tissue that has been injured by accident, or by rough handling during an operation. IMMUNITY 397 At certain times the bacteria may be present in abnormal numbers, as during epidemics, and the natural resistance may be overthrown on this account. Natural immunity is the unbroken resistance exhibited by a race or a species to certain diseases. Thus the negro is proved to be immune to yellow fever; the dog is immune to typhoid fever, the common infectious fevers, and other diseases of man, and man, on the other hand, to certain diseases of the lower animals. Acquired immunity may be either active or passive. By active immunity we mean an immunity that is the re- sult of previous bacterial activity in the body of the patient. This may be attained in three different ways: 1. By an attack of the disease. 2. By vaccination. 3. By certain forms of inoculation. Passive immunity is brought about by the injection of antitoxins. We know that if recovery is to take place from an in- fectious malady, at a certain point in the disease there comes a turning-point after which there are no fresh manifestations of bacterial activity. The symptoms of the disease subside, and in a short time convalescence follows. In some infections the turning-point is abrupt, and we say that the disease ends with a crisis; in others the improvement takes place more slowly, and we use the term lysis. In many diseases we can tell to within a few hours when the crisis will take place or the lysis begin. Not only is the further development of the disease arrested, but the body for a time is impervious to fresh infection from the same disease. Thus a patient just recovered from scarlet fever can mix freely with patients at the most con- tagious stage of that disease, without contracting the dis- ease a second time. As regards scarlet fever, they are in a state of acquired immunity. In many diseases the acquired immunity conferred by one attack lasts through life. Such are: Chicken-pox. Scarlet fever. Epidemic poliomyelitis. Typhoid fever. German measles. Typhus fever. Mumps. Yellow fever. 398 ELEMENTARY BACTERIOLOGY AND IMMUNITY Second attacks of these infectious diseases are un- common. Second attacks of measles and whooping- cough occur somewhat frequently, and in small-pox also second attacks are known. In typhoid fever second at- tacks do occasionally occur, but are not considered the rule; a form of reinfection during the early stage of con- valescence is, however, frequently observed. An error of diet, or conditions that exhaust the vitality of the pa- tient, such as exertion, are commonly the predisposing causes. To this form of reinfection the term relapse is applied. In other infections the immunity conferred is only temporary, and one attack of the disease appears to pre- dispose to repeated attacks. Such are: Erysipelas. Influenza. Malaria. Pneumonia. Rheumatic fever. Vaccination.—A very mild attack of a disease confers immunity as completely as a severe attack. This prin- ciple was for long applied practically in the East of Europe in the treatment of smallpox, a disease in its severe form frequently fatal. It was the custom to puncture the skin of persons likely to be exposed to smallpox infection and introduce in this way a drop of the smallpox virus. Patients thus inoculated developed a mild form of the disease, from which they usually recovered, and which apparently protected them from another attack. The custom attracted the interest of Lady Mary Wortley- Montague, the wife of the British Ambassador to Con- stantinople, and, through her, the attention of the scientific men of the day (about 1718). The method had the draw- back, however, that the disease, though mild, was con- tagious. Toward the end of the eighteenth century another English woman observed that during an epidemic of small- pox none of her dairy-maids fell sick. She found that they attributed their protection to the fact that they had all had cowpox (or vaccinia), which they had acquired from IMMUNITY 399 the cows they tended through abrasions on the hands or arms. Inquiry showed that the belief that vaccinia pro- tected from smallpox was .general among the farming classes. Edward Jenner, a noted London physician, conceived the idea of inoculating with the virus of cowpox instead of smallpox, thus producing the same immunity with a disease which had the advantage of being mild and non- contagious. To this form of inoculation he gave the name vaccination. ■ Jenner first practised vaccination in 1796. So great a success attended the practice that it rapidly became the customary means of protection against smallpox. Later, with the idea of stamping out effectually so dreaded and wide-spread a disease, it became law in many parts of the world that all infants should be vaccinated. Only in late years have the laws been relaxed. The immunity to smallpox conferred by vaccination is not considered to last more than a few years, nor is the immunity always absolute. If the disease is contracted, however, after recent vaccination, it is in a mild form. Technic.—The process of vaccination consists in super- ficially scarifying the skin with a sterile needle or fine knife, and rubbing over the surface a drop of lymph from a calf previously inoculated with vaccine. Cowpox vaccination produces few physical symptoms, its chief manifestation being a characteristic cowpox pustule at the seat of vaccination. inoculation.—The system of inoculation originated by Louis Pasteur, by which work he is most widely known, consists in injecting what he calls an " attenuated virus," that is, a poison highly diluted, into the blood, with the effect that an extremely mild form of the disease is de- veloped, which yet is sufficient to confer immunity. The Pasteur school employs many different methods of obtaining this attenuation, some of them very com- plicated. Pasteur's method of inoculation is universally used as a preventive of hydrophobia in persons who have been bitten by rabid animals. It is also used in some other diseases of animals. (See also page 399.) 400 ELEMENTARY BACTERIOLOGY AND IMMUNITY Tuberculin.—In 1892 Koch introduced inoculation in the treatment of tuberculosis, using tuberculin, a heated 50 per cent, glycerin solution of the product of the tubercle bacillus in culture fluid and such portions of the bacillus as go into solution. On persons that are free from tubercu- losis no effect is produced; on others both a local reaction and pronounced physical symptoms develop. At first im- mense hopes were raised that a cure for tuberculosis had been discovered. Its use, however, was soon found to be attended with danger to the patient, and it was abandoned as a method of treatment. It is at present used on cattle and pigs for purposes of diagnosis in those parts of the world where the law requires that animals to be used as food should be destroyed if proved tuberculous. Skin Tests for Foreign Proteins.—These tests are similar to the tuberculin diagnostic test. Many persons show an idiosyncrasy or hypersensitiveness to various protein substances. An attack of asthma may be brought on by the inhalation of such minute quantities of horse protein as are contained in the air near horses. Horse- hair and the hair of cats and other animals may cause the same reaction. Likewise hay-fever is caused by the pollen of various plants—goldenrod, ragweed, etc.—and skin eruptions by poison ivy and sumac. Many foods, such as eggs, milk, pork, shell-fish, and many fruits and vegetables, may act as poisons to persons who are hyper- sensitive to them. The specific cause of all these reactions may be deter- mined by means of cutaneous tests which are made by scarifying the skin and rubbing into it a minute portion of the protein to be tested. A local reaction at the point of inoculation indicates a positive test. , Desensitization may be brought about by the injection of minute doses of the specific protein or by the feeding of small and non-toxic amounts of the food causing the reaction. In some cases of hay-fever and asthma a great deal of relief has been afforded by this treatment. Antitoxins.—In producing active immunity the whole process is developed in the system of the patient; in pro- ducing passive immunity, half the process is developed in IMMUNITY 401 one of the lower animals. The immunizing agent is con- tained in the serum of an animal, usually the horse, which has been injected with repeated increasing doses of a bac- terial toxin until an extremely high degree of resistance has been developed. The serum is injected under the skin of a patient suffering from the disease, and after a varying number of doses produces a temporary immunity in the patient. Such a serum is spoken of as an antitoxin. An- titoxins are thus produced from the toxins of diphtheria, tetanus, streptococcus infections, pneumonia, cerebro- spinal meningitis, and a few other infections. At the pres- ent day the use of diphtheria antitoxin is universal, and has enormously reduced the death-rate of this malady. Tetanus antitoxin is considered efficacious as a prophylac- tic if injected at the time of an injury or soon after, but is not considered of much use once the disease has manifested itself (p. 418). The use of antistreptococcus serum is gain- ing in favor in many parts in the treatment of general sepsis. Technic.—In producing an antitoxin the procedure practised at the present day is as follows: the bacillus of diphtheria, for example, is cultivated in a bouillon and developed in an incubator. In growing, the bacillus ex- cretes its toxin, which permeates the culture-media. When sufficient toxin is formed, the culture is filtered to get rid of the living bacteria, and a small dose is injected into a horse, with the result that a mild attack of diphtheria is developed. From time to time fresh injections of the toxin are administered, until the horse is able to receive enor- mous doses of the toxin without developing symptoms of the disease. The horse is then bled, and the serum, which contains the immunizing agent, is collected and put up in hermetically sealed tubes, after the strength of the serum has been tested on guinea-pigs, rats, or similar animals. Measurement.—The antitoxin serum is measured by its potency and not by its bulk. The standard of measure- ment has been named the immunity unit by Behring, the scientist who first introduced the methods of developing and using antitoxins. The unit represents an antitoxic principle sufficient to enable a guinea-pig weighing 250 26 402 ELEMENTARY BACTERIOLOGY AND IMMIN1TY grams to resist an injection of the toxin 100 times stronger than a normally fatal dose for four days (Williams). Persons exposed to diphtheric infection usually receive an injection of 500 to 1000 units; patients with diphtheria, 4000 to 8000 units at a time, repeated at intervals until the physical symptoms show a decided improvement. Passive immunity is developed much more rapidly than active immunity; in many cases the effects of a dose of antitoxin are perceptible in a few hours after the first injection. The immunity thus conferred is, however, transitory; whereas, as we have seen, in many instances active immunity may last through life. Without the phenomenon of immunity, either natural or acquired, the human body would be a constant prey to infectious diseases; bacteria once invading a body would continue to develop and produce their toxins until the death of the victim took place. Theories of Immunity.—Many theories are advanced to explain the phenomenon of immunity, no one of which is yet considered conclusive. Pasteur held that during an attack of an infectious disease the bacteria fed on cer- tain organic elements in the body until the supply was ex- hausted, following which the bacteria were starved out; immunity then lasted until this necessary food was renewed in the body, in many instances for the rest of the life. This hypothesis is known as the exhaustion theory. Others hold that bacteria, by their own excretions, produce a medium in which they cannot develop. Others again attribute immunity to chemical changes in the blood, the result of bacterial activity, which give to the blood certain bactericidal powers, such as the development of bodies known as alexins, which, by a complicated process, have the power of dissolving bacteria (bacteriolysis). Other substances produced in the blood during certain infections are called agglutinins; they cause clumping or agglutination of certain bacteria, with a loss of motility where the bacteria have this property. We have seen that the blood of typhoid-fever patients has this property. (See Widal Reaction.) It is not yet determined whether the agglutinins play an active part in the production of immunity. IMMUNITY 403 Without directly bearing on her work, it is worth while for the student nurse to understand those theories on this subject most generally referred to, and to which she will frequently find allusion in the text-books she may consult. 1. The Theory of the Feeding Cell.—Experiments show that certain of the leukocytes, or white corpuscles, have the property of fastening on certain substances in the blood and ingesting them. From this property they are called phagocytes, or feeding cells. The phagocytes are the scavengers of the body. If a part of the body receives an injury, we know that at once there is a migration of leukocytes to the point of lesion; these, fastening on the inflammatory processes, ingest them, sometimes destroy- ing them, sometimes conveying them to remote parts of the system. Where their efforts are successful, we say that the inflammatory processes have become absorbed, or that resolution has taken place. Metchnikoff, a modern scientist, proposed (about 1890), as a theory to explain the action on the body in encounter- ing bacteria, a similar attraction of the part of the leuko- cytes for bacteria invading the system. We may imagine the invading bacteria being met by a host formed of leukocytes. If the leukocytes win in the struggle, the bacteria are destroyed; but if the leukocytes fail to de- fend the body, the bacteria are victorious, and the body succumbs to the disease. The theory, however, falls short in many circumstances. For example, it does not explain immunity from infections produced by toxins excreted by the bacteria. 2. Ehrlich's Theory.—A second theory of immunity ad- vanced by Ehrlich to explain the resistance of the body-cell to toxins is more difficult to follow. It pictures hypo- thetically each body-cell as being surrounded by a number of molecules which he calls side-chains. The function of these bodies is to attract the necessary food-substances for the cell. Each molecule of a side-chain is called, from this fact, the receptor. The receptor has a peculiar shape into which it is necessary for the food atom to fit exactly, as one piece of wood may be dove-tailed into another or a ball may fit exactly a socket. A food-atom fitting ex- 404 ELEMENTARY BACTERIOLOGY AND IMMUNITY actly to the receptor is then passed into the cell, where it is devoured by the many atoms which comprise, accord- ing to this theory, the body-cell. Ehrlich now imagines the invading bacteria to produce substances (toxins) of the same form as the food mole- cules, and, therefore, also fitting the receptors. These bodies are pictured in two parts. The first, to which he gives the name haptophore, is the body that must exactly fit the receptor. To the haptophore is attached a poison- ous substance, the toxophore, which is thus introduced into the receptor by the haptophore, and through the receptor invades the cell which it attempts to destroy. A conflict now takes place between the toxophores and the cell atoms. If the former prevails, the cell is destroyed. In many instances, however, the presence of the toxophore excites the cell to abnormal activity, with the result that many additional side-chains are developed—more than are necessary to the individual cell. The superfluous receptor is thrown into the blood-stream and there meets the toxin molecule (haptophore and toxophore), which it engages, thus preventing the harmful molecule from reaching the cell. Should a sufficient number of receptors be present in the blood-stream to engage the large majority of toxin molecules, the effect is to neutralize their activity and immunity results. This theory demonstrates immunity by the develop- ment of a neutralizing body or antitoxin, which has an affinity for the molecules of a soluble toxin developed in the body as a result of bacterial activity. It is a condi- tion of acquired immunity. It may also serve as an illus- tration of natural immunity. As it is necessary for the haptophore exactly to fit into the receptor, should the cell possess no receptor into which the haptophore will fit, the cell will be safe from the invasion of that particular toxin molecule. The knowledge of antibody production in the body has led to the development of many laboratory tests for specific diseases. The most valuable of these are the typhoid agglutination test and the various comple- ment-fixation tests, of which the Wassermann reaction is the most important. IMMUNITY 405 3. The Opsonic Theory.—In quite recent years much attention has been attracted to what is known as the opsonic theory of immunity, advanced by Sir A. E. Wright, of London. Wright teaches that in the blood-serum are certain substances which he calls opsonins, from the Latin word opsono, I prepare for dinner. This substance apparently acts on the bacteria in such a way as to prepare them as food for the leukocytes, or, on the other hand, it may act on the leukocytes so as to stimulate their appetite for the bacteria. Experiments show that there is no attraction between the leukocyte and the bacterial cell except through the medium of the blood-serum. The resistance of the body, according to Wright's opsonic theory, de- pends on the presence of the opsonins. The amount of " opsonins " present at different times varies greatly, causing a corresponding variation of the amount of re- sistance shown by the body to the invasion of bacteria. Wright teaches that this substance is either produced or increased by the presence of dead bacteria. In the ordinary course of an infectious illness a large number of bacteria die, and by this theory become themselves the source of this immunizing power. In carrying this hypothesis into practice, bacteria that have been devitalized by heat are injected into the cir- culation of the patient, with the result of increasing the " opsonins " and hastening the period of immunity or establishing a cure. Each bacteria apparently produces only its own variety of " opsonins." For example, an injection of dead tubercle bacilli does not increase the resistance of the body to any bacteria except the tubercle bacillus. This teaching of Sir A. E. Wright has opened up a new method of treatment for many infectious diseases by repeated injections of devitalized preparations of the germ which causes the specific disease. This method of bacterial inoculation has had its most notable results in the treatment of typhoid fever and cholera. To its use is due the remarkably low percentage of either of these diseases among the armies in the late war. Inoculation may be 406 ELEMENTARY BACTERIOLOGY AND IMMUNITY used as a prophylactic measure on those to be exposed to infection, or in the treatment of the disease itself. The number of diseases capable of being combated by these vaccines, as they are called, is constantly being added to. The practice has also met with great success in the treat- ment of skin diseases. Vaccines have been prepared from many of the infec- tious bacteria, but not all are valuable. Mixed vaccines of staphylococci, streptococci, pneumococci, micrococcus catarrhalis, and bacillus influenza? are often valuable as prophylactic agents to those subject to colds and attacks of influenza. Meningococcus vaccine has been found to have no preventive effect, but has been valuable in curative treat- ment in some cases. Autogenous vaccines, or those made from the organism isolated from the patient, are valuable in infections of a pyogenic nature, especially in chronic cases, such as furunculosis and acne, and in the subacute stages of a localized streptococcic infection. In connection with.this treatment the term opsonic index is met with. The index of an individual rep- resents the degree of opsonic potency his blood-serum evinces toward a particular germ. This is ascertained by taking a counted number of leukocytes which have been isolated from the patient's blood and mixing them, in some of his own serum, with a known number of devital- ized germs of the infection under consideration. After a period the bacteria are again counted. Say, for ex- ample, that in a given case it is ascertained that each leukocyte will account for six bacteria—the patient's index is said to be 1 in 6. Under treatment, i. e., by injection of devitalized bac- teria, the opsonic potency may be greatly increased, each leukocyte accounting for a larger number of bac- teria; the index is then said to be raised. Conditions which lessen the normal resistance of the body as de- scribed above cause the opsonic index to be lowered. Repeated examinations of the blood are necessary to keep watch on the opsonic index, and the injections are given according to the indications of the index. ACTION OF PATHOGENIC BACTERIA 407 The above are only epitomes of theories of immunity on which an immense amount has been written in later years. They will serve, however, to present a picture to the imagination of ways by which, in the first place, the bacteria themselves, and, in the second place, the toxins they produce, may be met and overcome in the body tissues. We must remember that these theories are all links in a chain of evidence that is slowly being accumulated by patient research and logical deduction. A discovery of to-morrow may alter the whole teaching of to-day, or, on the other hand, may establish what has been regarded as a doubtful hypothesis as a principle of the first importance. ACTION OF PATHOGENIC BACTERIA To return once more to the consideration of the action of the pathogenic bacteria on the tissues: Incubation Period.—Between the actual time that the germ of a specific disease gains entrance to the body and the development of the first symptoms of the disease is a period of apparent quiescence known as the period of incubation. This period varies in the different diseases and to some extent also in the same disease in different patients, depending probably on the resistance of the individual. During this time the toxin is being developed. As the toxins begin to be absorbed by the tissues the preliminary symptoms or prodromes make their appear- ance. The average time of incubation in the infectious fevers is as follows: Diphtheria .... Scarlet fever Smallpox...... Chicken-pox Measles....... German measles Typhoid fever . . Typhus fever . Mumps........ Erysipelas..... Tetanus....... Cholera....... Yellow fever . .. Two to seven days. A few hours to seven days. Ten days to two weeks. Fourteen-to sixteen days Ten days to two weeks. One to three weeks. Two to three weeks. A few hours to two weeks. .Two to three weeks. .Three to seven days. . A few days to three weeks. Two to five days. , Two to three weeks. —From A. A. Stevens. 408 ELEMENTARY BACTERIOLOGY AND IMMUNITY Surgical infection due to a variety of the staphylo- coccus or streptococcus bacteria requires about three days for incubation. The methods of combating surgical infection are discussed in the following chapter. Period of Invasion.—Immediately following the period of incubation is the period of invasion, corresponding to the elaboration of the toxins and the beginning of their absorption by the tissues. During this period the tem- perature rises until it reaches its height. It is accom- panied by physical manifestations, such as malaise, languor, gastric disturbances, chilliness, or rigors, and in some cases by characteristic premonitory symptoms of the special disease, which are known as prodromes. Such, for example, are the coryza of measles, the sore throat of diphtheria and scarlet fever, and others. Fastigium.—The significance of the fastigium and the decline of a fever have already been briefly pointed out. (See also p. 157). The fastigium is the period of toxemia during which the body-cells are poisoned by the toxin elaborated by the activity of the bacteria. Besides the characteristic symptoms of the special disease, the condition is accompanied by general symptoms common to the acute infectious disorders, of which the most im- portant are fever, prostration, emaciation from inter- ference with the processes of nutrition, digestive disorders, especially constipation or diarrhea, and nervous symptoms, such as wakefulness, delirium, stupor, or unconsciousness. The decline is coincident with the elaboration in the body, probably we have seen in the blood, of substances with antitoxic properties, and ushers in a period of im- munity of greater or less duration. At the present day, except in one instance, no remedy is in general use which will actually cut short an infectious fever. The treatment of such cases is entirely directed to the amelioration of the symptoms and the support of the bodily strength by confinement to bed, quiet, and judi- cious diet. The exception is the use of antitoxin serum in diphtheria, the remedial effects of which are frequently demonstrated in a few hours after the injection of the serum. NURSING IN INFECTIOUS DISEASES 409 Drugs with Specific Action.—In the department of materia medica a few drugs are recognized as having a specific effect on certain infectious disorders. Such are quinin, largely used as a prophylactic in malaria; salicylic acid, which relieves the pain and reduces the fever in acute rheumatoid affections; mercury and iodid of potas- sium and arsenic preparations largely used in the treat- ment of syphilis; ethylhydrocuprein (optochin) which has recently been proved to have a specific action on pneu- mococci. As has already been stated, the scientists of the pres- ent day are devoting much of their time and energies to the discovery of immunizing agents for the various infectious disorders, which shall prove as effectual as the diphtheria antitoxin has been shown to be. Their work is, however, still largely in the experimental stage. NURSING IN INFECTIOUS DISEASES In nursing an infectious fever the sources of contagion must be recognized and protective measures taken ac- cordingly. It must be remembered again that the germs of a disease are usually found in greatest numbers in the lesions characteristic of the disease. Any abnormal discharge, therefore, the result of the disease, will probably contain the germs of the infection, and must invariably be disinfected. In the water-borne diseases, typhoid fever, cholera, dysentery, and summer diarrhea, the special lesions being in the alimentary tract, the stools are the chief source of infection, and must be rigorously disinfected until convalescence is established. In typhoid fever the usual rule is to consider conva- lescence established ten days after the temperature has become normal. Until this time the bed-linen must also be disinfected, and the dishes and utensils used for the patient should be marked and set aside for his use only. The diapers of a baby with summer diarrhea should be placed in a disinfectant immediately after they are re- moved. In typhoid fever the bacteria are frequently present in 410 ELEMENTARY BACTERIOLOGY AND IMMUNITY the urine, which should, therefore, also be disinfected. (See Disinfectants.) The germs may also be found in any discharge from a suppurative condition, in the vomitus, and in the sordes which collect about the teeth and lips of patients where the mouth has been neglected. In this latter condition the germs may also be in the breath. To those attending these cases the chief source of danger lies in getting the hands infected while attending to the patient, changing the bed-linen, or cleaning the mouth. It should be a rule with no exceptions that the hands must be washed and disinfected after every such act, and again invariably before going to a meal. In disposing of the stools, they should be disinfected (p. 443) before being thrown down the soil-pipe. In country places, where there is no water drainage, a hole should be dug and the stools placed therein and covered with lime. Great care must be exercised to choose a site away from all water-supply, and especially from natural wells. When the case is over, the bed and bed- ding should be disinfected. With the above precautions and scrupulous cleanliness, typhoid fever cases and cases of dysentery or diarrhea should not be a menace to the health of the other in- habitants of a house. Wherever possible they should be nursed in a room by themselves, but the room need not be isolated, in the strict sense of the word. Cholera ap- pears to be more actively contagious, and cases should be isolated. Diphtheria.—The germs in a case of diphtheria are present in the discharges of the nose and throat, conse- quently in the breath, and especially in the characteristic membrane. All such discharges, the sputum, the pieces of membrane, and vomitus must be disinfected. Sputum, etc., should be received on pieces of rag or paper and burned at once, if possible. If not, they should be thrown in a covered vessel containing a disinfectant until destroyed. The air immediately round the patient may contain germs, but the infection is not carried by fomites, unless actually soiled with the discharges. Since the breath is infected, kissing or nursing child patients in the arms NURSING IN INFECTIOUS DISEASES is forbidden, and the nurse must be careful to avoid let- ting the patient cough in her face. The patient should be isolated, and all vessels and dishes kept for his exclusive use. The linen must be disinfected before being sent to the laundry, and should be washed separately. The patient is actively infectious as long as there is any cough or discharge from the throat or nose.. He is not recog- nized as free from contagion until no culture of the Klebs-Lofner bacillus can be obtained from the throat, three negative cultures on successive days being required before the patient is discharged. Disinfection should include fumigation of the room and disinfection of the bed, bedding, furniture, etc., followed by thorough cleaning. In a private house the walls should be repapered. Scarlet fever is one of the most actively contagious of diseases. The germs are present in discharges from the nose and throat, or any other suppurative condition, such as otitis media, and in the particles of epithelium shed after the rash has faded. Desquamation lasts from four to eight weeks. As long as there is the smallest particle of desquamation or any discharge from throat, nose, or local abscess, the patient is in an infective condition, and must not mix with others. In these cases strict isolation is imperative. The room chosen should be as far removed as possible from the rest of the house. The doors should be kept closed, and a curtain, kept continually wet with a disinfectant, should be hung in front of the entrance com- municating with the rest of the house. The same precautions should be taken as in diphtheria. In addition, the separated particles of epithelium must be destroyed. Many doctors keep the skin lubricated with an antiseptic ointment or oil, and, in addition, after the fever has disappeared, daily hot baths are given to encourage desquamation. The sweepings of the room will probably contain the germs of the infection, and should, where practical, be burned at once. Even in the summer they may be wrapped in a newspaper and burned on the hearth or in an empty garbage-pail. Dusters and sweeping brooms should be disinfected and washed daily after use. 412 ELEMENTARY BACTERIOLOGY AND IMMUNITY Scarlet fever infection is also conveyed by fomites. Every unnecessary article in the sick-room is, therefore, a future menace. Letters, books, work, toys, actually handled by the patient cannot, as has been said, be dis- infected with any certainty. What are not destroyed are generally welcomed in a fever hospital. Nurses taking care of such cases should not go to the other rooms of the house, and should not associate with others unless out-of-doors, after their clothes have been changed and they have taken a bath. Clean linen wrap- pers should be provided to cover entirely the clothing of doctors or visitors to the sick room. When convalescence is complete, the patient receives a thorough disinfecting bath and is dressed in clothes that have not been near the sick-room. The room and all the contents are fumigated and cleaned. Repainting and papering should be done where possible. Whitewash is in itself a disinfectant, and is generally practical in the homes of the poor. Smallpox is the most readily communicable of all dis- eases. Infection is conveyed in the breath of the patient, the discharges of the nose, mouth, and conjunctiva, in the vomitus, sputum, probably in the excretions, and in the desquamating skin. The care to be taken is the same as in scarlet fever. The fomites are peculiarly tenacious of the infection, and everything practical used by the patient should be des- troyed except articles that can be boiled or disinfected with certainty. Old linen and old bedding, if available, should be used and destroyed when finished with. The room should contain the least possible amount of furniture and absolutely no rugs, hangings, or decorations. After fumigation, walls, ceilings, and floors must receive special cleaning. Repapering or white washing is imperative. In epidemics temporary huts or canvas tents are preferred to more permanent buildings. Protection for the attendants lies in vaccination. No nurse should be permitted to go on duty on a smallpox case unless vaccinated successfully within two years, and all likely to come in direct or indirect contact with the case should be vaccinated. NURSING IN INFECTIOUS DISEASES 413 As in scarlet fever, infection lasts as long as there is any discharge from the surface or cavities and until desquamation is entirely finished. Measles.—The infection of measles is also contained in the discharges of the nose and throat and in the des- quamating skin. Measles appears to spread more quickly through a community or a hospital ward than any other infection. The reason is probably the droplet infection from the accompanying coryza. For this reason, if measles is suspected, the patient should be isolated on the earliest appearance of the coryza. The same may be said of whooping-cough. Cases of measles should be isolated until desquamation is over. In all respects the precautions are the same as those used in scarlet fever. As desquamation is much less severe than in scarlet fever, the fomites are more readily disinfected. Chicken-pox, German measles, mumps, and whooping- cough, all air-borne infections, should also be isolated and precautions taken along the lines indicated. Tuberculosis.—The tubercle bacillus attacks practically all organs and structures of the body. The lesions are frequently complicated by suppuration, and in these cases the discharges contain the bacillus and must be disin- fected or destroyed. Pulmonary tuberculosis is the most generally infectious variety of this disease. The infection is contained in the sputum, and communicated to the air by droplet infection, or direct\y from the breath of the patient in kissing or in sleeping in the same bed. In nursing a case of pulmonary tuberculosis isolation should always be attempted and enforced where possible. The minimum care should insist on separate sleeping room and separate linen, dishes, and utensils for the patient's use. The sputum should be received in special cups or flasks which can either, according to their make, be burned or disinfected by boiling at least once a day. Patients must be taught to spit only into the cups and to keep clothing, hands, etc., free from contamination. Handkerchiefs, if these must be used, should be disin- fected before being sent to wash, and boiled in the process. The bed and personal linen should also be disinfected. In 414 ELEMENTARY BACTERIOLOGY AND IMMUNITY poor homes rags and pieces of soft paper should be given to the patient and he should be taught, after using them, to put them in a thick paper bag in which they can sul>- sequently be burned. Nurses should remember that, whatever compromises they may be obliged to make, scientists consider that isolation of the case from healthy people is the most important of all means of prophylaxis. Erysipelas.—The infection of erysipelas is contained in the desquamating particles of skin and in discharges from the affected area. It is readily carried in the cloth- ing of the attendants, and in instruments, dressings, etc., used for such cases. At the same time, as an abrasion of the skin is necessary for the entrance of the special germ, cases of erysipelas may be nursed with impunity in medical wards. Care should be taken to prevent any contact, however remote, with surgical cases. Nurses caring for erysipelas patients should not be allowed in the surgical wards or in the operating-room, and should not mix with others from these departments until the clothes have been changed. Dressings from erysipelas cases should be burnt where practical. The consideration of protection from surgical infection involves the whole process of modern surgical technic, and must be considered in a chapter by itself. CHAPTER XII SURGICAL BACTERIOLOGY, ASEPSIS Micro-organisms Commonly Met With in Surgery—Infection— Principles of Antisepsis and Asepsis—Sterilization by Heat—Arnold Sterilizer—Autoclave—Chemical Sterilization—Antiseptics in Gen- eral Use-pDisinfection by Vapor—To Disinfect a Room—Measur- ing Solutions. MICRO-ORGANISMS MET WITH IN SURGERY The bacteria now recognized as the common source of surgical infection belong, for the most part, to the micro- coccus group. Those most frequently encountered are of the staphylococcus or the streptococcus variety. They are classed as pyogenic, or pus-producing, bacteria. The principal varieties of these bacteria have already been described on page 379. WOUND INFECTION Bacteria that cause the acute contagious fevers are present only in more or less localized areas, and are looked for chiefly in the vicinity of persons suffering from these maladies. The pus-producing organisms, on the contrary, are widely distributed, and are specially liable to be found in the ordinary dust of human habitations, which must, therefore, be regarded as a source of infection for surgical wounds. Many of them are constantly found on the skin and on the mucous membrane surfaces, especially of the nose and mouth, and even in the alimentary canal. These bacteria invade the body through the broken surface of the skin or mucous membrane. They may be conveyed by the dust of the air, by water or lotions used in irrigating wounds, or by unclean articles that come in contact with the wound, such as dressings, instruments, or the hands that touch the wound. A wound invaded by pyogenic bacteria is described as infected. 415 416 SURGICAL BACTERIOLOGY, ASEPSIS As we know, the bacteria do not themselves actually attack the tissues. The symptoms resulting from their invasion are due to the toxins they elaborate during their development. At the seat of lesion the effect of staphylococcic infec- tion is—(1) local inflammation; (2) necrosis of the in- flamed tissues; (3) liquefaction of the necrosed tissues. The liquefied tissue, mixed with the cells of dead leuko- cytes, forms the thick, inoffensive, yellowish-green fluid we know as pus. A local, circumscribed collection of pus is called an abscess. Suppuration.—The breaking down of the tissues into pus is known as suppuration. The local condition of suppuration gives rise to certain general symptoms, of which the most important is a sharp rise of temperature, preceded, as a rule, by attacks of shivering, and accompanied by general malaise. The physical symptoms are due to absorption of the local toxins. They subside quickly if the abscess is opened, and further absorption checked by drainage. Occasionally the staphylococcus gains entrance by way of the hair-follicles, the skin apparently remaining un- broken. A pustule is produced at the point of invasion; under treatment the infection may be checked at this point, or it may spread to the surrounding tissues, pro- ducing a boil, or, where the deeper tissues are extensively involved, a carbuncle. Infection by the streptococcus pyogenes is accompanied by severe physical symptoms. The principal are: high fever of the intermittent variety, preceded by rigors (attacks of intense shivering), rapid emaciation, marked prostration, and persistent diarrhea; the intermissions of fever are accompanied by profuse sweating. In many instances the condition is fatal. The term blood-poisoning is often used to describe general streptococcus infection. The incubation period for the pyogenic bacteria is usually. about three days; it is, therefore, frequently possible to trace the origin of the infection by the time of the development of the symptoms. Mixed Infection.—Not infrequently an infected wound WOUND INFECTION 417 may be invaded by a second organism, both of which continue their activity in the same tissues. The condition is then described as mixed infection. The most common example is infection by the pyogenic organisms in tissues already infected by the tuberculosis bacillus. This is the process that produces the cavities in the lungs of phthisical patients, the strumous glands, and joint abscesses especially common in tubercular children. The tissues of a healthy human being present a consider- able resistance to the invasion of the staphylococcus and streptococcus organisms. As with other pathogenic bacteria, this resistance is lessened by conditions that lower the health or vitality of the individual, and especially by alcoholism and by chronic organic diseases, such as dia- betes. Of special importance is it to remember that local resistance is lessened by local injury to the tissues, such as laceration, bruising, or other damage from an accident, or even from rough handling of the tissues during an operation or dressing. Other local conditions that lessen the resist- ance are edema, hyperemia, anemia, and the presence of dead tissues or other foreign bodies that act as irritants. To some extent antiseptics also tend to irritate the tis- sues, and their use is by many surgeons almost entirely eliminated. A wound made by sharp instruments and where the tissues are carefully handled and little disturbed offers a considerable degree of natural resistance to bacterial invasion. Bacillus of Tetanus.—Another organism especially to be guarded against in surgery is the bacillus of tetanus, which is especially liable to infect wounds of accidental origin, and particularly those contaminated by the soil. The tetanus bacillus is found in the soil, and especially in soil covered by the feces of herbivorous animals. Usually the organism gains entrance to the system at the time of the accident, but open wounds, particularly wounds of the hands and feet, may readily become infected later. In wounds caused by blank cartridges the tetanus germ is particularly liable to develop. The source of the infection appears commonly to be the wad of the car- 27 418 SURGICAL BACTERIOLOGY, ASEPSIS tridge, but the germ is probably frequently also present on the soiled hands or clothing of the victim, and is driven in at the time of the accident. The tetanus bacillus is of the strict anaerobic variety, that is to say, the absence of oxygen is essential to its development. Punctured wounds and those caused by gunshot, both of which reach the deeper tissues with small external opening, offer, therefore, conditions peculiarly favorable to the growth of this organism. The tetanus bacillus produces no special local manifes- tations, but marked characteristic physical symptoms, the most important of which is the typical convulsion (p. 669). The acute form of this infection is very frequently fatal. Antitoxins are prepared for the treatment of tetanus and of streptococcus infections. In the late war a dose of tetanus antitoxin was given to each wounded man before he was removed from the field. To this is due the fact that tetanus rarely developed in the army hospitals, whereas in all former wars death from tetanus infection enormously increased the mortality of the armies. Bacillus Aerogenes Capsulatus (Gas Bacillus).—This is an extremely virulent infection which also attacks wounds of accidental origin and, like the tetanus bacillus, is found in the soil of certain districts. The tissues surrounding wounds in which this bacillus develops become infiltrated with gas; the physical symptoms are those of profound toxemia. The local treatment includes free incision of the tissues to allow the gas to escape. Like the tetanus bacillus this organism contains spores, a point to be remembered in disposing of dressings, etc. Flanders is a district in which the gas bacillus is found, and this infection was frequently seen among the wounded from the trenches. A specific serum has been produced which is valuable in preventive treatment, but is of no value when the wound has reached the stage of septicemia. ANTISEPSIS AND ASEPSIS Antisepsis.—As we saw in the last chapter, it is only of comparatively recent years that the sources and chan- nels of infection have been recognized. Following Lister's ANTISEPSIS AND ASEPSIS 419 deduction, that sepsis and suppuration were the result of the activity of micro-organisms produced by a process strikingly similar to the familiar phenomenon of fermenta- tion, the efforts of the surgeons were directed toward devising means that would protect the tissues from the invasion of bacteria. Experiments showed that certain drugs possessed the property of destroying or, at least, arresting the activity of these germs. The use of such drugs which were now classed as antiseptics in the preparation of dressings, in the cleansing of the hands, of the instruments used, and also of the skin of the field of operation, and, finally, the saturation of the air during the operation by an antiseptic spray, constituted the practical outcome of Professor Lister's teaching, and was known as the antiseptic method of treating wounds. The antiseptics most in use were carbolic acid, bichlorid of mercury, chlorid of lime, chlorinated soda, and iodoform, the latter as a powder applied directly to wounds, and at that time extensively used. The air was saturated by means of a fine carbolic steam spray, which was kept playing over the whole field of operation during each operation or dressing. The instruments were covered with carbolic solution some hours before each operation or dressing, and kept in the solution except when actually in use. In dressings, the old-fash- ioned poultice or ointment, spread on lint, was replaced by loose-meshed gauze, saturated with a disinfectant, and medicated absorbent cotton; the wound itself was cleansed with an antiseptic and powdered with iodoform. Sea- sponges used for cleaning were carefully washed after use and kept soaking in a disinfectant. Subsequently their use was superseded by sponges made of gauze or cotton and discarded after use. The results of Professor Lister's methods completely justified his theories. Epidemics of " hospital fever," or blood-poisoning from infected wounds, until then con- stantly breaking out in hospital wards, disappeared; wounds, closed at the time of operation, healed without suppuration. It was demonstrated that the cavities of the body could be entered, and operations performed on im- 420 SURGICAL BACTERIOLOGY, ASEPSIS portant structures without such a proceeding being fol- lowed by a general septic condition. It is difficult to reahze that forty years ago these familiar facts were looked upon as tentative discoveries. Antiseptic methods spread from the operating-table to all departments connected with the care of sick people. From disinfecting the air during an operation, the necessity came to be recognized of protecting the air from impurities by rigid cleanliness and antiseptic principles applied to domestic work. Absolute cleanliness, no longer a mere esthetic principle, was now recognized as a practical necessity in wards, operating-rooms, and all departments of a hospital for the prevention of infectious conditions. Dust and dirt, now found to be the favorite harboring places of pus-producing germs, were rigorously removed; in hospital construction and equipment materials that easily absorbed dirt and, therefore, bacteria, such as unpolished wood for floors or furniture, wall-papers, car- pets and hangings, disappeared; hard wood capable of being highly polished was largely used, and later marble, cement, glass, or metal, all presenting hard, smooth, non- absorbent surfaces, were proved to be the materials most readily kept free from germs. The same principles were applied to the clothing worn by those attending the sick, requiring that it should be made of washable material, especially of linen, which, when ironed, prevents a smooth, polished surface, less readily absorbent than many other materials. Fresh air and sunlight were proved to be natural anti- septics, and were now freely admitted to wards and sick- rooms, hitherto most frequently kept close and stuffy. The practice of disinfecting the air by means of the carbolic spray comparatively soon fell into disuse. The air purified of dust was found to be also freed from germs, and it was not considered to be of practical value to saturate it with a disinfectant. Otherwise antiseptic . principles, with various modifications and developments, were the accepted methods for some twenty years. For the last twenty years, however, asepsis has, at first gradually, and later almost entirely, superseded antisepsis by really direct logical sequence. ANTISEPSIS AND ASEPSIS 421 Antiseptic methods protected a wound by keeping it constantly surrounded by agents that destroyed bacteria or, at least, bacterial activity. It had certain disadvantages: if the agents were used in sufficient strength adequately to fulfil their function, many of them actually injured the tissues or the instruments, etc., used, and others had a toxic effect on the system. Asepsis.—The method we know as asepsis (literally, without poison) was developed from the principle that contamination of a wound came from without; therefore, if a wound were protected from contamination, there would be no development of manifestations attributable to germ activity, and it would not be necessary to apply antiseptics to the wound itself. To attain this, the room in which the wound is to be exposed must be free from germs and of dust, which is the common carrier of germs; the instruments and dress- ings, the hands of the operator and assistants, every- thing, in fact, that might come into direct or indirect contact with the wound, must be made free from bacterial invasion and kept so during the entire time the wound should be exposed. An illustration may serve to make clear the similarity of principle and the difference in methods in antiseptic and aseptic surgery. Suppose a hall filled with treasure and invaded by a band of thieves, who will destroy and carry off the treasure; let us take the hall and its treasure as representing the wounded tissues, and the band of thieves as a horde of bacteria. Now, let us imagine that the thieves have been followed by a guard sufficient in numbers and force to hold the thieves in check. The treasure is, for the time being, safe, and will remain so as long as the guard is stronger than the thieves. This we may take as repre- senting the antiseptic principle. The aseptic principle may be demonstrated by pictur- ing the same hall into which, by vigilant care outside the door, thieves have not been allowed to enter. There are no thieves, no guard is necessary; but if vigilance is re- laxed, if one gate of admission is unprotected, the hall lies completely at the mercy of the invading band. To 422 SURGICAL BACTERIOLOGY, ASEPSIS carry the illustration a little further, the gates of admission are represented by the instruments, dressings, and nil so- lutions or apparatus that come in contact with the wound, by the hands of the operator and all who assist at the operation, by the surrounding air, and by the surface of the skin covering the area of operation. It is necessary that these should, in the first place, themselves be free from bacteria, and that, once rendered free, they should be kept in this condition all the time the wound is exposed. STERILIZATION Substances or bodies entirely free from bacteria are said to be sterile, and the process by which they are rendered so is called sterilization. While antiseptic methods obtained in surgery, steriliza- tion was carried out entirely by the use of chemical agents, that is to say, by the use of antiseptics, in most cases producing not true sterilization, but merely a partial or temporary arrest of bacterial activity. In developing aseptic methods in surgery from the antiseptic methods, the limitations of chemical sterilization were recognized as a stumbling-block, and attention was turned to more effectual and reliable means of accomplishing the desired result. Sterilization by Heat.—For instruction, the surgeons turned to the bacteriologic laboratories. It was found that even highly resistant bacteria could be destroyed by being subjected to a high temperature for a definite period. In the laboratories sterilization was accomplished by the actual flame, by baking, by boiling, and by steam. In- genuity set to work to devise means by which perishable substances, such as dressings and delicate instruments, could be brought to the necessary temperature without being burnt or otherwise destroyed. As results, we have the varieties of sterilizing apparatus familiar at the present day in modern surgical methods. It is interesting, in this connection, to realize that in the early laws of the children of Israel the purifying property of heat was recognized. We read in the book of Numbers (Ch. xxxi, 23): " Everything that may abide the fire ye STERILIZATION 423 shall make go through the fire and it shall be clean," and, it is added, "all that abideth not the fire ye shall make go through the water." Actual Flame.—Sterilization by the actual flame is the least used form of sterilization. It is applicable to small articles, such as needles, platinum wires, cautery-tips, etc., which can be made red hot without melting. An alcohol lamp or a Bunsen gas-burner is used for the pur- pose, the flame of either being free from soot or impurities that would adhere to the article sterilized. Boiling was found a practical method of sterilizing, and was at once adopted for fluids, for instruments, basins, and vessels of metal, china, or glass, and all substances where boiling is practical. Boiling, to be effectual, must be done in a closely covered vessel, containing sufficient water completely to cover the articles to be sterilized. The time necessary for com- plete sterilization is usually considered to be fifteen min- utes of actual boiling. Fifteen minutes is, however, too long for some articles that stand boiling badly, such as rubber goods or fine sharp instruments, which become blunted in the process. These articles are capable of being thoroughly cleansed previously of all deposits which might contain bacteria and greasy substances to which bacteria would readily adhere. Needles and knives which are made of highly polished metal without joints or grooves, are usually boiled for only thirty seconds, and rubber goods or sharp instruments that have grooves or joints, from three to five minutes (Chapter XIII). Practically, these articles are better sterilized by chemical means. Baking, or sterilization by dry heat, was the earliest method employed in the sterilization of dressings, cloth- ing, and all varieties of " dry-goods." A hot-air chamber was used, somewhat similar in principle to an oven. It consisted of a strong iron box with double walls, provided with a closely fitting iron door; the space between the walls formed an air-chamber in which the hot air was kept circulating. In institutions such a chamber was frequently built near a furnace, with which it was connected as an ordinary oven is with the kitchen stove. These chambers 424 SURGICAL BACTERIOLOGY, ASEPSIS were frequently of considerable size, and were used for the disinfection of mattresses, blankets, and the clothing of infectious cases. Articles were baked for one hour at temperatures not below 150° C. (302° F.). With so long an exposure to dry heat, however, perishable materials were scorched and burned, so that the method had great disadvantages. Moist Heat.—Sterilization by dry heat was quickly replaced by sterilization by moist heat; in other words, by steam. Moist heat is more penetrating than dry, is not destructive to the extent of dry heat, and was proved to destroy bacteria as effectually and in a shorter time, fifteen to twenty minutes being sufficiently long for the destruction of highly resistant bacteria. Since its introduction, ster- ilization by steam heat has replaced all other forms, wherever practical, and its use at the present day is universal. Two methods of using steam are employed—steam just as it is generated by boiling, and steam under pressure. Arnold Sterilizer. — The apparatus most commonly in use for sterilizing by steam Fig. 148.—Arnold's steam ster- witn0ut pressure is the Arnold uizer. .7. c sterilizer. This is a simple apparatus in three parts—the sterilizing chamber, the jacket, and the water chamber. The sterilizing chamber is a cylindric metal box, usually of copper, completely inclosed in a movable outer covering of the same metal, which forms the jacket; the whole fits closely over a wide copper pan filled with water, from which the steam is generated, forming the water chamber. The bottom of the sterilizing chamber is provided with an opening through which the steam is introduced. The STERILIZATION 425 articles to be sterilized are packed on a perforated metal tray in the bottom of the chamber; the perforations allow the steam to percolate freely to all parts. Between the sterilizing chamber and the inclosing jacket a small air-space is left, which has two uses: First, it helps in maintaining an even temperature in the sterilizing chamber; second, the steam, coming in contact with the top of the covering, condenses, the water trickles down the sides of the jacket in the air-space, and returns to the water chamber through some small perforations at the bottom, thus, to a certain extent, replacing the water that has been converted into steam. The whole apparatus may be placed over a portable gas stove or on the kitchen stove. Improvised Steam Sterilizer.—An adequate steam ster- ilizer may be made with a clothes-boiler. About a fourth of the depth is filled with water, above which the articles are suspended in an improvised hammock of net or muslin, fastened by strings to the outside handles. If the boiler is to be permanently devoted to the purpose, it is worth while to have it fitted with a shelf or tray of perforated metal, which can be hung from two hooks attached to the rim of the boiler. If dressings sterilized in this manner become wet, they should be dried at once in an oven. In sterilizing with steam by this method thirty minutes should be allowed, counting from the time the steam is generated. It must be remembered that, although bac- teria are destroyed at a temperature of 100° C, spores are not. The Autoclave.—Steam under pressure can be raised to a higher temperature than steam generated at the ordi- nary pressure of the atmosphere. France was the first country to adopt sterilization under pressure, and in- vented the apparatus known as the autoclave, now in universal use in some form or other. Whatever the shape or size of the autoclave, it consists essentially of three chambers: (1) A closed water chamber, communicating with (2) a closed steam chamber, which is usually in the form of a jacket, surrounding and communi- cating with (3) the sterilizing chamber. During steriliza- 426 SURGICAL BACTERIOLOGY, ASEPSIS tion the sterilizing chamber is completely closed by a heavy metal door screwed down so securely that no steam can escape. The communications between the three chambers are guarded by valves which are regulated by handles placed on the outside of the autoclave. The water chamber is also filled from the outside. The steam chamber has at- tached to it a safety-valve to regulate the pressure to the required amount. For example, if fifteen pounds' pressure is wanted, the valve is set so that any pressure over fifteen pounds forces the valve up and allows suf- ficient steam to escape to reduce the pressure again to fifteen pounds. It is always of the first importance that this valve should be in work- ing order. The autoclave is also furnished, with a dial showing the pressure of steam and the tempera- ture attained, and with a glass gauge by which the amount of water in the water chamber can be estimated. The water in the cham- ber may be heated by gas placed below the autoclave. In institutions where steam is used for heating the autoclave is generally attached directly to a steam pipe, and gas is then not necessary. 149.—Autoclave. form. Horizontal STERILIZATION 427 The connection pipe is provided with a valve to regulate the amount of steam introduced, and a second pipe is necessary to carry off the superfluous steam. The articles to be sterilized are placed on perforated metal shelves, with one or more of which the sterilizing chamber is provided. In packing the sterilizer with objects that expand under heat, sufficient space must be allowed for such expansion. Two articles that expand must not be placed near together; thus, glass flasks or jars will crack if set close to each other or directly on the metal shelf: the shelf should first be covered with a towel folded to several thicknesses. Printed directions to be followed in the manipulation of the autoclave or sterilizer should hang where they can readily be referred to. At the same time, the pupils should be drilled in its use, and have each part carefully explained to them: The steps in sterilizing are as follows: 1. Examine the water-gauge, and, if necessary, add more water. 2. Pack the sterilizer and close the door. 3. Either light the gas or turn on the steam; then im- mediately— 4. Open the valve between the water chamber and the steam chamber. As steam is generated, the needle on the dial is seen to rise. When it reaches the desired pressure, and not before— 5. Open the valve between the steam jacket and the sterilizing chamber. This, of course, reduces the pressure temporarily and the dial needle falls. * Sterilizing does not begin until the needle shows a second time that the necessary pressure has been reached, this time in the sterilizing chamber. When sterilization is complete, the heat supply is turned off. The door is not, however, opened until the needle indi- cates not more than five pounds' pressure. If the door is opened at a high pressure, the face and hands ma}' be scalded, besides which the sudden change in pressure is liable to blow the corks and stoppers or the contents out 428 SURGICAL BACTERIOLOGY, ASEPSIS of jars and bottles containing fluids, and to cause crack- ing of glass flasks and similar objects. The usual pressure required is 15 lbs., which repre- sents a temperature of 120° C. or 248° F.; at this pressure sterilization is continued for fifteen minutes. An autoclave similar in principle, and but slightly dif- ferent in mechanism, is used to sterilize water where large quantities are constantly required. As the tanks contain- ing the water are hermetically closed, water once sterilized will remain sterile until fresh water is added, after which sterilization must be repeated. A temperature of 120° C. has a more powerful effect on bacteria than a temperature of 100° C. While the lower temperature will completely destroy fully developed bacteria in from fifteen to twenty minutes, it has no effect at all on the more resistant spores (p. 358). Fifteen minutes in an autoclave at 15 pounds' pressure will, it has been shown, destroy spores, while if either boiling, dry heat, or steam at ordinary atmospheric pressure is used, the spores must be exposed for a number of hours before they are destroyed. Few of the substances it is neces- sary to sterilize could be subjected to so prolonged an exposure without injury or completely changing their nature. To ensure that sterilization is complete, many hospitals use a control which is placed in each packet to be sterilized. A patent sterilizer control (by A. W. Diack, Detroit, Mich.) consists of a small glass tube containing a sand- colored tablet which melts and turns red when steriliza- tion is complete. A black string, attached to the tube, is led out through the wrapping by which the control can be withdrawn and examined. If the tablet is un- changed the sterilization is incomplete. In some hospitals the control used is a slip of paper with the date written in indelible silver ink. This is placed in the middle of the package; if sterilization is complete the ink turns red. Fractional Sterilization.—Where it is not practical to use steam under pressure, substances in which spores may exist are subjected to what is known as the fractional STERILIZATION 429 method of sterilization. These are substances which rep- resent media in which bacteria can live and propagate, such, for example, as gelatin, milk, and bouillon, etc., to be used as culture-media; oils, ointments; water to be used during operations, in the making of solutions, or for subcutaneous infusion; and so forth. By the fractional method such articles are either boiled or subjected to steam heat (100° C.) for fifteen minutes on three successive days. At the first boiling all fully developed bacteria are destroyed. The intervening twenty-four hours is sufficient to develop most of the spores, and as full- grown bacteria they are destroyed by the second boiling. Any spores left will develop between the second boiling and the third, at which any surviving bacteria are com- pletely destroyed. Between the sterilization the substance to be sterilized should be kept at a moderately high tem- perature—about 80° F.—to favor the development of the bacteria. Experiments show that this method is sufficient for the destruction of even the most resistant spores. The principles that govern the sterilization of milk to be used as food are discussed in the chapter on Food Values. Chemical Sterilization.—While sterilization by heat, or thermic sterilization, is used wherever practical, it is not applicable in all instances. Obviously, for example, it cannot be applied to living organic tissues. Modern asepsis has, therefore, retained from the antiseptic meth- ods the practice of sterilization by chemical agents. Three groups of these chemical agents are recognized, often loosely classed as disinfectants. 1. Antiseptics.—Their action is to arrest the activity and prevent the development of bacteria. 2. Germicides.—These actually destroy the bacteria. An- tiseptics used in sufficient strength and over a sufficiently long period act also as germicides. They cannot, however, be used in such strength on living tissue. Germicides are, properly speaking, true disinfectants. 3. Deodorants.—Some antiseptics possess the property of neutralizing disagreeable odors; such are permanganate of 430 SURGICAL BACTERIOLOGY, ASEPSIS potash, carbolic acid, cresol, and lysol. Other substances have also these attributes, but no antiseptic property, as, for example, eau de cologne and toilet waters. Antiseptics are used in the form of solutions, powders, oils, ointments, and vapors or fumes. ANTISEPTICS IN GENERAL USE For convenience, all forms of antiseptics in use will be considered together, as well as those especially in use for sterilizing in surgical work. The following are the prin- cipal antiseptics in common use. Bichlorid of Mercury or Corrosive Sublimate {Hydrar- gyrum Chloridum Corrosivum).—A white, highly poisonous powder, soluble in cold water, precipitated by the action of chlorid of sodium on the bisulphid of mercury. This is the most constantly used antiseptic in surgical work, but presents certain disadvantages, as follows: 1. It is inert in the presence of albumins or of alkalis: it is, therefore, (a) not a perfect disinfectant for organic secretions, such as excreta, etc., and (b) it is useless if mixed with soap, as for cleansing purposes. 2. It does not penetrate oily substances: to act, therefore, on the skin, all grease must first be removed. 3. On raw surfaces it is to some extent an irritant; it is considered to destroy cells and promote exudation, thus indirectly lessening resistance to infection; many surgeons, therefore, do not use bichlorid of mercury for clean wounds. 4. Unless very highly diluted it is too irritating for delicate tissues, such as the serous membranes and the conjunctiva. 5. Mucous membrane surfaces are made dry and rigid by solutions of the usual strength. It is not, therefore, suitable for douching in obstetric cases, where the parts must be kept flexible and lubricated during parturition. 6. If too freely absorbed through the tissues, it causes mercurial poisoning. 7. It stains white materials yellow, discolors paint, and to some extent corrodes metal, wood, marble, and porcelain. ANTISEPTICS IN GENERAL USE 431 8. In many persons the constant external use of bichlorid of mercury produces a skin eruption difficult to cure. The action of bichlorid of mercury in the presence of albumin, which is constantly present in all organic tissues, excreta, etc., is to coagulate the albumin, thus forming a covering impenetrable to the disinfectant, inside which bacteria can live. This disadvantage is overcome by the addition of common salt, chlorid of ammonia, or some simple acid, such as tartaric acid. The " bichlorid tablets " in common use contain 7.3 of corrosive sublimate and the same amount of chlorid of ammonia. One tablet dissolved in one pint of water makes a solution of bichlorid of mer- cury 1 : 1000. The average strength in which bichlorid of mercury is used is as follows: For sterilizing china, glass, etc., where steam is not used................................1:500. For disinfecting the skin....................1:1000 to 1:2000. For dressing and cleansing infected wounds. . 1:2000 to 1:3000. For vaginal douching and disinfecting mucous membrane surfaces.......................1:4000 to 1:5000. For irrigation of sensitive membranes, such as the conjunctiva, urethra, etc..............1:10,000 to 1: 40,000. Bichlorid of mercury in a strong solution (1 :500 to 1 : 1000) is frequently used to destroy pediculi that infest the human hair. Carbolic acid, or phenol, is a coal-tar derivative, ob- tained as crystals which become liquefied on the addition of 5 per cent, cold water; the liquefied crystals are known as pure carbolic acid. Pure carbolic is not used unless as a local application in the treatment of badly infected wounds. If the wound is extensive, the application is usually followed in a few minutes by a washing with alcohol, which arrests the action of the acid. For ward use the standard solution of carbolic acid is usually 1 part carbolic in 20 parts water, familiarly referred to as " one in twenty." As carbolic acid does not stain linen, discolor paint, or injure wood or metals, it is a good disinfectant in many circumstances. In common with other acids it will, however, injure marble. On account of its poisonous 432 SURGICAL BACTERIOLOGY, ASEPSIS properties it cannot be used in dressings where the sur- face is extensively denuded, as in burns and scalds, since poisons may be absorbed through the broken skin. The oily liquid of pure carbolic acid does not mix readily with water. It should be shaken in a bottle or stirred until entirely dissolved, otherwise any tissue coming in contact with the pure carbolic will be burned. Should a burn be caused in this way, the area should be immediately washed with the antidote, alcohol; care must also be taken to use neither oil nor ointment in the immediate dressing of such a burn, since oils aid in the absorption of the carbolic acid. Salt solution or a sterile dusting-powder is the dressing generally used. The average strength in which carbolic acid solution is used is as follows: For instruments and hardware.................. 1:20. For the skin and for linen and clothing.......... 1:40 to 1:60. For vaginal douching or in dressing of wounds... 1:80. For sensitive membranes, conjunctiva, etc....... 1:100 or weaker. In isolating an infectious case a sheet wrung out of carbolic acid 1 : 20, and kept well sprinkled with the same, may be hung across the doorway, and arrests the passage of germ-laden dust to the rest of the house. Carbolic acid acts to some extent as a local anesthetic. Its use as a disinfectant for the hands causes frequently an unpleasant numbness. This property makes it a soothing application for such skin affections as urticaria, the rash of poison ivy, etc. Carbolic crystals may be vaporized by placing them on a heated metal plate over a lamp, or by wrapping them in brown paper and setting it alight; in this way they are sometimes used to disinfect the air of a sick-room. Bowls of carbolic acid solution placed about a sick-room act also to a limited extent as a disinfectant. On account of its irritating properties on the tissues and of its ready absorption into the system, carbolic acid is not commonly used for wounds or for mucous membrane surfaces. For the latter use two other coal-tar derivatives are generally preferred, lysol and creolin. ANTISEPTICS IN GENERAL USE 433 Lysol is obtained by the action of nascent soap on cresol, a derivative of carbolic acid. Mixed with water, it forms a soapy liquid. This makes it peculiarly useful for douching, especially in obstetric work, as it also acts as a lubricant. It is used for vaginal douching and for the hands in a solution of 1 to 2 per cent. For infected conditions, 3 per cent, solution is generally used. Creolin is an emulsion of cresol, and has high anti- septic value; it is also a deodorant, and to some extent a hemostatic. Mixed with water, it forms a milky solu- tion. It is a popular antiseptic in the treatment of infectious wounds, and as a rectal disinfectant in a solution of 1 to 2 per cent. Creolin is the antiseptic generally pre- ferred in rectal surgery. Gauze which in preparation has been saturated with creolin (5 to 10 per cent.) is also used in surgical dressings. Boric acid or boracic acid (acidum boricum) comes in white crystals, generally obtained by the action of sul- phuric acid on borax. The crystals are soluble in 25 parts of cold water or in 3 parts of hot water. It is a mild anti- septic, non-irritating to the tissues, and, therefore, pre- ferred for delicate or specially absorbent tissues, or where large areas are denuded. It is the antiseptic generally used in the treatment of the eye, ear, nose, mouth, and bladder. The dry powder mixed with an equal quantity of talcum or starch powder is used as a dusting-powder for broken surfaces. A saturated solution of boric acid in water has a strength of 4 per cent., or 1:25. The saturated solution diluted with an equal quantity of water, making a solution of 2 per cent., or 1 :50, is the usual strength preferred for douching, irrigating, etc. Hydrogen peroxid or solution of hydrogen peroxid {aqua hydrogenii dioxidi, a watery solution of the dioxid of hydrogen) is greatly in favor at the present day for the cleansing of suppurating wounds and in the treatment of infected conditions of the throat, mouth, etc. When brought in contact with a suppurating area, oxygen is set free and an effervescence produced, which has the effect of carrying off dead tissue and inflammatory products. It 28 434 SURGICAL BACTERIOLOGY, ASEPSIS is considered to act by destroying the food on which bac- teria live. Usually it is diluted to half its strength with sterile water, or, if used as a throat spray or mouth-wash, with lime-water. In cleansing a wound a small quantity is taken in a glass syringe and injected into the cavity. Peroxid of hydrogen is not suitable for douching or the irrigation of large surfaces. It should also be remembered that the volume of gas liberated is considerable, and for this reason peroxid of hydrogen must be used with caution in irrigating sinuses or deep wounds not well open to the surface. It is inactive and, therefore, ineffective as an application on the unbroken surface. Permanganate of potash {polassii permanganas) occurs as royal purple crystals, soluble in 16 parts of cold water. As a saturated solution it is used in disinfecting the hands and skin by the Kelly method (p. 448). As a deodorizer and mild antiseptic it is used in irrigating offensive wounds and cavities, in strength of from 1 to 5 per cent. As the crystals are readily carried about, permanganate of potash is a popular antiseptic for douching, etc., in district work. Vessels containing a strong solution of this disin- fectant may be set about a sick-room to neutralize offen- sive odors. Alcohol, absolute alcohol, containing 99 per cent, pure alco- hol to 1 per cent, water, is not used except for pharmaceuti- cal or laboratory purposes. Pure alcohol is 94.9 per cent. pure ethyl alcohol by volume, with 5.1 per cent, water. For surgical use a solution of 70 to 75 per cent, alcohol in water is considered sufficient and by many preferred, as less readily causing coagulation of albumins, which to some extent limit the utility of alcohol as a disinfectant. Alco- hol is used in surgery to preserve organic material, such as catgut, or specimens of organic tissues, in the steriliza- tion of fine needles and delicate knives after boiling for thirty seconds, and for the removal of fat and grease from the skin before bichlorid of mercury is applied (see above). For this latter purpose ether is also used. Proof spirit, equal parts of alcohol and water, or dilute alcohol, about 48 per cent, alcohol in water, are used in nursing, chiefly in giving alcohol rubs and not for purposes of disinfection. ANTISEPTICS IN GENERAL USE 435 Iodoform.—Iodoform is obtained as fine yellow crystals, precipitated by heating iodin with potassium carbonate, alcohol, and water. The crystals have a characteristic permeating odor, very disagreeable to most people. Iodoform checks the growth of bacteria by the formation of iodin, which takes place when iodoform comes in con- tact with the secretions from wounds. The action of the iodin also stimulates the growth of fibrous tissue, so important in the healing of the sinuses and cavities of tubercular lesions. From this property it has its chief use in the treatment of tubercular wounds. Iodoform is used as a dusting-powder for raw surfaces, as an emulsion, usually with glycerin, in the treatment of tubercular sinuses, or as a dressing in the form of iodoform gauze. In rectal lesions, especially also those of tubercular origin, it is applied in the form of a suppository or as an ointment. like peroxid of hydrogen, iodoform is active only in contact with wound secretions. In its dry state, in com- mon with other dusting-powders, iodoform should be sterilized before using, as it may become contaminated by bacteria (p. 472). Iodin, tincture of, as a dressing for wounds, either clean or infected, and for use in the preparation of the field of operation (p. 450), became popular in the field surgery of the late war. Iodin checked bacterial develop- ment and stimulated the growth of fibrous tissue; it also reduces secretions. The usual strength is a 7 per cent, solution; this is used full strength in cleansing infected wounds and diluted three-fourths as a dressing. Acetanilid (acetanilidum), a carbon compound, is used to some extent, in the form of fine white crystals, as an antiseptic dusting-powder for raw surfaces, to stimulate indolent secretions. It should be used with caution, es- pecially with children and feeble persons, as it is quite apt to be absorbed from the broken surface, producing danger- ous collapse. A compound antiseptic dusting-powder with stimulating properties is composed of equal parts of boric acid powder, 436 SURGICAL BACTERIOLOGY, ASEPSIS bismuth subnitrate, and calomel. It is familiarly known as B. B. C. powder. Blue stone, or sulphate of copper {cupri sulphas), and nitrate of silver stick, or lunar caustic {argenti nitras fusus), are used as local applications to wounds, to stimu- late indolent granulations, and to destroy those that are redundant. They also possess antiseptic properties. For delicate membranes, such as the conjunctiva, a milder form of the silver stick is used, known as mitigated silver stick. A solution of nitrate of silver in water, 2, 4, and 8 per cent., is also used, especially in the treatment of ulcerated conditions of the mucous membranes, in purulent ophthalmia, and in many infected conditions of the throat. Nitrate of silver is a true germicide. Argyrol {silver vitellin) and protargol (silver protein) are silver compounds, discovered in recent years, which to some extent replace nitrate of silver as an application. They are considerably less irritating to the tissues, but do not possess the true germicidal quality of silver nitrate. Common salt in water is used as a local antidote if nec- essary. The action of these applications is strictly local. A shallow slough forms at the point of contact, which, on separating, should leave a healthy granulating sur- face. Normal Salt Solution.—A solution of common salt in water is so called because the proportion of salt in the fluid is the same as that in the blood. It is in common use at the present day as a substitute for irritating antiseptics, its action being mildly antiseptic and stimulating. In this respect it may be used in dressing wounds where the surface is extensively denuded, as in burns, in douching or irrigating the bladder, vagina, or rectum. Some surgeons use it in operations involving the serous membranes, especially in irrigating the peritoneal cavity. For these purposes it is preferable to plain sterile water, which has a macerating effect on the tissue. The most important use, however, is to restore fluid to the body after hemor- rhage, etc., or as general stimulant in conditions of lowered ANTISEPTICS IN GENERAL USE 437 vitality. (See Enemata, Hypodermoclysis, Intravenous Infusion.) The standard strength of normal salt solution at the present day is ^ of 1 per cent, that is, 9 in 1000, or nine grams of salt to the liter of water (21 drams to the quart). Formerly the standard was f\ of 1 per cent. In making the solution sterile filtered water and common table-salt are used. The solution is filtered through filter- paper into sterile glass flasks, free from the least speck of dust or foreign particles. The filtering is repeated until not the smallest sediment can be detected. The flask is filled two-thirds full and plugged with sterile cotton bound securely into place with a bandage, which serves also to prevent dust settling on the rim of the flask. The solution is then sterilized either in the autoclave or by boiling by the fractional method. Whitewash, or milk of lime, made by mixing one part of slaked lime in four parts of cold water, is frequently a convenient domestic disinfectant, especially for the walls of dwellings in which infectious maladies have occurred. It is also used as a disinfectant for the excreta (see below). Milk of lime is best freshly made: at most it should not stand more than two days. Chlorin, a non-metallic element obtained from sea-salt, is a greenish-yellow gas with a penetrating, pungent odor, highly irritating to the mucous membrane of the air-passages. It has powerful antiseptic properties. As a gas, it is used to a limited extent in disinfecting dwellings (see below). Chlorin is soluble in water in the proportion of 2 parts gas to 1 of water: it forms the antiseptic principle in chlorinated lime and Labarraque's. solution. Chlorinated lime (incorrectly known as chlorid of lime) is a white salt, formed by the action of chlorin on slaked lime. A solution of the salt in cold water is used for disinfecting purposes. In mixing, a wooden vessel should be used, on account of the strong corrosive action of the mixture. The solution is used in two strengths. For the disinfection of excreta (see below) one pound is mixed 438 SURGICAL BACTERIOLOGY, ASEPSIS with one gallon of water (10 per cent.); for other purposes the strength is 6 ounces to the gallon (3 per cent.), some- times known as " American standard." The latter is used in the disinfection of closets, sinks, garbage-cans, etc. Chlorinated lime is irritating to the tissues and destroys fabrics; its uses as an antiseptic are, therefore, limited. If no better disinfectant is available for the disinfection of clothing, the solution (3 per cent.) should be strained, and the clothes rinsed in cold water after they have been immersed in the disinfectant not more than four hours. In combination with carbonate of soda a paste of chlorin- ated lime is used by some in the surgical preparation of the hands (p. 449). Labarraque's solution, or solution of chlorinated soda, is a greenish-yellow liquid with a mild odor of chlorin; its composition is sodium carbonate 10 parts, and chlo- rinated lime 8 parts, in 100 parts of water. It is also used in the disinfection of closets and sinks, etc. In ward work it is often found useful in removing stains from bath-tubs, sinks, and glassware. It is too destruc- tive to be used in disinfecting fabrics. Formaldehyd, a gas obtained by the oxidation of wood-alcohol, has powerful antiseptic and germicidal properties. A 40 per cent, solution of the gas in water is known as formalin. A 4 per cent, solution of formalin in water is considered to equal in antiseptic value a 1:1000 solution of bichlorid of mercury or of 1:20 carbolic acid. Cold water is used in making formalin solutions, as the gas is given off if heated. Formalin injures metals to some extent, but at the present day is a popular disinfectant for linen, clothing, utensils, rubber goods, and all kinds of hardware (furniture, etc.). A 2 per cent, solution is gener- ally used. The vapor is highly irritating to the air-passages and to the eyes, which to many is an objection to its use. Other antiseptics are not in general use, but are fre- quently met with in surgical work and preferred by certain surgeons. Harrington's alcoholic solution of bichlorid of mercury is frequenty used in the preparation of the skin and for disinfecting glass, china, or enamel ware by immersion. ANTISEPTICS IN GENERAL USE 439 The formula is: Bichlorid of mercury..................... 1.5 gm Hydrochloric acid........................ 100 c.c. Glycerin................................ 100 c.c. Alcohol, 95 per cent...................... 1200 c.c. Distilled water.......................... 2000 c.c. Ringer's Solution. Iodin chlorid............ Calcium chlorid......... Potassium chlorid........ Distilled water to 5 gallons It is used undiluted. Dilute 4 ounces of the solution with 28 ounces of dis- tilled water; filter through filter-paper into sterile flasks; plug with sterile absorbent cotton and sterilize by boiling twenty minutes. It is used in preparing the field of opera- tion, especially in emergency work, in place of alcohol or corrosive sublimate. Thiersch's solution is made of boric acid, lj ounces, salicylic acid, 2 drams, to 1 gallon of hot water. The solution is sterilized before using. It is used chiefly for douching and irrigation in place of boric acid solution. A. B. C. antiseptic douche contains alum, 1 ounce, boric acid, 4 ounces, carbolic acid crystals, 3 drams, and oil of peppermint, \\ drams. One dram of the powder is used in one pint of water. It is used chiefly in gynecologic work as an antiseptic vaginal douche. Precautions.—It must be remembered that practically all disinfectants are highly poisonous, and care must be taken to prevent accidents in their use. The bottles in which they are put up are usually of dark glass, and ribbed as an additional precaution; they should always carry a poison label in a prominent part. In hospital work it is often the custom to color the solutions commonly used with one or other of the anilin dyes. Thus, bichlorid of mercury may be lavender, carbolic, blue, and so forth. This is a specially useful precaution with those antiseptics that are placed about a ward in basins, as hand lotions, or used in the sputum-cups. 150 oz. Troy. 2 oz. " 1 oz. " 440 SURGICAL BACTERIOLOGY, ASEPSIS DISINFECTING A ROOM The vapors or gases of certain disinfectants are also used for purposes of disinfection, more especially for dwell- ings, furniture, bedding, and clothing. Formaldehyd.—Of all, the most popular germicide at the present day is formaldehyd. As a general disinfectant ^_,.__._7_s^_ --^—;,-,,,_r.,v;, for a sick-room or ward "'■* after an infectious case it is unrivaled. Several methods are used: 1. The gas may be lib- erated from the solution by heat in a special ap- paratus designed for the purpose. The apparatus stands outside the her- metically sealed room, and b'ig. 150.—Formaldehyd fumi- gator. Fig. 151.—Apparatus for generating formaldehyd from tablets of polymerized formal- dehyd: A indicates the cup in which the tablets are placea (Abbott). the gas is introduced through a fine tube which fits into the keyhole (Fig. 150). 2. Formaldehyd tabloids are vaporized by being heated DISINFECTING A ROOM 441 on a metal plate over a special lamp designed for the purpose (Schering's lamp). The lamp is placed inside the closed room. To prevent risk of fire, the lamp should be placed on an inverted plate or tray, in a basin the bot- tom of which contains some water. 3. A simple method is to wring sheets out of a solution of formalin, 10 per cent., and hang them on screens or clothes'-lines about the room, which is then hermetically closed. 4. Formaldehyd may be liberated by combining 4 ounces of formalin (40 per cent.) with 1 ounce perman- ganate of potash crystals. This liberates a sufficient volume of gas to disinfect a space of 1000 cubic feet. For each additional 1000 cubic feet a similar quantity is added. A pail or tub large enough to hold at least 5 gallons of water is necessary, as the combination of the two ingredients causes the mixture to boil up violently. Some device must be used to retain the heat thus gener- ated, without which the gas will not be liberated. The vessel may" be covered with asbestos, or old blankets may be secured round it. The vessel must be placed where it will not upset, and the floor round should be protected. The fumes of formaldehyd are exceedingly irritating. If it is absolutely necessary to enter a room filled with formaldehyd, the gas may be precipitated by sprinkling ammonia water freely about the room. Sulphur.—Sulphur, in the form of candles, powder, or rock sulphur, was in earlier days burnt as a disinfectant for rooms, clothing, and furniture. It is now considered of little value as a.germicide. It has one valuable prop- erty, however: the fumes destroy insect life. Sulphur fumigation is a reliable method of destroying bedbugs. Five pounds of sulphur are required for every 1000 feet of cubic space. The powdered sulphur is heaped in an old iron plate or flat basin, which should be raised on a couple of bricks in a tub or wide basin containing water, in order to avoid risk of fire. The tub should stand on three bricks placed evenly on the floor. The sulphur is wet with a little alcohol, which is lighted when all the preparations are made, 442 SURGICAL BACTERIOLOGY, ASEPSIS The fumes of sulphur will discolor metals and any gild- ing on decorations. Chlorin.—Chlorin gas may be liberated in the following way, and is sometimes used in disinfecting rooms: Mix 2 drams of common salt and 2 drams of black oxid of manganese; place in a saucer, and add j ounce strong sulphuric acid diluted one-third with water. Enough chlorin is liberated to disinfect a space of 32 square feet (L. L. Dock). To ascertain the number of cubic feet in a room, multi- ply the length by the breadth, and the result so obtained by the height. For example: Length Breadth Height 20 feet X 15 feet = 300 feet X 10 feet = 3000 cubic feet. In preparing a room for disinfection all the furniture is arranged so that every part is exposed to the fumes. Drawers and doors of closets should be wide open and emptied of their contents. Clothing, linen, etc., should be hung about the room on screens or improvised clothes- lines. The window-shades should be drawn down. All chinks in doors or windows should be stuffed with tow, old cloths, or pasted over with strips of newspaper. The radiator must be closed, and if there is an open chimney, it must also by some means be stopped up, preferably with a closely fitting board. When all is ready, the disinfectant is started, and the door immediately closed, the keyhole and door chinks being also stuffed up. Nurses have been known to use adhesive plaster for this purpose: the extravagance of such a proceeding has only to be pointed out. The room is left closed for from twelve to twenty-four hours, after which fresh air and sunlight are freely admitted and every available part of the room and the furniture thoroughly cleaned with soap and water. DISINFECTION OF EXCRETA The proper disinfection of the excreta is an important part of a nurse's duties in those infections where the bac- Figs. 152, 153, 154.—Sterilizing hopper for the safe disposal of infectious excreta in hospitals. When infectious discharges are to be sterilized the gate valve is closed. Through the rubber hose at the right water is turned on for washing of utensils, and is allowed to enter the hopper to the line H. Steam is then turned on through the steam inlet. Boiling takes place almost immediately, and after five minutes' boiling the gate valve is opened to allow the contents to escape, and the hopper is flushed by means of the hose attached to the faucet. (Aikens.) 444 SURGICAL BACTERIOLOGY, ASEPSIS teria of the disease are present in the excreta, as in typhoid fever, cholera, and dysentery. Chemical disinfection is attained by mixing the stool (or urine, sputum, etc.) thoroughly with a strong, anti- septic solution. In many hospitals bichlorid of mercury (1:1000) or carbolic (1: 20) are used. We saw, however, that these were not perfect disinfectants for organic secre- tions, their tendency being to coagulate the albumin and thus arrest the action of the disinfectant on the bacteria inclosed in the albuminous capsule. To be effective, an equal quantity of the disinfectant must be stirred into the stool and set aside for several hours in a closed vessel; as a rule, this is not practical. Formalin (2 to 4 per cent.) is, on account of its volatility, also not an ideal disin- fectant for the purpose. Chlorinated lime (10 per cent.) is, on the whole, considered the best chemical disinfectant for excreta. An equal quantity of the solution should be thoroughly mixed with the stool, and allowed to stand fif- teen minutes before being emptied down the soil-pipe. The vessel should be covered meanwhile with a cloth wrung out of bichlorid of mercury (or other disinfectant). Boiling.—In some hospitals a special hopper in which stools and urine are sterilized by boiling is used. The hop- per is connected with a steam pipe; some water is mixed with the stool in the hopper, the hopper closed, and the steam turned on. The stool is allowed to boil, usually for five minutes, then the steam is turned off, the valve connecting the hopper with the soil-pipe opened, and the hopper flushed as in an ordinary water-closet. In country districts where there is no water system the stool may be emptied into a covered pail and mixed with a generous allowance of freshly made whitewash or with chlorinated lime, and the whole buried in some spot away from the habitation and at a safe distance from all possible contamination of any water-supply. In the camp hospitals of the late war the stools were destroyed by burning, an ideal method where large num- bers are assembled in primitive sanitary conditions. The vessel which has' contained an infectious stool should also be disinfected immediately after use. In MEASURING SOLUTIONS 445 modern hospitals medical wards are usually provided with a sterilizer in which bed-pans, urinals, and sputum- cups can be sterihzed by steam. Where this is not the case, they may be kept, after being cleaned, soaking in a tank filled with a disinfectant, usually bichlorid of mercury (1:1000) or formalin (2 per cent.). MEASURING SOLUTIONS Disinfectants, lotions, etc., are usually sent to the wards in concentrated solutions, to which water is added to dilute them to the required strength. Practice is necessary to teach nurses to reckon the percentages accurately. Metric System.—The simplest and most accurate method is to employ the metric system. The percentage is then easily understood, as so many grams (solid) or cubic centimeters (fluid) in each 100 cubic centimeters of water. To find the total amount it is only necessary to multiply the percentage by the number of hundred cubic centimeters required: thus, to make 500 c.c. of a 2 per cent, solution, multiply 2 by 5, and we find we shall want 10 c.c. or 10 grams of the drug. Similarly, 1 in 20, 500, or 1000 signifies one gram or cubic centimeter in each 20, 500, or 1000 c.c. of water. Apothecaries' Measure.—In using the apothecaries' measure the proportion is most easily found by using the ounce as the basis of measurement. The ounce contains 480 minims; for practical purposes, in making up anti- septics in the large bulk in which they are used, it is usually considered sufficient to consider the ounce as a measure of 500 minims. The amount of the drug re- quired in each ounce is then readily found by multiplying the percentage by 5. Thus: 1 per cent, requires 5 grains or minims in each ounce; 5 per cent, requires 25 grains or minims in each ounce; 10 per cent, requires 50 grains or minims in each ounce, and so forth. Where the percentage is expressed as 1 in 20, 25, etc., one part of the drug is allowed in every 20, 25, etc., of the whole quantity, whether minims, drams, ounces, or pints. Solutions of which the percentage is reckoned in thou- 446 SURGICAL BACTERIOLOGY, ASEPSIS sands (1: 1000, etc.) may be prepared by, in the first place, adding to each ounce (500 minims) one grain or one minim of the drug. We have then, as a basis, a solution of the strength of 1: 500, which can be diluted to the required strength by adding sufficient water. To find the amount of water to be added to a solution of known percentage in order to make a solution of a weaker strength, divide the strength required by the strength of the original solution and subtract one {i. c, one part) from the answer. For example, to make 1: 3000 from 1: 500—3000 -J- 500 = 6-1 = 5. The division shows we want a solution one-sixth the strength of the original; we make this by taking five parts water and one part of our original solution. In mixing solutions from the crude drug, warm, not hot, water should be used, except for carbolic acid, boric acid, and normal salt solution, which are more thoroughly and quickly dissolved in boiling hot water. Cold water is used in making solutions of alcohol, formalin, and prepa- rations of lime. Cold water is also used (5 per cent.) to liquefy the carbolic crystals. The bottles used should be clean and sterile, and pro- vided with glass stoppers instead of the ordinary cork, which is an absorbent material. Before pouring a solution nurses should be taught to wipe the rim of the bottle with a gauze sponge soaked in a little of the solution to remove any dust that may adhere. CHAPTER XIII PREPARATION AND STERILIZATION IN SUR- GICAL WORK The Hands—Field of Operation—Instruments—Rubber Vessels —Sutures and Ligatures: Catgut, Plain, Iodin, Formalin, Chrom- icized, Cumol—Dusting-powders—Oils and Ointments—Dressings —Sea-sp onges—Brushes—Cultures. In carrying the principles of asepsis into practice at an operation or a surgical dressing, we have two points to consider: 1. The preliminary preparation of all things to be used which may be channels of infection. 2. The methods by which, at an operation or dressing, they are so handled as to insure their remaining "sterile." The object of either is, first and last, the prevention of infection or bacterial invasion of the wound. Under the first heading we must consider the prepara- tion of the hands of the operator and of those concerned in assisting him, and of the field of operation, the sterili- zation of instruments, ligatures, sutures, dressings, and appliances. The following are the methods accepted at the present day in the leading American hospitals, and, with some modifications, are in practically universal use. THE HANDS The most important part of any preparation involving the skin is a preliminary scrubbing with hot soap and water, using a small scrub-brush whenever possible. This is especially important in the preparation of the hands. In operative work the so-called preparation of the hands includes always the forearms to a point above the elbow. Liquid green soap or tincture of green soap (an alcoholic preparation of green soap) is usually preferred; it can be sterilized and kept in sterile flasks. A hand-brush and 447 448 PREPARATION, STERILIZATION IN SURGICAL WORK nail-cleaner, sterilized since last used, should be provided for each person. The water should be changed at least twice during the process; unless the water in the pipes is actually sterile, it is not* usually practical to provide sterile water for the mechanical part of the preparation of the hands; it should, however, be carefully filtered. The preliminary scrubbing should be invariably carried out by the clock. Thus: 1. Scrub arms to elbows in a lather of soap and hot water one minute, then hands two minutes, using a brush and paying particular attention to the inside of the fingers; rinse in running water—change the water. 2. Clean the nails and remove loose epithelium round the nails with the nail-cleaner. (Any one actively en- gaged in surgical work should keep the nails very short.) 3. Scrub vigorously with the brush five minutes. The preliminary scrubbing effectively carried out, there are two or three methods of chemical disinfection in general use. In many hospitals the hands and forearms are im- mersed in alcohol, 75 per cent., unheated, for two minutes. Solutions used should be contained in sterile basins of sufficient size and depth to allow the arms to be immersed. Schatz method, also known in America as the Kelly method: 1. After scrubbing as above, immerse in a saturated solution of potassium permanganate until the skin is brown. 2. Immerse in a saturated solution of oxalic acid until the color is removed. 3. Rinse in sterile lime-water to neutralize the acid. 4. Immerse in bichlorid of mercury 1 : 1000 and scrub the skin briskly for a full minute. A modification of this method, omitting the lime-water bath, is in common use. Furbringer Method.—1. After scrubbing as above, im- merse in alcohol, 75 per cent., unheated, for one minute, rubbing the skin briskly to remove the superficial epithe- lium and fat. 2. Repeat the process in bichlorid of mercury (1 :1000) for three minutes. THE FIELD OF OPERATION 449 Weir or Stimson Method.—1. After scrubbing as above, make a paste of equal parts of chlorinated lime and car- bonate of soda, with cold sterile water. Rub the paste into the skin of the hands and forearms for five minutes. 2. Rinse in sterile water. 3. Wash in weak solution of ammonia water to neutral- ize the odor of chlorin. Once the hands have been sterilized, care must be taken that they come in contact with nothing unsterile. Nurses should be taught to hold their hands after "scrubbing up" with the elbows acutely flexed and the hands on a level with the shoulder. This keeps the hands out of the way, and the position is a reminder of the care to be exercised. THE FIELD OF OPERATION On account of the irritation to the tissues the field of operation is not prepared more than about twelve hours before the operation. Almost all surgeons at the present day prefer no preparation other than washing with soap and water, shaving when necessary, until the patient is on the table. In preparing the field, a wide area is scrubbed with soap (tincture of green soap usually) and hot sterile water, using, wherever possible, a hand scrub-brush, and shaved with a sharp razor and a good lather. At least five min- utes should be given to the scrubbing. The scrubbing over, the soap is removed with hot water and the area washed with alcohol and then ether (some omit the ether), in order to remove all grease and debris of superficial epithelium and to prepare the way for the disinfectant. Finally, the surface is freely flushed with a hot solution of bichlorid of mercury, 1 : 2000. Nurses should be taught to use sponges for the alcohol and ether washings and not to flush the area from the flasks, a practice that is quite unnecessary and very extravagant. In those cases of abdominal section where there is local tenderness or distention, preparation of the area is usually postponed until the patient is under the anesthetic. If 29 450 PREPARATION, STERILIZATION IN SURGICAL WORK it is carried out, it must be done with extreme gentleness, using sponges only and no brush. Some gynecologists use Kelly's process of skin prepara- tion for abdominal sections, using sponges in place of the immersion. Great care must be taken that the oxalic acid is completely removed, and that none is allowed to escape and run down the patient's back, where it will irri- tate and possibly burn the skin. In emergency work a solution of tincture of iodin is often used for the skin preparation, and is also favored by some surgeons in geneuil surgery. A 7 per cent, solution of iodin in alcohol is used (adults) for septic and emergency cases, a three-quarter strength of 7 per cent, for clean cases. Benzin is applied before the iodin to prevent burning. The iodin is removed after the operation by alcohol. The skin preparation should be carried out with the same care in preparing an area for minor operations, such as exploration, aspiration, hypodermoclysis, etc. A minimum preparation is permitted in giving hypo- dermic injection of medicines. Provided that all that is to be used is sterile, it is considered sufficient to wash a small local area with alcohol (p. 319). The puncture is so fine that it practically closes as soon as the needle is withdrawn. In preparing the field of operation, the preparation should also include a generous portion of the surface in the vicinity of the proposed incision. In determining the area to be prepared for various operations the follow- ing list is compiled from the instructions issued to the nursing staff of Johns Hopkins Hospital, The Pennsylvania Hospital, Philadelphia, and the Philadelphia Polyclinic Hospital. Abdominal Cases.—From the nipple to the knee, and from the bed-line on either side. Shave the pubes and the abdominal wall from the umbilicus four inches on either side the median line. Stomach.—From the clavicle to the pubes, and from the bed-line on either side. Kidney.—From sternum to spine on the affected side, and from axilla to hip. THE FIELD OF OPERATION 451 Breast.—From the hair-line and ear to the waist-line; from the nipple on the opposite side to behind the shoulder of the affected side; the arm to the elbow and the axilla of the affected side, shaving the axilla. Glands of Axilla.—From the sternum to the spine on the affected side, and from neck to waist; the arm to the elbow, shaving the axilla. Glands of Neck.—Hair-line (above, if the glands are high) to nipple; axilla and shoulder on affected side, shaving the axilla; the arm to the elbow. Brain.—Shave the whole head, prepare the skin of the head and neck. Limbs.—Shave and prepare well above and below the affected part. Nurses may have to be warned against shaving where it is unnecessary. A razor should never be used on the face, neck, breast, or arm (except the axilla) of a woman without distinct orders. When an area has been shaved, the hair is always apt to grow in again more strongly, which may be disfiguring. An eyebrow is also not to be removed without definite instructions. Vagina and Cervix.—Place the patient in the lithotomy position. Shave the labia and lower half of pubes; pre- pare the external genitals, covering the area from the pubes to the bed-line; continue the preparation to the inner sur- face of the thighs and buttocks, about eight inches on either side. Cover the genitals with a large sterile perineal pad applied with a T-bandage. A hot antiseptic douche (bichlorid o: mercury 1:5000, boric acid, 2 per cent., or lysol, 2 per cent, is usually ordered as part of the preparation. Some gynecologists order the vagina washed with soap and hot water before the douche. The patient lies in the lithotomy position, the vagina held open with a Sims speculum; the cleansing is done with gauze sponges on long sponge-holders. This preparation is usually post- poned until the patient is under ether. The Rectum.—Shave in the vicinity of the anus, and prepare the buttocks and inner surface of thighs about eight inches on either side and to the bed-line (lithotomy 452 PREPARATION, STERILIZATION IN SURGICAL WORK position). Cleanse the rectum by enemata of hot soap and water, repeated until the lower bowel is entirely empty. No dressing is applied. An irrigation (such as creolin, 2 per cent.) an hour before the operation may be ordered, and in particular cases a medicated suppository may be necessary. This is a special order, and not part of the routine treatment. The Mouth, Tongue, Palate, etc.—For some days pre- viously an antiseptic mouth-wash is used two or three times a day. Usually peroxid of hydrogen, diluted with equal parts of lime-water, is the wash preferred. For major operations the mustache and beard are shaved. The teeth are previously put in order by a dentist. The Nose.—For an operation of any extent on the nose the mustache is shaved and the face from hair-line to chin prepared in the usual way. A preliminary nasal douche of warm boric solution (2 per cent.) or other antiseptic may be ordered. The Ear.—For minor operations on the auditory canal or the ear-drum cleanse the external ear and the auditory meatus, using for the latter small pledgets of cotton. Leave a pledget soaked in the antiseptic in the meatus. For mastoid operations shave and prepare half the head, and prepare face, neck, and upper half of shoulder on the side of the affected ear. Douching is not usually ordered. The Eyes.—1. Wash the face from hair-line to lips with soap and water, and sponge with alcohol, taking care to keep the eyelids closed. 2. Hold the conjunctival sac well open and douche thor- oughly with warm boric solution (2 per cent.) or with bichlorid of mercury 1: 10,000; boric is usually preferred, as mercury produces a dry, uncomfortable sensation. No force must be used. 3. Cover the affected eye with a sterile gauze pad, and over that place a gauze dressing to cover the face on the affected side. The preparation is usually ordered about one hour before the operation. Eye drops of atropin are frequently ordered as part of the preparation. (See Chapter IV.) They will, however, THE FIELD OF OPERATION 453 be introduced at a specified time, and not necessarily at the time of the skin preparation. If both eyes are ordered to be prepared, or if neither is covered, the eye to be op- erated on should be indicated by some intelligible mark. One accident is on record where the wrong eye was re- moved, resulting in total blindness. Skin-grafting.—In the preparation of a wound to be grafted {i. e., to be covered over with living tissue) anti- septics are avoided, as they coagulate the albumin and to some extent destroy the vitality of the tissues. The wound is usually cleansed with normal salt solu- tion and covered with a wet dressing of the same. The area from which the grafts are to be taken is pre- pared according to the usual formula, followed by a thor- ough washing with normal salt solution, and covered simply with a dry, sterile towel. After the preparation no antiseptics are used either in covering the area or dur- ing the operation. Many surgeons, indeed, omit the anti- septics also from the preliminary preparation, and order only a thorough cleansing with soap and water and flush- ing with normal salt solution. The grafts are usually taken from the inner surface of the thigh. The whole of the inner surface is prepared. Cauterization; Wet-cupping.—In preparing the skin for cauterization by the actual cautery or for wet-cupping neither alcohol nor ether is generally used, the reason being that, unless completely removed from all parts, such inflammable substances may readily ignite and cause a burn. The preparation is done immediately before the application. Dirty and Infected Wounds.—The preparation of such depends on the extent and nature of the injury, and no special rules can be laid down. The area round the wound should first be cleansed, washing away from the wound; where necessary, as in scalp injuries, it must also be shaved. The wound itself is then first washed free of all dirt, using soap and water and flushing with sterile water, following which it is washed with a 7 per cent, solution of tincture of iodin and dressed with the same diluted to three-quarters the strength. (See p. 450.) 454 PREPARATION, STERILIZATION IN SURGICAL WORK INSTRUMENTS Instruments, except those with cutting-edges, are ster- ilized by boiling for ten minutes. To prevent spotting with rust, the water should be actively boiling at the time of immersion, and should completely cover the instru- ments. Bicarbonate of soda, 1 per cent, (about three level teaspoons to the quart), is frequently added to the water, also for the prevention of rust, but must be omitted if rubber or silk materials are boiled at the same time. Shot and safety-pins are boiled with the instruments— the shot in small muslin bags, the safety-pins, for con- venience, strung six at a time on a safety-pin. In hospital work the instrument sterilizer is a wide metal boiler filled with one or more trays on which the instruments are placed for sterilization, and on which they can be removed and carried to the operating-table without handling. In private work a fish-kettle makes an excellent substitute. After use, instruments should at once be covered with cold water until ready to be cleaned; this is in order to dissolve the albumin in the blood-stains. In cleaning, the steps are as follows: 1. Remove the blood-stains with cold water. 2. Place in boiling water and boil for ten minutes. 3. Scrub vrith hot water and Sapolio, Bon Ami, or similar soap. 4. Drain on a towel, dry thoroughly, rub up with a little alcohol. Whiting, made into a paste with alcohol and ammonia, is sometimes used to polish plated instruments. Ex- treme care is then necessary to remove all traces of powder from joints and teeth. In many hospitals the use of paste is forbidden. Scissors, forceps, needle-holders, and all shutting instru- ments should be open while being sterilized, and should be kept open while in the instrument closet, in order not to strain the spring unnecessarily. During operations it is, however, a convenience to string artery forceps (closed) together, six at a time on a safety-pin. This is generally allowed, provided they have previously been sterilized open since the last operation. INSTRUMENTS 455 Sharp Instruments.—Boiling in water to a great extent blunts sharp instruments, such as knives, needles, scissors, etc., and their care is slightly different from other instru- ments in consequence. Before an operation knives may be immersed in boiling water for one minute and then laid in 5 per cent, alcohol for fifteen minutes, or in carbolic 1 : 20 for. two minutes. At the present day many surgeons favor a preparation known as Russian oil in which fine cutting instruments are immersed and boiled for five minutes without danger of blunting the edges. After boiling they are wiped with a sterile sponge and used without immersion in alcohol or an antiseptic. After an operation knives are cleaned as above, sterilized according to the formula preferred, and sent to be sharpened. Cutting instruments are protected when not in use by winding the blades with a fine strand of cotton; they should always be sterilized separately from other instru- ments. Needles may be run through a piece of gauze for con- venient handling; when not in use, they may be kept in covered glass boxes with a little emery powder to prevent rusting, or they may be put up in pairs between two folds of gauze, and a convenient number kept thus ready for immediate use in sterile, covered glass jars. Each jar should contain needles of only one variety. Spots and rust-marks are removed from needles and blades with emery powder. A small board covered with flannel is kept for the purpose; the instrument is laid flat on the board and covered with emery powder and rubbed. Delicate instruments, as cystoscope, urethrotome, etc., are spoiled by boiling. They may be sterilized in the auto- clave or by soaking half an hour before use in alcohol, 5 per cent., in carbolic acid, 1 : 20, or in formalin, 2 per cent, Corrosive sublimate is never used for instruments. Where there are hinges or screw parts these should be oiled after cleaning. Needles.—The different needles, and the purposes for which the varieties are used, should be taught the pupils in a demonstration class. For the skin and connective tissue, which are tough, resistant tissues, needles with 456 PREPARATION, STERILIZATION IN SURGICAL WORK cutting-blades are used; for tissues that are easily torn and vascular, such as the kidney, intestines, cervix, etc., rounded needles, the point only sharp, more like the ordi- nary sewing-needle, are preferred; needles with flat blunt blades, the point only sharp, are used for suturing deep fascia without injury to the adjacent tissues; needles for superficial work are usually straight or semi-curved; those used for the deeper fascia are curved. Needles for the deeper facsia are mounted on holders, of which there are a large variety, almost every surgeon having some special preference in this respect. According to conve- nience, the eye of the needle may be at the blunt end or at the point. For the deeper fascia, where a holder is necessary, the eye is more frequently at the point. A few needles for special purposes are frequently made with their own handles; such are the needles used in operations for hernia (right and left), for cleft-palate, and for suturing the pedicle or stump in operations for removing the ova- ries. An aneurysm needle is also mounted on its own han- dle; it is a flat, blunt, semi-curved blade, the eye at the point, used in transfixing blood-vessels, as, for example, in the simple operation of intravenous infusion. The needles are, as a rule, in charge of the nurse at an opera- tion. A card with a sample needle of each kind used in the hospital is a great help to the operating-room nurses; the card should show the name of the needle and a couple or so of cases for which the special needle is used. (Massa- chusetts General Hospital.) Hollow needles, such as those used for hypodermic injection, exploration, aspiration, intravenous infusion, etc., require special care in cleaning and sterilizing to pre- vent the fine tube becoming clogged with rust or with coagulated albumin. Invariably, immediately after use, they must be washed in cold water, which must run freely through the needle. If attached to a syringe, the water is drawn and expelled repeatedly through the needle. The wire must be passed through the needle repeatedly during the process, to help INSTRUMENTS 457 in the removal of any deposit. When clean they are sterihzed as above. Before putting away, the needle must be dried by briskly moving the wire in and out, drying it each time. Wlien perfectly dry, the wire is inserted and kept in place. The wire must come well beyond the point of the needle in order to protect it. The hypodermic needles in constant use in the wards are conveniently kept in covered glass boxes with a little emery powder or fine shot, which keeps them free of rust. Trocars and Cannulas.—Cannulas are cleaned with the same special care as hollow needles, but may be boiled for the full time, like non-cutting instruments. The trocar, being a sharp instrument, is sterilized according to the formula, the point being protected with cotton. Trocars and cannulas should be separate while being steril- ized ; a flexible probe is used in place of the trocar to clean the inside of the cannula. Silver catheters must also be cleaned with minute care under running cold water immediately after use. The stilette is used like the wires of needles to clean and dry the inside, and is kept in place while the catheter is not in use, but is removed during boiling. Not being sharp instruments, catheters are sterilized by boiling the full time. No paste or powder should be permitted in clean- ing catheters, as it is difficult to prevent it lodging in the eye. Scrubbing with hot water and Sapolio, followed by rubbing with a dry chamois leather, is sufficient to keep them bright. Paquelin Cautery.—An instrument requiring a special process in sterilizing is the Paquelin cautery. The tips, which must be sterile, are made of hollow platinum (p. 105) and are readily indented when heated. After use, the tips should immediately be brought to white heat for one minute, in order to burn off any organic matter that may be adherent; they must then be allowed to cool slowly, in such a position that they will not be exposed to knocks or falls while soft. When thoroughly cooled, they may be washed, if necessary; usually rubbing with chamois leather is all that is required. The heating is adequate 458 PREPARATION, STERILIZATION IN SURGICAL WORK sterilization. The same process is used in sterilizing the platinum wires used in taking cultures. The closet in which instruments are stored should be dust proof. Those made of glass with a metal frame are the most easily kept clean. To prevent rust, a dish con- taining plaster-of-Paris, which absorbs moisture from the atmosphere, should be kept in the closet and renewed from time to time. The instrument cases made by the leading firms are provided with a barometer, so that the humidity of the air in the case can be gaged. For the same reason the closet should be in as dry a place as possible. It should not, for example, be exposed to steam from hot- water supply or the sterilizers. Nurses should be taught to arrange the instruments in convenient groups, and invariably in the same order. Syringes.—Glass syringes with a glass piston or with asbestos packing can be sterilized by boiling. The water must be cool when the syringe is first put into it or the glass will crack. With metal attachments and rubber washers boiling is impracticable. The syringe is then cleaned by drawing first cold water and then hot soap and water in and out of the syringe repeatedly, finally rinsing thoroughly. It is sterilized by drawing alcohol, 75 per cent., formalin, 2 per cent., or other disinfectant into the barrel and then placing the syringe in the antiseptic for half an hour, taking care that it is completely covered.1 This is necessary if the syringe is to be used for exploratory pur- poses or for the administration of antitoxin serum. For ordinary use it is not necessary that the outside of the syringe should be sterile. If the washers have shrunk, they must be soaked in sterile water to swell them again. The air-pump attached to an aspirating apparatus is sometimes mistaken for a syringe and ruined by having water drawn into the barrel. The air-pump cannot be thoroughly sterilized without spoiling it; for this reason when aspiration is performed the pump is worked by an "unsterile" assistant. (See Chapter XIV.) 1 If the syringe is to be used for exploratory purposes or for antitoxin serum injections, alcohol is preferred to an antiseptic. RUBBER 459 RUBBER Prolonged exposure to heat destroys rubber; acids cor- rode it; if in contact with oil or grease, it becomes soft and partially dissolved; soap, on account of the grease, has also a deteriorating effect, while all rubber, if put aside, readily becomes dry and cracked. Rubber appliances, therefore, are extremely difficult to care for, and are, in addition, expensive items. Some general rules for their care are applicable to all rubber articles. Do not use soap where it can be avoided; in scrubbing, use tepid water in place of hot, remove the soap quickly, and rinse very thoroughly in cold water. Clean in cold water immediately after use if the articles have come in contact with organic matter. If boiling is necessary allow ten minutes, keeping the water actively boiling; use no carbonate of soda and protect from con- tact with the metal of the sterilizer by laying the articles on a folded towel; keep light rubber articles from floating by folding in a towel, or by tying loosely in a square of gauze and clipping to the little package a pair of artery forceps to act as a weight. Each surface of the article to be cleaned or sterilized must be equally thoroughly cared for. Gloves and nipples must be turned inside out, and cleaned on either side. Tubing and catheters must have the water or solution run freely through them; this is most thoroughly done by attaching a funnel or the barrel of a glass syringe to one end, and holding under a spigot of running water. Hard-rubber articles (catheters, nozzles, tracheotomy tubes, etc.) are temporarily softened by exposure to heat and lose their shape. To avoid this, if boiling is neces- sary, insert the stilette or a probe bent to the shape and keep it in place during boiling, and until the rubber hardens again on cooling. Where chemical sterilization is preferred, immersion must be complete, and should be continued for a specified time, and no more. Alcohol, 70 per cent., formalin, 2 per cent., or corrosive sublimate, 1 : 5000 are the antiseptics usually preferred. After immersion rinse thoroughly in cold sterile water before putting away. Before use place in 460 PREPARATION, STERILIZATION IN SURGICAL WORK alcohol, 70 per cent., for fifteen minutes or in a 2 per cent. solution of boracic acid. Dry all rubber goods thoroughly before putting away, and keep in as cool a place as possible. In drying tubing, catheters, etc., stretch repeatedly to squeeze all moisture from the inside; dry gloves and nipples, etc., on both sides. In putting away, avoid all folding. Keep double surfaces apart, either by inflation (air-cushions and beds, etc.) or by keeping gauze or cotton between. An ice-bag, for exam- ple, not in use should be kept blown up and lightly packed with gauze. If the articles are out of use for any length of time, they should, when practical, be soaked from time to time in cold water. Gloves of thin, flexible rubber are at the present day used during operations and for other surgical proceedings, such as dressings, and vaginal or rectal examinations, as they can be made more certainly sterile, and are more easily kept so, than the hands. Unless quite intact, they may be a source of danger, since they cause the hands to sweat and the sweat will readily ooze through any small opening. Pricks and cuts are detected by holding the glove in a basin of water; as it fills under water, little air-bubbles will appear at any puncture, however minute. The punctures must be sought for and repaired with rubber cement after each use. Mended gloves can be used by the nurses or for ward dressings, but are not safe for operation, on account of the risk of the small patch becoming separated. After use, blood-stains and all organic matter should be removed with cold water while still wet, after which each glove is scrubbed inside and out with tepid soapsuds, using a brush thoroughly, but lightly, and rinsed well in cold water. New gloves are treated the same way before use. In sterilizing, some hospitals use the autoclave, espe- cially for gloves that are to be used in. operating. After cleaning, dry thoroughly, powder both surfaces freely with talcum powder, wrap in the usual double cotton covers, and sterilize with the dressings twenty minutes at fifteen pounds' pressure. In other hospitals gloves are sterilized RUBBER 461 by boiling ten minutes, and have no other treatment beyond thorough cleaning. For chemical sterilization clean as described, then place for fifteen minutes in alcohol 75 per cent., corrosive sub- limate 1 : 5000, or in formalin solution 2 per cent. Before use soak again in the solution for thirty minutes. As smooth rubber presents an almost non-absorbable surface, provided the cleansing is thorough, the articles are readily made sterile. Gloves are less liable to tear and more easily adjusted if put on wet and inflated either with sterile water or anti- septic solution. Rubber Tissue.—Sterile rubber tissue is frequently used as a dressing to cover granulating surfaces. It pro- tects delicate granulations from being torn, which is liable to happen when dressings that have stuck to the tissues are removed. To prepare: Scrub lightly first in cold water, then in tepid soap and water, and rinse in cold water. Place over the tissue a layer of gauze the same size and cut both together to the required shape and size. Pack in sterile jars, a layer of gauze between each piece of tissue. Fill the jars with bichlorid of mercury 1 : 10,000, and leave ior twenty-four hours. Pour off and refill either with fresh solution of the same or sterile normal salt solution. The latter is usually preferred, especially if the tissue is to be used for skin- grafting or extensive granulating wounds. Rubber tissue should be tested before using, as it is liable to become brittle. In good condition it is pliable and slightly elastic. The tissue is dissolved by heat, ether, chloroform, turpentine, and similar preparations. Rubber Catheters, Rectal Tubes, Etc.—The cleansing and sterilization of these articles, and more especially of catheters, is so important that a special formula should be insisted on in caring for them. Immediately after use, wash under running cold water, using a funnel, as described, two minutes by the clock; leave soaking in cold water at least three minutes longer. 462 PREPARATION, STERILIZATION IN SURGICAL WORK Scrub in tepid water and suds; rinse under running cold water. Run boracic 2 per cent., or formalin 2 per cent, through the catheter repeatedly (at least ten times), and soak in the same thirty minutes; rinse again under running cold water. Boil ten minutes. Stretch repeatedly between the fingers until dry, and put away dry. Repeat the boiling for five minutes immediately before use, and wrap in a sterile towel until required, or, if pre- ferred, place in a 2 per cent, boric acid solution. The formula may be applied to rectal tubes, stomach- tubes, and rubber tubing used for drainage if required to be used again. Rectal tubes used for oil enemata quickly deteriorate, as it is practically impossible wholly to remove the oil from the inside. They should be kept by them- selves, as other rubber articles, if put with them, are also spoiled by the oil. In most hospitals it is a rule that new rubber tubing, catheters, etc., are thoroughly washed as above, and boiled for fifteen minutes as a preliminary precaution, or it may be sterilized in the autoclave under 15 pounds pressure for forty-five minutes. Catheters of Glass or Metal.—These are sterilized by boiling, usually ten minutes after use and cleaning, and five minutes before use, are required. As they can be sterilized with certainty, glass catheters are used wherever practical in preference to rubber ones. The finest (filiform) catheters and bougies of hard rubber or of silk may be roughened and cracked even by the above method of sterilizing, and should never be boiled. Frequently they are simply thoroughly cleaned with soap and water and laid in alcohol, 75 per cent., half an hour before use. Carbolic solution 1 :20, or formalin 2 per cent., may be used instead of alcohol, or they may be sterilized in the autoclave. Rubber catheters, tubing, and similar articles are so difficult to sterilize with any certainty that if used for an infected case, they should be reserved for the individual use and destroyed when finished with, SUTURES AND LIGATURES 463 Rubber sheets or mackintoshes are hot usually re- quired to be sterile. After use, however, especially after an infectious or a septic case, they must be carefully dis- infected. Remove organic material with cold water; if it is not practical to clean them immediately, stained rubber sheets should be put to soak in cold water while still wet. This will dissolve the albumin and prevent stain-marks. Scrub with soap and tepid water and rinse very thor- oughly in cold water: sand-soaps scratch and spoil the rubber and must not be used. Immerse in an antiseptic solution for a specified time— for example, corrosive sublimate 1 :5000 or in formalin 2 per cent, for one-half hour. Rinse, wipe, and hang in the air until dry. Avoid fold- ing in putting away; hang over a wide wooden rail, or lay extended on an unused mattress. GLASS. CHINA, AND ENAMELWARE Glass and china are easily cracked in the autoclave if carelessly packed without due allowance for expansion (p. 427), if placed directly in very hot water, or if too rap- idly cooled; otherwise articles of glass, china, or enamel- ware can equally well be sterilized in the autoclave, by boiling, or by soaking in a strong antiseptic, such as bichlorid of mercury 1: 500 or carbolic acid 1: 20 for one hour, or formalin 2 to 5 per cent, for half an hour. Glass or good china stand sterilization better than enamelware, which either with heat or chemicals quickly loses its pol- ished surface. Exposure to heat, as in the autoclave, also seems to loosen the enamel and leave it liable to chip easily, and the rough surface so exposed is a harboring-place for dust. SUTURES AND LIGATURES These may be divided into two classes—non-absorbable and absorbable. Non-absorbable Sutures.—These are used where strength and security are the requisites, as in closing wounds. Those in general use are: 464 PREPARATION, STERILIZATION IN SURGICAL WORK Silk-worm gut. Horsehair. Silk. Silver wire. Linen. All the above may be sterilized by boiling ten minutes except silk, which is weakened if boiled for longer than five minutes. Silkworm-gut (fishing-gut) is the ordinary suture or stitch used in closing wounds. It is the silk-producing gland of the silkworm, stretched into a long strand and dried while fully stretched. It forms a smooth, white, strong strand, non-absorbable and non-porous, stiff and bristly when dry, but softened by hot water. The strands vary from 12 to 18 inches long, the average length being about 14 inches. The different thicknesses cannot be accurately assorted, depending, as they do, on the size and the stretching quality of the gland. They are sold in three sizes,—fine-, coarse, and medium,—with an extra fine and an extra coarse not always easy to be obtained. The tied ends of the sutures when dry are sharp and prickly; where this may cause discomfort, they may be clamped with shot. As silkworm-gut causes a certain amount of scarring, it is not usually used on exposed surfaces, such as the face or hands. Silkworm-gut contains in itself no pathogenic organisms, is not altered by exposure to dry heat, nor spoiled by boil- ing, and is permeable to antiseptics; it is, therefore, readily sterilized. Frequently the silkworm-gut is dyed, usually with iron dye, which gives it an antiseptic quality. The formula is as follows: Cut off the ends and boil eight minutes. Pour off the water. Boil fifteen minutes in ferrous sulphate, 25 per cent. Pour this off. Boil five minutes in tannic acid, 10 per cent. Stand a few hours, then pour off and dry. After drying wash in cold water; it is then ready for use. To prepare: Wash by scrubbing on a board with hot soap and water, and rinse thoroughly under running cold water. Fold in a piece of gauze, a dozen strands at a time, put SUTURES AND LIGATURES 465 up in the usual wrapper of double muslin, and sterilize in the autoclave with the other dressings for forty-five minutes under 15 pounds pressure. Immediately before use soften by immersion in boiling water for one minute. (Longer immersion will not injure the suture.) A second process of sterilization is as follows: Place so many strands, six or twelve together, for example, in glass-stoppered jars filled with a 1 :500 solution of bi- chlorid of mercury; the solution should be hot. After twenty-four hours empty the solution and fill two-thirds full with pure alcohol, taking care to cover the strands; boil ten minutes in a water-bath. The strands are kept in the jars in which they are sterilized until they are to be used, when they are softened by immersion for not less than a minute in boiling water. Many hospitals sterilize the silkworm-gut only by boil- ing ten minutes just before use; soda must not be used in the water. Repeated boiling is not considered to injure the suture. In threading the needle pass about one inch through the eye, bend sharply, and twist together twice to prevent slipping. Silk.—A good quality of silk, both black and white, of various sizes, is frequently used for suturing, especially in operations about the face, where it is important to avoid scarring. For different purposes plain, twisted, or braided silk is preferred, in sizes 5 to 8. Silk is also used in work on delicate tissue, such as the intestines, kidneys, and gall-bladder, and other internal organs, and for tying pedicles, etc. Its advantages are that it is strong and very pliable, and that the knot does not slip. To prepare, for convenience, strands 27 inches long are wound on separate glass spools. Four or six spools of one size of silk are prepared and placed end to end in a wide glass tube, a wad of cotton being laid at the lower end and between each spool to avoid knocking together; the tube is also plugged with cotton. The size of the silk should be marked on the tube. Silk may be sterilized by boiling five minutes, or the 30 4()(> PKKPAKATION, STKRILIZATION IN SlHGICAL WOliK lubes, filled and plugged, are placed in the autoclave and the silk sterilized twenty minutes. The sterilized tubes may be kept, conveniently in cov- ered glass jars. Linen.— Some surgeons use linen in place of silk for intestinal sutures, etc. It is stronger than silk, more easily fastened and tied, stiffer and easier to thread when wet. Also, having less capillarity, linen is considered to present more resistance than silk to infection passing along the thread. Two varieties are used: Black, sizes 0 and e. Pagenstecher, sizes 0, 3, 5 (fine, medium, heavy). Linen is sterilized by boiling ten minutes. Horsehair.—Sutures of horsehair, taken from the horse's tail, are not much used at the present day, but are still occasionally preferred for fine stitching on the face or scalp. The sutures are removed at an early date. Horsehair forms a fine elastic suture, but breaks easily under tension. They require careful preparation, espe- cially on account of the risk of possible contamination by the tetanus bacillus, one of the spore-producing organisms. To prepare: Separate coarse from fine hairs, and cut in strands of equal length (16 to 20 inches); knot 12 together at either end, and scrub on a board with hot soap and water. Rinse under running water. Cut the strands an inch below each knot, and twist into a loose coil. Place the coils in sterile, glass-stoppered jars, filled with sufficient pure alcohol to cover the coil, and sterilize in the autoclave, or, if preferred, place the closed bottles in a water-bath and boil ten minutes on three successive days. Keep in the alcohol jars until required. In threading the needle a surgeon's knot is tied below the eye to pre- vent it slipping. Silver Wire.—Wire sutures of pure virgin silver are used chiefly in suturing bone, and are removed when their purpose is accomplished. To prepare: Scrub on a board with hot soap and water, rinse, dry, wind in a loose coil, and keep in a clean, covered box in a dry place. To sterilize, boil ten minutes. SUTURES AND LIGATURES 467 In threading, pass half an inch through the needle, bend sharply, and twist once. Silver in itself has certain antiseptic properties, and the sutures have an antiseptic influence on the tissues with which they come in contact. Absorbable Sutures.—Catgut, Kangaroo tendon. The value of these sutures is that, being themselves organic substances, they are absorbable by the human tissues, and can, therefore, be used for ligatures and for deep sutures which are to be retained. Catgut.—Catgut is obtained from the small intestine, of the sheep. Its preparation is not invariably left to the nursing staff; in many hospitals, and usually in private practice, it is procured, fully prepared and sterilized, in sealed tubes from surgical dealers. (See below.) Very careful preparation and sterilization indeed are necessary, for the reason that the tissues of the sheep may contain organisms that produce disease in man, and the catgut itself, being an organic substance, can act as a me- dium, under suitable conditions, for the development of germs with which it comes in contact; such, for example, as the pus-producing organisms. The sheep may be in- fected by such organisms as the tetanus and the anthrax bacilli. Both these varieties, we remember, are subject to spore formation (p. 359); the methods of sterilization must, therefore, be sufficient to destroy spores. At the same time the process must not make the catgut brittle or weak, nor must antiseptics be used that will irritate the tissues into which the catgut is introduced. If catgut, in its unprepared state, is exposed to boiling, a substance named collagen, of which catgut is largely composed, is converted into gelatin, completely spoiling the suture. Dry heat does not alter catgut if the catgut itself is perfectly dry; the least moisture, however, is sufficient to act upon the collagen and convert it into gelatin when the catgut is exposed to heat. Catgut is, in fact, an extremely difficult substance to prepare, re- quiring conscientious care at every step. Properly prepared catgut is free from fat or moisture, pliable, smooth, and tough. A ligature that feels hard and wiry is usually brittle, and should be discarded. In tying, 468 PREPARATION, STERILIZATION IN SURGICAL WOHK good ends must be left to the knot, as, in contact with the warmth, moisture, and cell activity of the human tissues, catgut swells, and if allowance is not made, the knot may slip. This is the common cause of post-operative hemor- rhage. In most of the processes of preparation the catgut is wound on glass spools; care must be taken to wind in a single layer, otherwise, where the strands cross, the pressure prevents the necessary drying and hardening from taking place, and a weak spot results, which will break under strain. The coil is most conveniently cut into three lengths. Catgut comes in various sizes, numbered from 00 to 8. In some of the preparation methods the time required for immersion in the agent varies with the different sizes. The minimum is reckoned for 00, the maximum for 8. The sizes most used are from 0 to 4. Prepared catgut is conveniently stored in wide-mouthed glass bottles with ground-glass stoppers. These must be carefully washed and sterilized before being used. All necessary handling during the process of preparation and sterilization must be done with sterile forceps. The best media for storing catgut are alcohol, glycerin, or simple oils; these have no action on the collagen, provided all moisture has been removed. The following methods are in use in many hospitals where the catgut is prepared by the nursing staff, and can be carried out without special apparatus: Plain Catgut.—Cut the strand into three lengths and wind in a single layer on glass spools; place the spools in a sterile jar, cover with ether, and stopper closely; leave for twenty-four hours, shaking the jar at intervals. This process removes the fat and so prepares the catgut for the antiseptic. Pour off the ether and refill the jar with 1:500 solution of bichlorid of mercury in pure alcohol; replace the stopper and stand aside for one hour. Transfer the spools to sterile, wide-mouthed bottles, and cover with pure alcohol; stopper closely and place in a water-bath; boil ten minutes on three successive days. By this process the collagen has been removed and the boiling will not injure the catgut. The boiling is repeated SUTURES AND -LIGATURES 469 each time before use. The catgut is not taken from the jar until required for use. Other methods of preparation have for their object the making of the catgut resistant for a longer time to absorp- tion by the tissues. According to the process used, liga- tures may be produced that will remain unabsorbed from two to six weeks. This is desirable in many important operations on the internal organs. The agents used are: iodin, cumol, formalin, chromic acid, tannic acid, alum, and others. The date of absorption cannot be measured absolutely, as the process may be modified by many conditions, such as the state of the health, the condition of the tissues, etc. The following are the processes in common use where such preparation is carried out by the nursing staff: Iodized Catgut.—Cut the strand in three lengths; make a loose coil of each over three fingers; thread the coils on one strand, like beads on a string. 2. Place in a glass beaker, capacity, 500 c.c. 3. Place the beaker on a sand-bath or asbestos mat in a hot-air oven (as used in laboratories). 4. During fifteen minutes raise the temperature to 100° C; maintain at this temperature fifteen minutes further {dry heat). 5. Pour liquid albolene into the beaker, sufficient com- pletely to cover the catgut, arid raise the temperature gradually during fifteen minutes to 140° C; maintain fifteen minutes and then turn off the flame {moist heat). 6. Leave to cool for twelve hours; relight, and bring to 140° C. in fifteen minutes; maintain at 140° C. fifteen minutes further; turn off the light. 7. Leave to cool for three hours; lift out the coils with sterile forceps, cut the connecting thread, and drop into wide-mouthed, stoppered bottles, previously sterilized, containing y^ per cent, solution of iodin in pure alcohol. The catgut is ready for use after forty-eight hours in the iodin solution (Philadelphia Polyclinic and others). Formalin Catgut.—1. Wind a whole coil of catgut on any convenient cylinder (such as an empty ether can) in a single layer. 2. Soak in formalin (3 per cent.) for from one and one- 170 PREPARATION, STERILIZATION IN SURGICAL WdliK half (size 00) to five hours (size 8), according to the size of the catgut. The catgut will be brittle if left too long in the formalin. 3. Wash in running water for twice the time that the catgut has been in the solution. 4. Roll in a single layer on a wide muslin bandage, and dry in the sun and open air. Finally— 5. Wind in a small coil round three fingers and store in glass-stoppered jars. Catgut prepared in this way may be boiled without injury, as the gelatinizing substance has been removed. The ligatures are boiled fifteen minutes before use. A Second Process.—After the immersion in formalin and washing in running water, as in the first process, transfer directly to sterile, glass-stoppered jars; fill with sufficient pure alcohol completely to cover the catgut; place the jars in a water-bath and boil fifteen minutes on three successive days. In place of the pure alcohol some use a 10 per cent, solution of glycerin in pure alcohol. Chromicized Catgut.—For this process a special glass spool is used, with a notch on either flange, by which the catgut is kept stretched and prevented from shrinking. 1. Cut the coil in two lengths, wind each tightly in a single layer on one of the reels, pass each end through its notch, and secure by passing one end through the barrel and tying both together. 2. Immerse the spools for from twenty-four hours to three days, according to the size of the catgut, in a chromic acid solution, as follows: Bichromate of potash............... 1.5 gm. Glycerin and pure carbolic, each..... 10.0 c.c. Water............................. 1000.0 c.c. 3. Remove and drain for a few hours. 4. Immerse the spools in 1: 500 solution of bichlorid of mercury in pure alcohol for six days. 5. Transfer with sterile forceps to sterile, wide-mouthed bottles, cover with pure alcohol, and stopper closely. Chromicized catgut can also be boiled without injury. It is boiled for fifteen minutes before use. Instead of using the bichlorid solution, the chromicized SUTURES AND LIGATURES 471 catgut may be treated with 3 per cent, formalin, as described, using the second process, and stored in a 10 per cent, alcoholic solution of glycerin. Cumol Catgut.—Cumol, a chemical compound with a boiling-point of 165° C, is, at the present day, much in favor as a preparation for catgut ligatures. It dissolves the fat in catgut, but unless carefully used is liable to make it brittle. To avoid this, the catgut must be very slowly dried by carefully graduated dry heat before the cumol is added; if this is done, a glue-like substance forms on the gut which will keep it supple. Cumolized catgut is most conveniently prepared in a special sterilizer, with which full directions are given. The preparation may, however, also be carried out, using a sand-bath and a glass beaker. The beaker should have a cardboard top, through a hole in the center of which a thermometer is passed, in order to ascertain the tempera- ture at each step, which is of the first importance. As cumol is highly inflammable, the beaker should be cov- ered with copper-wire netting to prevent accidents. The bottom of the beaker is covered with a layer of cotton, on which the catgut, wound and stretched on the special glass spools just described, is placed. The first process is to dry the catgut. Placing the appa- ratus over a gas Bunsen burner, the temperature is slowly raised to 80° C, as follows: First hour........................20u C. Second " ........................40° C. Third " ........................55° C. Fourth " ........................70° C. Fifth " ........................80° C. Sixth " .......................80°-85° C. By the end of the sixth hour the catgut should be free from moisture and ready for the cumol. Seventh hour: Lower the light and add cumol at a tem- perature of 100° C. sufficient to cover the catgut. Bring the temperature to 165° C. and maintain at this tempera- ture for one hour. Pour off the cumol and keep in the sand-bath at a tem- perature of 100° C. for two hours, in order to dry the catgut. 472 PREPARATION, STERILIZATION IN SURGICAL WORK Store either dry, in sterile tubes, or in pure alcohol in the usual stoppered bottles. Not only the time involved, but the risk that the process should not be effectually carried out, cause most hospitals to prefer buying their catgut ready prepared from some reliable firm. The iodized catgut of Davis and Geek, New York, is one of the most popular at the present day. It is sent out in hermetically sealed jars, which have been dehydrated to prevent deterioration. Besides the catgut in each jar is enclosed a glass tube containing 45 grams of iodin crystals. The jar is made with a hollow glass chamber in the center. The jar is opened under strict asep- tic precautions, the tube opened and the crystals poured into the center chamber. The jar is then filled with 6 ounces (180 c.c.) of 95 per cent, alcohol, covered securely and allowed to stand ten minutes, then gently shaken to distribute the iodin evenly, and the catgut is ready for use. It is more supple if allowed to stand for twenty-four hours. The strength of the iodin solution so formed is \ of 1 per cent. This is highly germicidal and at the same time non- irritating. At the present moment iodized catgut is preferred to all other forms. Kangaroo Tendon.—In special cases, where it is desir- able to retain a suture for an unusually long period, as, for example, in suturing bone, a suture made from the split sinew of the tail of the kangaroo may be preferred in place of catgut. The methods of preparation are the same as for catgut. DUSTING-POWDERS Some preparations, such as iodoform, are actively germ- icidal only when in contact with wound secretions; others are mixed with non-antiseptic preparations, such as starch powder, etc. These may be contaminated with bacteria from dust, etc., and should, therefore, be sterilized regu- larly in the autoclave and kept closely covered. If per- forated metal covers are used for the dusting pots, they (the covers) should be boiled daily and the pots kept in wide covered glass jars. Iodoform is altered if subjected to a temperature of DRESSINGS 473 239° F. or over. The powder is sterilized in the auto- clave at 7 pounds pressure for forty-five minutes. Dur- ing sterilization iodin vapor is given off; this should be allowed to escape by covering the jar only with a fold of gauze; if retained in the jar, the whole powder will become iodized and useless for its purpose. When this has hap- pened, the iodoform is turned brown. OILS AND OINTMENTS These may be sterilized twenty minutes in the auto- clave at 15 pounds pressure. If to be sterilized by boiling, place the jar or flask in a water-bath of warm water, bring to boiling-point, and maintain half an hour. Cool slowly to avoid cracking. Glycerin is usually sterilized in this way. The boiling should be repeated on three successive days, as oils and ointments readily harbor germs. Jars and flasks should be only two-thirds full. Flasks are plugged with absorb- ent cotton; jars should have the lids lightly adjusted over a double layer of gauze. Lids should not be screwed on during sterilization or the glass jar may break. Small bottles or jars previously sterilized may be conve- niently filled for use in the wards from the sterile supply. SOLUTIONS Provided the vessels are sterile and that the solutions are made from filtered sterile water, no further steriliza- tion is necessary for the ordinary dressing solution. Any solution, however, that is to be introduced directly into the circulation (as normal salt solution), or used to irrigate a closed cavity (as the peritoneum), must be ster- ilized in the autoclave twenty minutes under 15 pounds pressure or by boiling by the fractional method. DRESSINGS Loose-meshed, bleached gauze is now universally used for surgical dressings and for sponges. Hospitals, as a rule, have their own special shapes and sizes for these dressings. The cut edges should be turned in to avoid ravelings, which might adhere to raw surfaces. This is especially necessary in making gauze sponges. 474 PREPARATION, STERILIZATION IN SURGICAL WORK For sterilization a known quantity of cut gauze is wrapped in a double cover of unbleached muslin and ster- ilized in the autoclave for forty-five minutes at 15 pounds pressure. Not more than is necessary for one complete dressing should be done up in one wrapper. Dressings, such as perineal pads, eye-pads, etc., may be done up six or twelve in one wrapper, the wrapper so folded that only one pad is unfolded at a time. Sponges are put up in packets of 6 to 12 as required. The contents of all pack- ages should be marked on the wrapper in blue pencil. In many hospitals gauze dressings and sponges which are to be used inside the abdominal cavity are sterilized by the fractional method. After the first sterilization they are left twelve hours, then again sterilized at 15 pounds press- ure for thirty minutes. Besides the dressings cut to cover wounds, gauze is used to establish drainage and to pack cavities. Gauze bandages, \\ inches wide, are used for this purpose, to avoid the raw edges of the cut gauze. These are cut into lengths of one yard and packed into ster- ile glass tubes, which are stoppered with absorbent cotton. They are sterilized with the other dressings in the auto- clave. Towels, sheets, caps, gowns, etc., are wrapped, like the dressings, in covers of double muslin and sterilized twenty minutes in the autoclave at 15 pounds pressure. All sterile articles should be kept in their covers until actually required for use. It is the only certain way of keeping them from possible contamination by dust or handling. Portions of dressings not used must be col- lected and resterilized. Medicated Gauze.—For special purposes dressings and packings of medicated gauze are used—gauze, that is to say, impregnated with some agent, usually either anti- septic or stimulant. During the antiseptic period of sur- gery gauze impregnated with carbolic acid, with bichlorid of mercury, and other antiseptic preparations were much in favor; at the present moment iodoform gauze is the only one of such dressings much in use. It is chiefly used in the packing and dressing of tuberculin- sinuses. Iodoform Gauze.—Iodoform gauze may be sterilized in the autoclave at low pressure (7 pounds for forty-five DRKSS1NGS 475 minutes), when prepared, but there is always the risk, if the temperature is accidentally raised, of the whole dress- ing being spoiled by the action of the iodin vapor given off by the iodoform at 239° F., as described above. The composition of the dressing is altered, and the dressing useless for its purpose. To avoid this risk, each of the articles to be used may be previously sterilized separately and the whole process carried out with strict aseptic precautions. All the ves- sels are sterile, and the nurse scrubs up her hands as if for an operation, and wears gown and gloves. Gauze is cut to the necessary sizes and shape, and ster- ilized in the usual way. Make an emulsion as follows, the ingredients previ- jusiy sterilized: Iodoform powder and glycerin, equal parts, to which -ome add bichlorid of mercury, 5 grains to every half pint of the mixture. Rub together in a mortar; when perfectly smooth, add to the whole mixture half the quantity of pure alcohol; mix by shaking thoroughly in a good-sized bottle. Place the gauze in the mortar, pour on the emulsion, and work with the hands until thoroughly impregnated. Fold, roll lightly, and store in closely stoppered jars ot dark glass. If dark glass is not available, the jars should be kept in a dark closet, away from direct sunlight, which will iodize the iodoform, or the jars may be covered with asbestos paper. Different prescriptions are used in various hospitals foi the emulsion, thus: (a) Iodoform............................1 ounce. Salt solution (9:1000)................5 ounces. Castile soap, sufficient to make thick suds. (b) Iodoform............................1 pound. Glycerin.............................1 pint. Boiling water........................2 pints. Castile soap, sufficient to make thick suds. Plain gauze after use can be washed, sterilized, and used again, thus diminishing the expense of dressings. 476 PREPARATION, STERILIZATION IN SURGICAL WORK In one hospital that makes a practice of washing the gauze the following procedure has been found practical: The used gauze is collected, at the dressings or opera- tions, in stout mesh bags, such as are used in machine laundries for the washing of small articles; the bags must not be more than half full. The bags are kept until col- lected in covered garbage-cans. They are collected twice a day, placed directly in one of the laundry tubs, and washed in the following order: Cold rinse Hot suds. Hot rinse. Cold rinse Boiled... The bags are then drained and hung in the drying closet until partially dry; while still damp the gauze is pulled into shape, trimmed, and packed for sterilization like other dressings. The only drawback to the process is the labor involved in pulling the gauze into shape again. The washed gauze is softer and more free from fluff than the unwashed gauze. SEA-SPONGES Sea-sponges are not entirely out-of-date. On account of their absorbent property, they are frequently preferred in operations complicated by copious mucoid secretions, as, for example, on the mouth and tongue, or, more rarely, the cervix. In preparing, care must be taken to remove thoroughly the sand and lime deposits found in sea-sponges. 1. Beat with a wooden mallet to break up and remove shells, sand, and dirt; wash at intervals in cold running water, soaking in cold water between the times. Repeat until free of dirt. 2. Soak in 1 : 64 solution of hydrochloric acid to dissolve lime deposits. 3. Soak in a saturated solution of permanganate of potash fifteen minutes. 4. Soak in a saturated solution of oxalic acid until bleached—usually about half an hour. 5 minutes. 10 5 5 5 CULTURES 477 5. Wash in two waters. 6. Soak for twenty-four hours in bichlorid of mercury 1 : 1000. 7. Transfer to sterile jars, fill the jars with carbolic 1 : 20, and cover closely. Keep in this solution until required. Before use the sponges are wrung out in normal salt solution and washed in the same during use. As they will not keep in this way more than about two weeks, only a small number should be kept ready for an emergency. If used for a clean case, they may be washed and resterilized. After an infectious case they should be discarded. HAND-BRUSHES AND NAIL-CLEANERS After use, wash under running cold water and soak in formalin (2 per cent.) for thirty minutes; wash in hot suds and dry quickly, to prevent softening of the bristles. Put up in convenient packages and sterilize with the dressings in the autoclave. During an operation they are usually kept in an antiseptic solution. A fresh set should be put out for each operation. CULTURES Sterilized articles should be examined from time to time to insure that the process is adequate. To do so, a cul- ture is taken of the material to be examined. A small fragment of the sterile object is removed, with strict asep- tic precautions, and dropped carefully into a tube of sterile culture bouillon. The tube is plugged with cotton (which should be ignited for a moment before being replaced), and kept in a dark place at a temperature of about 98° F. for twenty-four hours. If the specimen is sterile, the bouillon remains clear. If it becomes cloudy, the micro- organisms should be developed and examined in the usual way (p. 372). Cultures should also be taken from time to time from the finger-nails of those engaged at an opera- tion CHAPTER XIV SURGICAL TECHNIC AND MINOR SURGICAL EVENTS Principles Governing Technic—Duties of Sterile and Unsterile Nurses—Technic in Preparation of the Skin—Surgical Dressings -■ Carrel-Dakin Method—Hypodermoclysis—Intravenous Infusion — Venesection—Injection of Antitoxin Serums—Exploration—Lumbar Puncture—Venous Puncture for Blood Culture—Paracentesis— Aspiration of Chest Wall; of Pericardium. PRINCIPLES OF TECHNIC Having carefully prepared and sterilized everything that is to come in contact, direct or indirect, with the open wound, we have now to consider how to keep all "sterile" during an operation, a surgical dressing, or other surgical procedure. At the present day the methods used have become a species of drill, in which each has a definite part to play. From early days it is to be recommended that proba- tioners should be taught their drill until it is performed with mechanical precision. The demonstration can be carried out in the class-room with dummy dressings. Some nurses will at once grasp the principles involved, but they will work better and more quickly for having their duties well defined; others will require to be drilled again and again until perfect, but under present-day methods it is far too important a point to be left to pick up in any haphazard way. While everything that comes in contact, directly or indirectly, with the wound must be surgically clean, there are many things necessarily involved at an opera- tion, etc., that are, so to speak, surgically "dirty." For example, the patient's body, with the exception of the field of operation; the gown and coverings of the patient; the table and stands; the outside wrappings of sterile dress- ings: spiggots and door-handles; besides bottles, stoppers. 47^ PRINCIPLES OF TECHNIC 479 exhaust pumps, and any appliance that it may be imprac- tical or unnecessary to sterilize. Sterile and Unsterile Nurses. To overcome this dis- advantage in carrying out surgical technic, as we call it, these unsterile objects must be handled by persons who do not come in contact with the open wound. In tech- nical language, the assistants at an operation, etc., are divided into "clean" or "sterile," and "dirty" or "unsterile." A "clean" nurse is one whose hands are "scrubbed up" according to formula, in addition to which, except for very minor proceedings, her ordinary dress is covered with a sterilized gown; gloves must also always be worn where the hands have to come in contact with the raw surface or with discharges, and are desirable in most surgical pro- ceedings. A clean nurse is no longer "clean" if she touches any unsterilized object; in technical language, she has "broken her technic"; an unsterile nurse, if she touches any sterile object, whether with her hands or skirts, has opened a channel of possible infection and broken the technic pos- sibly of an entire operation. An unsterile object laid down among sterile objects must, in strict technic, be regarded as having rendered the whole unsterile. Thus if a dirty instrument is placed in a tray of clean ones, the whole must be resterilized. WTater and lotions are no longer sterile if touched with the unsterilized hand, as, for example, to test the temperature, or if an unsterile sponge or instrument is thrown into the basin; dirty instruments, etc., must not be added to objects in process of sterilization; if this happens accidentally, the whole must be resterilized with the article just added. Constantly a nurse meets with the direction " with strict aseptic precautions"; the measures these words are intended to imply should present themselves to her mind, down to the most minute detail, without hesitancy or confusion. While there are always several ways of attaining results, perfection in nursing is best arrived at by teaching one way thoroughly and leaving little for individual initiation. A practical plan in teaching technic to a young class of probationers is to smear the fingers of " clean " and 480 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS " unsterile" nurses respectively with rouge and with charcoal: a touch in the wrong place is then quickly de- tected. Strict technic is not possible unless two work together. In certain conditions, as on night duty or in private nurs- ing, this may be impossible; it is then important that the nurse should understand exactly the point at which she must prepare her hands and beyond which she must keep " clean." The duties of clean and unsterile nurse may be briefly detailed as follows: The Clean Nurse (Nurse No. i).—As she is responsible for the dressing (or etc.), she first collects and arranges conveniently all that is to be used, and places articles to be boiled in the sterilizer. At this point she summons the unsterile assistant and prepares her own hands according to formula, and after this she is " clean," and must touch nothing but the sterilized objects and the actual area of operation. She must not, for example, help to move the patient, touch the bed-clothes, or the outside of lotion bowls or bottles, etc., open a door, or turn on a spiggot; neither must she touch her own face or any part of her dress not protected by a sterile gown. If a sterile gown is worn, it is put on after her hands are prepared; the gloves are drawn on last of all. In beginning her dressing, etc., her first act is to provide herself with a sterile area to protect her hands and sterile appliances from contact with unsterile objects. For this purpose sterilized towels are used, one to cover a table on which she can place the necessary instruments and dress- ings, and others to cover the area, etc., in the immediate neighborhood of the dressing, disposing them above, below, and on either side of the part to be dressed. She must remember once the towels have been placed on an unsterile object, only the upper surface remains sterile. She finishes her preparation by taking from the open packets handed her by her unsterile helper the necessary dressings and appliances. Her remaining duties vary with the requirements of the individual process. She remains clean until the open sur- face, puncture, etc., is covered by the dressing. Before PRINCIPLES OP TECHNIC 481 applying the outer bandage after a dressing, she removes her gloves, or, if these are not worn, rinses her hands thoroughly in antiseptic lotion, otherwise the bandage itself may be infected with any organism present in the wound secretions, and become a channel of infection. For the same reason, before leaving the bedside, after any except surgically clean proceedings (such as hypod er- moclysis), the hands should be immersed as a matter of routine for one full minute in the antiseptic solution pre- ferred, and must be washed and disinfected again, accord- ing to formula, before any other object is touched. In minor surgical proceedings, if by accident technic is broken, the hands must be immersed a full minute in antiseptic solution before resuming; should a sponge or instrument that is to come in actual contact with the tissues touch an unsterile object, it must, in strict technic, be discarded, or the whole process of sterilization repeated; for this reason, and to provide against accidents, it is best, in preparing for catheterization, hypodermoclysis, explor- ation, etc., to prepare two catheters or two needles, rather than risk delay if a second is required. Should the clean nurse be obliged to handle an unsterile object, for example, a flask or the air-pump of an aspirator, the object must be covered temporarily with a sterile towel or piece of gauze. If she touches a dressing not strictly sterile, she uses sterile forceps and discards them after use. The danger of indirect infection is often overlooked. For example, a nurse may have dressed an infected wound with strict aseptic technic, and, before disinfecting her own hands, afterward, may touch a spiggot, a door-handle, or perhaps the patient's bed-clothes; on the spot she touches some of the organisms will, in all probability, be deposited. A second person may touch the same spot, her fingers will become infected, and she may quite innocently convey the infection in this way to a third. The risk is very much lessened if forceps are used instead of fingers, and gloves are worn. The Unsterile Nurse (No. 2).—The duties of the un- sterile nurse should be as clearly defined as those of the sterile nurse. The unsterile objects which it is her part 31 482 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS to handle include, besides the patient and the bed-clothes, the wrappers containing the sterilized objects, mackintoshs or Kelly pad, bottles, flasks, the outside of lotion bowls, douche-cans, or pitchers, bandages, splints, and other appliances, and the receiver for the soiled dressings. These she should place together conveniently for her to handle, and out of the way of the sterile table. While the clean nurse is scrubbing her hands, nurse No. 2 arranges the patient in proper position, pours out lotions, adjusts mackintoshes or Kelly pad, if required, and unpins the sterilized packages, holding them open for No. 1 to take from them what she wants. If the skin is to be prepared, the preliminary scrubbing and shaving is the part of the unsterile nurse; she follows it with an alcohol wash (p.449), and if there is any delay, covers the part with a towel wrung out of bichlorid of mercury 1 : 1000; the sterile nurse begins the disinfection by repeating the alcohol wash, or, if another formula is used, with the application of the antiseptics. For the pre- liminary scrubbing mackintoshes are used to cover the clothing—one, or two, as required; they may then be removed or covered with sterile towels, as indicated by circumstances. They should, for example, be retained for douching, irrigation, or if there is likelihood of bleeding. The clean nurse prepared, nurse No. 2 fastens the gown behind, since No. 1 can hardly do this without touching her ordinary dress. She then unpins and opens the packages and hands them to No. 1, beginning with the towels for the sterile area; finally she brings the boiled articles from the sterilizer. These may be carried in the tray on which they were sterilized, or removed to a sterile towel with a pair of sterile forceps. Throughout the process she fol- lows what No. 1 is doing carefully, anticipating her wants, and guarding herself carefully from touching any sterile object, even with a view to helping. Frequently a limb may have to be held, movements restrained, or such an object as a tourniquet controlled, in the immediate neighborhood of the sterile area. Nurse No. 2 must then place her hands underneath the sterile PRINCIPLES OF TECHNIC 483 coverings, taking care not to touch the upper surface of the towels or to get in the way of the clean operator. If the unsterile nurse has to touch a sterile object, as, for example, in transferring an instrument from the sterilizer, or taking a towel or sponge from the sterile packet, she uses a pair of sterile forceps. An old pair of forceps should be kept standing in antiseptic lotion beside the sterilizer. In all aseptic proceedings a basin of antiseptic lotion, usually bichlorid of mercury, 1: 1000, hot, should be placed in readiness in case the technic is accidentally broken. With two nurses working together this should not happen. The replenishing of the lotion bowls is the duty of No. 2. It is not necessary or practical to keep the outside of lotion bowls sterile; in handling the bowls care must be taken not to hold them by the brim, since the inside must be kept sterile. Volatile drugs, such as alcohol, ether, etc., are used when required directly from the flasks. The necessary quantity is poured by the unsterile nurse onto a sterile sponge held by the clean nurse. In pouring solutions, etc., from bottles, the brims of the bottles should be wiped free of any possible dust with a sponge soaked in a little of the solution; the stopper should be held in the little finger of the left hand, to pre- vent it coming in contact with other objects. In giving an aseptic douche, irrigation, or hypodermo- clysis, the rubber tubing is best divided into two parts connected by a piece of glass tubing; the lower length alone is handled by the sterile nurse, and kept strictly sterile throughout. Although the whole apparatus is sterile to start with, the douche-can, flask, etc., and the upper length of tubing are most conveniently handled by the unsterile nurse. The principal aseptic measures in which nurses are con- stantly engaged are: the preparation of the field of opera- tion; minor dressings; catheterization; hypodermoclysis; to which may be added, assisting at minor surgical pro- cedures in the ward. It is an immense help that the technic required for each of these1 proceedings should be written down. The direc- 484 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS tions should include a list of the articles required, any special method for sterilizing the articles, the formula required for preparing the hands, the area of the skin to be prepared, and, for convenience, the position in which the patient must be placed. The technic should be reduced to the simplest com- patible with good standards; elaborate technic is too often an excuse for carrying it out imperfectly. Where only one nurse is available for aseptic measures, as may happen in private nursing or on night duty, it is important that the nurse should understand exactly the point at which she must "scrub up," and beyond which she must keep "clean." For the proceedings that are constantly called for, the preparation of the skin, catheterization, and hypodermo- clysis, etc., trays may be kept ready with all the articles necessary. Cleansing the Hands.—The technic required for the cleansing of the hands should be typed and posted in a conspicuous place, preferably over the wash-stands, since the importance of this part of all technic cannot be over- estimated. The hands of nurses and dressers are con- sidered, without doubt, the most common channels of infection in hospital work, and the weak link in the chain of aseptic methods. Two formulas for preparing the hands are in use in the wards: The first, Formula A, should be the same as that required for the purpose in reparing for operations; this is used in the preparation for minor operations, for important dressings, and other circumstances especially indicated. A second formula {B), a modification of the first, is used in preparing for minor dressings, catheteriza- tion, vaginal douching, and similar proceedings. The directions for special technic should state which formula is to be used. Formula A.—Whichever preparation is in use in the hospital operating room (p. 448). Formula B.—Turn the sleeves up above the elbows and scrub the hands and well above the wrists three minutes in hot soap and water, using hand-brush; change water once; clean round nails with blunt orange-stick. Immerse in hot solution of bichlorid of mercury (or DRESSINGS 485 Harrington's solution, etc.) for two minutes; rub the solution briskly into the skin. The mechanical scrubbing is the most important part of either formula. N. B.: To lessen the risk of establishing a channel of infection, the hands must be immersed and rubbed in the antiseptic solution for one full minute before leaving the patient's side wherever a raw surface has been exposed, if the hands have come in contact with organic secretions, and after changing £he linen or removing the bed-pan, etc., from an infectious case, after which they must imme- diately be again cleansed according to formula. The custom of using gloves for all aseptic proceedings is a great safeguard against infection; in the wards the mended rubber gloves may be used, or cheap cotton gloves, which can be washed and boiled. PREPARATION OF THE SKIN The formula used in preparing the skin for minor surgical events varies in different hospitals. For the most important the same formula in use in the operating-room is required (Formula A). For simple punctures (Irypo- dermoclysis, etc.) the skin is thoroughly washed in soap and water, sponged with an antiseptic solution, and covered till ready with a piece of gauze wrung out of the solution. Alcohol may be preferred to the antiseptic solution (Formula B). This is the duty of the unsterile nurse. DRESSINGS In present-day methods a general dressing-room, fitted for any emergency, is a common part of hospital equip- ment; the patients are taken from the wards to have their dressings changed, and most minor surgical measures are likewise carried out with more privacy than can be looked for in a ward. In a large school it is not always easy to give each nurse her full time in this department, and there is further the disadvantage that, where all is kept prepared for every sort of contingency, the pupil nurse loses sight of what is essential for each different event, and is at a loss when on her alone falls the responsibility of preparing one or the other. Thus the very perfection of equipment may be a stumbling-block in the training unless steps are taken to counteract this drawback by individual teaching. ISC) sl'RGH'AL TECHNIC AND MINOR SURGICAL EVKNTS For an ordinary dressing the following articles should be prepared: Towels (4 a good average). > Sponges (12). T .. , ^ , . > In sterile packages. Gauze dressing. Absorbent cotton pads. Dressing scissors, probe, and forceps (boiled ten min- utes), bandage, and safety-pins. Bowl of sterile water or antiseptic solution (in case the dressing should stick or the wound require washing). Bowl of antiseptic solution for the hands. Receptacle for soiled dressings. Fig. 15.5.—A surgical dressing. Where there are cavities requiring to be treated with injections of special preparations, such as iodoform emul- sion, peroxid of hydrogen, etc., a glass syringe and small measure-glass or gallipot are further required, and may be boiled with the instruments. A tube of gauze packing should also be prepared. If irrigation is necessary, the douche-can and tubing are prepared and wrapped until required in a sterile towel, together with a convenient flat bowl, usually of the kind known as kidney shaped: this latter is boiled with the DRESSINGS 487 instruments and kept sterile throughout. A Kelly pad or a piece of rubber sheeting should be put in readiness for all irrigations. In preparing for a dressing after an operation, a pair of scissors with sharp points and an extra pair of forceps should invariably be ready, in case a stitch should require to be removed unexpectedly. Where an incision is to be made, the following should be prepared, in addition to those mentioned above. All. of course, are sterilized: Knife. Sharp scissors. 2 artery forceps. Surgical needle. Catgut ligature. Suture, either of silk or silkworm-gut. If an abscess cavity is to be opened, there should also be added curet, drainage-tubing, and tube of gauze pack- ing. In many instances the knife only may be used, but in preparing the above, all emergencies are provided for, such, for example, as severing a blood-vessel, or the neces- sity for closing part or all of an incision. It will also probably be necessary to have ready the local anesthetic. For clean incisions, punctures, and similar proceedings, anesthetics, such as novocain, cocain, eucain, etc., are generally administered by hypodermic along the line of incision, and a hypodermic charged with the neces- sary amount should be in readiness; where an abscess is opened, freezing is the usual form of local anesthesia (p. 329). For a dressing the hands are prepared by Formula B, if gloves are worn; if not, Formula A must be used; a gown also should be worn. Where several dressings follow each other, the hands are cleaned by Formula B between each dressing, and always immersed in the antiseptic solution a full minute before leaving the bedside. The instruments used must also be cleaned and resterilized between dress- ings. Two sets are necessary, in order to avoid delay. . The minor dressings intrusted to nurses are usually ol the chronic variety of wounds with discharging surfaces. 488 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS The surface is cleaned with sterile water, or, more usually, with antiseptic solution. In cleansing a wound, the surrounding area must first be cleaned, washing always away from the wound, and the raw surface last. Sponges are wrung out as dry as possible, and each sponge is dis- carded after using once. In the first treatment of a wound due to an accident, where the surrounding tissue is dirty, the actual wound should be covered with a sponge soaked in an antiseptic, while the area round is thoroughly cleaned, usually with soap and water. In removing a dressing or packing that has become dry, force must not be used; not only will pulling cause needless pain, but delicate granulations will be destroyed and troublesome bleeding may be started. The dressing should be moistened until it comes away easily. In packing a cavity or sinus, no rule can be laid down; in some cases just sufficient is required to establish drain- age and keep the surfaces apart; in others pressure is ap- plied by packing a cavity firmly. The tube of packing is held, and the cotton plug removed by the unsterile nurse; the clean nurse draws out the length she requires with sterile forceps, and cuts it with sterile scissors, taking care not to come in contact with the outside of the tube; holding the strip with the forceps in her left hand, she introduces the packing little by little into the cavity with the probe. The strip must not come in contact with the surrounding tissue or even with the sterile towels, since during the dressing these may very easily become contami- nated with any organism present in the wound. She should also, in removing packing, hold the soiled gauze so that it does not fall on the area round the wound, which, if technic is strictly followed, should remain sterile. Nurses must be taught to use forceps and not the fingers in removing and applying dressings and in cleansing wounds. A nurse's training should make her fastidious to the last degree in keeping her hands from possible con- tact with infectious organisms. In applying a dressing, just sufficient for the purpose and no more should be used. If oozing is expected, the gauze dressing is reinforced with pads of absorbent cotton; DRESSINGS 489 the bandage should be applied firmly, but not tightly, and be sufficient to keep the dressing in place; safety- pins are used to fasten the bandage, except for band- ages about the head, where an ordinary long pin is pre- ferred. Where there is much local inflammation and in condi- tions where it is desirable to encourage discharge, the gauze is applied wet; sterile water, normal salt solution, or an antiseptic lotion may be used. The wet dressing is covered with a light cotton pad and bandage, or it may simply be held in place with a bandage and kept wet, either by constant dripping or by repeated application of the lotion used, without removing the bandage. In most cases the gauze, either wet or dry, is placed directly on the wound or denuded surface. Where, how- ever, the granulating surface is large, as in burns, for example, it is covered first with a protective, usually rubber tissue, in order to prevent injury to the delicate granula- tions if the gauze should stick and be removed with force. The tissue should either be perforated freely, or it may be laid on in strips, leaving a small space between the strips, otherwise the dressing will act as a poultice and encourage oversecretion. Collodion Dressing.—Punctures are usually closed with a collodion dressing. For this are required: Small bottle of flexible collodion. Fragment of sterile cotton. Sterile applicator or brush. In applying the dressing, the puncture is wiped free of blood, and a thin strand of cotton, merely a few threads, laid over the small wound. Over this an application of collodion is painted, and then a second layer of teased-out cotton again covered with collodion; the cotton layer and the collodion application are repeated until the wound is covered sufficiently. The dressing falls off in a day or two, but, if necessary, it can be dissolved with a little ether. The practice, not unknown, of keeping a brush in the eollodion bottle and applying it to all and sundry is not only dirty, but contrary to all modern principles of technic. The dressing after an operation is not, as a rule, left to 490 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS tie nurse. Her duties will be to prepare all that is re- quired and to act as unsterile assistant. Unless oozing occurs, the dressings are usually left undisturbed until the incision is healed. Oozing is, however, common in many conditions, whether of blood from small, unligated vessels, serum, or solutions where cavities have been freely irri- gated. Some surgeons, for example, after special ab- dominal operations, irrigate the peritoneum with salt solution, leaving a certain amount in the cavity to be ab- sorbed gradually. When oozing occurs, it is usual to remove the top dressings and apply a fresh one with the same aseptic precautions as for a full dressing. The nurse is expected to watch such dressings and report promptly if oozing is taking place, as once it reaches the outer dress- ing a channel of infection is opened between the wound and the outside air. Removal of Stitches.—Stitches after an extensive opera- tion are commonly removed about the ninth day, though symptoms of tension or local irritation, or the necessity for establishing drainage1, may require their removal at an earlier date. Stitches about the face are removed after a much shorter interval, in order to avoid scarring. After stitches are removed, an incision is frequently supported by strips of adhesive strapping. A small dressing of dry gauze is generally kept over an incision until the scar tissue is quite strong. THE CARREL METHOD Carrel Method for the Treatment of Infected Wounds. —This method, usually known in America as the Carrel- Dakin method (from the antiseptic solution commonly used, see below), is considered the most important con- tribution to surgical technic evolved in the recent war. It was introduced by a French surgeon, Dr. Carrel, in his treatment of war wounds, and is at the present date in common use in all kinds of septic surgery. By this method every part of the wound is irrigated at regular intervals by an antiseptic solution withoul disturbing the dressings. The Carrel method has two procedures: 1. The local treatment. THE CARREL METHOD 491 2. The observation of the progress of disinfection by means of smears taken at regular intervals and examined in the laboratory. Local Treatment— A special apparatus is necessary, comprising: Fig. 155a.—Various sizes of instillation tubes. Tubes 5, 10, 15, and 20 cm. in perforated length; also simple and loop tubes. (From Technic of the Carrel Method, by I. Dumas and Anne Carrel, trans- lated by Adrian V. S. Lambert.) 1. Flask. 2. Conducting tube. 3. Distributor. 4. Instillation tube or tubes. Instillation or distributing lubes (Fig. 155a) are made of fine catheter rubber, size 16 French (4 mm. interior diame- ter), from 0.3 to 0.5 m. long, open at both ends, the lower 492 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS end usually tied with linen thread, which is easily removed when cleaning the tubes. A simple tube has one large lateral opening close to the end and is not tied; perforated tubes have openings ^ to 1 mm. in diameter, 1 cm. apart to a distance 5, 10, 15 or 20 cm. from the tied end; in a loop-shaped tube the Fig. 1556.—Distribution of instillation tubes covered with Turkish toweling and provided with guy threads for fixation at edge of wound. (From Technic of the Carrel Method, by I. Dumas and Anne Carrel, translated by Adrian V. S. Lambert.) central portion is perforated. Where the treatment is for extensive flat surfaces the tubes used are usually covered with Turkish toweling the length of the perfora- tions (Fig. 1556). This aids considerably in the distribu- tion of the fluid. The toweling is firmly sewn round the tubes. A pair of hnen threads are passed through the THE CARREL METHOD 493 toweling long enough to extend beyond the wound, where they are fastened to the skin by strips of adhesive plaster, thus keeping the tubes in position. The instillation tubes are attached to a glass distributor, A B Fig. 155c.—Conducting and instillation tubes: A, Conducting tube, CT, shown connected with distribution or instillation tubes, IT, by a glass distributor, C, with four outlets. B, Loop instillation tube connected up with a glass distributor. (From Technic of the Carrel Method, by I. Dumas and Anne Carrel, translated by Adrian V. S. Lambert.) of which there are several shapes (Fig. 155c); the comb shape is perhaps the most frequently used. The distributor is connected at the upper end with the conducting tube, a length of rubber tubing 7 mm. in diam- eter, attached to the flask containing the antiseptic fluid 494 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS and provided with a stop-cock, by which the flow is regu- lated. Where desirable, a double set of instillation tubes may be fed from one flask by dividing the conducting tube with a Y-shaped glass connecting tube (Fig. 15fW), Fig. 155rf.—Glass conducting connector and glass distributors. Glass connector, A, is 7 mm. diameter throughout; glass distribu- tors (B, C, D) have a diameter of 7 mm. at the larger end and 4 mm. at the smaller. E is a small connecting tube of 4 mm. diameter. (From Technic of the Carrel Method, by I. Dumas and Anne Car- rel, translated by Adrian V. S. Lambert.) to each arm of which a secondary conducting tube is attached. The flask, usually of glass, holds 1 liter; the neck is stoppered with sterile cotton, the lower part ends in a short open tube, over which fits the rubber conducting tube. The flask is suspended from 2 to 2\ feet above THE CARREL METHOD 495 the wound to be treated, usually from a wooden post attached to the foot of the bed and provided with a hook at the required height. If preferred an adjustable support- ing stand such as depicted in Fig. 155e may easily be contrived. The antiseptic at present used is Dakin's solution of Fig. 155e.—Irrigation apparatus, showing supporting stand with flask in place. Attached are main conducting tube, glass conductor, secondary conducting tubes, glass distributors, and instillation tubes. (From Technic of the Carrel Method, by I. Dumas and Anne Car- rel, translated by Adrian V. S. Lambert.) sodium hypochlorite, strength between 0.45 and 0.5 per cent.; a weaker solution is ineffective, a stronger is irritating to the tissues. The solution is decomposed by heat and is used cold; light also changes its composition and reserve supplies should be kept in dark bottles. 496 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS Dakin's solution is free from any trace of caustic soda, and must for this reason be distinguished from other commercial hypochlorite solutions, such as Labarraque's solution and Javel water. The apparatus in position, the instillation tubes are placed over the surface and into the cavities of the wound or wounds. The dressing used is usually gauze wrung out of Dakin's solution and laid over the tubes; cavities and flaps are lightly packed with the same, the dressing aiding in the distribution of the fluid. Bandages or binders when necessary must be lightly applied so as not to constrict the tubes. In prolonged treatments it is usually advisable to smear the adjacent skin with sterile vaselin. Where necessary the bedding is protected by rubber sheeting on which are laid pads of gauze and cotton which can be changed with little disturbance. The customary technic for dressing is used. The dressing in place, every two hours day and night the cock is opened from one to three seconds, allowing the fluid to seep into every part of the wound. All parts of the apparatus are cleaned by washing in soap and water; the flask is rinsed with Dakin's solution and the glass parts and conducting tube soaked in the solution for two hours before use. The instillation tubes are put up in large glass test-tubes stoppered with cotton and sterilized in the autoclave at 120° C. for twenty minutes, and remain in the test-tubes till ready to be used. Microscopical Examination.—The progress of disin- fection is followed by means of smears taken from the infected area (page 364) at regular intervals, some- times every second day, or at longer intervals at first, and more frequently as disinfection progresses. These are examined in the laboratory, and according to the report the surgeon decides when the wound is ready to be closed. When a smear shows "only isolated cocci or diplococci, and only one is found in every four or five fields (micro- scopic), and if this result has been verified by two or three successive examinations at intervals of one or two HYPODERMOCLYSIS OR SUBCUTANEOUS INFUSION 497 days, the disinfection is practically accomplished. The surgeon may then close the wound with a fair assumption of success, no matter whether it is a wound of the soft parts or a compound fracture."1 «toe;----?£------:-------—Xui •■----^Z^: *•* Nature of Muni. JZ~*&u- ^33Z*J''(fa&!£z$£/i %>nthL October November o -ly. ' Z3 I V K i 6 3 feet above the bed. Fig. 156.—Giving hypodermoclysis. The solution may be siphoned directly from the flask in which it has been prepared, using a glass drinking tube and a length of rubber tubing, to which the hypodermo- HYPODERMOCLYSIS OR SUBCUTANEOUS INFUSION 499 clysis needle is attached. Usually in hospital work a special apparatus is reserved for hypodermoclysis. Kelly's infusion flask (Fig. 156) is a graduated glass flask with a narrow neck and opening at the lower end, like that of a douche-can, to which the tubing with the needle is attached; the flask is graded to 700 c.c, the numbers be- ginning at the top, so that the amount given may be read at a glance. The hands are prepared by Formula A or Formula B, if gloves are worn. Gown and gloves are not considered essential, but some hospitals insist on them for all aseptic measures. On the side of the " clean " nurse is placed a table partly covered with a sterile towel, on which she arranges the gauze sponges, the needles, and the sterile length of tubing; the basin of hand lotion is placed on the uncovered part of the table. On the opposite side the unsterile nurse keeps irriga- tion apparatus, stand, and the flasks of water or normal salt solution, one hot and one cold; also the sterile packets mentioned until the clean nurse is read}' to have them opened. The bandage is cut from the brim of the flask, but the cotton stopper is kept in place. The contents of the flask are heated over a gas ring or in a water- bath. While nurse No. 1 is preparing her hands, nurse No. 2 washes the skin area with soap and water and covers it with a piece of gauze wrung out in bichlorid solution; her next act is to take the apparatus from its wrapper, hang it on the stand, clamp the tube, and fill the flask to the top graduation with the solution of the required tem- perature. The outside of the flask and tubing can no longer be considered sterile, and are not touched by nurse No. 1. The "clean" nurse begins by arranging her sterile area. She next attaches the needle to the sterile length of tub- ing, and, taking the glass connection tube in a piece of sterile gauze, joins the two lengths of tubing. The clamp is now loosened. 500 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS Technic.—Before inserting the needle, the clean nurse allows the water to run freely over the back of her hand. This is both in order to expel all air and to gage the tem- perature. The temperature should be from 114° to 120° F. The usual test is that the fingers should just be able to rest on the glass flask. The temperature may also be tested Fig. 157.—Sites for hypodermoclysis: 1, Under the mammary glands; 2, in the subcutaneous tissue between the crest of the ilium and the last rib; 3, in the subcutaneous tissue in the axillary space; 4, in the subcutaneous tissue on the inner surface of the thighs (Morrow). by keeping a long dairy thermometer in the flask during the process (Fig. 156). This must, of course, also be sterile, and should be kept until actually required in an antiseptic solution, bichlorid of mercury 1 : 1000, or formalin 2 per cent. From time to time it may be necessary to add hot water or hot solution in order to keep up the temperature, Fig. 158.—Showing two needles arranged for hypodermoclysis (Morrow). if the process is a long one and the fluid runs very slowly. The quantity added must be noted accurately, so that it can be known how much the patient is having. In a woman the site usually chosen is the base of the breast; other favorable sites are the loose skin just below the axilla, the muscles of the chest wall or the abdomen, HYPODERMOCLYSIS OR SUBCUTANEOUS INFUSION 501 the thigh, and under the shoulder-blade. The needle is introduced horizontally about two-thirds of its length, and withdrawn about an inch; while inserting the needle, the skin is held stretched by the left hand. As a rule, not more than 500 c.c. should be intro- duced at one site. The fluid should flow slowly: about twenty minutes is required to introduce 500 c.c. with one needle. If desirable, the injection may be given at two points simultaneously, as in both breasts. In this case a T-shaped glass connection-tube is attached to the upper length of rubber tubing, to each arm of which a sepa- rate length of rubber tubing, with needle attached, is connected. The infusion started, in ordinary circumstances the sec- ond nurse may be dispensed with unless she is required to add hot solution. The clean nurse may do this if she is careful to handle the flask with a sterile towel or piece of sterile gauze. Care must be taken to withdraw the needle while there is still some solution remaining in the flask. The tube is clamped before the needle is withdrawn, in order to avoid spilling the contents. A nurse may frequently have to give hypodermoclysis single handed. She must then arrange all required, heat the solution, and fill the flask before "scrubbing up"; she then prepares the site, as this involves touching unsterile objects; after this part is complete she rinses her hands in the bichlorid solution, puts on gloves, before introduc- ing the needle. By this process fluid is introduced into the lymphatic circulation, and conveyed in due course by the lymphatic vessels to the blood-current; some of the solutionis also directly absorbed by the capillary blood-vessels. The tis- sues immediately around the puncture become infiltrated with the fluid, causing a circumscribed swelling, which is gradually absorbed without intervention. A cotton pad and bandage will hasten the absorption, but this is not generally considered necessary. In the treatment of diabetic coma a solution of glucose (solid grape sugar) is frequently given, either by hypoder- 502 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS moclysis or intravenous infusion. (See below.) The strength used is 5 per cent, glucose dissolved in boiling sterile distilled water (50 grams in 1000 c.c.). The solu- tion is filtered into flasks and sterilized by boiling in the flasks for five minutes. INTRAVENOUS INFUSION Where a more immediate stimulation to the circulation is required, the fluid may be injected directly into the blood-current by opening a vein in the forearm. In addition to the articles required for hypodermoclysis, the following must be prepared: Scalpel. Aneurysm needle and silk ligature (heavy). 2 artery forceps and catgut ligature (for emergency). Surgical needle and suture, usually silk (medium size, for closing the incision). Scissors, probe, and dressing forceps. Intravenous needle. Sterile, flat-bottomed basin. Gauze dressing, extra sponges, towels, and gauze band- age. Tourniquet or muslin bandage. The intravenous needle is a fine cannula, 3 or 4 inches long, resembling a hypodermoclysis needle, but slightly curved and with a blunt point. The operation is, of course, performed by a doctor, but a clean assistant is necessary to act as a free pair of hands. The hands are prepared by Formula A; gown and gloves are worn. The surface of the forearm to a point well above the bend of the elbow is prepared by Formula A. The instruments are arranged on the sterile table, with the gauze sponges, sterile length of tubing, and sterile basin; the tourniquet, bandage, and unopened dressings, with the infusion apparatus, on the unsterile side. The preliminary part of the skin preparation is, as usual, carried out by the unsterile nurse. A piece of rubber sheeting is kept under the arm during the whole process; in arranging the sterile area, one towel is placed below the INTRAVENOUS INFUSION 503 arm, covering the rubber sheeting; one covers the upper arm, and one envelops the forearm. The sterile basin is placed under the arm, below the point of incision. Before the incision is made, a tourniquet or a tight bandage is applied around the upper arm, in order to dis- tend the veins of the forearm. The tourniquet should be sufficiently tight to distend the veins, but not so tight as to obliterate the pulse at the wrist. The control of the tour- niquet is the duty of the unsterile nurse; in order to be free, she must previously have prepared everything necessary; packets must be opened, instruments brought from the sterilizer, the apparatus ready for use. When the needle is in place, the tourniquet is gradually loosened and finally removed. The nurse is careful to keep her hands under- neath the sterile covering. The sterile assistant will be required to keep the arm extended and still, and, if the patient is restless, this will take her entire attention; with a quiet patient she can spare a hand, if desired, to help with any sterile object. Before taking her place, she must attach the needle and connect the two pieces of tubing as described, and also see that the fluid is running freely. Technic.—The operation is as follows: the vein is ex- posed by a light incision; the silk ligature is passed, by the aneurysm needle, under the vein, below the point to be opened, and tied; the vein is then opened, and the cannula inserted, making sure first that it is free of air, and running the solution over the back of the hand to test the temper- ature. As the vein fills, the tourniquet is slowly loosened and finally removed, leaving the unsterile nurse free to watch that the temperature of the fluid is kept up, and help, if necessary, to control the patient. About 500 c.c. are injected. The cannula is then withdrawn, the incision closed, usually with a stitch, and a gauze dressing applied. The bandage should be applied sufficiently firmly to keep the elbow extended, and the patient should be cautioned to keep the arm still for the first day. Great care must be taken to stop the injection while 504 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS some fluid is still in the flask, otherwise air might be forced into the vein. Air in any quantity forced sud- denly into a vein causes dilatation of the left chambers of the heart and of the pulmonary vessels, a condition always fatal, and usually causing death in a few minutes. Such an accident could take place only through gross carelessness in such a process as intravenous infusion, as, for example, by allowing the flask to become perfectly empty and refilling it with the needle in place. Still, nurses should be cautioned that such a risk exists. VENESECTION; PHLEBOTOMY Intravenous infusion is also carried out with the object of diluting the toxins in the blood in such a condition, for example, as uremia. A certain quantity of blood is then first allowed to flow from the vein before the needle is introduced. A flat, graduated vessel should be sterilized and placed below the arm at the point of incision, so that the amount withdrawn can be estimated at a glance. The operation is, otherwise, precisely similar to that, just described. The pulse is taken and recorded before and after either hypodermoclysis or intravenous infusion, and a note made of the same, with the hour, the amount injected, and, in the latter case, the quantity of blood withdrawn from the circulation. BLOOD CULTURE In certain infectious diseases and acute septic conditions bacteria are found in the blood, and for diagnostic purposes it may be desirable to make a culture directly from the blood of the patient. For this purpose a small quantity of blood is withdrawn from a vein. Several test-tubes con- taining the culture-media preferred must be in readiness, as it is important the blood should be immediately placed in the culture-media before it has time to clot or become in any way altered. This is also a puncture operation, apparently a very simple process, but in which want of care in strict atten- tion to detail would have disastrous results. Strict BLOOD CULTURE 505 asepsis is necessary to avoid infection, since the needle directly enters a large blood-vessel, and further care must be taken that no air is allowed to enter the vein. The risk of the latter is not great, and is avoided altogether if the vein is well distended, as the pressure so effected causes the blood to flow into the needle as soon as it is introduced into the vein. The articles required are: Small exploring needle with tube attachment. Test-tube. Culture tray. Preparation tray and hand lotion. Gauze pad. Bandage. Tourniquet. The needle and test-tube should be as carefully steril- ized as for lumbar puncture. A special needle attached to a small glass tube is frequently used in place of the ordin- ary exploring needle. The forearm is prepared by Formula A and the veins distended by the application of a tourniquet or tight bandage to the upper arm. As in intravenous infusion, it must not be so tight as to obliterate the pulse at the wrist. In venous puncture the tourniquet is retained until the process is over. The hands are prepared by Formula A: gloves and gown are worn; the unsterile nurse, besides her usual duties, will be required to apply the tourniquet and to hold the arm extended (under the sterile covering) during the operation. When the vein is sufficiently distended, the needle is plunged into the vein without a preliminary incision; the blood is caught in the sterile test-tube, and transferred immediately to the culture-media. About two drams is generally taken. The wound is covered with the gauze pad and a firm bandage; sufficient ^pressure should be applied to control any tendency to bleeding, and the arm be kept extended and at rest for some time. Discoloration or tenderness round the puncture must be reported at once. Antiseptic compresses, either hot or iced, are usually applied if such a condition arises. 506 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS TRANSFUSION By transfusion is meant the transfusion of the blood of a healthy individual directly into the vein of the person in need of such treatment. The transfusion tube most in use consists of a glass tube with a capacity (for adults) of 10 ounces. The lower end terminates in a fine pipet, the upper is closed with a rubber cork. A short glass arm near Fig. 158a.—Kempton-Brown transfusion tubes; two sizes, 100 c.c. and 250 c.c. cautery bulb (Mason, in "Surgery, Gynecology, and Obstetrics"). the upper end is for the attachment of a simple ball hand- pump. The inside of the tube is prepared with a coating of paraffin renewed each time the tube is used, which prevents the blood from coagulating. To line the tube proceed as follows, using strict aseptic precautions: Prepare a sterile table, with a packet of sponges, a packet of towels, and rubber gloves. TRANSFUSION 507 On a second table have an alcohol lamp and a pan of paraffin. Sterilize; the tubes for thirty minutes under 15 pounds pressure; on removal from the autoclave place upright on the sterile table for a few moments till all moisture is dried off. The hands scrubbed up and the gloves put on, take the tube, adjust the cork, and move the tube to and fro over the alcohol flame till evenly heated. Attach a piece of tubing to the short upper spout and suck the melted paraffin up into the tube through the spout to about one-quarter the capacity of the tube; remove the tubing. Take the tube in both hands with a gauze sponge held tightly over spout and pipet; revolve it till the paraffin has coated the entire inside; pour back a little through the spout and pipet and round the cork to about one-third of its depth; stand upright to cool and harden. A sponge soaked in alcohol rubbed over the tube will hasten this part of the process. If the lining is not evenly done it must be repeated. Wrap each tube in a sterile towel with two pieces of rubber tubing. After use, blood is cleaned from the inside with cold water followed by ammonia or peroxid; the paraffin is removed with a piece of gauze soaked in benzin. When thoroughly clean the tube is wrapped with a cork and two or three pieces of rubber tubing ready for sterilizing. The Operation.—In this operation two are concerned, the donor (the healthy person from whom the blood is to be obtained) and the patient. The Donor.—The procedure is the same as that described above for intravenous infusion. When the vein is opened the pipet is introduced directly into the vein, when the blood will flow into the tube. If the blood does not flow easily it may be helped by using the hand-pump. As this is not sterile, it is worked by a non-sterile assistant, and connected by a piece of glass tubing to a short length of sterile rubber tubing fitted on to the short glass spout at the upper end of the tube. Sixteen to 20 ounces is usu- 508 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS ally taken. The operation over, the wound is closed as described above. ■ The Patient.—The procedure is again the same as de- scribed above for intravenous infusion. As soon as the tube is filled with the blood of the donor it is taken to the patient and the pipet introduced directly Fig. 1586.—Transfusion. Donor's vein exposed, ligated centrally, and tube ready to be introduced into vein, the tip directed periph- erally (Mason, in "Surgery, Gynecology, and Obstetrics"). into the vein of the patient. The wound is closed as described above. The above method is known as indirect transfusion, and has practically replaced direct transfusion where the vein of the donor was temporarily united to the vein of the patient. Transfusion is used in conditions of grave anemia from disease, or following severe hemorrhage. INJECTION OF ANTITOXIN SERUMS 509 INJECTION OF ANTITOXIN SERUMS The injection of antitoxin serum (p. 401) is not essentially different from other hypodermic injections. The syringe commonly used is like a large hypodermic syringe, with a needle three or four inches long. For more convenient handling the needle is connected with the syringe by a short piece of rubber tubing. As always, special care is necessary to see that all air is expelled, and the needle filled with the serum before it is inserted. The articles required for the injection are as fol- lows: Syringe and needle. Phial of antitoxin serum. Packet of towels (2). Packet of gauze sponges (4). Preparation tray. Collodion dressing. Bowl of antiseptic lotion for the hands. The hands are prepared by Formula A; gloves and gown are worn. Fig. 159.—Mulford antitoxin phial. The sites usually chosen are the sides of the abdominal wall or the loose tissue under the shoulder-blade; the site is prepared according to formula. The strictest care must be taken to keep the serum from contamination during the process. The phial is not opened until the hands are prepared and the gown and gloves put on; the syringe is filled directly from the phial 510 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS after every part has been carefully sterilized. Scrum, being highly albuminous, the syringe and needle must be carefulh' cleaned in cold water immediately after use, to dissolve the albumin. The syringe used should be kept strictly for this purpose. To insure absolute sterilization, the diphtheria antitoxin sent out by the Mulford laboratories is put up in sealed phials, shaped like a small glass syringe, with sterile needle and small length of tubing. A mark across the nozzle of the phial indicates the point at which it is to be broken and the needle connected with the phial by the piece1 of tubing. The drugs administered by " piqure " on the continent of Europe are put up in the same way. Flasks of normal salt solution, 500 c.c, are also, on a larger scale, prepared on the same principle, and are exceedingly con- venient for private practice. MINOR SURGICAL PROCEDURES The following surgical measure's are frequently performed by the surgeon in the wards or the patient's room, the nurse usually acting as unsterile assistant. If required to help as " clean " assistant, she scrubs her hands by Formula A, and puts on gowns and gloves, keeping her- self as carefully "sterile " as though for a major opera- tion. As unsterile nurse, she will be required to prepare all that is necessary, keeping sterile and unsterile articles separate, to place the patient in the proper position, to prepare the skin area, and to remain at hand to handle unsterile objects, to fetch anything accidentally omitted, or to support the patient. If the operation is carried out in a private room, she must provide the necessaries for the surgeon to prepare his hands according to formula, and have gown and gloves in readiness. The possibility of shock after minor operations, per- formed without a general anesthetic, especially those that are lengthy and fatiguing, must be borne in mind. An extra blanket and hot-water bag should be in readiness, and a stimulant prepared, such as whisky or brandy, or EXPLORATION 511 a hypodermic syringe charged with a dose of strychnin or of atropin. If local anesthesia by hypodermic injection is ordered, it should be given from five to ten minutes before the operation. EXPLORATION It is often important, for diagnostic purposes, to explore one or other of the cavities of the body, either to determine Fig. 160.—Method of performing exploratory puncture of the pericardium, in order to determine the nature of a pericardial exu- date (Eisendrath). the presence of abnormal fluid, or to obtain a specimen of a fluid for microscopic examination. A large hypodermic syringe, similar to that used for antitoxin injection, is used; the needle, about four inches long, is attached to the syringe, usually, for convenient handling, by a piece of rubber tubing. It is of the first importance that these should be absolutely sterile and the needle sharp and smooth. The other articles required are: 512 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS Sterile test-tube plugged with cotton (or culture tray). Collodion dressing. Bowl of hand lotion. The patient in the required position and the area care- fully prepared, the needle is passed into the cavity and the fluid drawn up into the syringe. The puncture is closed with collodion dressing: The fluid obtained is transferred to the test-tube for examination, or a culture may be taken (Chap. XI). LUMBAR PUNCTURE Puncture of the spinal canal, with the object of removing a portion of the spinal fluid, is employed for diagnostic purposes, or with the object of relieving pressure in such disorders as meningitis, hydrocephalus, etc. More re- Fig. 161.—Lateral position for spinal puncture (Morrow). cently, the process has been used for the injection of cer- tain remedies, especially tetanus antitoxin. In recent days anesthesia has been produced by in- jection of the special anesthetic into the spinal fluid. The method is still in an experimental stage. The process is similar to other explorations, and the same articles are required: usually an exploration needle, about four inches long, with a short length of rubber tubing attached, is used without the syringe, or a fine trocar and cannula may be preferred. Some surgeons make a small preliminary incision in the skin before inserting the needle. In this case a scalpel will be required. Two sterile test- tubes should be prepared, and marked 1 and 2; in some LUMBAR PUNCTURE 513 conditions it is important to distinguish between the fluid which flows as the puncture is made and that which comes after. As these tubes are most conveniently handled by a sterile assistant or the operator, they should be sterile outside also. The needle, or trocar and cannula, with the tubing, are best sterilized in the autoclave and kept Fig.-162.—Sitting posture for spinal puncture (Morrow). wrapped until actually to be used; if not, they should either be boiled five minutes and laid in alcohol at least half an hour before use, or simply boiled for full ten minutes. The hands are prepared by Formula A; gloves and gown are worn. In order to introduce the needle between the vertebrae, the spinal column must be fully extended. For an ex- ploratory puncture the patient lies on his side, the spine rounded, the head and shoulders bent forward. In con- ditions where the patient's health permits the patient usually sits upright, the arms crossed in front, and the head and shoulders bent forward. It will probably be necessary to support the patient in the required posi- tion, taking care to keep him absolutely still during the whole process. 33 51 1 STROMAL TKCHNIC AND MINOR Sl'KOICAl, EVENTS The puncture is most frequently made at a point just below the fourth lumbar vertebra, which may be taken as the center of the area, to be prepared; Formula A is used. The needle introduced, the fluid is caught in the sterile test-tubes, one or two as required, which are immediately plugged with sterile cotton. The puncture is closed with Fig. 16.'}.—Spinal puncture: collecting the cerebrospinal fluid (Morrow). a collodion dressing. The quantity of fluid removed, with the hour of the operation, should be carefully noted on the chart. Simple though the process seems, it must not be over- looked that a channel of communication is opened into the most highly organized system in the body, and that in- fection will certainly be followed by the gravest results. There is no process in which strict aseptic technic is more absolutely necessary in every detail. PARACENTESIS, OR TAPPING Paracentesis, or tapping, is the method used to remove fluids from a cavity or a tumor in conditions where free opening is not suitable. The cavities of the pleura or PARACENTESIS, OR TAPPING 515 the pericardium may be evacuated in this way, but most frequently paracentesis is performed for the removal of fluid from the peritoneal cavity, in the condition of ascites, or dropsy of the abdomen. The following articles are required for paracentesis of the abdomen: Trocar and cannula, with long piece of ^ fine tubing. Scalpel. Needle and suture, either silk or silk- worm-gut. L ., Abdominal binder, with opening in the ( *■ center. Towels, 4. Gauze sponges, 6. Dressing of large gauze and cotton pads. _, Second abdominal binder. Small empty basin (sterile). Slop-jar or bucket. Preparation tray and basin of hand lotion. As the operation is long and the position fatiguing, it is always wise to have a stimulant in readiness. The most suitable cannula is one with a short arm near the further end, to which the tubing can be adjusted while the trocar is in place. Otherwise some spilling is inevit- able when the trocar is withdrawn before the rubber can be connected to the cannula. Trocar, cannula, and tubing are best sterilized in the autoclave. The hands are prepared by Formula A; gown and gloves are worn. Immediately before the operation the urine should be voided, as the bladder, when distended, rises above the pubes and might be injured. The patient is supported in the upright position during the process, to insure better drainage. Some doctors prefer him to sit in an arm-chair or on the edge of the bed, the feet comfortably supported on a stool. In either case he must be made thoroughly comfortable, with pillows and warm coverings, and carefully watched for symptoms of fatigue or faintness. Where sitting up is not possible, 516 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS the patient lies on his side, the abdomen close to the edge of the bed. A rubber sheet is arranged to protect the clothing from getting wet. With a little care there should be no spill- ing. The tubing is directed into the slop-jar, placed con- veniently on the floor to catch the fluid. The whole abdomen is prepared by Formula A, and, except in the case of children, generally shaved. The preparation over, the patient is placed in position, and the wide sterile binder is applied, the opening over the center of the abdomen, and fastened tightly behind. The antiseptics are again applied to the exposed surface of the abdomen, which bulges forward through the opening in the binder; two sterile towels are adjusted over the binder, one above and one below the point of incision. A minute incision is made in the skin, the trocar and cannula introduced, and the trocar withdrawn. From time to time, as the abdomen empties, the binder is tight- ened from behind. When sufficient fluid has escaped, the cannula is withdrawn and the incision closed, usually with a suture. A generous dressing of gauze and cotton pads is applied under a binder or a scultetus bandage. These will require to be changed later, as some leaking is bound to continue. The necessity for keeping the area sterile during the entire process must not be lost sight of; some care will be required to keep the patient dry; wet towels must be re- placed by dry ones. A similar operation is sometimes used to remove fluid from the lower extremities in advanced cases of dropsy. Small perforated silver cannulae, known as Southey's tubes, with fine rubber tubing attached, are introduced at different points, and the fluid allowed to run slowly away into a convenient receptacle. Similar aseptic pre- cautions are used. ASPIRATION Aspiration is a method of tapping which precludes all risk of introducing air into the cavity. For this reason it is preferred to paracentesis, as described, for the re- ASPIRATION 517 moval of fluid fron the cavities of the pleura or the pericardium. Usually, as a preliminary step, the presence of fluid is first ascertained, and its nature determined by a pre- vious exploration, as already described. For aspiration a special apparatus, known as an aspirator, is used (Fig. 167). This consists of a large glass bottle with a rubber cork, into which fits closely a two-armed metal tap; each Fig. 164.—Aspiration of the peritoneal cavity. First step: appli- cation of the abdominal binder (Morrow). arm of the tap is provided with a stop-cock; to each arm is connected a length of solid rubber tubing (the ordinary rubber tubing collapses when air is withdrawn). The rubber tubes are furnished with metal connection attach- ments at either end. One length of tubing is connected to an air-pump, the other to an exploring needle or a trocar and cannula. By the air-pump the air in the bottle is exhausted, thus producing a vacuum; when the exploring 518 Sl'RCICAL TECHNIC AND MINOR SURGICAL EVENTS needle is introduced into the cavity, the fluid naturally escapes into the vacuum. The aspirator should always be tested immediately before being prepared for use. While each part must be carefully cleaned and sterilized after use, only the exploring needle and its connecting tube should be resterilized be- fore use, as the sterilizing process is very apt to destroy the absolute adjustment of the different parts on whicl Fig. 165.—Aspiration of the peritoneal cavity. Second step: nick ing the skin at the point of puncture (Morrow). the proper working of the apparatus depends. This tube should be in two parts, connected by a piece of glass tubing; the length to which the needle is attached is to be kept sterile throughout, and should be of a convenient length, so that the aspirator can stand on a table securely out of the way of the clean operator. The needle and upper part of the tubing are usually sterilized in the autoclave, and kept until required in the sterile wrapper. The inside of the bottle is kept sterile, ASPIRATION 519 in case the fluid is required for examination. The bottle, the stop-cocks, and air-pump are managed by an unsterile assistant, or, if this is impracticable, are handled with sterile gauze. The air-pump can be removed when the vacuum is formed. To test an aspirator, fill a bowl with sterile water, adjust the parts, and open the stop-cock connecting with the air-pump; keep the other closed; work the pump until Fig. 166.—Aspiration of the peritoneal cavity. Third step: showing the method of inserting the trocar (Morrow). stiff, which is a sign that the air is exhausted. Close the stop-cock; place the needle in the basin of water, and open the stop-cock connecting it with the bottle; the water should run into the bottle. If the apparatus does not work easily, the cause must be sought. Part of the apparatus may be blocked by coagulated albumin from imperfect cleansing; usually the fault is in some leakage of air caused by drying and 520 SURGICAL TECHNIC AND MINOR SURGICAL EVENTS shrinking of the rubber cork, which may be overcome by soaking the cork in water. After use, the greatest care should be taken to wash every part of the apparatus, with the exception of the air- pump, immediately under running cold water until all organic deposit is dissolved and removed. Besides the aspiration apparatus, the usual necessaries for preparing the area, towels, gauze, sponges, hand lotion, and a collodion dressing will be required. Some surgeons prefer to make a small preliminary in- cision with a scalpel before introducing the needle. This is no bigger than a puncture, and does not require suturing. Fig. 167.—Aspiration of the pleura (Morrow). Unless, however, a nurse is perfectly familiar with the methods of the surgeon, when a scalpel is ordered, she should prepare against emergencies, needle, silk suture, artery forceps, and catgut ligature, since, with our modern methods, these cannot be got ready in a minute. In watching the surgeon introducing an aspirating or exploring needle, you may frequently notice he will pull the skin a little upward with his finger before beginning the insertion. By doing this the incision in the skin and the incision directly into the viscera are, when the needle is withdrawn, not exactly opposite each other. A simple puncture is closed with a collodion dressing; ASPIRATION 521 if the incision is made with a scalpel, a small gauze pad is applied, with cross-strips of adhesive plaster. For aspiration, the hands are prepared by Formula A; gown and gloves are worn. Aspiration of the Chest-wall {i. e., the Pleural Cavity).— A collection of fluid in the pleural cavity is a frequent accompaniment of disease or injury to the lungs. If the fluid is found on exploration to be purulent, the chest- wall is generally opened and the abscess drained. As a means of temporary relief, and in conditions where non- purulent fluid is largely in excess, the cavity is more con- veniently emptied by aspiration. For this process the patient lies on his sound side, in a semi-recumbent position, the arm of the affected side raised above his head, and the shoulders turned forward. Pillows arranged under the side of the chest help to bulge the ribs over the affected area. The chest is prepared from the spine to a point beyond the axilla, and from the shoulder to the waist. The needle is usually introduced either near the angle of the shoulder- blade, or below and in a line with the axilla. A stimulant should always be in readiness for this operation; a dose of whisky is frequently ordered as a preliminary precaution, especially if a local anesthetic is not used. Coughing during the operation usually signifies that the visceral layer of the pleura has been pricked. The needle is withdrawn, or the lung may be injured. The sputum should be watched subsequently for traces of blood. Attacks of syncope, sometimes even fatal, are not un- common after the removal of a large quantity of fluid from the pleura, due, it is considered, to change in the position of the thoracic organs caused by the emptying of the sac. Pa- tients should be cautioned to lie still and to make no sudden movement or attempt to sit up for twenty-four hours after the operation. The pulse should be carefully watched. Aspiration of the Pericardium.—The operation does not differ in any essential from that of aspiration of the pleura. In cardiac disorders the patient is frequently compelled to keep the upright position, and in all circumstances the 522 SURGICAL TECHNIC; AND MINOR SURGICAL KVENTS position in which he can breathe most easily must be preferred. The needle is introduced at a point near the left margin of the sternum, generally between the fourth and fifth rib. This point may be taken as the center of the area to be prepared. If the chest is very hairy, shaving is necessary, but usually the process is shortened as much as possible in order to make no demands on the patient's strength. A stimulant, preferably whisky, should be prepared, but in this case is generally given after, rather than before, the operation. Local anesthesia is not usually ordered. The condition of the patient makes aspiration of the pericardium always an important process. He must be closely watched throughout and subsequently for signs of syncope, such as changes in the pulse-rate, pallor, yawning and sighing, or coughing. Many doctors order the hy- podermoclysis apparatus in readiness before beginning the operation. Where the exploring needle has shown the fluid to be purulent, the more usual operation is the open- ing of the pericardium, in order to drain the abscess. Nurses cannot be too carefully impressed with the necessity for strict aseptic precautions, both in preparing for any of the above surgical proceedings and during the operation. Small though the puncture of an exploring needle or cannula may be, it is sufficient to form a channel of infection to these important organs. CHAPTER XV THE OPERATING-ROOM Equipment—Duties—Operations in Private Work. A pupil that has been carefully taught practical asepsis, and has intelligently grasped the principles on which sur- gical technic is based, will find no insurmountable diffi- culties in learning her duties in the operating-room. Still, the operating-room is a region in which emergencies constantly arise, in which action must follow judgment promptly, and in which a clear head, self-control, and alertness are essential qualifications if confusion is to be avoided. No pains should be spared to make each nurse perfectly familiar with each instrument or appliance used, with the purpose of all articles in the equipment, and to teach her the proper way to hold a limb, apply and control a tourniquet, or to perform any one of the services she may suddenly be called upon to give. An emergency is ob- viously not the time for instruction. EQUIPMENT OF THE OPERATING-ROOM The tendency of modern surgery is toward simplicity of equipment, and the rule in a modern operating-room is to have nothing but what is strictly necessary for the work in hand. The furniture preferred at the present day is made of white enamel, iron, and glass, which presents a non-ab- sorbent surface and is easily cleaned and disinfected. All vessels used, bowls, trays, etc., are also either of glass or of enamelware. The movable equipment consists of the operating-table, a convenient number of glass tables, and a couple of chairs or stools, usually in enameled iron. Of these latter, one is required for the anesthetist, and one for certain opera- tions, such as on the perineum, at which, as a rule, the 524 THE OPERATING-ROOM operator sits. The tables are provided with large rubber castors or with slides, in order that they can readily be moved without lifting. A " clean " person, for example, can move such a table into position with the foot and so avoid breaking technic. The operating-table in general use is also made of white enameled iron and glass, and so constructed that it can be shortened or extended and the angle changed while the patient is in place. The nurses should be familiar with EQUIPMENT OF THE OPERATING-ROOM 525 the simple mechanism by which the changes are made. The glass is arranged on the iron framework in panels sloping toward the center of the table, and with openings between the panels; by this arrangement fluids run off the table into a trough underneath, and so keep the surface comparatively dry. Fig. 169.—Boldt's hospital examining and operating-table, showing an adjustable stirrup with strap and a heel stirrup (Asnton). A special bracket table of similar make may be attached to the table for operations on an extremity. The angle of the table is altered by means of a cog- wheel, turned by a detachable handle. By this means the Trendelenburg position can be assumed (Fig. 51), and the height adjusted without disarranging the operation. In doing this while an operation is in progress care must 520 THE OPERATING-ROOM be taken to work under the sterile coverings, or the technic will be broken. About one-third from the lower end the lower panels can be folded down, in order to shorten the table. At this point are a pair of metal holders, one on each side, into which the " crutches " are fitted when required, and held in place by a screw. The crutches are a pair of long metal rods from which are suspended " stirrups," usually made of broad webbing (Fig. 169). Their object is to keep the lower extremities raised and separated, as in the lithotomy position. The feet rest in the webbing stirrups. When in place, the " crutches " should be at such a height that, with the feet in the stirrup, the knees are well flexed and separated. The crutches are used for operations on the perineum, rectum, vagina, and adjacent parts. Near the head of the table are a pair of shoulder sup- ports, for use if the patient is put in the Trendelenburg position. These should not be used unnecessarily, as the prolonged pressure involved is quite apt to cause edema of the arm, numbness, and even temporary paralysis. Pillows or pads of some sort are necessary to keep the patient from resting entirely on the hard table. These should be adjusted with care, as bruising of the coccyx from long pressure on the glass of the operating table is, not uncommonly, the starting-point of a bed-sore. If pads are preferred, they should be two in number, placed lengthwise on the middle division of the table, and should not meet in the center or they will prevent the fluids draining from the table. They should be flat, stuffed with hair, and covered with rubber sheeting; they should not be larger than the panels they are to cover, or they will be in the way if the table is to be shortened. Some hospitals use a folded blanket as a pad. The blanket is covered first with a rubber sheet, and above the rubber a cotton sheet, both tucked smoothly under the blanket. This makes an excellent pad for private work, but has the disadvantage of preventing the fluids from draining away, and in many operations keeps the back lying in a puddle. EQUIPMENT OF THE OPERATING-ROOM 527 A common practice is to use small hair pillows, covered in rubber sheeting, adjusted so as to keep bony prominences off the table. The usual requirement is one for the head, one under the shoulders, and one under the coccyx. Pads or pillows should be covered with cotton slips when in use, as rubber in contact with the skin makes it hot and moist, and favors the formation of bed-sores. After use every part of the table is scrubbed with soap and water, and when clean, usually wiped with an anti- septic, either carbolic 1 :20 or formalin 2 per cent. In many hospitals the operating-table and the sterile tables are wiped with an antiseptic again before use. This is not actually necessary, since they are entirely covered by the sterile coverings during the operation. The other tables considered necessary vary somewhat in different operating-rooms. One or two, according to the assistants available, are covered with sterile towels and kept " sterile " throughout. On these are placed the instruments, sutures, sponges, dressings, and all sterile appliances. Some surgeons use a narrow instrument table placed across the operating-table at a convenient height; in most cases an ordinary glass table is used, placed beside the assistant who is to hand the instruments. Besides the sterile tables, one table is required for the anesthetist, one should be kept set out with the usual rer quirements for emergencies, and a third will be required for other articles to be handled by the unsterile nurse. The anesthetist's table, which is placed at the head of the operating-table, should contain the following, all arranged conveniently: The anesthetic to be used, as— a. Ether and ether cone. b. Chloroform in drop bottle and chloroform mask. c. Tube of ethyl chlorid and square of folded gauze. Tongue forceps. Sponge holder. Mouth-gag. Gauze sponges. Small towels. Small jar of sterile vaselin. Small jar of boric solution, 2 per cent., with eye-dropper. 528 THE OPERATING-ROOM Local anesthetics, such as Schleich's solution, cocain, eucain, etc., if required, should be ready in the hypodermic syringe in the dose ordered, or if required for an eye, in a small sterile bottle with the eye-dropper. The tongue forceps are used to pull the tongue forward if it should drop to the back of the throat, especially in operations where the head cannot be turned to the side. The sponge-holder, with small gauze sponge, is to clear the throat of accumulations of mucus; vaselin is used to smear the lips, nose, and chin in giving chloroform, as if chloro- form is dropped on the skin a burn will be produced; if the same accident happens to the eye, it is immediately irrigated with the boric-acid solution. On the emergency table are placed the following: Hypodermoclysis apparatus. Flasks of sterile water or normal salt solution, both hot and cold. Hypodermic tray. Enema tube, funnel, and pitcher, with small bottle of whisky or brandy. The oxygen apparatus stands beside the table. The hypodermic tray should contain the hypodermic tablets most frequently required (atropin, strychnin, nitroglycerin, morphin, and cocain), two syringes ready charged, one with strychnin (-jV to tV grain) and one with atropin {teh to tttt grain), wrapped, until required, in a piece of gauze soaked in alcohol, a small flask of sterile water, a small bottle of alcohol, and a jar of sterile gauze sponges. It is always a good plan that this table should be pre- pared as a matter of routine, if only because it familiarizes the pupils thoroughly with what is required in cases of emergency. Reserve Table.—On a table, conveniently on one side, are placed reserve packets of sponges, towels, dressings, gloves, and gowns, to be unpinned and passed to the clean nurses or assistants, as required. On this table will also be placed bandages, pins, adhesive strapping, appli- ances, such as splints, tourniquets, extra pillows or sand- bags, if likely to be required; dusting-powders, iodoform emulsion, and similar articles not constantly used. A EQUIPMENT OF THE OPERATING-ROOM 529 small tray with the necessaries for taking cultures (p. 372) should also always be in readiness, and may conveniently be kept on this table. In some hospitals it is a routine practice to wash out the stomach after prolonged anesthesia, especially in abdominal operations. A large pitcher, a deep basin, and the stomach-tube and funnel should be prepared, together with any drug that may be ordered. Castor-oil (1 to 2 ounces) is frequently left in the stomach after the lavage. Extra flasks of normal salt solution and of sterile soap, ether, and alcohol, and covered glass jars containing sterile sutures, ligatures, drains, and tubing, are con- veniently kept on glass shelves or stands, either in the operating-room or close at hand. Preparation Table.—It is often a convenience to arrange a separate table with the necessaries for the preparation of the area of operation. On it are placed flasks of soap, alcohol, ether, and the antiseptic solutions used, sterile basin and brush in wrapper, packet of sponges, packet of towels, razor, a pair of bandage scissors, and two pieces of rubber sheeting. For a vaginal preparation long sponge-holders and small sponges are added. Cupboards, Stands, etc.—A closet at hand should con- tain a supply of blankets, ether hose and gown, pillows, pillow-slips, and hot-water bags. During an operation some blankets and a set of hose and gown should be kept on the steam-pipes or other hot place, as the patient should be returned to bed in warm, dry clothing. The instrument cupboard, usually also at the present day made of glass, with a metal framework, should be arranged conveniently, instruments of one kind arranged together in orderly rows. No instrument wanting repair, and no old-fashioned instrument not commonly in use, should be kept in the instrument cupboard. Separate stands, each to hold one large basin, are gener- ally used for hand lotion or sterile water, as preferred. One is placed near the operator, and one by the sterile nurse or assistant. In some hospitals iron rings take the place of the basin stands, and are fitted into sockets on the sterile stands or on the walls. If desirable, these 34 530 THE OPERATING-ROOM rings may be sterilized with the basins, and the whole then handled by the sterile nurse. Sponge Receptacle.—A special receptacle is kept for used sponges only. This may be a wire basket, slop bucket, etc. Some hospitals use a large bag of stout muslin tied to the four corners of the frame of a glass table or stand in place of the glass slab, by which means the bag is held conveniently wide open. The wash-stands, whether in the dressing-rooms or operating-room, should be provided with liquid soap, sterile brushes, orange-wood sticks, and nail-files, one set to each basin. These are usually kept standing during the operation in an antiseptic solution—carbolic, 1 : 20, or bichlorid, 1 : 1000. A fresh set of brushes, etc., is put out for each operation. At hand are basins contain- ing the lotion according to the formula used in preparing the hands. Basins and Pitchers.—A sufficient supply of sterile basins, pitchers, and small bowls must be in readiness. According to the method by which they are sterilized these will be in cotton wrappers, or taken when required from the sterilizer in which they are boiled. A large sterilizer in which a number of vessels can be boiled at one time and kept until wanted is a great saving of time in an operating- room. Water-supply.—All modern operating-rooms are pro- vided with a generous supply of sterile water; generally the necessary sterilizers are placed near the operating- room, and in charge of the operating-room nurse. Care must be taken to keep a sufficient amount sterilized for all demands. In many hospitals of quite modern construction all the water laid on in the pipes of the operating-room is actually sterile, and can be used for ordinary purposes (solutions, skin preparation, and so forth) directly from the taps. Fluid to be used for hypodermoclysis or irriga- tion of closed cavities must be further sterilized in the autoclave or by the fractional method. We saw in the last chapter that surgical technic, as we EQUIPMENT OF THE OPERATING-ROOM 531 understand it today, usually calls for two pairs of hands, " clean" and " unsterile," thus doubling labor. In modern operating-rooms many devices have been intro- duced to obviate this necessity to a great extent. Foot-pedals are used to turn on the water in wash- basins, etc., thus doing away with any need for touching taps. The water sterilizer may also be fitted in the same way. Large sterile glass jars are provided for the lotions, fitted with stop-cocks also worked by foot-pedals; these are placed on a glass bracket of suitable height. By these arrangements the sterile nurse can draw water and pre- pare the lotions without coming in contact with an un- sterile object. Where the dressings, etc., are put up in packets (or jars or tubes, etc.), an unsterile assistant is required to open the packets. In place of the packets large metal drums are provided, into which the dressings, etc., are packed and sterilized without the need for separate wrappings. The drums are placed on special stands in the operating-room, furnished with foot-pedals by which the lids of the drums are raised. Generally, three drums are provided: one for the gowns, caps, and gloves, hand-brushes and nail-cleaners, and the covers for sterile stands; a second for sterile towels; and the third for dressings, including sponges, tubes of pack- ing, etc., sufficient for a full day's operating. The sponges and dressings are tied with tape into bundles of a given number. A fourth drum is often provided, fitted with an electric heater in which towels and gauze pads to be used in walling off the viscera in certain operations can be kept sterile and hot, thus doing away with the need of wringing them out in boiling water. From these drums the sterile nurse can help herself without assistance or risk of breaking her technic. A large boiler in which all the basins, pitchers, etc., to be used are sterilized may be provided in the same way with a foot-pedal for raising the lid. There remain only the jars in which sutures are stored, and the small flasks of soap, ether, and alcohol to be used 532 THE OPERATING-ROOM in the skin preparation. These are tightly corked with ground-glass stoppers, and are immersed in a disinfectant (formalin, 2 per cent.; bichlorid of mercury, 1 :1000, etc.) for at least one hour before they are to be used. A glass graduate, to be used in measuring the solutions, is prepared with these bottles. In an operating-room fitted in this way one " sterile " nurse can set out the entire operating- room for whatever number of operations, in a very short time, without requiring the help of an unsterile assistant, as she must do if packets, etc., are to be opened. Mops.—The last item of equipment to be remembered is a mop, with which, from time to time, to wipe up the floor and keep it from getting greasy and slippery. This should stand on one side, in a bucket of disinfectant, usually carbolic 1 :20. After use it must be well washed in hot soap and water and dried in the open air and resterilized. Gowns.—A special uniform is usually required in the operating-rooms. The nurse's consists of a skirt and loose, short-sleeved blouse of unbleached muslin. The skirt is short—about eight inches from the ground. For the doc- tors a loose, short-sleeved shirt and trousers of the pajama shape in the same material are provided. These uniforms are clean, but not sterile. Over these uniforms, during the operation, is worn the usual sterile gown. The gown is not put on until after the hands are scrubbed up. Most of these gowns are made with long sleeves, which, at the wrist, are tucked inside the cuff of the rubber glove. The hair is also covered with a sterile cap. The operator and his assistants also frequently wear sterile gauze masks during the operation, and have the beard tied up in sterile gauze. If this is not done, it is the duty of an "un- sterile " nurse to wipe the faces free from perspiration from time to time with a sterile towel. Patient's Dress.—In most hospitals a special dress is provided for the patient during operations. This usually consists of jacket and hose of Canton flannel or other warm washable material. The jacket should be roomy and long enough to reach below the hips; it is fastened behind with a single button at the neck. The hose are made like DUTIES OF THE NURSES 533 loose, roomy stockings, and reach to the hip. Jacket and hose are kept on during the operation, unless they are in the way of the part to be operated on. The linen supply necessary for each operating-room in- cludes the following: Doctors' suits, gowns, and caps. \ In heavy unbleached Nurses' dresses, gowns, and caps, j muslin. Sheets for the operating-table. Pillow-slips. Towels (dressing, used sterile). Hand-towels. Wrappers for sterile dressings, etc. (double fold of un- bleached muslin). Ether jackets and hose. The stock cupboard should also contain hot-water bags with washable covers; rubber bathing caps, to pro- tect the patient's hair in operations about the face, etc.; rubber bandages; tourniquets; and various pillows of different shapes and sizes, some stuffed with hair and others filled with sand. These are required in keeping a patient in a fixed position during an operation; they should be covered in rubber sheeting. Pillows of bolster shape, about 18 inches long, firmly stuffed with hair, are conven- ient to place under a patient lying on his side in certain operations, such as on the kidney or on the spine. To these may be added the foot-rest and pelvic rest described in the chapter on Bandaging. A hot closet in which blankets can be kept is a helpful addition to the operating equipment. DUTIES OF THE NURSES It is not possible to lay down any fixed rules as to the duties of the nurses in an operating-room: they vary with the number of assistants and with the facilities of equip- ment. The minimum assistance required at an operation under aseptic methods is one " clean " assistant and one unsterile; this does not include the anesthetist. In a hospital operating-room three nurses is often a practical number, a head nurse permanently in charge, and two 534 THE OPERATING-ROOM pupils. During the operation one pupil, or both if required, remains clean. It is usually best that the head nurse remains free to supervise and direct the pupils, to see that everything required for the succeeding operations is prepared in time, and to keep watch that no one breaks the technic. In small hospitals, however, she may be the only one actually attached to the operating-room, and frequently called upon by the operator to act as a second surgical assistant in minor details, such as sponging, holding the retractors, etc. In these circumstances the charge nurse should be " clean," as she must accustom herself to the methods of the different surgeons, who must also feel that she can be relied on to understand what is required—a confidence naturally not extended to the transient pupil. In order to get the necessary training, the pupils in turn must also act as " clean " nurses and help her in her duties. The clean nurse usually has charge of the sponges, towels, dressings, ligatures, sutures, and needles. These she arranges after she is clean, on a table previously cov- ered by a sterile towel, taking them from the packets, jars, etc., opened by the unsterile nurse! The instruments may be in her charge also, arranged in a convenient row on her table, and handed by her as required. The in- struments are brought to her by the unsterile nurse in the tray in which they are sterilized. If two nurses are clean, the junior may be given the sponges and dressings as her care, and the senior the instruments, ligatures, sutures, and needles. The instruments are often regarded by nurses as a special bugbear, and much needless anxiety is caused by leaving the pupils vague as to the uses of the different instruments and the special requirements of the different operations. In hospital work the operating-room staff should be provided with a book in which the instruments, special needles, and the kind of sutures required for each kind of operation are clearly listed. At the same time the charge nurse should go over the instruments in the instrument DUTIES OF THE NURSES 535 closet with each pupil, grouping those required for special work together. Many instruments are called by special names, usually after a surgeon who has added some im- provement to the instrument. With these also the pupil must be familiar, as there is nothing in the name to suggest whether the instrument may be a needle-holder, a retrac- tor, or something widely different, and she finds herself at a loss if it is asked for by its special name. The Clean Nurse.—The routine duties of the clean nurse (or nurses) consist in passing the sterile objects mentioned as required, and in keeping the sterile area surrounded with sterile towels. She must keep close watch that she touches nothing unsterile. She may be called upon, where there is not much assist- ance, to prepare the area of operation. This she usually does after she has prepared her hands by formula, but before putting on her gown and gloves. After the preparation she again sterilizes her hands and puts on her gown and gloves, while the assistant operator repeats the disinfecting part of the preparation. If there has been no previous preparation, the patient is shaved and the whole process completely carried out once by an unsterile assistant or nurse before it is touched by any one clean. During the preparation rubber sheets are placed one above and one below the site of operation, to protect the coverings, and are removed when this is complete. The Sheet.—The preparation complete, the clean nurse arranges the sterile coverings. During the operation patient and table are covered with a sterile " operation " sheet. A proper operation sheet is cut one yard longer than the table and one yard wider; three-quarters of a yard from one end an opening is fashioned, either square or oval, usually eight inches long by six wide. The sheet is arranged so that the opening comes exactly over the site of the operation. Practically the operation sheet is found inconvenient if the table has to be rearranged during an operation. Usually a large sheet to cover the lower half of the table and patient, and a smaller sheet laid across the 536 THE OPERATING-ROOM upper part of the patient's body, is found a more convenient arrangement. The sheets must be adjusted to suit the operation. For example, for an abdominal section the upper margin of the lower sheet is turned over and under the edge of the covering blanket at the pubes, and the lower margin of the upper sheet in the same manner over and under the patient's upper garment, about the tip of the sternum. The immediate sterile area is arranged above the sheets; usually it is made with four sterile towels arranged sym- metrically round the site of the incision. To prevent the towels slipping they are either pinned together or held together with clips; the towels are changed from time to time during an operation by the sterile nurse. The sterile area in operations on the vagina, perineum, rectum, etc., with the patient in the lithotomy position, is a little mdre difficult to arrange. A Kelly pad is placed under the pelvis, and over it a sterile sheet covering the lower end of the table, and gathered into a sterile bucket on the floor; each extremity is wrapped in a sterile sheet,and and a corner of each brought over and pinned together above the pubes; a fourth sheet covers the patient and table above, overlapping the side sheets at the pubes and thighs. The immediate area is covered by four sterile towels previously pinned together to leave the necessary opening. The clean nurse should keep one or two reserve sets of towels pinned in readiness, as it is difficult to adjust them separately in this position without slipping. If a nurse has to remain clean for a second operation, her duties end when she passes the sterile dressings. The dressings are kept in their wrappers until actually required. If the case has not been perfectly clean throughout, she is required to change her gown and gloves and prepare her hands again by formula. Otherwise she stands aside and waits until the unsterile nurse brings her the fresh packets of towels, sponges, etc., and the instruments for the next operation. In an active operating-room the tables are, for the different operations, usually prepared beforehand, and brought into the operating-room with the fresh case. If possible, the pupils should then act as clean DUTIES OF THE NURSES 537 nurse in turns, thus avoiding delay and also mitigating the fatigue. The Unsterile Nurse.—On the unsterile nurse devolves the placing of the patient in the required position on the table, the adjustment of the table at the proper angle, and the arrangement of the unsterile coverings. Position of Patient.—The patient is usually fully anes- thetized when brought into the operating-room. In placing him on the table, the nurse must take particular care to adjust the pads or pillows so as to protect bony prominences from contact with the hard surface of the table, or the prolonged pressure involved may be the starting-point of a bed-sore. The usual position of a patient under ether is on the back, the body fully extended, and the head turned to one side. The body, except the part to be exposed, is covered with a woolen blanket well tucked in round the lower limbs. A single light blanket may be thrown across the chest—generally the ether jacket is sufficient covering. The jacket should be unbuttoned at the neck before the anesthetic is begun. The ether hose are kept on, except when a lower limb is to be operated on. The Patient's Arms.—Different methods are employed for keeping the arms at rest and out of the way, especially in operations on the abdomen. Many cross the arms on the chest and fix them by turning the lower margin of the jacket over the arms and tucking the ends firmly under the body. Others consider that the arms crossed on the chest impede, to some extent, the breathing, and keep the arms extended on either side. As the table is narrow, it is necessary to fix the arms, or a slight movement may cause them to roll over the side of the table and perhaps be injured. One method is as follows: Lay a draw-sheet across the table, so that it will lie under the patient's body, reaching from the axilla to the hips; the arms, fully extended, are laid close to the sides. Bring the ends out on either side, between the chest-wall and the arms. 538 THE OPERATING-ROOM Turn the ends over and under the extended arms, and tuck them back well under the patient. In tucking, leave a few inches of the margin hanging out; with one quick pull on the free margin the arm is instantly freed. Patients may also require to be placed in the lithotomy position, with the knees flexed, as described, with the crutches, in the Trendelenburg or Sims' positions (Chap. VI), on the side, or with one or other limb extended on a separate attachment of the table. A nurse often finds the arrangement of a patient in his unconscious condition one of her most difficult duties; she should be given the oppor- Fig. 170.—Showing method of fixing arms during operation. tunity to practise until she can do it deftly, and carry out any change of position during the operation without unduly disturbing the operation or coming in contact with sterile objects. The patient in place, she next arranges the rubber sheet- ing, one above and one below the site of operation, re- moves the bandage and top preparation dressing, and waits on the clean assistant as she prepares the area. During the operation she must be on the alert to fore- stall the wants of the operator or his assistants or of the clean nurse; she changes the lotions, keeps up the supply of towels and sponges, sterilizes instruments that may be DUTIES OP THE NURSES 539 called for, and performs any service about the table for which an unsterilized pair of hands may be required. She is expected to keep close watch that technic is not broken, and to call the attention of one of the assistant operators to the fact in the event of its occurring. In emergencies she may be required to administer a hypodermic, to prepare for hypodermoclysis, or to give a stimulating enema. If hypodermoclysis is required, she prepares the necessary apparatus, hands the needle and sterile length of tubing to the clean nurse, and prepares the skin for the puncture. When all is ready, the clean nurse removes her gloves and introduces the needle into the tissues, with the usual precautions; the rest of the process is usually left to the unsterile nurse, unless an extra clean assistant is available for the whole process. If irrigation is necessary, the nozzle and a sterile length of tubing are brought to a clean assistant, the unsterile nurse preparing the rest of the apparatus. In connecting a sterile length to the rest of the tubing, which does not remain strictly sterile, she holds the end of the sterile tubing with a piece of sterile gauze. The unsterile length of tubing, either for hypodermoclysis ,or for irrigation, must always be sufficiently long to come well beyond the sterile coverings of the operating table. At the present day cavities are usually irrigated, when necessary, with normal salt solution in preference to sterile water or an antiseptic solution. Where the Paquelin cautery (p. 105) is to be used, the unsterile nurse prepares the instrument, heats the tip, and manages the pump, passing the handle only to the operator, who takes it in a piece of sterile gauze. Counting Sponges, etc.—One of the most important duties of the nurses during an operation where a cavity is opened is to keep count of the sponges and of the instru- ments used, especially of the artery forceps (clips, hemo- stats), of which a considerable number may be in use. Accidents have occurred in which a sponge or a pair of forceps has been left in the abdomen. To facilitate the counting the numbers used must be known accurately. Sponges are given to the clean nurse 540 THE OPERATING-ROOM in packets of a known number, ten or twenty usually, and the forceps in bunches of six strung together on a safety-pin. On receiving the sponges the clean nurse counts them twice, and writes the number on a piece of sterile slate placed on her table. As the sponges are used and discarded the unsterile nurse places them on one side and recounts them, entering the number in tens or twenties in writing. Before the cavity is closed, the two counts are taken and compared, to insure that no sponge is left in the cavity. The same care is taken with the instruments. If an in- strument falls fron the table or becomes otherwise unsterile, it is either resterilized and returned to the clean nurse for use again, or put on one side, to be counted with the instruments. It is usually a rule, in such cases, that no sponge or instrument put out for an operation may be taken from the operating-room during the operation. The nurse must never hesitate to notify the operator before he begins closing the wound if she finds herself with a sponge or instrument short. The operation is then stopped until the missing article is found. Some surgeons have the sponges for abdominal sections made after special patterns, to lessen the risk of such an accident. Some use wide strips of gauze, about two yards long, folded so as to avoid raw edges, and rolled like a bandage; others have special pads of gauze made to which a length of tape is sewn; a pair of artery forceps clipped to this tape acts as an additional guard. Once a piece of gauze is saturated with blood, it may easily be lost sight of among the tissues and get buried under a coil of intes- tines or other viscera. When the incision is closed, instruments and soiled towels are removed and the skin cleaned and dried before the dressings are applied. The dressings should not be taken from their coverings until immediately required; there is no object in leaving them uncovered on a table during an operation that may last an hour or more. The dressing applied, the unsterile nurse may be required to help in the adjustment of the bandage and in drying the patient and removing him on to the stretcher. Par- ticular care should be exercised in drying the back thor- OPERATIONS IN THE PATIENT'S HOME . 541 oughly. The covering blanket must be changed if wet, as it is important to return the patient to bed in warm, dry clothes. One nurse should always accompany the patient with the anesthetist to the ward, where she should give the head nurse a written memorandum of any emergency treatment that has been necessary during the operation; thus: 11 a. M.: Hypodermic strychnin sulphate, -fo grain. 11.15 a. m.: Hypodermoclysis normal salt solution, 500 c.c. These are entered on the special chart (p. 175); nothing of this sort should be left to the spoken word— memories are too uncertain. She should also mention briefly anything that has been done other than the opera- tion for which the patient was prepared. Between operations the unsterile nurse removes soiled things from the operating-room, places stained instru- ments to soak in cold water, wipes the table, if the same is to be used again, with a towel wrung out in the antiseptic preferred, mops the floor, changes the lotions, water, etc., and replenishes the different tables with all that is required, bringing, as before, the sterile towels, sponges, etc., to the clean nurse in their packets, and the freshly sterilized instruments in their tray. In all large schools many of the duties assigned to the unsterile nurse are performed by orderlies. The more, however, a nurse does herself of the actual work, just so much the more thorough is her training. OPERATIONS IN THE PATIENT'S HOME A very large proportion of a private nurse's work at the present day is surgical. Frequently she is called upon at short notice to prepare for an operation. The prepara- tion will include not only the patient, with the details of which process she is familiar, but the preparation of the room and the operating-room equipment. For the for- mer she will receive definite instructions from the surgeon; for the latter she may find herself left altogether to her own ingenuity, and must be prepared to arrange a modern operating-room from furniture, utensils, etc., intended for 542 THE OPERATING-ROOM entirely alien purposes. As a rule, nurses enjoy this part of the work, and it is more necessary to warn them against unnecessary extravagance in their demands than to sug- gest ways in which what they find to hand can be trans- formed into the requirements of the occasion. Requirements.—In order that nothing may be over- looked, the best surgical nurses invariably keep a list of what is necessary to prepare, so easy is it, in trusting to the requirements of the moment, to overlook something essential. The instruments the surgeon brings with him, and the anesthetist, as a rule, provides the anesthetic and the cone or mask. In a city a nurse will be able to hire, if desired, sterilized dressings, towels, gowns, and utensils from one or other of the nurses' registries, giving notice of what she requires in good time. In many circumstances this is, however, out of the question, and she must prepare and sterilize everything herself on the spot. The dressings and the solutions required are generally ordered especially for the occasion from a drug-store or surgical supply place. If the ordering is left to the nurse, she should be careful not to order more than will be used. One dozen tabloids of bichlorid of mercury will make six quarts of solution 1 : 1000; if the Kelly preparation is to be used, one ounce of permanganate of potash crystals and four ounces of oxalic acid crystals will be sufficient. A pint of alcohol (90 per cent.) may be ordered, as what is not used in the preparation of the skin and the sterilizing of knives and needles may be used later, diluted one-half with water, for the alcohol rubs. Gauze and cotton in sterile packets from the drug-store are expensive items; where expense is a consideration, they may be bought by the pound and by the yard un- sterilized, cut into the necessary dressings and sponges, and wrapped in improvised covers for sterilization. The nurse should ask especially for the oldest linen, old sheets, table-cloths, towels, and dusters, etc., or old discarded cotton clothing that may be cut up into wrappers and towels. Besides the dressings, the nurse must sterilize OPERATIONS IN THE PATIENT'S HOME 543 a good supply of towels, a couple of sheets to cover the patient and table during the operation, and covers for the sterile tables. Outfit.—Many nurses in their outfit provide themselves with the following articles, the cost of which is trifling when weighed with the convenience of having them always at hand: Gown and cap. Gloves, rubber and white cotton. Nail-brush, file, and orange-wood sticks.. Hypodermic syringe and two needles. Scissors, probe, and dressing forceps. Rectal tube and funnel. 2 glass catheters. Hypodermoclysis needle, with rubber tubing and glass siphon tube. 6-ounce bottle of concentrated sterile salt solution (the cork of ground glass). Tabloids of bichlorid of mercury. Bottle of alcohol. Sterile packets of gauze and cotton (small quantities). One or two bandages and safety-pins. To this list a small portable instrument sterilizer and alcohol lamp are often added. What may be used for one patient can be paid for at cost price and replaced. Hypodermoclysis is such a common form of treatment in all conditions of lowered vitality that the means for hypodermoclysis should be at hand, at all events in major operations. If normal salt solution is desired, it can be procured in special sealed sterilized flasks put up with tubing and needle complete. The nurse has merely to bring the solution to the required temperature by placing the flask on a gas-ring or in a hot-water bath. Where she has to prepare the solution herself, she will probably be unable to sterilize either by the fractional method or by steam under pressure. (See Salt Solution, p. 436.) The flask she is to use should be washed clean of dust or foreign particles and sterilized by boiling for half an hour. The water should boil actively for twenty minutes in a kettle used only for water before the salt 544 THE OPERATING-ROOM solution (or salt) is added; the solution is then filtered through several folds of sterile gauze until absolutely clear, poured into the sterile bottle, and placed in a water- bath to boil again for half an hour. The solution can be siphoned directly from the bottle, using a sterile glass drinking-tube as a siphon, to which the rubber tubing and hypodermic needle are attached. Sterilizer.—The ordinary clothes-boiler makes a prac- tical sterilizer for dressings, towels, etc., as already described (p. 425). These should be sterilized, when practical, the day before the operation, the packets dried off in the oven or on the hot-water pipes, and wrapped until required in a clean sheet. The basins and other utensils to be used may be boiled in the clothes-boiler for half an hour and kept in the boiler, closely covered until re- quired. If this is impractical, they should be thoroughly scrubbed and immersed in an antiseptic (formalin, 2 per cent.; carbolic, 1 :20; or bichlorid of mercury, 1 : 500) at least a full hour before the operation. The bath-tub or a good-sized laundry tub can generally be used for this purpose. The nurse should sterilize a couple of basins for hand lotion, a couple of pitchers for sterile water, etc., and two or three smaller basins or bowls for various uses. A flat pie-dish is a useful substitute for a kidney-shaped pus-bowl, and a soap-dish, a convenient size to provide for the anesthetist's table. A graduate measure or a small pitcher of known capacity for measuring solutions should be included. A couple of buckets, slop-jars, or a good-sized tub should be scrubbed clean to collect used sponges, etc. Sterile water will be required, both hot and cold. Boiled water, kept in the receptacle in which it has been boiled, is generally accepted as sterile. Time must be allowed for one kettleful to be quite cold by the hour of the operation. To cool a kettleful quickly, stand the kettle in the sink, the lid in place, and let the cold water run over it. Room.—The nurse frequently has the responsibility of deciding upon the room to be used for the operation and selecting the furniture. Remember that what the OPERATIONS IN THE PATIENT'S HOME 545 surgeon wants chiefly is a good light, a steady table, and no dust. A room that is too sunny is almost as great a disad- vantage as a room that is too dark; for this reason a south room is, speaking generally, to be avoided; a north room with a good window is the ideal choice, a north light being always clearer than any other; for a morning operation a west light is practical, or an east room if the operation is in the afternoon. If the window is overlooked, the glass may be made opaque by rubbing over with soap, or a piece of mosquito-netting may be tacked tightly across. This should always be done if, as in the heat of summer, the window is to be open and is not already screened, and is especially necessary in cities, where the air is grimy and dust-laden. That the room should be absolutely clean, a nurse will recognize as a first essential. If she arrives at least a full day before the operation, she has time to make it so. All hangings, curtains, carpets, pictures, and movable decora- tions should be removed, the walls and ceiling swept down, the floor and woodwork washed. If, however, she arrives only the morning of the operation, a strenuous cleaning will only set dust floating in the air. Usually some one will be available to wash the floor, and the nurse must be con- tent with removing the hangings, carpet, lighter furniture, and wiping everything within reach with a cloth wrung out with a disinfectant. Where it has been possible to prepare the room the day before it is an excellent plan, especially if the walls are papered, to disinfect by some simple means, although this is not as effective and must not take the place of thorough cleaning. A sheet wrung out of formalin, 10 per cent., may be hung over a screen, and a basinful of the same solution be sprinkled with a clean whisk over the room. Doors and windows are closed for six hours, after which air is admitted freely through the screened window. If the case is not "clean," the process may be repeated after the operation before the room is again used by the family. Other considerations will also influence the choice of the operating-room. The room should, unless in a house 35 546 THE OPERATING-ROOM with an elevator, be on the same floor as the patient's bed-room; it should be as quiet as attainable, and espe- cially removed from the noise of streets or the shaking of passing trains or cars. To equip the room for an operating-room, the nurse will get ready an operating-table, a " sterile " table, a reserve table for pitchers, water, lotion, and unsterile objects, a couple of small tables, stools, or chairs, one for hand lotion, and one for the anesthetist, also a chair for the latter; a wash-stand for the surgeon to prepare his hands is added, unless a bath-room is available. Table.—The solid, narrow, old-fashioned kitchen table makes the best operating-table, or a well-made dining table. If no table long enough is available, two of the same height can be tied together firmly by the legs. To protect the table from staining, it should be covered first with a rubber sheet. The oil-cloth often used in coun- try kitchens as a table-cloth makes a practical substitute for a rubber sheet if one is not procurable; failing this, sev- eral thicknesses of newspaper will answer the purpose. The pad is made of a blanket folded to the exact size of the table; this is covered with a second rubber sheet, and the whole folded tidily in a sheet. To prevent slipping, the pad should be secured to the table with strips of a wide band- age passed over the pad and tied below the table. A clean old blanket will be necessary to cover the patient, and a couple of small sheets should be sterilized to use during the operation. Position of Patient.—If it is necessary to place the pa- tient in the Trendelenburg position, a chair may be placed on the table, as described previously (p. 194), and the whole covered with the operating pad. In order to raise the table, either the whole or one end, blocks may be made of bundles of magazines tied firmly in packets and covered in newspapers or old towels, or hassocks may be wrapped in newspaper or covered with old towels. If the lithotomy position is required, the patient is brought to the bottom of the table, the legs elevated and separated, the knees flexed, and the feet made to rest on a couple of small tables or high stools, placed beside the OPERATIONS IN THE PATIENT's HOME 547 bottom of the table. The feet are tied in position with a wide bandage. The position may also be kept by tying each ankle to the wrist on the same side. This is, how- ever, an awkward method if it should be necessary, as in an emergency, to alter the position of the patient suddenly. All the tables should be protected by newspapers of several thicknesses, covered with a clean towel. If the furniture is polished, ask for some plain wooden boards to cover those on which lotion, water, etc., are to be placed; an ironing- board makes an excellent stand for pitchers of hot water and lotion bowls. To protect the floor, unless a large rubber sheet is avail- able, it may be covered with several thicknesses of news- papers, over which a clean old sheet or curtain is stretched and tacked down. Unless the floor is of brick or stone, special attention should be paid to this part of the prepa- ration. Blood-stains are very unsightly, and are difficult to remove entirely from wood, especially unvarnished wood. In country homes a piece of tarpaulin can gener- ally be procured for the purpose; it must, of course, be absolutely clean. Sterilizing Instruments.—The instruments can be boiled in any vessel of convenient size, provided with a lid; they should be placed first on a flat pie-dish or cake-tin, in which they can be removed without handling the in- struments. A small fish-kettle, with its movable perforated tray, makes a perfect instrument sterilizer, and can be boiled on the kitchen stove. A small flat dish should be sterilized and filled with alcohol for the knives and needles, as it is frequently preferred not to boil them (p. 455). Arrangement of Room.—The sterile table, covered with a sterile towel, is placed beside the surgeon's assistant, and on it are arranged the instruments, needles, ligatures, sutures, and sponges; the latter counted and the count written down. On the unsterile table are the packets of dressings, towels, gowns, etc., the pitchers of water and lotion, the latter covered with a towel wrung out of the antiseptic solution, the requisite for the skin preparation, the salt solution, bandages, pins, etc.—all that is to be handled by 548 THE OPERATING-ROOM the unsterile assistant. A watch or clock, and a pencil and paper should not be forgotten; any special treatment should be noted in writing. The stool or chair for the hand lotion is also covered with a sterile towel and placed close to the operating sur- geon; if a chair is used, the back is also covered; the gloves can be placed in this lotion. The anesthetist's chair and small table are placed at the head of the table. On this table are placed a soap-dish, a sterile glass containing sterile water, a second with a little alcohol, some squares of old clean linen or cut gauze, the hypodermic tabloids, and a hypodermic syringe, ster- ilized and wrapped in a gauze sponge soaked in alcohol. The anesthetic and apparatus are usually brought by the anesthetist, who will also probably have with him the usual hypodermic tabloids. If irrigation is to be expected, a Kelly pad or its equivalent must be prepared. A rubber sheet, or, fail- ing this, wax cloth may be used. At one end is placed a lightly rolled small blanket (or newspaper, etc.), and the rubber is rolled over the blanket for about a third of its length, forming a little bolster. The bolster is bent round like a horseshoe, and forms the pad, the free part of the sheet forming the apron. On the floor may stand conveniently the kettles of hot and cold sterile water, the tub or wash-boiler with the sterilized basins and bowls, and a slop-jar for the used sponges* Gowns.—A nurse who is doing surgical work will have an operating gown and cap in her outfit. In an emergency she can sterilize a large gingham apron and simple cotton blouse with the dressings, and cover her head with a sterile towel. A sheet also can be converted into a fairly practical sterile gown, either for herself or the surgeons. Before sterilizing,-the sheet is folded so that the two ends come together at the back, allowing sufficient space for the neck; the upper margins are then pinned together closely with safety-pins (or stitched together) over either shoulder and the upper part of the arm, leaving enough room for the arms to be thrust through, much after the OPERATIONS IN THE PATIENT^ HOME 549 manner of the Greek dress. The impromptu gown is pinned behind at the neck, and if too voluminous, may be tied round the waist with a sterile bandage. For carrying a patient to and fro, a light rattan porch couch may be available, or a stretcher may be improvised in several ways. The patient is carried feet first. A couple of plain, high-backed chairs may be tied together firmly, the back of one overlapping the back of the other; on this two or three cushions are laid, on which the patient lies flat, the legs of the chair forming the handles of the stretcher. This stretcher is too short for the patient's legs, which are thrust through the arms of the fore- most carrier; in many homes it is impossible, however, to get a longer stretcher through the narrow doors and landings. A stretcher may also be made out of a couple of stout sacks, such as are used for flour or potatoes, and a pair of light curtain-poles; at either end a walking-stick is firmly tied to each pole, to keep them sufficiently apart. Where no stretcher can be contrived, the patient may be carried in his sheet, one carrier at the head, one at either side, and one at the feet. Frequently the patient is nursed afterward in the room prepared for the operation, and is then easily lifted from the table to the bed. If his former bedroom is on the same floor, he may in many cases be allowed to walk to the operating-room, or be carried in the upright position. A carrying chair is easily made from a piece of strong ticking cut the shape and size of the seat of an ordinary chair; the sides are strongly stitched with wide hems, through which short stout poles are thrust. This is a comfortable way of carrying a patient, and can be taken up and down a narrow staircase much more easily than any ordinary carrying chair. A nurse who knows exactly what she requires will be able to set available members of the family to help in preparing the room, etc., while she is busy with the patient, who may often leave her time for little else. She will generally find they are thankful to have something definite to do to keep their thoughts from the ordeal before them. In the houses of the wealthy the nurse will have little 550 THE OPERATING-ROOM trouble. The surgeon in a wealthy practice usually has his own operating nurse, trained exactly in his ways, who brings with her all that is required, even to a port- able operating-table. It is in the homes where expense is a consideration that she will most often have to exercise her ingenuity. She should make it her pride, as well as one of her special duties, to reduce her requirements to a minimum. We often see at the present day "demon- strations" given to pupil nurses on the subject of pre- paring an ordinary room for an operation. The ingenuity shown and the dainty effect produced are certainly to be commended, as well as the excellent technic practised. One remembers a demonstration where it was recom- mended to hang clean sheets round the walls from the picture-line; where the backs of chairs were encased in pillow-covers, and numerous sheets and table cloths used skilfully to cover all the necessary furniture. The effect was produced at the cost of a very large laundry- bill, and nothing but effect was really gained. No sen- sible woman would do anything but censure such need- less extravagance, and one would beg nurses to realize that it is by such thoughtlessness that they are among &o many a byword for extravagance, and their presence so often looked upon as an intolerable burden. After the operation the nurse will necessarily be occupied entirely with her patient for some hours, and unless the operation is performed in the patient's own room, she must leave clearing up until later. She should see, however, that all stained linen is placed at once to soak in cold water, and that the room is left in as little an unsightly condition as possible. A good training should teach a nurse to do all work in an orderly way, and to " clear as she goes." The instruments she can take with her, usually, to the patient's room, removing the stains with cold water and drying with a little alcohol. The surgeon will generally get them cleaned and sterilized in his own office. If a nurse intends to take up surgical nursing specially, she will be wise to spend some weeks in helping an ex- perienced nurse in the preparation for operation cases, so difficult is it to realize conditions or imagine emergencies from any but the standpoint of experience. CHAPTER XVI THE CARE OF OPERATION CASES Preparatory Period—Immediate Preparation—Ether Bed—After- care—Restlessness, Nausea and Vomitmg, Thirst—Abdominal Sec- tion—Distention—Stercoraceous Vomiting—Shock—Hemorrhage— Sepsis—Care of Eye Operations—Tracheotomy—Intubation. PREPARATION OF THE PATIENT The care of operation cases, especially major operations, should begin, whenever possible, two days before the day of operation. The Preparatory Period.—During the preparatory period all physical fatigue and mental excitement or worry should be avoided; to insure this, many surgeons, and especially gynecologists, keep the patient in bed and forbid all visitors for from twenty-four to forty-eight hours before the day of operation. In hospital patients the heart and lungs are examined on admission as a routine duty, and a specimen of urine is saved for examination. These examinations are repeated on the morning of the operation; the patient should not be sent to the operating-room until the report of the urinary analysis has been returned (p. 246). Catharsis.—If the patient has a history of constipation or other intestinal irregularity, some form of catharsis is begun at once. Many surgeons order a course of calomel as a routine treatment. In normal conditions, however, treatment is frequently not begun until the day before the operation. According to the hour of the operation, a purgative is administered, either in the morning or the afternoon of the day before the operation. If the purgative does not act in six hours, the dose is either repeated or an enema is given to excite the peristalsis. 551 552 THE CARE OF OPERATION CASES On the day of the operation, usually six hours before the time fixed for the operation, a copious enema of warm suds is given. This is repeated in two hours, and again if necessary, until the fluid returns clear, which is a sign that the lower bowel is empty. The purgatives preferred are salts of magnesia or castor oil, but some surgeons pre- scribe milder drugs. For operations on the rectum thorough catharsis is especially essential. Treatment is begun at least forty- eight hours before the operation. For the twenty-four hours prior to the operation only liquid diet is given, and special care is taken in giving the enema to insure that the bowel is thoroughly emptied. In operations for chronic conditions on any part of the alimentary tract, as, for example, in the radical cure for hernia, the same care is necessary. In emergency operations thorough preparation is not possible. If more than four hours elapse between the ad- mission of the patient and the operation, a suds enema may be ordered, otherwise the bowels are left undisturbed. An exception may be made in the case of injuries pro- ducing compression of the brain; in this case a drastic, quick-acting purgative, such as croton oil (1 to 2 minims), is frequently ordered. All nourishment is, of course, withheld. In acute abdominal conditions, such as appendicitis, intussusception, obstruction, perforation, etc., no treat- ment of any sort is given without special orders. An enema may be ordered, but commonly even this is omitted. The diet is nourishing and digestible, avoiding fried foods, coarse vegetables, and highly seasoned or rich dishes. The patient is usually given his ordinary meals until the evening before the day of operation. On this evening a light supper is served, as, for example, a cup of clear broth, sweetbreads, oysters, or a soft-boiled egg, without vegetables, and a simple dessert. After this meal no solids are given, unless the operation is to take place later than 12 noon. In this case a breakfast of tea or coffee, roll, or a piece of toast and a soft-boiled egg may PREPARATION OF THE PATIENT 553 be ordered. Four hours before the operation a small cup of hot broth or beef-tea is given, and nothing further. The reasons for such preparation are readily under- stood. If food is present in the stomach, vomiting will occur. The convulsive retching accompanying the act interferes with the operation, and in some cases may actually be dangerous. At the same time there is risk of the vomited matter falling into the larynx and choking the patient. If the rectum is not emptied, the bowels will probably act when the sphincters become relaxed under the anesthetic, while, if the intestines are distended with food or gas, they are more liable to injury if the abdominal cavity is opened. Cleansing.—During the preparatory period a hot tub- bath is given to the patient daily, taking special care to cleanse the area of the operation thoroughly. (For the local preparation see Chap. XIII.) For an abdominal operation the nurse should herself examine the abdomen and make sure that the umbilicus is perfectly clean. If this is not the case, it should be well washed, and, if necessary, a small soap poultice applied. It is, however, always a disadvantage to irritate the tissues. Immediate Preparation.—An hour before the operation the immediate treatment of the patient is begun. The temperature, pulse, and respiration are taken and charted. A woman has her hair brushed and braided in two plaits, which are pinned out of the way round her head. Any false teeth are removed. The clothing usually consists of the loose jacket and long hose of Canton flannel already described; in private work an old night-gown should be used, choosing one that is loose round the neck. For operations on the face, mouth, nose, etc., the hair is cov- ered with a rubber bathing-cap. A quarter of an hour before the time set for the anes- thetic the urine is voided. If the operation is on the pelvic organs, the patient is usually catheterized, and a note to that effect made on the chart, with the hour and the quantity of urine obtained clearly stated. The charts and history notes generally accompany the patient to 554 THE CARE OF OPERATION CASES the operating-room. In special conditions a stimulating enema is ordered to be given half an hour before the anes- thetic is begun. In other cases a hypodermic injection, usually of atropin and morphin, may be given immediately before the anesthetic. These, as a rule, are special orders, and not part of the routine treatment; they must be en- tered on the chart before it is sent to the operating-room. ETHERIZATION For all major operations the patient is taken to the ether- izing room on a stretcher; in some minor cases a wheel- chair is permissible; it is undesirable that a patient should walk or stand immediately before taking an anesthetic. It may be necessary to etherize the patient in his own bed. As the bottom rail is usually lower than the head- rail and stands free from the wall, the patient lies with the head at the bottom of the bed, a single pillow under the head. Until the patient loses consciousness, the struggling movements are merely guided to prevent the patient injuring himself, and no force is used. During the few moments when consciousness has been lost, and before relaxation has set in, considerable strength is frequently necessary to control the patient and prevent his injuring himself. The greatest quiet should be maintained during the giving of an anesthetic. The patient's hearing is pre- ternaturally acute, and his nervousness is much increased by chance noises or talking. At the same time he is liable to misunderstand words that are used and take all remarks as allusions to his own condition, often working himself into a state of needless alarm. Irrelevant topics are obviously out of place, and rightly construed as heartless and un- dignified. The ward nurse usually remains with the patient until he is placed on the operating table in the required position. She should see that the pads or pillows are adjusted to prevent his back being injured by pressure on the table. In the ordinary position the lower half of the body is wrapped in a warmed blanket, over which a rubber sheet is ETHERIZATION 555 tucked until after the cleaning-up process is finished, when it is replaced by the sterile sheets and towels. Records of the pulse, respiration, physical treatment during an operation, and some details of the operation are kept by the anesthetizer, and are not usually the respon- sibility of the nurse. In small hospitals, however, where there is not much assistance, the care of the pulse is some- times given to a nurse. In this case she should realize the importance of her responsibility, and not for one moment let her attention wander from her special duty to the details of the operation. Fig. 171.—Ether bed No. 1: A bed arranged for return of a patient from operation. The Ether Bed.—As soon as the patient has been sent to the operating-room, the bed is stripped, the room aired and put in order, and the ether bed is made up. A full-length rubber sheet is spread over the mattress and on the top of this the under sheet; on the top of the sheet a cross rubber sheet and draw-sheet. A clean towel is laid in place of the pillows, which are removed unless, as in some head operations, orders are given to the con- trary. Three or four cans filled with boiling hot water are 556 THE CARE OF OPERATION CASES placed on the bed and covered with a blanket. These are removed before the patient is placed back in bed. The upper coverings, sheet, blanket, and spread, are smoothly rolled together to one side. An extra blanket and a couple of hot-water bags should be in readiness in case of emergency. A towel is hung over the bed-rail, and on a table by the bed are placed a small shallow basin and a packet of gauze sponges. Fig. 172.—Ether bed No. 2: The same, with the bottom elevated. Collapse.—In cases of collapse the lower end of the bed is generally elevated. As this emergency is always liable to occur, many hospitals finish the preparation of the ether bed by securing a firm hair pillow upright against the head railing. A draw-sheet placed over the pillow and pinned behind the bed-rail keeps the pillow in position. By this arrangement there is no danger, if the lower end of the bed is raised, of the patient's head slipping through the rails. IMMEDIATE CARE AFTER THE OPERATION When the patient is returned to bed, the nurse quickly ascertains if any of the clothing is wet, and removes it if necessary. The blanket, warmed by the cans, is tucked IMMEDIATE CARE AFTER THE OPERATION 557 round the patient, and the upper covering unrolled and adjusted. Except in special conditions, the patient is laid flat on the back, with the head carefully turned to one side. This is in order to prevent the risk of vomited matter falling into the larynx and choking him. It is a rule in most hospitals that no hot-water bags may be put into the bed of an unconscious patient without a special written order. If hot-water bags are ordered, they must be hot enough to give the warmth for which they are ordered, and are, therefore, hot enough to burn the patient should they rest against the skin. To prevent this, first, they must be securely covered; second, the patient's body must be protected by a light blanket, which must intervene between the skin and the hot-water bags; third, he must not be left one moment alone while the hot-water bags are in his bed. Once in bed, the patient is left alone with his nurse. The room should be warm, between 70° and 80° F. (un- less the contrary is especially ordered), the light shaded, and absolute quiet maintained. Fresh air should be admitted freely, avoiding a draught on the patient. No unneces- sary talking should be allowed, and visitors and avoidable coming in and out forbidden. A note should be made on the record chart of the pulse, respiration, and the gen- eral condition of the patient immediately on his return from the operating-room. Thus: Time. 11.15 a.m. Temp. Pulse. 110 Resp. 25 Returned from oper- ating-room . Sweat- ing profusely. In good condition. However slight the operation, a patient must not be left alone until he is fully conscious and out of the influence of ether. As reaction sets in, some restlessness is sure to de- velop; the patient throws himself about and frequently tries to get out of bed, and if left to himself, may seriously injure the parts freshly operated on, strain the stitches, and possibly cause a hemorrhage. As consciousness re- turns, vomiting occurs. If the nurse is not at hand to keep the head turned to one side, there is risk that the vom- 558 THE CARE OF OPERATION CASES ited matter may fall into the larynx and cause fatal as- phyxia. Further, in all operations there is risk of shock, the first symptom of which must be appreciated. In ward cases it is usual to isolate major operation cases for the first twenty-four hours after the operation, most surgical wards having a room or rooms reserved for the purpose. If the construction of the hospital does not admit of this arrangement, the space round the bed should be screened off, in order to insure as little disturbance as possible. The pulse and respiration must be closely watched. The pulse is the most important indication of the patient's condition after any operation. Under the anesthetic both pulse and respiration become considerably raised; as reaction sets in the pulse should become steadily slower, and at the same time the respirations gradually return to normal. A good pulse, steadily below 80, is the best sign that the patient is in good condition. Any quickening of the pulse is a significant symptom. It may be due to an attack of vomiting, sudden disturbance or restlessness, in which case the condition is only tempor- ary. A pulse that becomes suddenly soft, small, and rapid, is the first symptom of hemorrhage, and frequently, to inexperienced eyes, there may be no other symptom of the condition (p. 581). The first twenty-four hours after an operation is com- monly one of extreme wretchedness, hardly made tolerable by even the best nursing. Its chief symptoms of discom- fort are restlessness, nausea and vomiting, and thirst. Restlessness.—Many surgeons keep their patients under the influence of morphin for the first day, and fur- ther, if circumstances require it. Others, however, con- demn the practice as further upsetting the gastric condi- tion, and running some risk, however remote, of establish- ing a habit. Where it is essential to retain a fixed position, it may be necessary to restrain the movements by passing a sheet folded lengthwise over the lower limbs from the hips to below the knees; the sheet is secured with safety-pins to the frame of the bedstead. A second sheet may be necessary, IMMEDIATE CARE AFTER THE OPERATION 559 fixed in the same way across the chest, but leaving the arms free. In extreme cases ankle-straps and wrist-straps may be necessary. All these restraints, however, naturally tend to increase the nervousness, and should never be kept on a moment longer than necessary. Where the position may be changed, it is comparatively easy to relieve the restlessness. In cases of abdominal section, permission is frequently given to mitigate the enforced recumbent position by a small flat pillow placed under the small of the back, and by flexing the knees over a pillow. The latter has also the effect of relaxing the abdominal muscles, and so relieving tension on the stitches. Other means of soothing restlessness are sponging the face and hands with hot water, gentle massage to the calves of the legs, or an alcohol rub to all parts of the body that can be reached without moving the patient from the pre- scribed position. An ice-bag to the head or the back of the neck may also relieve restlessness and induce sleep, especially if, at the same time, a hot-water bag is placed at the feet. This treatment should not be used unless the condition of the pulse indicates that the normal con- dition of the circulation is reestablished. A cause of restlessness sometimes overlooked is the con- dition of the bladder. Usually, after abdominal section, an hour is set after which, if the patient has not voided, the catheter is passed. This is usually eight hours after the operation is over. In some cases, however, this may be too long to wait, and to empty the bladder at an earlier hour may considerably mitigate the restlessness. Nausea and Vomiting.—Some nausea and vomiting almost invariably occurs after ether (unless with children, who frequently escape), and to a less extent may be ex- pected after chloroform. After nitrous oxid gas there is usually no vomiting. If the alimentary tract has been properly prepared, the vomitus consists of a little greenish fluid with a bitter taste, mixed with mucus and saliva. During the act of vomiting an unconscious patient must have his head turned forcibly to the side and the jaw pushed forward and up- 560 THE CARE OF OPERATION CASES ward. This closes the epiglottis, and prevents the patient being choked by the vomitus falling into the larynx. The mouth is cleansed with pieces of gauze, either dry or soaked in water, to which a little listerine (or other mouth- wash) may be added. After operations on the mouth, throat, nose, etc., espe- cially such operations as for the removal of adenoids and tonsils, a quantity of blood may be swallowed, and is usually vomited as reaction begins. Many throat sur- geons encourage vomiting in these circumstances by order- ing the patient to drink water freely as soon as he is con- scious. The water is cold or iced, in order not to encour- age bleeding from the recent wound. Some hospitals make a practice, in abdominal operations, of washing out the stomach before the patient is removed from the operating-table. Warm sterile water is used, and generally one to two ounces of castor oil is introduced after the lavage and left in the stomach. Where there is much retching, there is some risk that stitches about the abdomen may be burst by the strain. To guard against this, the nurse should support the abdo- men during the attack by placing her hands on either side and pressing, very gently, toward the incision. For the first twelve hours little treatment is ordered for the vomiting. If the condition does not improve and the vomiting is persistent, treatment becomes necessary. Hot stupes, a hot-water bag, or a mustard plaster may be applied to the epigastrium. Cracked ice is given to suck, though this has the disadvantage of increasing the thirst. Boiling hot water in sips is also ordered. Some doctors wash out the stomach by inducing the patient to drink a couple of tumblers of warm water, in each of which a pinch of bicarbonate of soda is dissolved; enough is taken to induce vomiting, and the stomach is thus washed out. Lavage may also be ordered in the usual manner. Where stimulants are permitted, an ounce of champagne or half an ounce of brandy may be poured over a glass of cracked ice and given in sips. The position of the bed may also be a help. Usually it is best to keep the head low and the feet elevated; ABDOMINAL SECTION OR LAPAROTOMY 561 if vomiting is persistent, the reverse may be tried, and is sometimes, apparently, successful. Drugs that may be ordered to check vomiting are: Cocain hydrochlorid (i to i grain), cerium oxalate (1 to 5 grains), bismuth subnitrate (5 to 15 grains), and others. The bromids are sometimes given by rectum with good effect where the vomiting is due to the nervous condition. Hypodermoclysis, or intravenous infusion of normal salt solution, also has frequently the indirect effect of relieving the condition. Thirst after an anesthetic is the symptom most trying to the average patient. It is chiefly due to the loss of fluid to the tissues caused by the necessary hemorrhage, and the sweating which a general anesthetic usually causes, but it is also to some extent the result of the irritation of the anesthetic. Fluid may be restored to the body by enemata of hot water or normal salt solution, by seepage or constant rectal irrigation, by hypodermoclysis, and, in the severer cases of loss of blood, by intravenous infusion of normal salt solution. In cases other than abdominal section the patient is usually allowed to satisfy the thirst. Very hot water, or hot weak tea, allays thirst more effectually than ice or cold drinks. Cold toast-water is often agreeable, and frequently also helps to check the vomiting. Where the operation has not involved any part of the alimentary tract, the ordinary diet is usually resumed as soon as the gastric irritation due to the anesthesia has subsided. ABDOMINAL SECTION OR LAPAROTOMY Under the heading of abdominal section we have opera- tions on any of the important organs reached by opening the abdominal cavity; in other words, by entering the peritoneum, the most important closed cavity of the body. This includes operations on both abdominal and pelvic organs; on the intestines—for hernia, intussusception, dis- eased appendix, perforation, or ulcerated conditions; on the liver and gall-bladder; on the stomach; on the pan- creas; on the uterus and its appendages. The post-opera- 36 562 THE CARE OF OPERATION CASES tive care of cases of abdominal sections forms the larger part of a modern surgical nurse's work, and it is of the first importance that she should be familiar with the routine treatment and recognize the earliest indications of un- toward symptoms. While special conditions call for some modification of the treatment, the general care of the patient is similar in the large majority of abdominal sec- tions, and to mention the operations separately would, in most cases, involve needless repetition. The diet may to some extent be varied with the different cases, especially in operations of the alimentary tract, but on this point the nurse will always receive definite instructions. Position.—The strict recumbent position is inforced for a specified time. Usually each doctor has his own method. Some allow the patient to be turned for a short period on the second day; others keep the patient flat on the back for a longer time. The extent of the operation and the structures involved obviously influence the treatment. The return to an upright position must be managed very gradually. One pillow is usually allowed as soon as the patient is out of ether, provided the pulse is below 80 and regular. A second is added for the daytime, per- haps on the fourth day, if the condition is good; later a third is added while the patient is taking his meals. After the stitches are removed the patient is propped up on a bed-rest at intervals and is gradually accustomed to the upright position. Doctors differ greatly over the length of time the recum- bent position should be inforced and the time the patient must remain in bed, but the modern tendency is generally in favor of returning to normal conditions as soon as pos- sible, provided always that the condition of the heart is good. The period of the strict recumbent position is the time when bed-sores may easily form (Chap. I). To prevent this the bed must be kept smooth, cool, and absolutely dry. If heat or pain in the region of the coccyx is complained of, the surgeon should be notified, and permission obtained, if possible, to vary the position. If not, it may be per- mitted steadily to raise the pelvis a few inches from the ABDOMINAL SECTION OR LAPAROTOMY 563 mattress and rub the spot with alcohol, drying it off with powder. This is repeated constantly. To raise steadily, the nurse should rest her elbow on the bed and place the palm of the hand flat just above the coccyx. The scultetus bandage, still in common use in abdominal surgery, is a prolific source of bed-sores. The lower mar- gin becomes creased, soiled, or damp from perspiration, and if the nurse has orders not to move the bandage or turn the patient, a bed-sore may be extremely difficult to avoid. In many hospitals the scultetus bandage is replaced by strips of adhesive strapping, to one end of which tapes are sewn (p. 289). If a scultetus bandage is also used, it may then be changed or readjusted without danger of dis- turbing the dressings. Drainage.—In operations on the bladder and in many on the gall-bladder drainage may be necessary, sometimes for a considerable time. To keep the bed dry and the patient comfortable, a bottle or jar may be attached to the bed- frame; in this is introduced a length of rubber tubing connected by a short glass tube with the catheter (bladder) or drainage-tube (gall-bladder) inserted at the site of operation. The vessel should be of glass, so that the con- tents may be seen. A strip of adhesive strapping attached to the outside of the bottle may be marked off in gradua- tions, and forms a better guide than the eye of the amount passed from hour to hour. If the fluid is not flowing, the cause is usually a clot that has lodged in the tube. The lower tube should be disconnected and irrigated under the water-tap; if no impediment is found, the surgeon must be notified, as it then becomes necessary either to irrigate or remove the stationary tube. In order that a stoppage may be at once detected, the nurse should make a prac- tice of examining the bottle at regular intervals. Diet.—After an abdominal section it is necessary to keep the intestines at rest, so that the parts operated on may be undisturbed. Nothing, therefore, that may excite peristalsis or lead to the formation of gas must be given for a specified time. The usual treatment is, after six hours, to give every hour teaspoon doses of boiling hot water; after twelve 564 THE CARE OF OPERATION CASES hours, the amount is gradually increased. Patients fre- quently find it a relief to suck pieces of gauze soaked in lemon-juice and water. Some surgeons feed their patients entirely by enemata for the first forty-eight hours, and longer if nausea persists. Beef peptones, broth, meat- juice, raw egg and milk are administered in this way, and, if necessary, a stimulant is added. The enema should not exceed six ounces, and may be repeated every eight hours. After twenty-four hours fluid nourishment is begun in small amounts. Albumin-water, liquid peptones, strained chicken or beef-tea, or, more rarely, milk, are given, be- ginning usually with half an ounce at a time, until it is seen what the stomach will retain. In operations on the digestive organs a longer period of starvation may be necessary. A restricted liquid diet is given until the bowels have moved, after which a soft diet is ordered, to which, gradually, solids are added, avoiding coarse vege- tables and seasoned or fried dishes. While on a liquid diet, and until the patient can use a tooth-brush, the mouth must be carefully cleansed at regular intervals (Chap. I.) Bowel Movements.—It is usual to induce an action of the bowels at the beginning of the third day after the operation: that is, at the end of the first forty-eight hours. Frequently a course of calomel is given, beginning twenty- four hours after the operation, followed by salts on the following morning; or a suds enema may be prescribed on the second morning after the operation. The nurse should always be able to report whether or not flatus has been passed by rectum, since this is an important indica- tion of the condition of the intestines. To induce a regular daily evacuation of the bowels is of the first importance, both during the critical period of nursing and throughout convalescence. When the period of strict starvation is over, the diet should be chosen to further this end. Raw fruit-juice in the early morning, meat extracts, thin oatmeal gruel, cream, all help and are usually preferred to milk, which in many patients produces constipation. If milk is given, it should be diluted or given in such form as junket, with cream, etc. (Chap. XXII). ABDOMINAL SECTION OR LAPAROTOMY The evacuations should be inspected, and in the case of operations involving any part of the alimentary tract, should be especially examined for any appearance of blood. Visitors.—It should be remembered that a major operation must always produce some nervous strain, of which, while the patient is lying quietly in bed, there may be but little symptom. If the regulation of visitors is left to the nurse she should proceed very cautiously, noticing carefully the effect on her patient, and erring rather in keeping the patient too quiet than in risking excitement for which the patient may pay later. Usually the nearest relation is admitted for a short time on the third day, all being well, and one visitor a day only allowed, for a specified time, until the patient is sitting up in bed. It is always wisest to get definite instruction from the surgeon on this point. Distention.—An untoward symptom of grave import in the nursing of abdominal sections is distention, or inflation of the intestines with gas. The condition is caused by intestinal obstruction; commonly it is a tem- porary (though serious) condition, due to gastric upset from the anesthetic, but occasionally complete obstruction may be present, caused by accidental twisting or other injury to a coil of intestine. The nurse must be on the watch for the first symptoms of tightening of the bandage at the upper margin. The abdomen is swollen and more or less rigid, and the breath- ing shallow; no flatus is passed. The condition usually occurs early, during the day of the operation or the day after. At this time the patient's temperature is easily upset, and will probably rise together with the pulse, whether the condition is due to gastritis or to complete obstruction. If due to the latter, the physical symptoms will be intensified and the vomitus will probably become stercoraceous (p. 699), always a very serious symptom. To relieve distention hot turpentine stupes may be applied to the abdomen and changed repeatedly, and the rectal tube be passed as high as possible up the colon. A hot suds enema may give relief (unless in operations on the 566 THE CARE OF OPERATION CASES lower bowel), or medicated enemata containing either milk of asafetida, alum (carminatives), sulphate of magne- sia, or castor oil (Chap. IV). All nourishment is, of course, stopped; the mouth should be washed out frequently. Drugs that may be ordered by mouth are asafetida (tincture of, 5 to 20 minims), turpentine (5 to 10 minims, in capsule), and eserin, usually given by hypodermic (inr to tV grain). The two former have a carminative action; eserin has the property of stimulating the peris- taltic action. If there is stercoraceous vomiting, the stomach is usually washed out with plain sterile water, and nothing is given by mouth. When entire intestinal obstruction is present, a second operation will probably be necessary. Still more serious is the true tympanites, when the peritoneal cavity becomes distended with gas. The con- dition is seen in general peritonitis, a complication which, if occurring after an abdominal operation, is very often fatal. It may be caused by infection at the time of opera- tion, or may be due to accident, such as a decomposing blood-clot in the cavity, or the escape of the intestinal contents into the cavity from a perforation. This form of distention occurs usually later than the third day. The temperature will probably be high, and the pulse quick, hard, and wiry; as the condition advances the feat- ures are pinched and anxious, and the patient is frequently delirious. The bowels are constipated, or there may be total obstruction. The appearance of the distention and the characteristic hard, wiry pulse are the most easily recognized diagnostic points. In intestinal distention the swollen bowel may be felt through the abdominal wall, unless the wall is unusually thick; in peritoneal distention there is a tense, drum-like swelling of the entire abdomen, which is absolutely rigid and tender to the touch. The chief hope of recovery lies in very early recognition of the condition. The cavity is usually opened, the peritoneum irrigated, and drainage established. Turpentine stupes, sprinkled with laudanum, may relieve the rigidity and allay pain. Many surgeons have an elaborate schedule for the post- ABDOMINAL SECTION OR LAPAROTOMY 567 operative nursing of their cases. These are a great help to the nurse, who then knows exactly what she is expected to do at given intervals and in special circumstances. At the same time a very little experience will show the nurse that each patient is a fresh proposition, and that rigidly iron rules may defeat their own object. There are three complications to be dreaded and guarded against in all operations—shock, hemorrhage, and sepsis. Shock.—Early shock is shown by rapid, small, feeble pulse; pallor, cold extremities, prolonged unconsciousness, profuse sweating, and, usually, subnormal temperature. If the condition is not promptly treated, the life may be lost. The usual treatment consists in the application of exter- nal heat (blankets and hot-water bags), in raising the bot- tom of the bed so that the head is lower than the feet, in order to flush the vital centers, and in hypodermoclysis of hot normal salt solution (500 c.c). Enemata of hot nor- mal salt solution, black coffee, or brandy may be ordered, and cardiac stimulants are given by hypodermic injection. Those most commonly ordered are atropin sulphate (yi^ to ttv grain), strychnin sulphate (3V to TV grain), and oil of camphor (3 to 5 minims). Later shock is evinced by heightened temperature, restlessness or marked prostration, delirium, and often by prolonged nausea and vomiting. The general treatment consists in maintaining absolute rest and quiet and in nursing up the patient's strength. Usually the bottom of the bed is raised to keep the head low, but in some instances this appears to increase the vomiting, and the orders may be to raise the head of the bed instead. Hypodermoclysis may be ordered daily or twice a day, and stimulants will probably be given. Digitalis is usually preferred (tincture, 5 to 10 minims), as it is a tonic to the heart, and brandy, whisky, or champagne may be ordered. The diet should be as nourishing as the state of the digestion permits. If nausea is persistent, the nourishment is given by rectum. (See also Chap. XVII.) Hemorrhage.—No nurse should be left alone with an operation case until she is perfectly familiar with the first 568 THE CARE OF OPERATION CASES symptoms of hemorrhage, since the life depends on the early recognition of the condition. Hemorrhage is either external or internal. If the hemor- rhage is external, a patch of bright blood may be seen on the dressing, quickly increasing in size. Where the patient is lying on his back, it must be remembered the blood will have a tendency to trickle under the dressing to the lowest point possible, and the bandage on which the patient is lying may be soaked through, while there may be no sign apparent on the dressing immediately over the incision. In abdominal surgery hemorrhage is prac- tically always internal, and the physical symptoms will be the only guide to this very grave condition. As has already been said, the pulse is the most important indication of a patient's condition after an operation, and any change is significant. The first physical symptom of hemorrhage is a steady quickening of the pulse, which also becomes soft and small; accompanying symptoms are pallor, syncope, clammy skin, usually (but not invariably) subnormal temperature, and the con- dition known as air-hunger, in which the patient fights and gasps for air. Later the patient becomes cyanosed, which is especially apparent round the mouth and under the nails. Not a moment must be lost in summoning the surgeon. If the bleeding is external, compression of the nearest digital point must be made meanwhile (p. 583). In hospital work the nurse's responsibility extends no further. The treatment consists in placing the patient at once on the operating-table, reopening the incision, and ligating the bleeding spot. The cavity is then usually irrigated with sterile water or normal salt solution in order thoroughly to remove the blood-clots, which, if left in the cavity, would decompose. If there is any delay, the bottom of the bed is raised, a light ice-bag may be applied over the area, and usually a dose of morphin is given at once (| to i grain). Stimulants are not given, as by quickening the heart's action they would increase the hemorrhage, and even water must be withheld. Fresh air should be admitted freely. ABDOMINAL SECTION OR LAPAROTOMY 569 When the patient is returned to bed, hypodermoclysis of sterile water or normal salt solution is usually given to restore to the circulation the fluid lost, or the fluid may be injected directly into a vein (p. 502). The patient is nursed with the head low until the pulse is normal. After a severe hemorrhage the pulse is markedly subnormal and may be reduced to 40 per minute. Severe thirst is a characteristic symptom, and is usually treated with rectal injection of hot water and washing out the mouth with lemon-juice and water. With external hemorrhage, of course, thirst may be quenched by drinking. (See also Chap. XVII.) Sepsis.—After a clean operation sepsis occurs only as the result of carelessness. The sources and channels of infection have been pointed out in the chapter on Technic, and it will be remembered that the whole aim and end of surgical technic is the prevention of infection. The first general symptoms of sepsis are malaise, shivering, and a rise of temperature. The importance of shivering as a symptom should be realized. In a few cases it may be due to a nervous condition only, which may or may not be sufficient to upset the temperature. An attack of shivering followed by a rise of temperature is the most characteristic symptom of the invasion of the body by an infection, whether local or general. (Rigors, p. 705.) Other causes may result in rise of temperature. Thus, a temperature on the day of operation is generally of nervous origin; on the second day it may be caused by a temporary condition, such as constipation or want of rest. The organisms which produce the phenomenon of sepsis take about three days to develop in the human body, therefore a rise of temperature on the third day, especially if preceded by shivering, is always looked on with suspicion. The local symptoms of sepsis are red- ness and tension in the region of the incision, and the formation of pus. The treatment varies somewhat with the nature of the operation. Frequently the incision is opened, the cavity cleaned with antiseptics, and drainage established, after which, if the disturbance is local, the temperature may 570 THE CARE OF OPERATION CASES drop and recovery result without further disturbance. A general septic condition is characterized by fever, either remittent or intermittent, rigors, prostration, rapid emacia- tion, the formation of secondary abscesses, and a tendency to bed-sores; in many cases it proves fatal. The treatment is directed locally toward free drainage and the use of antiseptics, and generally toward building up the strength with a nourishing diet and a generous use of stimulants. In extreme cases the patient is best nursed on a water- or air-bed, in order to counteract the tendency to bed-sores. Sepsis occurring in the second week is usually due to infection from the catgut. On opening the wound a small pocket of pus is discovered; after this is evacuated the symptoms commonly subside. Recovery is, however, delayed, since healing must now take place partly by granulation instead of entirely by first intention. In common with all wounds, operation wounds may become channels of certain special infections, of which the most important are erysipelas, scarlet fever, and tetanus. (See Chap. XVIII.) The above dangers are common to all operations. In surgery on special organs special conditions may arise, and in the nursing special details must be observed. EYE OPERATIONS An old-fashioned book on nursing opens one of its chapters with the words " no selfish or unconscientious woman should be given charge of a case of tracheotomy." Even more emphatically one might use the words in con- nection with the nursing of eye cases. Above all other kinds of nursing, success depends on the conscientious attention to small details, and failure may mean the loss to the patient of his most precious possession, since noth- ing can replace the sight. Operations on the eye are usually done under a local anesthetic, to avoid the restlessness, nausea, vomiting, and uncontrolled movements following etherization. Frequently the patient remains in his own bed in order to avoid the movements in taking him to and fro. The EYE OPERATIONS 571 preparation (p. 452) must be thoroughly performed, and will for most operations include the dilatation of the pupil with atropin. The head is placed so that the eye on which the operation is to be performed is in the best light. The hair is covered with a sterile towel and the sterile area arranged as in other operations. The requirements, besides the sterile instruments and an eye lens (also sterile), are very simple. A packet of gauze sponges, a couple of eye-pads and a bandage, a douche of warm boric lotion, 2 per cent., and small quantities (about 2 drams) of the special eye-drops, freshly prepared, in small sterile bottles with sterile droppers. The bottles contain cocain hydrochlorid the required strength for the local anesthetic (usually 2 per cent.), atropin sulphate (2 to 4 grains to the ounce, mydriatic), and eserin (1 grain to the ounce, myotic). After the operation both eyes are usually closed and bandaged for at least the first twenty-four hours, and, as a rule, a fixed position is enforced. The room is dark- ened, special care being taken to prevent streaks of light from an open door or from a badly fitting blind; these are more irritating than a brighter light well diffused. The dangers of the next twenty-four hours are, first, restless movements which may result in hemorrhage from the recent incision, and, second, that the patient may rub the eyes or put his fingers under the bandage. To rub the eyes if they are irritated is an almost uncontrollable impulse, and a patient may do it unconsciously if not closely watched. Not only is the wound irritated, but there is the greatest risk that it may in this manner become infected and the sight lost. If the patient is quiet and the pulse steady, all is well. Pain is a symptom that should be at once reported. Usually a surgeon will leave definite orders to be followed if pain arises. Commonly, 1 or 2 drops of atropin are dropped into the eye and compresses of sterile boric lotion (2 per cent.) are applied continuously. These may be hot or ice cold. (See Eye Applications.) The pain may be the result of a hemorrhage or may signify the beginning of inflammation, both of which conditions may be checked 572 THE CARE OF OPERATION CASES by prompt treatment. Another remedy used in eye sur- gery for the relief of pain due to inflammation is the appli- cation of leeches to the temple (p. 102). For the first twenty-four hours a nurse will require all her tact, patience, and vigilance. The patient must be fed in the recumbent position and must use the bed-pan. Even in sleep he must be closely watched, since then his movements are least under control. The nurse in charge should not leave the bedside unless some responsible person can take her place. Usually after twenty-four hours the dressing is changed, after which some move- ment is allowed and the sound eye is unbandaged. The affected eye should look clear, the pupil well dilated. If there is no inflammation the most responsible time of nursing is over, and the patient's own common sense may be to some extent trusted. Eye surgeons differ in the time necessary to keep the patient lying down or in bed after their operations, and young nurses are inclined to think lightly of strict rules in consequence. This is a mistake. Each step of a treatment is part of a whole; what is not necessary for one process may be essential in another. If infection takes place the sight will almost inevitably be lost. Leeches are usually ordered and constant com- presses, which must be applied without intermission under strict aseptic precautions. The patient's strength is kept up with nourishing diet, commonly some preparation of iron is ordered. If a stimulant is required, strychnin is ordered in preference to the alcoholic stimulants. TRACHEOTOMY Another operation case requiring special vigilance in the nursing is tracheotomy. The operation consists of an incision into the windpipe and the insertion of a tube, through which the patient can breathe. It is necessary in conditions where, from false growths, foreign bodies, or injury, breathing is obstructed at a point above the incision. Before the introduction of intubation, trache- otomy was a common treatment in diphtheria, and often TRACHEOTOMY 573 nad to be carried out as an emergency procedure with whatever instruments were at hand. In performing the operation the throat is exposed by bending the head back over a small sand-bag. When the windpipe is first opened there is a rush of air and blood- Fig. 173.—Position of patient for laryngotomy and tracheotomy (Morrow). streaked mucus and a considerable amount of coughing, which is allowed to subside before the tube is inserted. A special dilator is used to hold the incision well open. At first a double silver tube is used, the object being that if the tube becomes blocked with mucus the inner tube Fig. 174.—Tracheotomy tube (Morrow). is easily removed and cleaned, whereas if the entire tube is taken out it is often difficult to replace, and asphyxia may result. Later a single tube of either hard or soft rubber is substituted. The tube is kept in place by narrow tape. The best 574 THE CARE OF OPERATION CASES method of threading is to thread both ends of a piece a yard long through the holes in the plate; the loop thus formed is passed over the head and the ends are then brought behind and tied in a bow. A small dressing of soft sterile gauze cut to fit round the tube is placed between the plate of the tube and the skin. The air breathed is taken directly into the lungs without becoming warmed and moistened, as when drawn through the air passages. At first, therefore, the air must be arti- ficially warmed and moistened. To this end the bed is Fig. 175.—Showing the tracheotomy tube in place (Stoney). screened and a croup kettle is kept going, with the spout directed into the screened area (p. 332). Feathers washed in soap and water and sterilized in the autoclave are kept soaking in an alkaline solution, such as bicarbonate of soda, and used to clean the interior of the tube. When a single tube is used this is done with the tube in place, with the double tube the inner tube is removed, cleaned, and replaced. Constant watchfulness is necessary to prevent the tube becoming blocked, especially where there is much secretion from the lungs or bronchial tubes. If the single tube be- comes totally blocked, so that no air can pass and the INTUBATION 575 patient is in danger of becoming asphyxiated, the tube is entirely removed and the incision held open with the dilator till assistance is obtained. When the tube is finally removed the patient must also be closely watched until normal breathing is reestablished. Some patients take a long time to accustom themselves to breathing again in the natural way. INTUBATION Intubation has, in the majority of cases, superseded the operation of tracheotomy. This is the introduction of a Fig. 176.—O'Dwyer intubation instruments: 1, Tube with obtu- rator in place; 2, tube and obturator separated; 3, gage; 4, mouth- gag; 5, introducer; 6, silk thread; 7, extractor (Morrow). metal tube made to fit into the larynx and upper part of the trachea, so that the necessary opening is preserved in spite of inflammatory processes or swollen tissues. 576 THE CARE OF OPERATION CASES The patient is held in an upright position directly oppo~ site the operator, the head bent a little back, the chin in a straight line with the trachea. The mouth is opened and fixed with a gag. The tongue is depressed so as to expose the epiglottis and upper end of the trachea. The tube into which is inserted the obturator is held by an intro- ducer and slipped into the larynx, directly in front of the little leaf-shaped epiglottis. When it is in place the in- troducer and obturator are withdrawn. Where the throat Fig. 177.—Intubation, introducing the tube into the patient's mouth (Morrow). is roomy and the tissues are not swollen or inflamed, the process is comparatively easy; where there is much in- flammation, with copious discharge and impeded breathing, it is an operation requiring skill and experience. If the tube does not slip into the trachea it may be accidentally deposited in the esophagus, where it will be readily swal- lowed. To prevent this loss a long strand of silk or stout linen is threaded through a perforation in the tube, by which the tube can be withdrawn if it is not in the right place. This thread may be left in place, the free end being INTUBATION 577 brought outside the mouth over the patient's ear, and fixed by a piece of adhesive strapping behind the ear. The ad- vantage of this is that should the tube be coughed out of the larynx the thread will prevent its being swallowed. The tube can also be removed by gentle traction on the thread. If there is no thread, a special instrument known as an extractor (Fig. 176, 7) is used to remove the tube. Every variety of operation brings with it some special details in the nursing, and the difference between an un- successful and a good nurse is often just in the care which she gives to these various details. Thus, in operations on the extremities, the joints, or the bones, the physical con- dition is comparatively unimportant, but the success of the operation may lie entirely in the strict maintenance of a certain position, with the resulting difference between permanent lameness or cure. In operations about the head, especially where the brain has been exposed, as in trephining from any cause, quiet is almost the most essen- tial part of the treatment, and the light should always be shaded. In amputation cases there is a certain amount of risk of hemorrhage from the slipping of a ligature, either from abrupt movements or from the reestablished circulation as reaction sets in. This is especially to be dreaded in amputation of the femur, where bleeding from the femoral artery might be fatal in a short time. In these cases, therefore, we watch the pulse especially closely, and until all danger is past we keep a tourniquet at hand, which can be quickly adjusted. Here again we must remember not to rely on the outward sign of hemor- rhage, since from the patient's position the blood will probably run underneath the dressings to the bed before there is any appearance of blood on the top of the dressing. Only long experience can teach a nurse all she should know of the nursing of operation cases. But at least we should see that the essential details are carefully explained to her and the principal dangers and difficulties pointed out. CHAPTER XVII NURSING IN ACCIDENTS AND EMERGENCIES Shock—Hemorrhage: Varieties; Methods of Arrest—Pressure, Styptics, Ligatures, Torsion; Treatment of Physical Condition; Special Hemorrhages: External, Subcutaneous, Internal, Revealed, Concealed; Enterorrhagia; Hematemesis; Hemoptysis; Epistaxis: From the Throat; From the Ear; Antepartum Hemorrhage; Post- partum Hemorrhage; Hemorrhage from a Ruptured Tube; Hemor- rhage in Purpura, Scurvy, Bleeder's Disease; Perforation. SHOCK Shock is a profound general prostration or loss of vital- ity brought about by the effect on the nervous system of severe or violent physical strain, such as an operation or an accident, or, more rarely, by violent mental emotion, particularly fear. Shock follows some one event. When similar symptoms are produced by failing vitality, as dur- ing the course of a serious illness, the term collapse is used. The symptoms of shock are pallor; a rapid, feeble pulse, frequently irregular; shallow, sighing, irregular respira- tion, and subnormal temperature; pinched features, cold extremities, clammy skin, muscular relaxation, and, fre- quently, syncope. Mental apathy or drowsiness are com- mon, and, in severe cases, total loss of consciousness. On the other hand, the senses may at first be abnormally acute and the mind alert and clear, almost, in fatal cases, to the time of death. Nausea and vomiting may be present and are usually considered favorable symptoms, showing a return of vitality to the nerve-centers. The condition of shock or collapse is probably the most common emergency in nursing, and as the successful treatment depends upon early recognition of the symp- toms, the observation must be trained to detect the signs promptly. 578 SHOCK 579 Treatment is directed toward restoring the vitality of the nerve-centers and to the relief of the physical con- dition. It will be remembered that the important nerve-centers, such, for example, as those controlling the action of the heart or governing the movements of respiration, are contained in the medulla oblongata, the expanded end of the spinal cord which is situated at the base of the brain. By placing the patient in the recumbent position, with the head low, a further supply of blood is directed to the nerve-centers. The pillows should be removed and the bottom of the bed elevated. The loss of heat to the body is conteracted by the application of external heat, hot blankets, hot-water cans or bags, and friction of the extremities under cover. Fresh air is a necessity for the failing respiration, though its importance is sometimes overlooked. If not freely procurable, oxygen may be ordered. To stimulate the circulation either sterile water or normal salt solution (500 c.c. at a temperature of 115° to 120° F.) may be given by hypodermoclysis, by entero- clysis, or by intravenous infusion. Stimulants are usually given unless hemorrhage is also present, or in cases of injury to the head. Atropin, the most powerful respiratory and cardiac stimulant known, strychnin, ether, or camphor, are generally given by hypo- dermic to insure prompt action. Whisky, brandy, strong hot coffee, or tea may be given by mouth, or, if the patient is unconscious, by enema. If the abdomen or pelvis is injured or hemorrhage is present, nothing should be given by mouth without special orders. The electric battery, a mustard plaster over the heart, the hot mustard foot-bath, are means also employed for the purpose of indirect stimulation of the nerve-centers. After an accident the symptoms of shock may be marked by temporary excitement and develop after the lapse of some hours. Both in slight and severe accidents the probability of shock should be borne in mind. This is especially so in cases of burns and scalds, and particularly in children. The worst effects may often be averted by 580 NURSING IN ACCIDENTS AND EMERGENCIES prompt preliminary treatment of rest in the recumbent position, quiet, and the application of external heat. Close watch must be kept on the pulse, a rapid, feeble pulse being usually the earliest indication of the condition of shock. The after-effects of severe shock are a raised tempera- ture due to reaction, lightheadedness, and sometimes delirium; the physical prostration may last some time. In alcoholic patients delirium tremens is apt to develop and is first evinced by inability to sleep. The treatment is rest in bed, enforced quiet, and a light nourishing diet until the normal condition is attained. If there is excitement or wakefulness, sedatives or narcotics are generally ordered. If a stimulant is given it is usually digitalis, which is a tonic to the heart. HEMORRHAGE By hemorrhage is understood an escape of blood from a blood-vessel. A severe loss of blood to the system may prove rapidly fatal, and is always a serious drain on the vitality. It is, therefore, imperative that the presence of hemorrhage should be immediately recognized in order that it may be promptly controlled. Hemorrhage may occur from rupture of an artery, a vein, or a capillary. Bleeding from an artery is bright red in color and occurs in jets or spurts, corresponding to the beating of the pulse. If a large artery is injured, hemorrhage may prove fatal in a few minutes. In bleeding from a vein the blood is dark in color and the flow steady, slow, and uninterrupted. The reason for the difference of color is that by the time the blood has reached the veins it has parted with its oxygen, to which it owes its bright red color, and taken up carbonic acid gas, a product of combustion. After venous blood has been exposed to the fresh air it again becomes oxidized and bright red. The veins have not the elastic resistance of the arteries, therefore the stream flows without inter- ruption. HEMORRHAGE 581 Bleeding from the capillaries occurs as a general oozing. Over a large surface capillary bleeding may mean a con- siderable loss, and is often difficult to control. Varieties.—Hemorrhage is said to be traumatic when it is the result of a wound; spontaneous, when it occurs with- out previous injury to the tissues. Traumatic hemorrhage is primary when it occurs at the time the wound is in- flicted; secondary, if it occurs at a later period, in some instances hours, in others days, after the time of injury. The most common causes of secondary hemorrhage are the slipping of a ligature, usually occurring within the first twenty-four hours, and the separation of sloughs, occurring after the lapse of several days. It may also result from the quickening of the circulation due to a return of vitality after conditions of severe shock, in small unligatured vessels. Hemorrhage may be external, subcutaneous, or internal. Internal hemorrhage may be revealed or concealed. In revealed hemorrhage the blood escapes by the orifice nearest to the bleeding point, such as the mouth or nose, the rectum or vagina. In concealed hemorrhage the blood cannot escape and the condition is entirely diagnosed by the physical symptoms, the effect, that is, of the loss of blood on the system. Physical Symptoms of Hemorrhage.—The first and most important of these symptoms is a sudden change in the pulse, which becomes rapid, soft, and frequently irreg- ular, at the same time there are usually pallor and faint- ness. If the hemorrhage is not quickly checked, further symptoms rapidly develop. The most prominent are shallow and irregular respirations, accompanied by sigh- ing, yawning, and later the condition of air-hunger already described, in which the patient gasps and fights for breath; cyanosis or blueness of the skin and mucous membranes, noticeable first around the lips and later under the nails of the fingers and toes; restlessness, anxiety, and pro- found exhaustion. Fainting or syncope is a favorable condition, the feeble action of the heart causing the blood to flow less forcibly. Unless the syncope threatens to 582 NURSING IN ACCIDENTS AND EMERGENCIES become collapse no treatment is given for ihe relief of this condition until the hemorrhage is arrested, other than placing the patient in the recumbent condition. TREATMENT OF HEMORRHAGE The primary treatment of all hemorrhages is the arrest of the hemorrhage; second to this (unless the patient is in extremis) comes the treatment of the physical condition. To a certain extent the quantity of blood lost may be controlled by position. In the recumbent position the heart acts less forcibly, consequently the flow of blood from the divided vessel is also less forcible. The supply of blood to a part is also considerably lessened if the part is elevated. The first treatment in hemorrhage is to make the patient lie down flat and elevate the injured part. The head must be kept low (as in shock), the pillows removed, and, as a rule, the bottom of the bed elevated. If the bleeding is from an extremity, the limb is easily elevated by suspension or on pillows. The supply of blood is further lessened if at the same time the joint above the bleeding point is acutely flexed. In hemorrhage from the lower part of the trunk the elevation of the foot of the bed will also elevate the injured part. In hemor- rhage from the head or upper part of the trunk it is best to keep the patient quite flat unless special orders are given to raise the head of the bed, in which case the pulse must be very closely watched, in case fatal syncope should result. Hemorrhage is arrested by closing the blood-vessel, either by the formation of a clot, by causing contraction of the walls of the vessel, or by mechanical means. The methods used are as follows: Exposure of the bleeding point to the air. Pressure, either direct or indirect. The application of heat or cold. The direct application of astringents or styptics. The indirect action of styptics administered by mouth or hypodermically. Mechanical closing of the ruptured vessel either by ligation,or by torsion. HEMORRHAGE 583 Subclavian Axillary Brachial Palmar arch Femoral Popliteal Anterior tibial Posterior tibial Temporal Facial External carotid Common carotid Fig. 178.—The relation of the principal arteries to the bones and joints. The arrows indicate the points where pressure may best be applied (Morrow). 5S4 NURSINO IN ACCIDENTS AND EMERGENCIES Exposure to the Air.—Blood on exposure to the air naturally clots. In mild cases exposure of the bleeding point to the air may be sufficient to arrest the hemor- rhage, the part at the same time being elevated and the patient in the recumbent position. When the bleeding is controlled, a sterile dressing should be firmly applied. Pressure.—Direct pressure is usually applied by means of pads or packing of sterile gauze. Whatever the haste, it must not be forgotten that the bleeding surface may easily be infected, and should come in contact with nothing that is not surgically clean. Fig. 179.^—Digital compression of brachial artery (Marwedel). If the wound is deep, it is lightly packed with narrow strips of sterile gauze or a narrow bandage, over which a pad is applied with a firm bandage. Where the wound is in a hollow, such as the palm of the hand, the axilla, etc., several pads are applied, the first small enough to fit the wound, and each succeeding layer a littler larger, forming a graduated compress. • In hemorrhage from an orifice, such as the vagina, pressure may be applied to the bleeding point by packing the entire cavity tightly with gauze. (See Chap. VI.) Pads or packing applied for the purpose of arresting hemor- rhage must be closely and repeatedly examined to ascer- tain whether blood is not soaking through the dressing. At the same time it should be remembered that where HEMORRHAGE 585 a wound is hidden by thick dressings, a revealed hemor- rhage may be thus converted into a concealed hemor- rhage, of which the only evidences are the physical symp- toms of hemorrhage. The pulse, therefore, and the color of the patient must be closely watched, in order that the Fig. 180.—Forced flexion of the elbow (Morrow). first symptoms of a recurrence may be promptly noticed. In removing dressings for pressure, it will be found that the blood has caused them to adhere closely to the in- jured site. To pull on the dressing may reopen the bleeding point. They should be soaked with cold1 sterile water until they come away without force. The dressing 1 Warm water, by relaxing the parts, may again start the bleeding. 586 NURSING IN ACCIDENTS AND EMERGENCIES is removed usually after twenty-four hours. In some cases the outer dressing only is removed and that next the wound left for another twenty-four hours. Direct pressure is used in mild hemorrhages and in cases where the bleeding vessel is not sufficiently exposed to be easily ligated. {Hemorrhage from the Nares, see below.) Fig. 181.—Compression of the radial and ulnar arteries at the wrist (Morrow). Indirect pressure is used as a temporary means of arrest- ing external hemorrhage, especially in injuries to an ex- tremity. The pressure is applied at a point along the course of the main vessel, supplying the part, and either above or below the bleeding spot, according to whether the injury is to an artery or to a vein. Injury to a main artery is a very serious condition, cutting off the main HEMORRHAGE 587 supply of blood to the part, and may be followed by gan- grene. Owing to their protected position deep in the Fig. 182.—Compression of the subclavian artery (Morrow). Fig. 183.—Forced flexion of the knee (Morrow). tissues, the main arteries are less frequently injured than the smaller and more superficial vowels. The blood in 588 NURSING IN ACCIDENTS ANT) EMERGENCIES an artery flows from the heart toward the extremities; indirect pressure is, therefore, applied between the bleed- Fig 184.—Digital compression of femoral artery (Marwedel). Fig. 185.—Compression of the temporal artery (Morrow). ing point and the heart; in a vein the blood is flowing to- ward the heart, and indirect pressure is, therefore, applied HEMORRHAGE 589 below the bleeding point, that is, with the bleeding point between the heart and the point of pressure. The methods commonly used to apply indirect pressure are digital pressure and the application of a tourniquet. In digital pressure the main blood-vessel is compressed between the fingers and the bone, over the outer surface of which the vessel passes. In order to apply digital pressure the course of the principal blood-vessels must be known, and the points at which they can best be reached (the Fig. 186.—Compression of the facial artery (Morrow). digital point). This should be taught by the use of ana- tomical charts and by demonstrations in class. When pressure sufficient to control a hemorrhage is made on an artery, the pulse below the point of pressure is ob- literated. It is difficult, without experience, to make digital press- ure sufficiently firm to control hemorrhage. The appli- cation of a tourniquet, where practical, is, therefore, commonly the more reliable method. The principal digital points for the different arteries are as follows: 590 NURSING IN ACCIDENTS AND EMERGENCIES The forearm Brachial artery. Inner surface of the arm (upper), or hand. between the two large muscles, against the humerus, at a point about one-third the distance from the axilla to the elbow. The elbow should, at the same time, be forci- bly flexed and a pad inserted in the bend. The hand. Ulna and radial Preferably, as above, also at the arteries. wrist. Against the radius, on thr inner surface, at the thumb side, and against the ulna on the inner surface on the side of the little finger; the elbow is flexed and the hand elevated. The axilla or Subclavian Against the clavicle from behind, shoulder. artery about midway between the point of the shoulder and the sternum. The leg and Popliteal artery. Behind the knee, against the femur. foot. Best applied by placing a pad behind the knee (the popliteal space) and acutely flexing the knee. The thigh must also bo flexed in order to keep the part elevated. The thigh. Femoral artery. Against the rim of the pelvis in the groin, at the point where the femoral pulse is felt, i. e., about two-thirds the distance from the hip to the middle line of the body. The whole extremity should be elevated, the thigh slightly flexed. The scalp. Temporal Against the zygoma where the pulse artery. can be felt, directly in front of the ear, opposite the external opening of the auditory canal. The face. Facial artery. Against the lower jaw bone, where the pulse can be felt, at a point below the angle of the mouth, at the anterior edge of the masseter. A tourniquet is made of a piece of thick, strong elastic rubber, flat or round, sufficiently long to pass two or three times round a limb, and provided with some mechanism by which it can be securely clamped and held without slipping. Fastened tightly round a limb, it will effectually stop the circulation and, therefore, arrest hemorrhage. It should not be left on more than an hour, or gangrene of the part may result. In applying the tourniquet, the HEMORRHAGE 591 part should first be protected by a piece of lint, or several folds of gauze, etc., in order to prevent pinching and bruising of the skin. If it can be applied at the digital point, a small hard pad should be inserted under the tour- niquet, over the exact point of digital pressure. A roller bandage makes a serviceable pad. Fig. 187.—The field tourniquet (Morrow). A tourniquet may be improvised with a handkerchief or a piece of bandage. It should be passed twice round the limb, and knotted with a double knot over the digital point, a hard pad being inserted under the bandage below the knot. Through.the knot a piece of wood or a pair of scissors, etc., is slipped and twisted tightly round and Fig. 188.—The application of the field tourniquet (Morrow). round, thus tightening the tourniquet and pressing the pad against the artery. In applying indirect pressure to a vein the bleeding point itself must first be covered by a sterile pad, in order to exclude air from the empty vessel. In the case of injury 592 NURSING IN ACCIDENTS AND EMERGENCIES lo a large vein, for the same reason, pressure is applied above as well as below the lesion. As a rule, venous hem- orrhage is best controlled by direct pressure at the bleeding point. Fig. 1S9.—Improvised tourniquet (Stoney). Acupressure.—An old-fashioned means of applying indirect pressure is known as acupressure. A needle is passed through the tissue behind an artery. A piece of Fig. 190.—Showing so-called Spanish windlass, an improvised tour- niquet, compressing the brachial artery (de Nancrede). silk is then wound tightly round the needle, in a figure- of-8 in front of the artery, thus causing compression. The needle is removed in from six to eight hours. At HEMORRHAGE 593 the present day acupressure is rarely used. It is con- sidered chiefly of value for such parts where a tourni- quet is impractical, as in hemorrhage from the scalp or in the treatment of ruptured varicose veins. Indirect pressure is never more than a temporary treatment. For the actual arrest of hemorrhage it is necessary that the ruptured vessel should be sealed, either by the formation of a clot, by inducing the walls of the vessel to contract, or by mechanically closing the vessel. Heat and Cold.—Heat may be applied to a bleeding point in the form of a douche or irrigation of very hot sterile water (114° to 120° F.), or by the application of the actual cautery. The application of heat both induces Fig. 191.—:Method of employing acupressure by means of a threaded needle passed behind and a figure-of-8 wire passed in front of vessel (de Nancrede). the contraction of the arterial walls, and causes the blood to clot by coagulating the albumin; it is, therefore, a valuable agent. Hot irrigation of sterile water is a com- mon means of arresting hemorrhage from vessels in exten- sive operations or in troublesome capillary oozing. The water used must, however, be not less than the above temperature. Water merely warm encourages hemor- rhage by causing relaxation of the arteries. Care must be taken to prevent the skin from being scalded, the mucous membranes and the internal tissues bearing readily a moist heat that will injure the skin. The actual cautery (see Chap. Ill) is frequently used at operations to control a general oozing over a more or :w 594 NURSING IN ACCIDENTS AND EMERGENCIES less extensive surface. Its chief use is in rectal operations. If not used with caution, it may cause extensive sloughing. Cold arrests hemorrhage by causing contraction of the vessels. It is applied in the form of ice, ice suppositories, ice compresses and ice-bags, or irrigations of ice water. Cold water dissolves albumin, and thus delays the coag- ulation of the blood, though it favors contraction and constriction of the arteries. It is, on the whole, a less valuable agent for the purpose than hot water. It can, however, be used in many cases where the application of hot water of the necessary temperature is not practical, as, for example, in hemorrhage from a throat, where there is risk of scalding of the adjacent tissues, which would be a dangerous complication. Astringents and Styptics.—An astringent is a drug that produces contraction of the tissues and reduces secretions; many of them, such as the acid astringents, also coagulate the albumin of the blood, thus forming a ckot. Properly speaking, heat and cold are also astrin- gents. The most commonly used astringent in treating hemorrhage is acetic acid, or vinegar. It is generally given in conjunction with the hot douche—acetic acid, 2- ounce, to water, 1 pint (vinegar, 1 ounce to 1 pint). Powerful astringents are called styptics, or, from the fact that they check hemorrhage, hemostatics. The most commonly used are: Adrenalin chlorid (solution, 1 : 10,000 to 1 : 25,000); tannic acid (powder, or saturated solution in glycerin); alum (saturated solution); iron (either tinctura ferri chloridi, or Monsell's solution); nitrate of silver (solution, 4 to 10 per cent., or stick). They are applied directly to the bleeding point, either by an applicator or in the form of a spray (nose and throat). The metal astringents, while effectually checking hemor- rhage, cause later sloughing of the tissues, with the risk of further hemorrhage; their use, therefore, is limited. When available, either adrenalin or tannic acid is preferred. Preparations containing tannic acid, such as witch- hazel, are excellent as domestic remedies. Styptic collodion, a preparation of collodion and tannic acid (20 per cent.), and styptic cotton, an absorbent cotton charged with iron HEMORRHAGE 595 sulphate, are occasionally used in the dressing of wounds complicated by troublesome hemorrhage. A hemorrhage may also be controlled indirectly by the administration of hemostatics internally, either by hypo- dermic injection or by the mouth or rectum. Taken into the system, their action is to cause constriction of the smaller blood-vessels. Those most frequently used are: Adrenalin chlorid (mouth, 10 to 30 minims; hypodermic- ally, diluted ten times with normal salt solution), ergot (mouth, fluidextract, 30 minims to 1 dram: hypodermically, ergotin, 2 to 5 grains), and gallic acid (pill form, 10 to 30 grains). Ergot, besides causing constriction of the blood- vessels, acts directly on the muscular tissue of the uterus, causing powerful contractions; it is, therefore, of great service in the treatment of postpartum hemorrhage. In conditions that favor hemorrhages, such as the exist- ence of sloughing ulcers (as in typhoid fever), in the treat- ment of aneurysm, and of those diseases complicated by spontaneous hemorrhages (see below), substances that favor the clotting of blood are frequently administered regularly over a length of time. The principal are calcium chlorid (10 grains) and gelatin. The latter is generally given in the diet in the form of jellies, but may also be administered by rectum. In the latter case it must be diluted until sufficiently thin to flow through the enema tube. More rarely it is given by hypodermic injection, diluted to a 2 per cent, solution in sterile water. Ligature.—The mechanical method of arresting hemor- rhage is by ligating the bleeding vessel. The vessel is seized by a pair of forceps, slightly stretched, and the ligature tied round it in a firm surgical knot. Unless securely tied (p. 290), the ligature may slip, causing a secondary hemorrhage. Ligatures are usually of catgut, which can be absorbed into the tissues. Ligation of the vessels is the usual method of arresting hemorrhage caused by an operation. Torsion, or twisting of an artery, is a means of contrac- tion chiefly used for the smaller vessels. If an artery is cut clean across, the walls do not contract. If, however, the walls are torn or divided unequally, the elastic fibers 596 NURSING IN ACCIDENTS AND EMERGENCIES in the walls of the artery tend to curl up on themselves, thus contracting and closing the vessel, and forming, at the same time, an irregular surface on which fibrin is readily deposited. In torsion the artery is seized in a pair of forceps, stretched, and twisted. The walls are broken and contraction induced. Treatment of the Physical Condition.—Ordinarily, until the hemorrhage is arrested, the treatment of the physical condition is confined to placing the patient in the recumbent position, usually with the head low and the feet elevated, for the reasons given above, at the same time preventing any movement that may exhaust him and cause further loss of blood; always remember he should have plenty of fresh air. No stimulants should be given: Fig. 192.—Method of controlling hemorrhage by torsion (Da Costa). they tend to increase hemorrhage. If a drink cannot be denied, it should be cold water. Faintness need not be relieved unless it tends to pass into fatal syncope. Ex- ternal warmth, by restoring the vitality, also favors hemor- rhage. The general condition of the patient and the promptness with which surgical help can be obtained must frequently determine how far the physical condition can be relieved before the hemorrhage is checked. When the hemorrhage is arrested, treatment is directed toward restoring the vitality. The condition is one of extreme shock, and the treatment is on the same lines. The patient is kept in the recumbent position, with the feet well elevated. After severe hemorrhage, or if there is danger of recurrence, the position is maintained until a normal condition is reestablished, when the bed should HEMORRHAGE 597 be lowered gradually—not more than half a foot a day. External heat is applied in the form of hot blankets, hot- water cans, and friction of the extremities under cover. Large poultices are sometimes ordered to the calves of the legs and over the abdomen; in the collapsed condition of the patient they are, however, likely to cause burns, unless closely watched and removed on the first sign of reddening. Hypodermoclysis or intravenous infusions of normal salt solution (500 c.c), or enemata of hot normal salt solution (200 to 500 c.c), are generally given for the purpose of restoring fluid to the circulation. Intense thirst is a prominent after-effect of hemorrhage. Where practical, water, tea, etc, are given freely by mouth; in other conditions the thirst is best combated by sips of boiling hot water. Stimulants may be ordered, but are given with caution on account of the risk of a recurrence of the hemorrhage. For the immediate results, atropin, strychnin, or alcohol is generally ordered; in the after- treatment digitalis is preferred, as it acts as a tonic to the heart. Morphin (tV to \ grain) is frequently ordered, especially in hemorrhages connected with the alimentary tract. It reduces the general restlessness and, by check- ing peristalsis, restrains local movement. Where the loss of blood has been severe, auto-infusion may be practised in order to keep as much blood as pos- sible circulating in the vital organs. The extremities are elevated and firmly bandaged from the tips of the fingers or toes toward the trunk. Usually one of the four limbs is left unbandaged, and every ten minutes the band- ages from one limb are changed to the unbandaged limb. In this way no limb is bandaged for longer than half an hour at a time. The immediate after-effects of hemorrhage are exhaus- tion, intense thirst, and anemia. The pulse is slow— in severe cases frequently lower than 45. Later there may be fever, with lightheadedness or delirium. The treatment is the same described for delayed shock. Hy- podermoclysis of normal salt solution is frequently ordered at repeated intervals. Hot water and hot drinks, such as tea, relieve the thirst more efficiently than cold drinks or 598 NURSING IN ACCIDENTS AND EMERGENCIES ice. The anemia is treated with prolonged rest, fresh air, a nourishing diet, and usually iron in some form is ordered (Blaud's pills, or tinctura ferri chloridi, etc.). It is often a very persistent symptom, and is an undesirable complica- tion, especially after an operation, prolonging convales- cence and delaying recovery. SPECIAL FORMS OF HEMORRHAGE External hemorrhage is hemorrhage occurring on the surface of the body, and is almost invariably the result of violence. It is the most simple form of hemorrhage to treat, being quickly recognized, and the local treatment generally easy to apply. Care must be exercised to keep the wound sterile. Arterial external bleeding may be controlled by any of the methods described above. If the hemorrhage is venous, the best method of con- trolling it is usually direct local pressure with a graduated pad, the part being well elevated. The commonest form of venous bleeding is a ruptured varicose vein in the leg. After the pad is applied, the whole limb is enveloped in a rubber bandage, beginning at the toes and bandaging upward. In obstinate cases, where bleeding tends to recur, an operation may be necessary, and the vein is ligated. For these cases also acupressure is still occa- sionally performed. In external capillary bleeding ex- posure to the air may be sufficient to check the oozing. If not, direct pressure or the application of heat, cold, or an astringent is next tried. A powerful styptic, such as iron, will always stop hemorrhage, but where the physical symptoms are not urgent, other methods should be tried first, on account of the tendency of strong styptics to cause sloughing. Subcutaneous hemorrhage is an extravasation of blood into the tissues. It may be the result of injury (traumatic) or disease (spontaneous). The appearance of traumatic subcutaneous hemorrhage is familiarly recognized as bruising. The bleeding is diffused over a more or less extensive area, producing a discoloration of the tissue, at first purple, then fading as absorption takes place into HEMORRHAGE 599 green and yellow. Such an extravasation of blood is called ecchymosis. The treatment consists in the application of cold, usually in the form of a compress, unless the injury is extensive, when the lessening of the blood-supply to the part increases the danger of sloughing. Hot applications, which dilate the vessels, thereby increasing the blood- supply and restoring the vitality of the part, are then preferred. The cold application may with advantage be combined with an astringent, such as arnica or witch- hazel, which aids in checking exudation. They are best applied in the form of compresses. Some diseases are characterized by minute extravasa- tions of blood under the skin, giving the appearance of a rash of small purplish spots known as petechias. A pete- chial hemorrhagic rash is common in purpura, scurvy, and typhus fever. It is also met with in malignant forms of smallpox and measles, and may also less frequently be met in other conditions. Small localized subcutaneous hemorrhages are common in arteriosclerosis, a condition in which the arteries become hard and inelastic and are easily ruptured. Extravasation of blood under the con- junctiva has a bright-red appearance, owing to the con- stant exposure of the clot to oxygen through the thin membrane of the conjunctiva, and often causes unneces- sary alarm. For these small extravasations no treatment is necessary. They gradually become absorbed and dis- appear. Internal hemorrhage is always a grave condition. It may be serious from the amount of blood lost, or, where the blood cannot escape, from the effects of the hemorrhage on the adjacent structures. For example, a small hemor- rhage in the brain may, from the pressure caused by the clot, give rise to a fatal apoplexy; a slight hemorrhage into the lung may cause septic pneumonia; bleeding into the peritoneal cavity, though not extensive, will shortly set up septic peritonitis from decomposition of the blood. As has been said above, internal hemorrhage may be revealed or concealed. In revealed hemorrhage we have 600 NURSING IN ACCIDENTS AND EMERGENCIES the evidence of an escape of blood, either from the orifice of the body nearest to the injured structure or from a wound. The bleeding point may frequently be reached and local treatment applied. In concealed hemorrhage the condition is only demon- strated by the physical symptoms already described. It is, therefore, the graver condition, being more liable to be overlooked. The common causes of internal hemorrhage are as follows: After an internal operation, from imperfect closing of a vessel, the slipping of a ligature, or the separa- tion of sloughs: from an accident causing injury to an internal organ, for example, fracture of the pelvis or the skull; sloughing of an ulcer causing perforation of a blood-vessel at some point in the alimentary tract: rup- ture of the tube in a case of Fallopian gestation: separa- tion of a portion of the placenta previous to labor; relaxa- tion of the uterus after labor: injury or disease of one of the kidneys: spontaneous hemorrhage, usually from the mucous membrane of some portion of the alimentary tract. The symptoms accompanying internal hemorrhage are greatly modified by the function and position of the organ affected. The characteristic symptoms and the special treatment necessary must, therefore, be considered in detail. Hemorrhage from the Bowels (Enterorrhagia).—The common cause of enterorrhagia is rupture of a vessel from the perforation of an ulcer, usually due to separation of a slough, in the walls of the intestine, as in typhoid fever. It is sometimes directly caused by acute distention of the walls of the intestines before the ulcers have healed; enterorrhagia may also occur spontaneously in purpura or scurvy. It is always a grave condition, and frequently fatal to life, especially when the patient's strength is re- duced by prolonged illness, as in typhoid fever. A discharge of blood and mucus from the rectum is a common symptom in inflammatory conditions of the alimentary tract, as in enterocolitis, or in poisoning by corrosives or irritants. It is not dangerous to life in the same sense. Hemorrhage from internal hemorrhoids oc- HEMORRHAGE 601 curs usually at the time of defecation, and is bright red and passed on the top of a stool. The symptoms of enterorrhagia are those of internal hemorrhage in a marked degree, as already described; usu- ally there is a sudden fall in temperature and a sharp rise in the pulse-rate; distention is frequently present; sooner or later there is a discharge of blood from the rectum. If the bleeding point is low, the blood may be bright red in color and either gush from the anus or be passed in clots. If the point is high in the bowel, the blood is " altered " by the digestive juices, and appears as a dark-brown or black, viscid fluid, mixed with fecal matter. Some hours after the hemorrhage has occurred the stools are black in color and sticky; they are known as tarry stools (p. 227). The treatment consists in absolute rest on the back, with the bottom of the bed elevated higher than the shoulders, and the pillows removed. An ice-bag or Leiter's coils are applied to the abdomen, especially to the right side, which is the site of the glands usually first attacked in typhoid fever. All other treatment is stopped. No nourishment or water by mouth is allowed for at least twenty-four hours. No movement of the pelvis must be permitted; the stools are received on pads of tow. The skin of the coccyx may be protected by a ring air-cushion slightly inflated. The room is kept at a low temperature (55° to 60° F.); the bed-clothes should be light and pre- vented by a bed-cradle from weighing on the abdomen. No stimulants are given. If exhaustion is severe, hypo- dermoclysis of water or normal salt solution is usually given. Morphin is generally ordered CrV to j grain), and the patient kept under the influence of the drug until the danger is past. Hemostatics, such as ergot, may be ordered and are generally given by hypodermic. If the hemorrhage tends to recur, a course of calcium chlorid (10 grains) or gelatin is frequently ordered by mouth or rectum. Close watch must be kept for symptoms of perforation (p. 610). Treatment by mouth is renewed with caution, generally beginning with sips of hot water after twenty-four hours to two days have elapsed. Three days from an attack the patient is usually allowed to be turned, using no effort 602 NURSING IN ACCIDENTS AND EMERGENCIES himself, after which the bed is gradually lowered and normal conditions cautiously resumed. Hemorrhage from the bowel arising from hemorrhoids is not so serious a condition; the loss is usually not sufficient to cause acute physical symptoms. Rest for a short time in bed, the introduction of ice suppositories or of a suppository containing an astringent, usually gall or tannic acid, is generally all the treatment required. If there is severe pain, opium or cocain is frequently combined with the astringent. The feces are kept soft by mild laxatives. Hemorrhage Due to Purpura, etc.—(See Spontaneous Hemorrhage.) Hemorrhage from the Stomach (Hematemesis).—The usual cause of hematemesis is perforating gastric ulcer; it also occurs spontaneously in purpura or scurvy. The first symptom is frequently the vomiting of darkish blood mixed with mucus and food-particles. (See Chap. VII.) If the bleeding is slight and the blood has remained any length of time in the stomach, it is altered by the digestive juices and has the appearance of coffee-grounds. Later, the stools are tarry from the presence of blood which has passed into the intestines. The physical symp- toms are mild or grave according to the loss of blood and the frequency with which the hemorrhages recur. The treatment is the same as in hemorrhage from the bowels. When treatment by mouth can be resumed, gelatin is frequently ordered as part of the diet. In severe cases, where attacks of hemorrhage recur, an operation is frequently performed by which the ulcer is excised and the wall of the stomach repaired. Hemorrhage from the Lungs (Hemoptysis).—Hemop- tysis may result from: \l) The breaking-down of a cavity- involving the wall of a blood-vessel in pulmonary tuber- culosis; (2) the rupture of an aneurysm; (3) the result of venous congestion in heart disease; (4) injury, as in per- foration of the lung by a fractured rib or a gunshot wound. In the first condition the first sign is usually, but not invariably, a preliminary cough, followed by the taste of a warm, salty fluid in the mouth, which proves to be HEMORRHAGE G03 blood. The quantity lost at a time is usually slight. The blood is bright red and frothy, from being mixed with air-bubbles. If a large vessel is ruptured, the quantity may be sufficiently great to flood the respiratory passage, and death results from asphyxia. The usual immediate treatment is rest in bed, generally with the shoulders elevated, and plenty of fresh air. The patient should be out-of-doors or by an open window. If he is in a room, the temperature should usually be as low as can be obtained. Movement is limited, but not entirely prohibited. An ice-bag is sometimes applied over the affected part, but more often is found to increase the ten- dency to cough. Morphin (tV to i grain) is generally or- dered, as it helps to reduce the cough and quiet the patient. Hemostatics are not much given, nor are astringent inhala- tions usually considered of value. Ice to suck takes away the taste of blood and diverts the patient's mind. No stim- ulants are given. The diet is kept low (milk and eggs) for a day or two. Movement and exercise are resumed with caution—usually not before twenty-four hours have elapsed. If the hemorrhages tend to recur, gelatin is frequently given in the diet. Hemoptysis, caused by venous congestion, is coughed up a little at a time and mixed with expectoration. A con- siderable quantity may be lost in twenty-four hours. It is not an emergency, but one of the symptoms of a disease, and treatment is influenced by the underlying cause. Rupture of an aneurysm into the lung causes death in a few minutes from the flooding of the lungs and respiratory passages with blood, as well as from syncope from the loss of blood. Bright red blood pours from the mouth and nose and no treatment is possible. Hemoptysis caused by injury is grave or mild, according to the extent of the injury. In mild cases the treatment consists in absolute rest, repair of the injury, and the local application of an ice-bag. When an injury is severe, as in perforation of the lung by a gunshot, it is generally fatal. Hemorrhage from the Nose (Epistaxis).—The most common cause of nosebleed is a slight violence to a weak- walled vessel in the nose, as in blowing the nose with too 604 NURSING IN ACCIDENTS AND EMERGENCIES much force; it may also occur after an operation on the nares or tonsils, or spontaneously in the course of scurvy or purpura. Fig. 193.—Catheter for drawing plug into the posterior nares (Morrow). Fig. 194.—Showing the method of drawing a plug into the posterior nares by the aid of Bellocq's cannula (Morrow). For a mild attack the patient is laid flat on the back, and cold, usually in the form of compresses, applied to the HEMORRHAGE 595 nape of the neck and over the nose. In severe cases the nares may be sprayed with an astringent or mild styptic (vinegar and water, 1 ounce to 1 pint, or adrenalin chlorid, 1 : 10,000 to 1 : 5000), or plugged with strips of sterile gauze. The hemorrhage is usually from the anterior nares. Bleeding after an operation on the posterior nares is often difficult to control. Ice to suck, cold applications over the nose and to the nape of the neck, are the usual remedies first tried. Styptics may be applied to the spot, Fig. 195.—The posterior nasal plug in place (Morrow). if it can be reached, or used in the form of spray. Those most used are adrenalin chlorid (1 : 10,000 to 1 : 5000), tannic acid (20 to 50 per cent.), or persulphate of iron. In some cases it is necessary to plug the posterior nares. A plug of sterile gauze or cotton is introduced in the following way: A fine soft-rubber catheter is threaded with a double piece of stout linen thread. The catheter is passed through the nostril and by the pharynx, into the mouth. To pass the catheter push the tip of the nose upward and direct 606 NURSING IN ACCIDENTS AND EMERGENCIES the catheter straight backward into the passage exposed. The threads are seized and tied securely around the plug, leaving an end about six inches long free. The catheter is then withdrawn, carrying the one end of the thread with it; the plug is guided into the posterior nares by a finger inserted into the mouth, and pulled firmly into place by the string through the nostril. The anterior nares are then packed with gauze. At the end of twenty-four hours the packing is removed and the nose gently douched to soften the plug and prevent it adhering. Traction is then made on the string in the mouth and the plug removed. Bleeding may continue after the plug is inserted, and be concealed by the application. Any change in the pulse, and such symptoms as pallor and yawning, must be promptly reported. Bleeding from the throat may result from severe slough- ing, as in cases of scarlatina anginosa, or follow excision of the tonsils. The blood may escape by the mouth or nose. If much is swallowed, it is usually vomited. Enough may be swallowed to give the stools a tarry appearance. The treatment consists in giving ice to suck, ice-cold or as- tringent sprays, or the direct application of styptics, adrenalin chlorid, tannic acid, or iron. Bleeding from the ear is most commonly associated with fracture of the base of the skull (p. 626). Post-operative Hemorrhage.— (See p. 567). Hemorrhage Connected with Childbirth.—Hemorrhage occurring during pregnancy or during labor, before the actual birth, is known as antepartum hemorrhage. The cause is the separation of the small portion of the placenta, usually the result of an accident, such as a fall; during labor it is commonly due to malposition of the placenta. The hemorrhage, which is usually slight, may be revealed or concealed. In the former case the blood escapes from the vagina; in the latter, the only symptoms are the physical symptoms of hemorrhage. If the bleed- ing is excessive, it tends to separate the placenta further and may cause premature labor. If the symptoms are not severe, rest in bed for a few- days in the recumbent position, with the feet elevated, and HEMORRHAGE 607 a light diet, is all the treatment necessary. If the symp- toms are severe or the hemorrhage recurs frequently, premature labor is induced by mechanical means. An ice- bag may be ordered over the probable site of the placenta. Packing the vagina, unless the bleeding point can be reached, is useless; in the majority of cases the fetus intervenes between the bleeding point. Occurring at the time of labor, the hemorrhage may be severe. As it cannot be stopped until the birth is over, the treatment consists in hurrying the labor as much as possible. No styptics can be given until the uterus is empty, when the hemorrhage will probably be arrested by the natural contraction of the uterus. The patient's strength is spared in every way. Hemorrhage after the birth of the fetus is called post- partum hemorrhage. Occurring at the time of labor, it is primary; at any time after the uterus has been contracted, secondary. The cause is usually failure of the uterus to contract (primary) or to remain contracted (secondary), due either to retention of a portion of the placenta or of the mem- branes, or to uterine inertia. Hemorrhages may also occur from accidents to the uterus, such as rupture, or from lacer- ation at some point of the birth-canal. The hemorrhage may be revealed or concealed. In the former the blood escapes by the vagina, sometimes gradually, more fre- quently in a sudden enormous rush. Until the uterus contracts, the large blood-vessels or sinuses, which have been exposed by the separation of the placenta from the uterine walls, are left widely dilated. The rush of blood may be so great that, if uncontrolled, life may be lost in a few minutes. The physical symptoms of hemorrhage are marked and develop abruptly. Through the abdomi- nal wall the uterus is felt like an inflated balloon, instead of the hard, contracted mass it should represent. All treatment is directed toward exciting uterine contractions. A hot intra-uterine douche (120.2° F.) of sterile water or normal salt solution is given, at the same time the abdomen is vigorously kneaded. Ergot (ergotin, 2 to 5 grains) is given by hypodermic. Contractions 608 NURSING IN ACCIDENTS AND EMERGENCIES have been excited in an emergency, where nothing else was at hand, by a pail of cold water thrown over the abdomen. If fragments of the placenta or membranes are retained, they are removed by hand. The hand moved forcibly around the internal wall of the uterus may also excite contractions. The necessity for absolutely strict asepsis must not be lost sight of, however great the emer- gency. In all labor cases the hot douche with sterile apparatus should be ready to hand. It is impossible to foresee when it may be required. When the uterus is well contracted, a pad is placed over the fundus and an abdomi- nal binder firmly applied. The usual after-treatment in cases of hemorrhage will be necessary. The pulse must be closely watched. If it rises above 80, the binder should be undone and the abdomen again kneaded until the uterus is felt hard and firm. Hemorrhage from a Ruptured Fallopian Tube.—The cause is the development of the embryo in one of the tubes leading from the uterus, instead of on the wall of the uterus. When the tube can extend no further, it ruptures, causing bleeding into the peritoneal cavity. The hemorrhage may be entirely concealed or partially revealed, a small trickle of blood escaping by the vagina. Sudden pain and syncope and the symptoms of shock are the usual chief indications. Though the actual hemorrhage is slight, the condition is a very grave one, recovery depending on prompt opera- tive treatment. Septic peritonitis is a common complica- tion from the discharge of blood and the contents of the sac into the peritoneal cavity. Hemorrhage from the kidneys or part of the urinary tract is recognized by the presence of blood in the urine (hematuria). (See Urine, Chap. VII.) It may be due to injury or disease of the organs, or to the action of irri- tant or corrosive poisons. The cause of the condition is treated. The quantity of blood lost is not sufficient to cause physical symptoms. An accident involving the pelvis, such as fracture of the pelvis (p. 627), is frequently complicated by internal hemorrhage. The condition is generally associated with profound shock. Blood may escape from the rectum or be HEMORRHAGE 609 mixed with the urine, which should, in these cases, always be carefully saved for examination. Cerebral Hemorrhage.—(See Paralysis, p. 695.) Hemorrhage Due to Fracture of the Base of the Skull. —(See Fracture of Base of Skull, p. 626.) Spontaneous Hemorrhage.—Setting on one side the subcutaneous hemorrhages already described as character- istic of certain diseases, spontaneous hemorrhage is usually associated with hemorrhagic purpura, scurvy, or the con- dition known as hemophilia. Hemorrhagic purpura is a disease of unknown origin; at the present day it is considered to be not un- likely an infection. It is characterized by a profuse petechial eruption and hemorrhages from the mucous membranes; the latter are frequently so profuse as to threaten life. Accompanying symptoms are malaise and moderate fever. In very severe cases death takes place from exhaustion and loss of blood. Generally the attack lasts about two weeks. The subsequent anemia is often persistent. The usual prompt treatment for hemorrhage will be necessary. The patient is, of course, confined to bed. The stools must be watched for traces of blood. Rest in bed, fresh air, nourishing diet, and iron for the anemia comprise the general treatment during convalescence. Gelatin or calcium chlorid are frequently ordered as pre- ventives against further attacks of hemorrhage. In young anemic girls spontaneous hemorrhages from the nose, stomach, or intestines may occur from time to time, usually about the monthly period, and, unless in excess, are not necessarily alarming. If severe, the attack is treated on the lines already indicated. Hemorrhage of Scurvy.—Patients suffering from scurvy are likewise liable to spontaneous hemorrhages, generally from the stomach or intestines, which are treated by the usual methods. As the disease is caused by a diet de- ficient in fresh vegetables or milk, the diet is an important part of the treatment (Chap. XXIII). The mouth should receive special care; the gums bleed easily, and the breath has a fetid odor. An antiseptic mouth-wash should be 39 610 NURSING IN ACCIDENTS AND EMERGENCIES used frequently, especially before feeding. Fresh air and good hygiene are important factors. Hemophilia, or bleeder's disease, is generally hereditary, and the family history suggests the condition. As a rule, it occurs in males, but is transmitted through the females of a family. The cause is unknown. The characteristic symptom is persistent bleeding, occurring either spon- taneously or after slight injuries. The disease is considered incurable—few bleeders grow up. A few are said to outgrow the condition. Patients with a family history of hemophilia are advised to lead lives with as little exposure to injury or overexcitement as possible, and should not undergo operations if they can possibly be avoided. Hemorrhage from so slight a cause as the drawing of a tooth may prove so persistent as to cause death from exhaustion. The attack of hemorrhage is controlled by the usual methods, but is often very intractable, breaking out again and again after the vessel has been closed by pressure, the application of styptics, etc. Hemostatics are generally given internally at the time of the hemorrhage. A course of gelatin or calcium chlorid is frequently ordered. PERFORATION By perforation is generally understood a complete rup- ture at one point in the wall of the intestines or the stom- ach (the latter is less common), resulting in escape of the contents of that portion of the alimentary tract into the peritoneum. Perforation may occur as the result of direct injury; after an operation on the intestines from sloughing of the tissue; and, the most usual cause, from the burrowing of an ulcer through the wall of the intestine or stomach. The symptoms are sudden pain (not always present), abdominal distention {tympanites), sudden fall of tempera- ture if it has previously been elevated, with rapid, feeble pulse and marked symptoms of shock. The treatment is instant operation. While surgical aid is being obtained the patient should be kept at abso- PERFORATION 611 lute rest in the recumbent position, with the head low, and external heat applied. If a stimulant is ordered it is usually strychnin and is given by hypodermic. Nothing is given by mouth and all previous treatment is stopped. The dangers of perforation are fatal shock and septic peritonitis. The latter develops rapidly from decompo- sition of the food substances, which have escaped into the cavity of the peritoneum. It is in order to avoid this complication that prompt operation is necessary. The operation consists of irrigation of the peritoneum and repair of the perforation. After the operation mor- phin is usually ordered and the alimentary tract kept at absolute rest for three or more days. For the same time all movement of the body is forbidden. Fluid diet is then begun in small quantities. The bowels are relieved by enemata and all griping laxatives avoided. CHAPTER XVIII NURSING IN ACCIDENTS AND EMERGENCIES (Continued) Fractures: Varieties; Union; Immediate Treatment; Surgical Treatment; Pott's Fracture; Colles' Fracture; Fractures of Ribs; Skull—Vault, Base; Jaw; Pelvis; Spine. Dislocations: General Treatment; Jaw, Finger; Sprains; Wounds: Varieties; Healing of; Treatment; Dressings—Complications: Inflammation; Infection; Abscess; Blue Pus; Cellulitis; Slough; Gangrene; Embolism—Special Infections: Erysipelas, Scarlet Fever, Tetanus. FRACTURES A fracture is commonly described as a "break in the continuity of a bone." It is caused by direct or indirect violence or by the sudden contraction of powerful mus- cles. Violence is said to be direct when it causes a lesion at the immediate site of injury, as in a fracture caused by a blow or a gun-shot wound, etc In indirect violence the lesion occurs at a distance from the immediate site of injury. Thus, a fracture of the clavicle may be caused by a fall on the shoulder. An example of a fracture due to muscular contraction is that of a fractured patella in consequence of a fall on the feet, and directly due to the instinctive strong contraction of the quadriceps muscle in the common tendon of which the patella is contained. Varieties.—According to the direction of the fracture, it is described as transverse, oblique, or longitudinal. In long bones the fracture may occur at the shaft {diaphysis), at the ends {epiphysis), at the head, or at the neck. For convenience, the shaft of the long bones of the extremities is usually described in three parts—the upper, middle, and lower thirds. A fracture at the epiphysis separates the head from the shaft. 612 FRACTURES 613 Fractures at the neck of a long bone are described as intracapsular, if occurring inside the capsule that incloses the joint; or extracapsular, if occurring outside the capsule. Intracapsular fractures are liable to result in ankylosis, or permanent rigidity of the joint. Symptoms.—The characteristic symptoms of a frac- ture are: Sudden pain, in connection with a history of violence, deformity, abnormal movement, swelling and dis- coloration of the surrounding tissues (due to extravasa- tion of blood), crepitus or a grating sensation if the frac- tured ends are moved on each other, and interference with function. The function of the bones of the extremities is support and movement. When such a bone is frac- tured, it cannot be used to support the body, and volun- tary movement below the seat of fracture is either lost or restricted. In fractures of the extremities the injured limb is frequently altered in length in comparison with the sound limb; if the fracture occurs at or near a joint, there is, usually, a characteristic dislocation of the joint. - Fractures of the brain, pelvis, or spine are complicated by injuries to the adjacent structures, giving rise to special symptoms. Classification.—Fractures are divided into two chief groups—simple or closed, and compound or open. In a simple or closed fracture the injury is subcutaneous, the external tissues protecting it from contact with the air. Flesh wounds may exist, but do not form a channel of communication between the fracture and the surface. As long as a fracture remains simple, it is protected from infection. In a compound or open fracture there is also an open flesh wound, forming a direct channel of communication between the fracture and the surface. The fractured bone can be reached through the wound. A compound fracture is usually due to direct violence. Besides the two chief groups, fractures are also sub- divided according to certain characteristics. Greenstick Fracture.—This is one in which the bone is bent and only partially broken. Greenstick fractures 614 NURSING IN ACCIDENTS AND EMERGENCIES are common in the long bones of children, the bones being soft and easily bent. Comminuted Fractures.—A fracture in which the bone is splintered into several pieces. A comminuted fracture is more often also compound. Impacted Fractures.—A fracture in which the broken ends are forcibly driven together, or impacted, at the time of injury. Impacted fractures are usually simple, and occur chiefly in long bones as the result of indirect violence, as, for example, in a fall where the weight of the body is received on the outstretched limb. Fig. 196.—Compound fracture ("American Illustrated Medical Dictionary"). Fig. 197.—Partial or greenstick fracture of the radius. Multiple Fractures.—A fracture of one bone in two or more separate places. Complicated Fractures.—A fracture is said to be com- plicated if it is associated with serious injury to some important adjacent structure, such as the rupture of a large blood-vessel or injury to an internal organ. Depressed Fractures.—A fracture in which the broken fragment is forcibly driven inward against the underlying structures. Depressed fractures are the result of direct FRACTURES 615 violence and are frequently compound. They occur in fractures of the skull and upper jaw. Physical Symptoms.—Besides the local symptoms and those arising directly from injury to important structures, as, for example, compression of the brain, a fracture is usually accompanied by certain physical symptoms, more or less marked according to the circumstances of the accident and the condition of the general health. Some shock is always present, and may be severe. Slight fever, malaise, and gastric disturbances are generally present during the first few days. The condition is treated by rest, quiet, a purgative, and light diet. Severe shock is a prominent symptom in fractures of the pelvis and the Fig. 198.—Comminuted frac- Fig. 199.—Impacted fracture ture of the tibia (" International of the neck of the femur Text-Book of Surgery "). (Da Costa). skull. In alcoholic subjects mental excitement and in- somnia are common symptoms. They are usually treated with sedatives, in order to prevent the development of delirium tremens. The Repair of Fractures.—The time allowed for the union of a fractured bone varies with the size and im- portance of the bone and its position in the body. A fracture of a bone of a finger will unite in about two weeks, while for a fracture of the neck of the femur, z 616 NURSING IN ACCIDENTS AND EMERGENCIES bone that has to bear the whole weight of the body, from ten to twelve weeks are allowed. Repair of a fracture takes place by the deposit of new bony tissue, to which the name callus is given. The first callus is temporary or provisional, and resembles cartilage; it first forms on the outside of the fractured ends, incasing them like a natural splint, and later between the broken fragments, thus forming a temporary union. From the provisional callus a permanent callus is developed between the fractured ends of the bones, forming what is known as bony union. The provisional callus is gradually absorbed Fig. 200.—Callus of fracture Fig. 201.—Appearance of the (dog) four weeks; commencing ends of fragments (Da Costa). ossification of external callus (Warren). in the process of healing. In large bones about twelve months, it is considered, is required before the permanent callus is as strong as true bone. In some instances bones fail to unite. The usual causes are imperfect approximation, either by careless " setting " FRACTURES 617 or from failure to keep the fragments at complete rest, disease of the bone, or suppuration. Imperfect approximation may result in the deposit of fibrous tissue instead of bony tissue between the broken ends, forming what is known as fibrous union. This is especially liable to occur in fractures of the patella where a fold of the periosteum is apt to intervene between the divided fragments. Fibrous union is useless for the pur- pose of bone function. Permanent deformity and short- ening of a limb are also results of imperfect approxima- tion. Union may be delayed by physical conditions which affect the health of the patient. For malunion the treat- ment usually is to break the bone afresh and reset the fracture. For cases of delayed union a surgical operation is fre- quently performed, and the fragments either wired or screwed together. In aged people bony union does not commonly take place. If the patient recovers from the shock, he is usually moved out of bed on to a chair as soon as the symptoms of pain and inflammation have subsided, other- wise he may become bedridden. Whenever possible, such patients should be induced to learn to walk with crutches. Other complications that may arise from a fracture are as follows: Extensive sloughing of the adjacent soft tissues, destruction of bone, resulting in the for- mation of sequestrse, hemorrhage, either primary or secondary (see Hemorrhage), embolism (see Embolism), painful callus, caused by the pinching of a nerve, and infections, either local, causing suppuration, or general, as septicemia, erysipelas, and tetanus. As in all violent accidents, delirium tremens is a common complication in alcoholic patients. TREATMENT OF FRACTURES Immediate Treatment.—Wherever a fracture occurs, temporary means should be taken to keep the part at rest until surgical help can be obtained, otherwise in- judicious movement will increase the hemorrhage and 618 NURSING IN ACCIDENTS AND EMERGENCIES may cause serious injury to the adjacent structures, such as rupture of a large blood-vessel, or convert a simple fracture into a compound one. For the same reasons no attempt should be made by the bystanders to reduce or " set " the fracture, however apparent the deformity; where practical, the injured member may be elevated and cold applied over the seat of the fracture. This will help to control the hemorrhage, check the inflammation, and relieve the pain. Very frequently it is necessary to transfer the patient before surgical aid can be procured. In t hese cases temporary support of the fracture must be given. For a fracture of the leg (p. 250) the limb may be ex- tended on a pillow or folded coat, in as straight a position as can be obtained without force. Outside the pad so formed temporary splints made of boards, walking-sticks, rolled newspapers, etc., are placed, and the whole tied securely round the limb immediately above and below the seat of fracture, and again above the knee and round the foot. A fracture of the forearm may be treated in the same way. If the patient must walk, the elbow should be flexed ami the forearm supported in a sling. In a fracture of any part of the femur the patient must be kept perfectly- flat and transferred on a stretcher or board. If possible to devise a temporary splint, it should be applied on the outside of the injured member and extend from the axilla to beyond the foot. It should be kept in position by ties passing round the body and round both lower extremities, the uninjured leg thus acting as a second splint. A board must be kept under the pelvis. A fracture of the upper arm is usually best secured by placing a flat pad between the arm and the body, and pinioning the arm firmly against the side with a stout towel secured by several pins. To be correct, the posi- tion should be comfortable. If there is deformity about the shoulder, or if the patient must walk, the forearm may be supported in a sling. Should the elbow be affected, a temporary splint should be devised and applied on the inner surface of the elbow, so that the joint is kept extended. FRACTURES 619 In a fracture of the clavicle, usually due to indirect violence from a fall on the shoulder or outstretched arm, the shoulder is dropped and the patient's head is turned to the injured side; he cannot raise the hand to his head. He should lie flat, with the arm extended by his side. If it is necessary for him to walk, a pad should be placed in the axilla and the hand brought over and held on the opposite shoulder. In this position a stout towel is pinned round the body over the affected arm. The elbow should be supported by the free hand. If the movement causes pain or appears to increase the de- formity over the clavicle, it is better to allow the arm to hang, fixing it to the side with a broad towel. A small pad should be placed in the axilla. If a rib is fractured, the patient should be transferred with as little movement as possible. The initial injury may be slight, but injudicious movement may result in puncture of the pleura or of the lungs (see below). The local pain is commonly acute. A towel pinned firmly round the chest will help to minimize the movement of the chest-wall in the act of breathing. In compound fractures there is also the open wound to be treated. It rarely occurs that the means of treating it by aseptic methods are immediately at hand. If a sterile dressing can be had or devised, as by boiling a clean handkerchief, the wound can be temporarily dressed. Otherwise it is best left untouched, loosely covered with the cleanest article obtainable, and guarded carefully, as far as possible, from contact with soiled clothing or outside matter, particularly from contamination by soil, since in soil the bacillus of tetanus is frequently found. Should it be necessary to remove clothing, the injured limb should be steadily supported above and below the seat of fracture. It is rarely necessary to cut away and destroy the clothes. In removing trousers or a coat, the uninjured limb must first be divested; the garments can then be drawn over the injured limb with a minimum amount of movement or pain. In the suspected fracture of the skull (especially the base), the spine, or the pelvis, the patient should be placed 620 NURSING IN ACCIDENTS AND EMERGENCIES in bed in the recumbent position with as little movement as possible. To raise him, a sheet or blanket, if procurable, should be rolled beneath him, by the four corners of which he can be lifted on an improvised stretcher. The clothing should be loosened, but no attempt made to remove it until expert help can be obtained. Shock is always a feature of such accidents. It is treated by the recumbent position, with the head low and external warmth. Stimu- lants may be necessary if the patient is in extremis. They must, however, be given with caution, as they increase the hemorrhage. In accidents to the spine, pain and sensation of all kind will probably be absent, owing to the paralysis involved; none the less, movement may greatly aggravate the in- jury. In a fracture of the pelvis the patient can neither stand nor sit. If such an injury is suspected, the thighs should be flexed by pillows placed below the knees, and cold may be applied to the lower part of the abdomen. In severe injuries to the skull the patient is gen- erally unconscious. Cold may be applied to the head and all noise and bright light should be excluded. Should a patient be unconscious, his head must be care- fully kept turned to one side. The reason, of course, is that already emphasized—to prevent any vomited matter from falling into the larynx, since an attack of vomiting is a common accompaniment of reaction from shock. Surgical Treatment of Fractures.—The local treatment of a fracture consists, where practical, in the proper approximation of the broken ends by manipulation or traction. The process is familiarly known as " setting the bones." If the deformity is great or there is spasm of the muscle, it is frequently necessary to administer an anesthetic in order to reduce the fracture. After the reduction of a fracture in the shaft of a bone a splint that will keep the fractured fragments in proper position is applied. Provided the part is at rest in a good position, there is not usually any necessity to hurry in the setting of a simple fracture. A day or even two is frequently FRACTURES 621 allowed to elapse between the injury and the reduction. (See Splints, etc., Chap. VIII.) In applying a splint it must be remembered that the joint above and below the fracture must also be kept at absolute rest, and a splint large enough to extend gener- ously beyond the joints should be selected. As a rule, in bandaging the splint to the limb the bandage is applied above and below the seat of fracture, leaving the injured area free from pressure. Fractures at or near an important joint are fre- quently treated by extension (p. 281), either with or without splints. Extension treatment is also usually preferred in fractures of the femur higher than the lower third. The patient remains in bed. If the mattress is a spring mattress, or liable in any way to sag, it must be stiffened with fracture-boards (p. 284); if the fracture is to any part of the lower extremity, sagging of the mattress may interfere with proper approxima- tion. Until the swelling is reduced, cold, usually in the form of the suspended ice-bag, is frequently applied over the injury. In extensive contusions cold is contrain- dicated (p. 79). Blisters frequently form over the con- tused area. Generally they are protected from breaking with a light pad of cotton, and allowed to reabsorb. If they become broken, they form a channel for infection, and must be dressed at once with aseptic methods. At the end of a period that varies with the extent of the injury and the position of the bone in the body, the splints are removed and replaced by a stiff bandage or a plaster cast (Chap. VIII), which is retained until union is per- fect. In fractures of the lower extremity the patient is then usually able to get about on crutches. In fractures occurring at or near a joint, with the exception of the hip and the vertebrae, light massage and gentle passive movements are frequently prescribed as soon as the preliminary swelling has subsided, in order to promote absorption of inflammatory products and prevent the formation of adhesions. Two fractures very frequently met with are known as (322 NURSING IN ACCIDENTS AND EMERGENCIES Pott's fracture and Colles' fracture; both are serious acci- dents complicated by dislocation of an important joint. A Pott's fracture is a fracture of the fibula just above the malleolus, and accompanied either by fracture of the tip of the inner malleolus (of the tibia) or by rupture of the internal lateral ligament. There is a charac- teristic dislocation of the ankle, turn- ing the foot outward (eversion). On account of the dislocation of the ankle the reduction of a Pott's fracture requires special care and is usually performed under an anesthetic It is of great importance that a correct position should be maintained, or per- manent crippling and deformity may result. A well-fitting back and side splint may be used, or a Dupuytren straight splint may be preferred (p. 278). When the inflammation has sub- sided the splint is generally replaced by a plaster cast. Light massage and gentle passive movements are com- monly ordered at an early date. a Pott's fracture is compound. If ankylosis of the ankle-joint will Fig. 202. —Pott's fracture ("American Illustrated Medical Dictionary "). Not infrequently suppuration occurs, probably result. A Colles' fracture is a fracture of the lower end of the radius, accompanied by a characteristic dislocation of the wrist, often called, from its appearance, the " silver-fork " dislocation. It is caused by falling on the outstretched hand. The hand is dislocated backward and drops toward the ulnar side. The broken fragments are fre- quently impacted. A characteristic symptom is an acutely painful spot over the fracture. Reduction of the dislocation and the setting of the frac- ture are generally done under an anesthetic, and a special, closely fitting splint applied. (See Bond's, Levis' Splints, etc.) Massage and gentle passive movements are gener- ally begun early—sometimes at the end of the first week. FRACTURES 623 By a fracture of the knee, fracture of the patella, or knee-cap, is understood. Frequently it is caused by sudden violent contraction of the quadriceps muscle, as in saving from a fall. Unless bony union is obtained, permanent lameness results. Fibrous union is a not infrequent occur- rence, especially where the periosteum remains intact; a fold of the periostemn is very liable to fall between the broken fragments. To prevent this, it is often necessary to " wire " the patella ■, or the broken fragments are brought together by hooks, known as Malgaigne's hooks. If operative treatment is not necessary, a posterior splint Fig. 203.—Colles' fracture, showing characteristic deformity (silver-fork deformity) at the wrist, due to backward displacement of the lower fragment (Levis). is applied, the fragments are approximated, and held in position by strips of adhesive plaster adjusted above and below the seat of fracture, as.in a tortuous bandage (p. 254), and fastened to the posterior splint; above the plaster a figure-of-8 bandage is applied. The extremity is then placed on an inclined plane, the leg extended, and the thigh flexed. Light massage of the knee-joint, with gentle passive movements, is frequently ordered at an early stage of convalescence. A fractured clavicle (see above) is usually treated by the application of a Velpeau bandage or by Sayre's method 624 NURSING IN ACCIDENTS AND EMERGENCIES of adhesive strapping (p. 287). The arm is kept in position for three weeks, but if the physical condition permits, the patient is allowed to walk and move about freely. In some instances these methods fail to obtain perfect approximation. The treatment then consists in keeping the patient flat on the back on a mattress stiffened by fracture-boards, with the arm straight to the side. A pad is placed in the axilla to raise the shoulder, and the position is maintained by sand-bags placed on either side of the body. A small sand-bag is also placed against the head on the affected side, to correct the rotation toward the shoulder. A second small pad may be necessary between the shoulder-blades to keep the shoulder back. The fixed position is one of considerable discomfort; great care is necessary to prevent the forma- tion of a bed-sore. Fractured ribs are treated by strapping the affected side or by the application of a broad bandage to the chest (p. 287). Coughing and dyspnea are symptoms of injury to the pleura. If accompanied by blood-stained expectoration and the symptoms of shock, the lung has probably been damaged. A fracture puncturing the lung is a compound fracture, although there may be no external wound. Through the lung the broken fragments are in communication with the outer air. The pleura is a closed cavity; a fracture involving only the pleura is complicated, but not compound. Complications that may arise from a fractured rib are pleurisy, pneumonia, hemothorax, empyema, and pneumo- thorax" A rise of temperature, with quickened respira- tion, cough, and expectoration, are symptoms to be promptly noted. The skull may be fractured at the vault or the base. Fractures of the vault are due to direct violence. When simple, and if not depressed, they may easily be overlooked; their importance lies in the injury they may cause to the underlying structures, the meninges, or the brain. Unless there are symptoms of injury to the brain or compression, no treatment is considered necessary. With these acci- dents there is usually some concussion. A purgative is FRACTURES 625 administered, and the patient is kept in bed as long as the symptoms last. A compound fracture of the vault is generally depressed and frequently comminuted; in some cases the bone is also punctured. It is a serious accident, both on account of the immediate injury to the brain and the danger of subsequent inflammation or infection involving the brain. If the fracture is depressed, there may be symptoms of brain compression, of which the first symptoms are vom- iting, headache, restlessness, a slow, full pulse, facial con- gestion, and contracted pupils. Later symptoms are Fig. 204.—Comminuted fracture of the skull (Hoffa). unconsciousness, stertorous breathing, rise of temperature, slow pulse with high tension, dilated pupils, profuse per- spiration, and paralysis with involuntary evacuations. Epileptiform convulsions may occur, or profound coma, passing into collapse. Retention of urine is common, and should be relieved by the catheter. Some concussion is commonly present. Shock may be a prominent symptom, even in cases where the local injury is not great, and is treated by the recumbent position and external warmth. Stimulants are avoided as much as possible. A quickly acting pur- gative is usually given at once (croton oil, 1 to 3 minims). 40 626 NURSING IN ACCIDENTS AND EM URGENCIES If the patient is drunk, lavage is generally performed. The surrounding area of the head is shaved and washed. The wound is thoroughly cleansed, the clots and every particle of foreign matter patiently removed. In many cases the wound can be brought together with stitches, leaving, as a rule, an opening for drainage. For depressed fracture or fractures in which the bone is punctured, a surgical operation is necessary. Depressed fractures are elevated; an injured bone is removed by trephining. Complications, usually fatal, of a compound fracture of the vault are septic inflammation, which generally involves the meninges, and the formation of a thrombus in one of the cerebral vessels. The patient should be nursed in a quiet room, with the light shaded and all disturbances or excitement avoided. The head of the bed is elevated, or the head may be raised on pillows. The most important point is to keep the wound aseptic, and to prevent risk of hemorrhage from sudden movements. The diet is liquid until convalescence is established. The bowels must be kept active. Symp- toms for which special watch should be kept are twitchings of the muscles, convulsions, paralysis, and sudden changes of the pulse or temperature. The blood-pressure is an im- portant indication of the condition in all cases of brain compression; in nursing such cases a nurse may be ex- pected to take the pressure with the sphygmomanometer (p. 162). Fractures of the base of the skull are the result of indirect violence, commonly a fall. The immediate symptoms are those of shock and violent concussion, and may be mistaken for drunkenness. Symptoms of compression of the brain develop rapidly, as just described. In severe injuries consciousness is not regained from the first con- cussion, and the patient passes into a profound coma which ends fatally in a few hours. Characteristic diagnostic symptoms are a discharge of blood or clear fluid (cerebral) from the ears, nose, or mouth, and unequal dilatation of the pupils, that on the affected side being widely dilated. Later there is ecchymosis (discoloration due to subcu- taneous escape of blood) round the orbits and over the FRACTURES 627 mastoid process, and suffusion of blood in the conjunctiva. J.t must not be overlooked that external traces of blood may be due merely to local injuries. The fracture is simple; blood or fluid, however, escaping by the cavities, forms a channel of communication between the injury and the outer air, and may be the means of in- fection. Where the ears discharge, the external ear or nostril should be carefully cleansed by aseptic methods and the openings lightly plugged with sterile absorbent cotton. The physical symptoms are treated with rest in the recumbent position, in a darkened room, and an ice-bag applied to the side or back of the head. For threatened collapse stimulants are given, but are avoided otherwise. Complications to be apprehended are inflammation of the brain or meninges, and cerebral thrombus. Persistent coma with high tempeiature are regarded as fatal symp- toms. If recovery takes place, the mental faculties are frequently impaired. Fracture of an orbit may result from indirect violence, and is serious on account of the risk of injury or inflamma- tion to the eye, the optic nerve, or the adjacent portion of the brain. The patient is kept at complete rest in the recumbent position. The light is shaded, and the use of the eye forbidden until convalescence is established. The local treatment is according to the extent of the injury; an oculist should be consulted. Constant cold compresses are frequently ordered to the eye in the first instance, and the pupil is dilated with atropin. Fracture of the lower jaw is generally accompanied by injury to the tissues of the mouth, displacement of the teeth, and bleeding from the mouth. Where the injury is severe, it is often necessary to wire the bone. The jaw is supported by a Barton bandage or a close-fitting splint made of hard rubber or poroplastic felt is applied. (See Splints.) An antiseptic mouth-wash must be constantly used. Liquid diet is necessary for about six weeks, by which time union has usually taken place. Fractures of the Pelvis.—A fractured pelvis may result 628 NURSING IN ACCIDENTS AND EMERGENCIES from a severe fall or from crushing of the parts, as when the patient is run over by a vehicle. The prominent symptoms are those of severe shock and acute local pain; the patient is unable to stand or to sit. Internal hemorrhage from injury to a blood-vessel or rupture of one of the pelvic organs may occur. The urine should be kept for examina- tion; frequently it contains blood from injury to the genito- urinary organs. The patient is placed flat on his back on a mattress straightened by fracture-boards. The thighs are flexed by pillows placed below the knees; a binder or wide band- age is secured round the pelvis. If the patient is rest- less, sand-bags may be placed on either side, and a roller towel be passed over the pelvis and under either sand-bag. Where permissible, pressure on the coccyx should be guarded against by the use of a rubber ring cushion, very slightly inflated. Nothing must be given by mouth until the extent of the injuries has been ascertained. The chief immediate treatment is directed toward com- bating the effects of shock and controlling hemorrhage. Elevation of the bottom of the bed, hypodermoclysis. or intravenous infusion are the usual means. A bed- cradle is necessary to keep the weight of the clothes from the pelvis; at the same time care must be taken that the chest and extremities are warmly covered. An ice-bag may be suspended from the cradle over the lower part of the abdo- men. Stimulants are given with caution on account of the possible hemorrhage. Opium is generally ordered to relieve the pain and allay restlessness. Fractures of the pelvis are, in the majority of cases, fatal, either from the immediate shock, from internal hemorrhage, or from injury to one of the pelvic organs. Rupture of the bladder is shown by the extravasation of urine into the surrounding tissue. Where the condition of the patient permits, a surgical operation is performed and the bladder repaired. If the patient lives over a few days, septic peritonitis or perforation is a common com- plication. Such cases require skilled nursing. Where there are evidences of internal injuries or hemorrhage, the patient FRACTURES 629 must not be turned, and any movement must be the slightest possible. A slipper bed-pan may be used; if not procurable, the motions should be passed on pads of tow. Liquid nourishment is given, usually in small quan- tities at a time. For excessive thirst, sips of boiling hot water or hot tea are preferable to cracked ice. Close watch must be kept for such symptoms as shivering, sudden abdominal pain, distention, rapid rise of the pulse, sudden alterations in the temperature, and syncope. Bed-sores can be prevented only by constant vigilance and cleanliness. (See Bed-sores.) Fracture of the Spine.—A fracture of the spine may be due to direct or indirect violence. Commonly, they are simple fractures, but as the result of a violent accident involving crushing or tearing of the soft tissues they may be compound. They are invariably complicated by some injury to the spinal cord. Usually dislocation is also present. The characteristic feature of injuries to the spinal cord is paralysis, both sensory and motor, on both sides of the body (paraplegia), below the seat of injury, with marked hyperesthesia above. Control of the sphinc- ter is lost, and the urine and bowel movements are passed involuntarily. In severe lesions of the upper cervical vertebra death occurs instantaneously from paralysis of the respiratory muscles of the chest. The gravity of the condition depends on the extent to which the spinal cord is involved. In favorable cases the cord remains intact, and the paralysis is due to the pressure caused by the extravasation of blood and serum. There is no persistent dislocation. The limbs gradually regain their movements, and complete recovery, except for some local stiffness of the column, usually takes place. In the majority of cases the injury involves twisting or tearing of the spinal cord. Partial recovery with paraplegia may take place; most commonly the patient dies, either from shock during the first twenty-four hours, or, after lingering weeks or months, from exhaustion or one of the complications of the condition. Common complications are cystitis, bed-sores, bronchitis, and hypostatic pneu- monia. Compound fractures are usually quickly fatal, 630 NURSING IN ACCIDENTS AND EMERGENCIES either from shock or hemorrhage, or later from septicemia or meningitis. Where it can be procured, the patient should be nursed on a water or an air mattress, below which fracture-boards are placed. Scrupulous care is necessary to prevent bed-sores, as, owing to the paralysis of the sphincters, it is difficult to keep the bed clean or dry. After the imme- diate symptoms of spinal irritation have subsided, per- mission is generally given to turn the patient at intervals, beginning with once or twice a day, and gradually with greater frequency. Turning not onh- removes constant pressure, but also lessens the risk of hypostatic congestion of the lungs. In turning, the spine must be kept rigid by careful support above and below the injury, otherwise movement may at first cause acute local pain, and in- crease the injury to the spinal cord. The bladder is emptied at regular intervals by the catheter. To some extent, by careful management in the administration of laxatives and the use of enemata, the action of the bowels can be regulated and a daily evacuation at a regular hour effected. If cystitis occurs, the bladder is irrigated daily. Variations of the pulse and temperature, attacks of acute pain, and fits of mental depression or excite- ment commonly accompany the condition in its progress. The hygiene should be as good as can be obtained. The diet is liquid until the preliminary symptoms are passed; later it should be varied and nourishing, and tonics are usually prescribed. If recovery takes place, regular light massage and passive movements may be ordered to the lower extremities, in order to promote nutrition and prevent rigidity or contraction. In some cases an attempt is made to relieve the pressure by a surgical operation involving the removal of a portion of the vertebral arch. The operation is known as laminec- tomy. In other cases extension apparatus and the spinal jacket are used to overcome the local dislocation. In the treatment of a compound fracture the wound is dressed daily with strict aseptic precautions, and every care taken to keep the area free from infection. In other respects the treatment is the same as for a simple fracture. DISLOCATION OR LUXATION 631 DISLOCATION OR LUXATION A dislocation is a persistent separation of the articular surfaces of two or more bones, the articulation of which constitutes a joint. It is accompanied by a wrenching of the tendons and ligaments, and frequently by injury to the adjacent soft tissues. A dislocation in which the bones are immediately replaced is called a sprain. Varieties.—Dislocation may be complete or incomplete (mbluxation). Like a fracture, a dislocation is said to be ximple or closed, when unconnected with a wound, and compound or open, when combined with a flesh wound communicating with the surface. A dislocation is des- cribed as complicated if, together with the dislocation, a fracture exists, or a serious injury to important structures, as, for example, a dislocation of the spinal vertebrse, in- volving pressure on the spinal column. According to the position of the displaced bones, a dislocation is described as forward, backward, or to either side. The symptoms of a dislocation are deformity, pain, and rigidity; voluntary movement is either restricted or lost; passive movement causes severe pain; the surrounding tissues become swollen and discolored. A dislocation is distinguished from a fracture by the absence of crepitus or abnormal mobility. Dislocation may be due to congenital deformity, or the result of traumatism, disease of the bone, or violence, direct or indirect. The reduction of a dislocation means the replacement of the bones in their proper position, so that the function of the member is not impaired. Manipulation, traction, and the use of extension or counterextension are the means employed. When reduced, the parts are kept in proper position by the use of appropriate splints and bandages. Those used in the treatment of a fracture near a joint are usually applicable in the treatment of a dislocation. The part is kept at rest until the wrenched ligaments or other injury to the soft tissues are repaired, after which passive movements and massage are usually prescribed. Gentle massage without passive movement is often prescribed early in the treatment. 632 NURSING IN ACCIDENTS AND EMERGENCIES If not properly reduced, a dislocation may result in permanent deformity, with' more or less crippling. In- expert assistants should be careful to make no attempt at reduction, as they will probably only increase the injury. Until surgical aid can be procured, the limb should be supported in as comfortable a position as possible, and cold compresses or an ice-bag applied to the part, in order to reduce the swelling and relieve the pain. Hot applica- tions may be preferred if the pain is severe. Fig. 205.—Subcoracoid dislocation of the humerus (Hoffa). While a fracture can, without injury, usually wait hours or even one or two days before being set, a dislocation requires prompt treatment. If not seen until extensive swelling has occurred, reduction may be impossible. By the time the swelling has subsided, a growth of new tissue has taken place between the disarticulated ends of the bones, forming what is known as a fibrous joint, which is useless for the purpose of function. A compound dislocation is a serious condition. If the wound becomes infected, ankylosis of the joint with DISLOCATION OR LUXATION 633 permanent crippling will probably result. The wound from the moment of injury must be treated with strict aseptic precautions. The patient's health is usually built up with liberal diet and tonics, in order to increase his resistance to bacterial invasion. Dislocation of the lower jaw is a minor ill that may frequently be reduced without much difficulty. The jaw should be taken between the two hands, the operator stand- ing directly in front of the patient. The thumbs are Fig. 206.—Dislocation of the lower jaw. placed inside the mouth, over the molar teeth, as far back as possible. Steady pressure is then made downward and backward until the bone slips into its socket. If any considerable time has elapsed between the occurrence of the dislocation and its reduction, a small blister is usually applied immediately over the joint to prevent exudation. A jaw bandage is sometimes applied for a few hours. Dislocation of a finger is often reduced by grasping the hand and pulling the finger firmly and in a straight line from the hand. A finger splint should then be applied and a cold wet dressing to keep down swelling. Sprain.—A sprain may be described as a dislocation that is immediately and automatically reduced. The extent of injury in a sprain varies greatly. The displace- 534 NURSING IN ACCIDENTS AND EMERGENCIES ment may have been so severe as to cause severe wrenching or tearing of the ligaments and tendons. In these cases there are severe pain and much local swelling and discolora- tion, and it is frequently difficult to determine whether the condition is one of sprain or fracture. A severe sprain should be kept at rest, the joint elevated, and either hot fomentations or cold evaporating compresses applied. When the swelling has subsided, a splint or plaster-of-Paris bandage is applied and retained for one or two weeks, after which massage and passive movements are generally ordered, and the joint gradually accustomed to use. For slighter injuries a wet bandage is generally applied, and over it a compress of evaporating lotion, which is constantly renewed. After six to twelve hours massage and passive movements are given, and the bandage and compresses reapplied. In the case of sprained ankle, gentle exercise, helped with a walking-stick, is generally advised as soon as possible in spite of pain. Instead of the cold compresses, hot fomentations may be used or the joint may be douched alternately with very hot and very cold water. Another method of treatment, especially in sprains of the ankle, if it can be applied immediately, is to strap the joint (Chap. VIII). In this case the patient is generally encouraged to exercise the joint in moderation. WOUNDS A wound or trauma is described asa " solution in the continuity of the soft tissues " caused by violence. Though impaired, the tissues are not destroyed, as in the case of burns. According to the character of the injury, they are classed as incised, lacerated, contused, or punctured. An incised wound is inflicted by a sharp cutting instru- ment. The tissues are sharply divided. Hemorrhage is commonly present. If a wound is deep, important struc- tures, such as tendons, large blood-vessels, or an entire muscle mav be divided. WOUNDS 635 A lacerated wound is one in which the tissues are torn apart. Usually there is not much hemorrhage, as torn arteries tend to contract, and the surfaces thus roughened favor the formation of blood-clots. The surrounding tissues are generally bruised. Lacerated wounds are common in accidents caused by machinery. An animal in biting also inflicts a lacerated wound. A contusion is a bruise. Contused wounds may com- prise a slight bruising or complete crushing of the parts. They are inflicted by direct violence, such as a blow from a blunt instrument or a severe beating. In a punctured wound the tissues are pierced by a pointed narrow instrument, frequently a sharp-pointed nail or splinter of wood. They are also caused by a gunshot. The instrument'inflicting the wound is frequently left, whole or in part, in the wound. There is little hemorrhage, and the immediate injury to the tissues is often slight. Punctured wounds are peculiarly liable to certain bacterial infections, especially infection by the tetanus bacillus. Healing of Wounds.—Where the tissues have been di- vided, the wound is closed or healed by the formation of fresh tissue, which grows from the cells of the underlying connective tissue. The tissue so formed is spoken of as scar tissue. On the surface of the body, when fully formed, it is at first pinkish, and finally has a white, shiny appearance. Scar tissue is inelastic, and has neither hair- follicles nor secretory glands. In the young only it may become to a certain extent covered with true skin. Where the divided surfaces of a wound can be brought together and kept in close apposition, little new tissue is necessary, and healing takes place very quickly. Healing is then said to take place by first intention, or, in other words, primary union results. In primary union there is no inflam- mation, the surfaces of the wound appear to become glued together. Where the edges of a wound are finely adjusted, scarring is very slight. When there is destruction as well as separation of the tissues, primary union is not always possible. The wound then heals by a process known as granulatian. Healing is then said to be by secondary union. 636 NURSING IN ACCIDENTS AND EMERGENCIES A granulation is a minute process or new cell developed from a connective-tissue cell. Starting from the sides and bottom of a wound, the granulations grow slowly until the cavity of the wound is completely filled and level with the surface. A healthy granulation looks like a minute bright-red speck. Unhealthy or indolent granulations look pale and flabby. They are then stimulated by such applications as balsam of Peru, borine, oxid of zinc, or a weak solution of nitrate of silver. In some wounds granulations grow too rapidly, forming an uneven surface; they may be burnt away or reduced by applications of nitrate of silver stick or of blue stone (sul- phate of copper). Too free granulation is described as redundant. When extensive surfaces heal by granulation, the in- elastic scar tissue is apt to cause contraction of the parts. If the wound is near a joint, permanent crippling may result. The condition is guarded against in the treatment by the application of suitable splints or extension, and the early practice of passive movements. A deep wound may show a tendency to close at the top before healing is complete. The mouth has then to be kept open by a drainage-tube or a strip of gauze, etc. In flat superficial wounds healing takes place first from the margins and later from isolated spots over the surface of the wound. The granulation presents the appearance first of a red line, with, as healing progresses, an outer blue line forming a ring inclosing the wound. The ring gradually advances toward the center, leaving behind the freshly grown scar tissue. The healing of large superficial wounds is frequently hastened by the process of skin-grafting. TREATMENT OF ACCIDENTAL WOUNDS The treatment of all such wounds comprises: (1) The arrest of any hemorrhage; (2) the perfect cleansing of the part and adjacent tissues, including the removal of all foreign matter; (3) the placing of the part at rest; (4) the repair of the tissues. The possibility of shock must not be overlooked, and the WOUNDS 637 patient, as a matter of routine, should be spared unneces- sary standing or sitting upright or exposure to cold, such as waiting in a draughty hall. For the same reason wounds should be treated promptly. A point to be emphasized is that the tissues must be gently handled to avoid further bruising. Not only will the process of repair be prolonged, but bruised tissues are considered to present reduced resistance to bacterial invasion. Hemorrhage is arrested by one or other of the methods already described. Where possible, the bleeding vessels are tied. The thorough cleansing of a wound is probably the most important factor in recovery, whether the wound is small or great. The adjacent parts should be scrubbed with hot soap and water and covered with a sterile towel wrung out in an antiseptic solution. The wound is then gently and thoroughly washed, if free from foreign matter, with an antiseptic solution or sterile water; if dirty, with soap and water, followed by plentiful irrigation with an antiseptic solution. Every par- ticle of foreign matter must be picked away before a wound is closed, often a tedious process. If the pain is severe or the process protracted, it is sometimes necessary to place the patient under an anesthetic As soon as a wound is cleansed it is protected by a sterile dressing. Accidental wounds are rarely clean and frequently complicated by bruising, laceration, or extensive inflam- mation. In this condition the dressing usually takes the form of an antiseptic compress, changed at regular inter- vals or kept moist by some device. An ordinary method is as follows: The wound is covered with several pieces of gauze, wet with the antiseptic preferred, and kept in place by a light bandage. The member is laid on a pillow cov- ered with a piece of rubber sheeting. A douche can filled with the antiseptic solution, to which is attached a length of rubber tubing terminating in a glass pipet, is hung above the bed at a convenient point, so that the pipet drips directly on to the dressing. By this method the frequent changing of the compress is avoided. 638 NURSING IN ACCIDENTS AND EMERGENCIES REPAIR OF THE WOUND In an incised wound surfaces are brought together and kept in apposition usually by sutures, or in minor injuries by strips of adhesive plaster. In choosing the needle, where stitches are to be introduced deep into the tissues, as in large fleshy wounds, a needle in which part of the blade is sharp is often preferred. It passes quickly and inflicts less pain. Where the tissues are delicate and easily torn, as in wounds of the face or mucous membrane, such needles inflict injury, and one rounded like the ordi- nary sewing needle is used. Care must be taken that the needles are sharp or much pain is caused. The sutures must be a convenient length to tie in a surgical knot after they are in place. They must be tied sufficiently tight to keep the edges of the wound in apposition, but not so tight as to pucker the wound. Before putting in the stitches the edges of the wound must be nicely adjusted or unsightly scarring will result. The stitches themselves cause scarring, and are, therefore, not left in place longer than necessary. Superficial stitches about the face of the wound, thoroughly clean and kept strictly sterile, may often be removed as early as the fourth day. For deep wounds nine days are usually allowed to elapse. If sutures are removed too soon, the edges may gape and primary union fail to take place. If there is mucl i local inflammation, the tissues between the stitches become swollen and tense. To relieve the tension, one or more of the stitches may be removed. Local inflammation may frequently be the result of rough handling of the tissues or of imperfect cleansing. It is often the first sign, of infec- tion of a wound. To remove a stitch, a pair of sharp-pointed scissors and a pair of forceps are used. The stitch is divided close to the tissue. The long end with the knot is then seized with the forceps and gently and quickly pulled, following the direction of the curve made by the stitch. If the scar does not appear perfectly strong, strips of plaster should replace the suture for a few days. Strips of plaster should be cut narrow and cross the wound from either side, keeping a space between each pair, so that the incision is not entirely covered. Before REPAIR OF THE WOUND 639 applying, the edges of the wound should be held together by gentle pressure of the tissues on either side toward the wound. If a wound is perfectly clean and the tissues are not bruised, the closing is complete. In the contrary condition some inflammation will take place and discharge will form, which must be allowed to escape. The discharge may be an exudation of blood or serum, or, if the wound is infected, may contain pus. To provide for such dis- charge an opening is left at the lower end of a wound in which is inserted a drain, which may consist of a straight piece of sterile gauze, a few strands of silk or horsehair, or similar substances, or a short length of rubber tubing. (See p. 563.) The drain at first should reach to the bottom of the wound and be gradually shortened as healing takes place. When the discharge subsides, it is removed alto- gether. Sutured wounds are protected by a sterile dressing, and usually do not require dressing until the stitches are re- moved. If drainage has been necessary, they are dressed more frequently—daily or every second day for fresh wounds and usually at longer intervals for chronic varieties. The temperature chart is a guide for the necessity of dressing. A rise of temperature, especially if preceded by shivering or chilly sensations, frequently indicates local inflammation or the formation of pus. The wound is then examined and redressed. In both incised and in lacerated wounds the possibility of separation of the tendons must be remembered before the wound is closed. This is particularly liable to happen in injuries to the wrist or hand. The condition is demon- strated by inability to move the wrist or the fingers. If the ends of a divided tendon are exposed, they should be seized at once by whoever is first present, and trans- fixed by a needle or piece of sterile silk. Owing to the muscular contraction, they become readily withdrawn into the tissues and are often extremely difficult to find later. When several tendons are divided, it is obviously imperative that the right ends should be sewn together. The opera- tion is generally long and tedious. A lacerated wound is treated in the same way as an 640 NURSING TN ACCIDENTS AND EMERGENCIES incised wound, whenever possible. Provided the wound has been perfectly cleansed and kept strictly sterile, and that the surrounding tissues are not greatly bruised, the results are often extremely good. Wet dressings are usu- ally preferred. Where the laceration is extensive and the local bruising severe, the wound is left altogether open or only partially closed, allowing for drainage. In many cases sloughing takes place, or the wound becomes in- fected, usually from foreign matter at the time of injury. In such conditions the wound is frequently treated by constant irrigation, or the part is immersed in a local anti- septic bath (Chap. II). In a contused wound the treatment depends on the extent of injury. If the bruising is slight, cold com- presses may be used; if extensive, hot antiseptic compresses are preferred, as heat, by bringing a large supply of blood to the part, tends to restore vitality and promotes the absorption of inflammatory products. Contused wounds also are very liable to infection. When the injury is ex- tensive, they may be followed by sloughing or even, in severe cases, by gangrene. The treatment of a punctured wound is guided by the history of the injury. In all cases search should be made for fragments of the instrument that has inflicted the wound. If there is a possibility of dirt having been intro- duced into the wound at the time of the injury, as from the soil, the clothing, or even the skin of the patient, the treat- ment usually is to convert the punctured wound into an open one, thoroughly cleanse the part with an antiseptic, and provide for drainage. The reason for this should be understood. The com- plication most to be dreaded in the healing of wounds is tetanus. The tetanus germ, we remember, is anaerobic, that is to say, develops in the absence of air. The recesses of a punctured wound of which the opening is sealed by a sterile dressing forms an ideal medium for its cultivation. The danger of its development is lessened if the wound it freely exposed. The tetanus germ has been known to develop in a punctured wound so small and apparently so unimportant as that caused by a hat-pin driven into the scalp in a fall on the head. REPAIR OF THE WOUND 641 ■Even where the wound is clean, a wet dressing is usually preferred to a dry one, as helping to dislodge minute particles of foreign matter that may have been overlooked. A gunshot wound has frequently the characteristics of both a lacerated and contused wound. In a penetrating gunshot wound vital organs may be injured and important structures badly torn. Small gunshot wounds, such as those inflicted by toy pistols or fireworks, are liable to be followed by tetanus from the lodgment of pieces of soiled rags, etc., in the wound. They are generally laid open, cleansed, and dressed with a wet antiseptic dressing. The administration of tetanus antitoxin serum is generally advised. COMPLICATIONS OF WOUNDS The healing of wounds may be complicated by inflam- mation, local infection, the formation of abscesses, sloughs, gangrene, or emboli; and by special infections, of which the most important are erysipelas, general septicemia, tetanus, and scarlet fever. A condition developing from a wound is described as traumatic. Inflammation.—Except in the case of clean, incised wounds, wounds caused by accident are almost invariably followed by a certain amount of inflammation. The phenomenon of inflammation, its symptoms and treatment, are described in Chapter III. Inflammation in wounded tissue is treated on the same general principles, i. e., rest to the part, and, unless the inflammation is slight, the local application of heat or cold, in the form of stupes or compresses, constant local irrigation, or the local anti- septic bath. In wounds of the extremities the part is kept more especially at rest by the application of suitable splints. Inflamed tissues offer very reduced resistance to bacterial invasion; antiseptics, for this reason, are generally used in the dressing and treatment of accidental wounds, although the tendency of modern aseptic technic is to discard their use as far as possible. Infection.—In spite of strict technic and careful cleansing, local infection by one of the pus-producing germs, commonly the staphylococcus pyogenes aureus (p. 41 642 NURSING IN ACCIDENTS AND EMERGENCIES 379), is a common complication in the healing of wounds of accidental origin. The most prominent general symp- toms are shivering, rise of temperature, and malaise; locally there are inflammation, tension, and the formation of pus. The local treatment lies in the use of antiseptics and the encouragement of drainage; the hot antiseptic compress is a common form of treatment combined with regular irrigation with an antiseptic solution. Heat, favoring suppuration, may, however, be contraindicated in some conditions. If pus forms, the wound is opened up, the abscess cavity evacuated, and some form of drain in- troduced. Until the symptoms of acute infection have subsided, the wound is usually dressed at frequent intervals. It must always be remembered that an infected wound may infect others. Strict technic must be observed in changing the dressings. The dressing should be reserved scrupulously to the last, and no other wound should be exposed during the dressing of an infected one. Where- ever practical, infected wounds are not nursed in the same ward as clean operation cases. The most virulent form of local infection is by the bacillus pyocyaneus, a pus-producing germ belonging to the bacillus group (p. 358). The discharge has a blue- green or blue color, and is commonly known as blue pus. The condition is highly infectious. Wounds with this complication are usually isolated from the general surgical wards, and those concerned in dressing the wound or in nursing the patient are forbidden to enter the operatirrg- rooms or " clean" wards. Blue-pus infection is not infrequently followed by general septicemia. The treat- ment is the same as in other local infections, but special attention is given to building up the patient's strength by generous diet, good hygiene, and, usually, the use of a stimulant. Inflammation spreading to the adjacent cellular tissue is known as cellulitis, and, in severe cases, closely resembles erysipelas. The onset is usually less abrupt, the redness not so acutely defined, and the physical symptoms much less severe. Except as complicated by infectious processes, simple cellulitis is not considered contagious. The usual treatment for inflamed conditions is followed; if the tissues REPAIR OF THE WOUND 643 are infiltrated with infectious processes, free incision is usually performed, and drainage established; but the treat- ment is obviously guided by the structures involved. Slough.—A slough is,a piece of dead tissue in living tissue; in other words, a strictly localized gangrene. The word is used in connection only with soft tissues. A dead piece of bony tissue is called a sequestrum. Sloughs occur when, for some reason, there is not sufficient blood-supply to enable the wounded tissue to recover its vitality. The blood-supply may be cut off by the severing of important vessels, by the extensive crushing of the tissues, or by the prolonged application of cold to a large contused area. Lacerated or contused wounds and burns are most prone to the formation of sloughs. When a slough has formed, it is not reabsorbed, but must be thrown off. Nature accomplishes this by a local acute inflammation between the living and the dead tissue. The process is helped by hot fomentations, but as they tend to increase inflamma- tion and favor suppuration, they are not always considered advisable. Sloughs should not be pulled away, or hemorrhage may result. Portions already separated are generally carefully cut away from the remaining parts. On separating, a slough leaves an exposed surface, which heals by granula- tion. If the cavity is deep, it is usually packed with gauze, generally saturated with an antiseptic or a stimulant preparation. The wound is dressed daily, and thoroughly irrigated with an antiseptic solution. Another method is to dust the cavity with a sterile antiseptic powder and pack it with dry gauze. The granulations are apt to be indolent. The local suppuration has a tendency to spread along the connective tissue, causing the small accumula- tions of pus known as pockets, and the formation of small sinuses. A sinus is a passage leading from the skin surface to a pus-cavity. A similar passage opening on a mucous membrane is called a fistula. Gangrene, the total death of a part, involves both soft and bony tissues and occurs most usually in the lower ex- tremities. It is most commonly associated with condi- tions in which the blood-supply is deficient, especially diabetes and senility, when a small injury may be followed 644 NURSING IN ACCIDENTS AND EMERGENCIES by gangrene. In wounds it is caused locally by the cutting off of the blood-supply, as by—(1) the division of a large blood-vessel, such as the femoral artery; (2) strangulation, accidental, or from prolonged application of a tourniquet; (3) embolism, the blocking of a vessel by a blood-clot. Gangrene may be dry or moist. When the immediate result of a wound, it is distinguished as traumatic gangrene. A black local discoloration is first noticed, which spreads slowly or rapidly, according to the physical condition. As decomposition progresses the odor is very offensive. In time a line of demarcation forms, as in the separation of sloughs, and the part is thrown off, leaving a discharging unhealthy surface. In the aged or feeble death frequently takes place before separation occurs. The question of operation is decided by many conditions. Unless the gangrene shows signs of spreading very rapidly, it is not usual to amputate until the line of demarcation has formed—a process often requiring many months. In the local treatment the extremity is elevated and wrapped closely in many layers of warm absorbent cotton. If the gangrene is dry, the dressings are usually kept dry, and the part dusted with an antiseptic powder. In moist gangrene applications of warm or hot antiseptic compresses are frequently used (boric, 2 per cent., or bichlorid, 1 : 5000), and changed every four or six hours. In dressing, care must be taken that the surface is not chilled by ex- posure to cold air. The limb above the part is kept also closely wrapped, and should receive regular rubbing in order to promote a good circulation. The general treatment is directed toward supporting the health with a nourishing diet and good hygiene. The skin requires special care, as bed-sores form easily. Tonics and alcoholic stimulants are generally prescribed. Heavy pa- tients are nursed most comfortably on an air- or water-bed. Embolism is the blocking of a blood-vessel by a clot of blood. A clot that is set free in the circulation and finally lodges in a vessel is called an embolus; a clot remaining where it forms, and causing plugging of the vessel, is called a thrombus, and the condition is known as thrombosis. Nor- mal blood does not clot in an unimpaired vessel. If, how- ever, the walls of a vessel, or of the lining of the valves REPAIR OF THE WOUND 645 of the heart, are roughened by inflammation or injury, fib- rin tends to become deposited, and a clot is formed, which is readily swept into the blood-stream. Thrombosis is the result of a diseased or inflamed condition of a blood-vessel or of a valve of the heart. Common causes are phlebitis, arterial degeneration, infection, endocarditis, and aneu- rysm. The symptoms develop gradually, and are modified by the locality in which the thrombosis occurs. Thrombosis of a vessel in an extremity is accompanied by local swelling, with tenderness along the line of the vessel. Some physical disturbance is also present. An embolus is caused by—(1) Separation of a thrombus; (2) laceration of vessels, as by a fracture or other injuries; (3) use of styptics in the treatment of hemorrhage from large vessels, for example, the uterine sinuses. An embolus travels along the circulation until it arrives at a blood-vessel not large enough to allow of its passage. Lodging in a cerebral vessel, in one of the large vessels leading to or from the lungs, or in the heart itself, grave physical symptoms develop abruptly. In cerebral embolism the symptoms are those of apo- plexy, and are more or less severe, according to the vessel affected. There may be hemiplegia or general paralysis. Recovery is rare. In pulmonary embolism the prominent symptoms are sudden dyspnea, cyanosis, and loss of consciousness. Death follows quickly in a few hours at most. In cardiac embolism the symptoms are the same, but death occurs almost instantaneously from arrest of the function of the heart. Traumatic embolism is not a common complication in the healing of wounds. Keloid.—A keloid is a tumor occurring on the surface of a scar after healing is complete, due to an overactivity of the connective tissue. It is usually removed by opera- tion, but frequently recurs. The colored races are more prone to keloid than the white. General infections developing from wounds General septicemia following accidental wounds, the result of the absorption of septic processes into the general system, is in no respect different from the same condition 646 NURSING IN ACCIDENTS AND EMERGENCIES following an operation, the symptoms and treatment of which have been already described. Erysipelas is an infection due to a micro-organism of the streptococcus variety, which invades the system only through an abrasion of the skin or mucous membrane. The prominent characteristic of erysipelas is a crimson rash, with well-defined edges, occurring in the vicinity of a wound, accompanied by swelling and induration of the tissues (p. 716). The temperature rises abruptly, often to 104° F. or over; the patient shows the usual physical accompaniments of fever (p. 708), and is generally delir- ious. The rash fades after four or five days, and is followed by desquamation. If there are no local conditions to keep the temperature up, it usually falls about the end of a week, and frequently by crisis, after which convalescence is rapid. As the organism is introduced through the abraded surface, a case of erysipelas is a menace to any wound with which it may be in direct or indirect contact (through nurses, dressers, etc.). (See Chap. XIV). An erysipelas case is usually strictly isolated from other surgical cases The treatment comprises a liberal liquid diet, and, as in all conditions of general sepsis, stimulants—whisky or brandy—are given in considerable quantities; usually some form of iron is also prescribed, and the system is thoroughly purged. Local treatment consists in keeping the affected area covered, and such applications as ichthyol ointment, carbolic ointment, tincture of iodin, etc. True erysipelas is a comparatively rare complication in the healing of wounds. The so-called idiopathic variety occurs on the face, usually beginning at the nose and spreading to the hair-line. Although known as idio- pathic or spontaneous (in contradistinction to traumatic), it is considered that the germ usually gains entrance through some small abrasion, probably on the mucous mem- brane of the nose. Burns, where the surface is extensively denuded, are particularly liable to erysipelas infection. Scarlet Fever.—Traumatic scarlet fever is not in any respect different from the idiopathic variety. The attack REPAIR OF THE WOUND 647 is generally a mild one, but is capable of infecting a third person with a severer form. It is often impossible to trace the origin of the infection. Patients freshly operated on and women during the puerperium are specially liable to scarlet fever infection. A nurse who has been in contact with scarlet fever even indirectly should not undertake either an operation case or a maternity case without first notifying the surgeon of the fact. The usual precautions for isolation must be observed. Tetanus.—The tetanus germ is introduced by direct inoculation, usually at the time of an injury. Wounds contaminated by soil are especially liable to be infected (p. 417). The symptoms may develop shortly after an operation or not for a week or more. One of the early symptoms is a stiffness about the jaws, the first sign of which must be promptly reported. The chief symptoms of tetanus are the characteristic convulsions (p. 669), accompanied by irregular fever and great prostration. The present treatment is to give tetanus antitoxin serum at as early a period as possible; the wound is freely opened, as described above. The patient is isolated, and the. room kept as absolutely quiet as possible, since the slightest noise brings on a convulsion. A liberal diet is necessary; if the jaw is locked, the patient is usually fed by the nasal tube. Sedatives, such as bromid and chloral, are usually ordered. The tetanus bacillus may be present in the wound secretions. At the present day such cases are usually isolated from other surgical cases. A severe case of tetanus is very frequently fatal. As a rule, if there is any chance that a wound has been con- taminated by soil, tetanus antitoxin is administered without waiting for symptoms to develop. In the late war every wounded soldier in the British Army (presumably also in others) received an injection of tetanus antitoxin serum on the field, with the result that this most fatal complication was practically non- existant. In all previous wars death from lockjaw was the fate of thousands of wounded. Perhaps in no other way has modern scientific investigation shown itself so directly beneficial to life, CHAPTER XIX NURSING IN ACCIDENTS AND EMERGENCIES (Continued) Burns and Scalds—Immediate Treatment: Of the Eye; the Throat; Dressings—Stages—Physical Treatment—Complications— Burns by Lightning, Electricity—Bites—Stings—Frost-bite—Boils —Stye—Carbuncle—Whitlow—Convulsions: Tonic, Clonic, Epilep- tiform, Tetanic—Causes—General Treatment—Points to Observe: in Convulsions; in Epilepsy; in Alcoholism; in Uremia; in Children; in Tetanus; in Strychnin-poisoning; in Hysteria—Foreign Bodies: Eye, Ear, Nose, Throat, Esophagus, Larynx—Artificial Respiration: Sylvester Method; Marshall Hall Method; Drowning; Asphyxia of the New-born — Fainting — Concussion — Heat Exhaustion — Heat Stroke. BURNS AND SCALDS Burns and scalds are caused by the effect on the soft tissues of direct heat. Burns are caused by dry heat— fire, electricity, red-hot substances, or corrosives; scalds are the result of moist heat, steam, or very hot fluids. In burns or scalds three degrees of injury are recognized: (1) Reddening of the skin; (2) destruction of the true skin and the formation of blisters; (3) injury to the deeper tissues. Acute pain is a prominent symptom, especially in burns of the first and second degrees. A scald is usually of the first or second degree; serious scalding is often the effect of a boiler explosion, frequently involving an extensive portion of the body, and generally including the face. The symptoms and treatment of burns and scalds are the same and will be considered together. In all such accidents the physical condition is to be considered as well as the local. Of the two, the physical condition is the more immediately important. The extent of a burn is a more serious condition than the depth. A superficial burn of large area is more fatal to life than a deep burn of localized extent. A fatal result 648 BURNS AND SCALDS 649 is looked for if two-thirds of the body are involved, even if only by burns of the first degree. Unless a burn is very slight or very severe, it is not possible, at the time of the accident, to estimate the severity of the injury or to determine the degree to which the burn may belong. Nurses should be very careful in concluding that a burn is slight. Immediate Local Treatment (Scalds are Included under Burns).—Burns of the first and second degree cause intense local pain, which is most quickly relieved by the application of a cold wet dressing. Plain sterile water may be used, or a solution of boric acid (2 per cent.) or a weak solution of bicarbonate of soda. Contact with the air increases the pain; the burn should, therefore, be cov- ered quickly. The bandage must be applied lightly, as some swelling is sure to follow, and it is not possible at the time to gage the extent of the injury. Any clothing must be gently removed. Instead of applying a cold wet dressing, the surface of the wound may be freely dusted with flour or bicarbonate of soda (baking-powder), and covered with absorbent cot- ton. If vesicles form and break, however, dry substances are apt to cake and become difficult to remove. The burn may also be dressed with oil or an ointment spread on gauze or old soft muslin. Such a dressing relieves pain by effectually excluding the air, but is apt to become hot and uncomfortable. Any simple oil or ointment that is available serves for a first dressing; butter or lard will also answer the purpose. Carron oil, an equal mixture of lime-water and olive or cotton-seed oil, is frequently, in homes, kept for such emergencies, but is considered a dressing difficult to keep surgically "clean." If a burn is caused by corrosives, the injured surface should first be washed with plenty of cold water, in order to get rid of the irritating substance. An antidote is used if one is available. For acid corrosives, weak ammonia and water or a solution of bicarbonate of soda may be used; for alkaline corrosives, vinegar and water, lemon-juice and water, or a dilute acid solution. Boric acid is usually available. The antidote to carbolic acid is alcohol; 650 NURSING IN ACCIDENTS AND EMERGENCIES burns caused by carbolic acid are washed and dressed with alcohol; oil applications in this condition are especially to be avoided (p. 340), since oil helps in the absorption of carbolic acid. In burns of the second degree the first stage of conges- tion is followed in a few hours by the formation of vesicles. When fully risen, each blister is snipped at its most de- pendent part with a sharp-pointed pair of scissors and gently pressed to allow the fluid to escape. The cuticle is not cut away: it serves as a natural protection to the denuded surface. For the simple dressing, one containing a mild non-irritant antiseptic is then substituted. Burns of the third degree are always serious, and if involving more than two-thirds of the body, they are commonly fatal in a few hours. Other cases linger a few days. If less extensive, recovery may take place, with a long and tedious convalescence, or the patient may suc- cumb later to one or other of the complications associated with burns. Such burns are frequently the result of the clothes catching fire. The first examinations should ascertain that no smouldering is still going on. The charred remains of the clothes must be removed. If the physical condition permits, this is frequently done under ether; the burns may then be sprayed with peroxid of hydrogen, and irri- gated with warm boric solution. A dressing is then applied—either an ointment dressing or a wet dressing. In many cases of extensive injury the burns are treated without local dressing. Two methods are used—the " open treatment " and immersion. In the open treatment of burns the patient is laid between sterile sheets and the burns are freely dusted with a sterile dusting-powder, usually stearate of zinc A bed-cradle is necessary to keep the bed-clothes from press- ing on the burns. The air, which by this method is not excluded, must be kept at an even temperature. Where the trunk of the body is involved, the temperature should not be less than 80° F. This temperature may be main- tained by hot-water cans, bags, etc., or an electric light, where one is available, may be tied to the bed-cradle and BURNS AND SCALDS 651 the outer air carefully excluded by the bed-coverings, The patient's body then lies in a closed cabinet of warm air. A light of 16 candle-power is generally sufficient. (See p. 69.) Immersion may be local if a limb only is injured (see Local Baths, Chap. II), or the entire body may be placed in a tub sufficiently long for the patient to lie comfortably extended. To the water either boric acid or bicarbonate of soda is usually added. (See Baths.) The water must be changed at least once a day. During the process the patient is wrapped in a clean sterile sheet, the burns being meanwhile dusted with a sterile dusting-powder. The water excludes currents of air, keeps the surfaces clean, maintains the body temperature, and reduces the general restlessness. With children, total immersion is especially successful. Burns of the eye are usually caused by a corrosive or by an atom of red-hot metal. Treatment must be prompt. In burning by a corrosive the lids should be held open and the eye freely irrigated with cold or tepid water. The stream should be forcible, in order quickly to wash away every atom of the irritant. The eye may be held directly under a faucet if no other means are available. A little vaselin or a few drops of castor oil may then be put be- tween the lids. Cold or iced compresses should be con- tinuously applied until surgical aid can be obtained, and the patient kept lying down in a room with the light shaded. If, in order to act promptly, unsterile water has been used, the eye should, as soon as possible, be douched with warm boric-acid solution (2. per cent.). In burns to the eye from a red-hot metal not a moment must be lost in obtaining surgical assistance. Cold com- presses may be applied in the mean time, but no other treatment attempted. Unskilful attempts to remove the foreign body may involve extensive injury to the tissues and result in loss of the eye. Burns of the mucous membrane of the throat are com- mon in children from attempting to drink scalding water; they are also caused by drinking corrosive poisons. If severe, death usually Results from shock. Where treat- 652 NURSING IN ACCIDENTS AND EMERGENCIES ment is possible, the patient is nursed in a warm atmo- sphere, kept moist by a steam kettle to which some respir- atory disinfectant, such as benzoin or eucalyptus, is added. Feeding is administered by rectum. Stimulation is usually given by hypodermic. A throat spray, usually of equal parts of peroxid of hydrogen and lime-water, or of chlorate of potash (grs. v to the ounce), is used every two or three hours. If swallowing is possible, small quantities of milk, bland drinks, or sweet oil are given repeatedly by mouth, for the local action, as well as for the purpose of nutrition. The pain of swallowing may be lessened by spraying the throat with cocain. Where the swelling is great, trache- otomy may be necessary. The indications for trache- otomy or intubation are increased dyspnea and cyanosis. Dressings.—The first dressing of a burn is generally left on for twenty-four hours. On removal, any blisters are snipped, and a dressing containing a mild antiseptic is substituted. Vaselin, to which is added boric acid or salol (of either, 20 grains to the ounce), is commonly used if an ointment dressing is preferred. More commonly at present burns are dressed with wet dressings. Warm normal salt solution is generally preferred. A strong anti- septic is not advisable on account of the risk of absorption from an extensive surface. To prevent the dressing sticking, the surface is first protected with strips of gutta- percha tissue. The strips are kept in a solution of bichlorid of mercury, 1 :2000, which is washed off by soaking the strips in salt solution before applying. The dressing is remoistened before it gets dry. Dressings are usually changed daily, and must be done with strict aseptic precautions. From the nafure of the injury a burn is, in the first instance, an aseptic wound; it can, however, readily become infected. If a dressing sticks, it must be removed by soaking. Pulling not only causes great pain, but may destroy the young granulations or cause extensive bleeding. Burns treated by the open method become covered with scabs composed of dry discharges. When granulation is established, it is usual to remove the scabs, a small por- tion daily, with a pair of sterile forceps. BURNS AND SCALDS 653 In deep burns of the third degree the tissues are devital- ized. In this condition, when the injury is local, hot fomentations, usually of boric acid, are frequently used, until the surface begins to discharge freely. The wound caused by a burn runs a definite course, with four well-marked stages: (1) Congestion; (2) vesica- tion; (3) suppuration; (4) granulation. The dressing of burns in the first two stages is as already given. In the third stage the surface of the burns is covered with a copious discharge, which becomes very offensive if allowed to accumulate. The daily dressing is then accompanied by a free irrigation with a warm antiseptic solution, commonly boric acid. At this stage picric acid is frequently substituted, both as a wet dressing and for irrigation (picric acid, 40 grains; alcohol, J ounce; cold water, 1 pint). It is antiseptic and astringent, and promotes cleansing of the wound and healing. As the picric stains linen yellow, old worn sheets should be used on the bed and old night-shirts. During the stage of suppuration sloughs become sep- arated and are thrown off. They should be cut away when possible. (See Sloughs.) If the sloughs are deep, their separation may cause secondary hemorrhage. As the suppuration lessens the wounds should present a surface of healthy granulations. As in general wounds, indolent granulations require stimulating treatment, and redundant granulations are kept down by an application of silver stick or blue stone. The healing of extensive sur- faces is slow and tedious. When the period of suppuration is passed and the surface is clean, the healing process is frequently hastened by skin-grafting. As burns heal, the formation of the scar tissue is liable to cause contraction. If the injury is near a joint, this may result in permanent crippling. The danger is lessened by the use of suitable splints, extension, the early practice of passive movements, and by encouraging the use of the affected limb in spite of the pain caused by the first efforts to do so. Physical Treatment.—As far as life is concerned, the physical treatment in an accident by burning outweighs 654 NURSING IN ACCIDENTS AND EMERGENCIES in importance the local treatment. The physical effects of a serious burn are, at first, shock, extreme restlessness, and excessive thirst. Shock may not be apparent at first, but should always be apprehended, even when the injury appears comparatively slight, and especially so if the patient is a child. Frequently the patient seems to pro- gress favorably to a certain point, and then suddenly sinks. Death from shock occurs within twenty-four hours of the accident. (See Shock.) The immediate physical treatment is rest in bed and quiet, external warmth, and plenty of water to drink. A stimulant is generally given, either alcohol or strychnin, and in extensive burns morphin is usually necessary. With children opium is always given with great caution. Usually paregoric is the preparation preferred. A purge, generally calomel, is commonly ordered. If the patient lives, the period of shock is followed by a period of reaction. The temperature, subnormal at first, rises, probably above 103° F.; there are continued fever, delirium, great restlessness, and, generally, vomit- ing and diarrhea; convulsions may be present, especially with children. The condition may pass into fatal coma, or death may take place from exhaustion or other com- plications. The urine is scanty or suppressed. During this stage the patient is kept quiet, with the light shaded; the diet is liquid, and consists especially of milk, which may be diluted with lime-water or Vichy, and albumin- water. For the thirst, lemonade to which is added cream of tartar, | ounce to a pint (Imperial drink), is given freely. Besides relieving the thirst, the cream of tartar assists elimination and stimulates the activity of the kidneys. Bromid is usually given, and the bowels are purged with calomel or castor oil. If persistent, the vomiting may be relieved by hot applications to the epi- gastrium. Diarrhea is usually treated with astringents or opium. When the vomiting and diarrhea cease, beef- tea, broths, or beef-juice is added to the diet. As the condition improves, semisolids and, finally, solids are given. During the periods of suppuration and granula- tion the diet should be highly nourishing. Fresh air, BURNS AND SCALDS 655 good hygiene, and cheerful surroundings are important. Tonics, especially iron or bitters, to stimulate the appetite, are generally ordered. Complications.—The local complications of a burn are, as mentioned above, extensive sloughing, secondary hemorrhage, and permanent contraction of the part; un- sightly scarring may be added. Embolism may occur, es- pecially where there has been extensive sloughing or secondary hemoirhage. As in other wounds, a burn may be the medium of a general infection. Patients suffering from burns are peculiarly liable to infection by erysipelas or by scarlet fever. No one in any way in contact with such cases should be admitted near a case of burns. Shivering, an abrupt rise of temperature, a sudden attack of vomiting, and, in children, convulsions, are symptoms to be regarded with suspicion. Erysipelas is especially likely to occur where the face is the seat of injury. Septic absorption is liable to occur during the period of suppuration. The general condition is usually treated by drugs that promote elimination and by general stimu- lation. Other complications to be apprehended in burns of any extent are congestion and inflammation of the internal organs, bronchitis, pneumonia, nephritis, and intestinal inflammations. Bronchitis and pneumonia may especially be looked for after scalds of the mucous membrane of the throat. Nephritis and intestinal inflammation are most common in extensive burns of the trunk. In a large meas- ure the condition is caused by the extra work thrown upon the organs of elimination by destruction of a large area of the skin. Other causes are septic absorption and the direct local effect of the burn, which acts as a powerful counter- irritant, and, it is considered, probably causes important changes in the underlying structures. Burns about the abdomen are generally associated with inflammation of the intestines and frequently with ulcera- tion, especially of the duodenum. Death may occur from rupture of a duodenal ulcer or from hemorrhage. The stools should be watched for traces of blood. As the lesion 656 NURSING IN ACCIDENTS AND EMERGENCIES is high, the stools will have a tarry appearance. Localized abdominal pain, acute or persistent, and distention are important symptoms of this condition. The treatment is the same as in any other case of intestinal hemorrhage (p. 601). Nephritis is one of the most common complications of extensive burns. It is characterized by headache, albu- minuria with scanty urine, and puffiness of the face and feet. In severe cases hematuria may be present. The diet is usually restricted entirely to milk as long as albuminuria persists. Elimination is aided by purgatives and diuretics, water or Imperial drink is given freely. Burns by Lightning.—Burns due to lightning, electricity, or to prolonged exposure to the x-rays may also be met with. A burn by lightning is branched like a flash of forked lightning. The patient is severely shocked, and frequently unconscious. On recovery, loss of sensation and temporary local paralysis are commonly present; there are frequently disturbances of vision, and the patient may remain per- manently blind. The local treatment is the same as for burns from other causes. The tissues are necrosed and healing is slow. In treating the condition of shock electricity must not be used. Burns by electricity may be slight or severe. The shock is frequently fatal. A severe burn is practically the same as a burn by lightning. In an accident by electricity it is of immediate impor- tance to break the electric circuit. If an interruption is at hand, this is easily done, or if the wire is insulated at any available point, it can be removed; if not, the patient must be pulled away. Until the circuit is broken, any one touching the person struck with bare hands will also be shocked. Silk and wool are non-conductors if perfectly dry. The hands may be closely wrapped with anything available of these mate- rials; the clothes of the victim may then be grasped, and he can be pulled away, thus breaking the circuit. If the available force is not sufficient to move him, a thickly folded blanket should be pushed under him, using which as a pad he may be raised from contact with the earth, which BITES AND STINGS 657 is the other pole of the circuit, and moved to a place of safety. The patient is unconscious and in an extremely critical condition. The treatment must be prompt. The clothes are loos- ened, fresh air is admitted, external heat and stimulation of the circulation by friction, etc., applied. Artificial res- piration is usually necessary, and should be continued as long as the heart can be felt to beat. Cardiac stimulants may be given by hypodermic. Once respiration is re- stored, the subsequent treatment is the same as for any condition of shock, avoiding only all use of electricity. BITES AND STINGS The bite of an animal inflicts a punctured wound, which, in the majority of cases, is also lacerated. The wounds are usually slow in healing and readily become infected. Superficial wounds are usually dressed with hot antiseptic compresses. Where the puncture is deep or there is dirt in the wound, the usual treatment is to open up the wound freely. Strong astringents or the actual cautery should not be applied unless there is actually hemorrhage to be con- trolled. • Extensive bites, where the tissues are much lacerated, are commonly accompanied by extreme shock. The possibility of shock in any case must be borne in mind. A bite by a rabid animal is rare, and cases so reported are frequently not authentic Many dogs in hot weather suffer from heat-stroke. In this condition they appear mad, and if molested are apt to bite. Every effort should be made to keep the dog alive and under observation— expert, if possible. If the dog is proved not to be rabid, much needless anxiety is spared the victim. Until recently the only treatment advised for such wounds was instant cauterization. It is now considered that, by thus sealing the tissues, absorption of the poison is furthered. The present treatment consists in laying open the wound, thoroughly cleansing the part with anti- septics, and the application of hot antiseptic compresses. If the dog is known to be rabid, the patient is usually ad- vised to undergo the Pasteur treatment at once. 42 658 NURSING IN ACCIDENTS AND EMERGENCIES Snake-bite.—The action of the venom of a snake-bite on the system is similar to the action of bacterial toxins. The poison acts directly on the central nervous system, producing profound prostration, and sometimes fatal collapse. The venom also attacks the blood-cells and destroys the coagulability of the blood. Extravasations of blood causing a petechial rash are common. The bite of even the most venomous snake is not now considered necessarily fatal, provided treatment can be prompt. The local treatment usually advised is to apply a tourniquet above the bite (if in an extremity), with the object of preventing the poison from reaching the general circulation, and to cover the small wound with a wet dressing, in order to encourage bleeding. Cupping is advocated if it can be done immediately. Cauterization is not considered advisable. The physical treatment consists in rest, external heat, and the free use of stimulants. Doctors advise strychnin or atropin in preference to the alcoholic stimulants; they are, however, frequently not at hand. The patient should be reassured and encouraged to a hopeful view of his con- dition. • Stings.—In a sting we have a minute puncture into which a poison has been introduced, which has a local irri- tant action. The poisons of insects are acid; the irritation is, therefore, best relieved by an alkaline application, such as ammonia, soda, common soap, or laundry blue, all of which are usually available. An acid, such as carbolic acid, also relieves irritation by causing a superficial anes- thesia. A bee or wasp may leave its sting in the wound. This should first be removed by pressing some hollow round object, such as an old-fashioned key, firmly on the tissue immediately round the mark of the bite. The area, which is often considerably swollen and painful, may then be bathed with hot water and ammonia, and finally dressed with a cold compress of dilute ammonia water or other alkaline preparation. If a patient has been attacked by a swarm of bees, he is probably in a highly nervous condition, and may be considerably shocked. Bromid, bromid and FROST-BITE AND EXPOSURE 659 chloral, or a small dose of morphin is often necessary. The injured part may be covered with hot compresses con- taining ammonia, heat soothing pain more effectively than cold. FROST-BITE AND EXPOSURE A frost-bite is the local result of prolonged exposure of the body to extreme cold, most commonly occurring on the more exposed parts of the body, the fingers and toes, the ears, nose, and the skin over the cheek bones. The extreme cold causes contraction of the superficial blood- vessels; if the circulation in the part is not maintained, the blood-supply is entirely cut off, resulting in the death of the part. In mild cases a slough is formed; in more severe cases, gangrene results. ' If seen early, the part attacked has a blanched appear- ance, and should be briskly rubbed with a lump of snow or a cloth wrung out of ice-cold water, taking care not to bring the sufferer into a warmer atmosphere until the normal color is restored. In severe cases, involving pro- longed general exposure, the patient may be in a comatose condition. The first treatment is then to restore the cir- culation of the body. The patient is laid in a room of low temperature (about 50° F.), and the whole body briskly rubbed with the hands. As the warmth of the body returns the temperature of the room is gradually raised and the body is covered with warm blankets. Hot drinks and alcoholic stimulants may then be given. If the patient remains unconscious, hot rectal irrigation with normal salt solution, coffee and brandy enemata, and cardiac stimu- lants by hypodermic are given, with the usual treatment for shock. When the circulation is restored, the local injuries are dressed. An anodyne, such as tincture of opium or opium liniment, is frequently applied first, and the parts are wrapped in absorbent cotton. Later, when sloughing occurs, hot antiseptic applications may be used to hasten the separation of the sloughs and lessen the risk of septic absorption. Should gangrene result, the part is enveloped in cotton until separation takes place, and the surrounding 660 NURSING IN ACCIDENTS AND EMERGENCIES tissues regularly rubbed and protected from changes of atmospheric temperature. In some cases, as, for example, where the whole foot is involved, amputation becomes necessary. In the after-treatment the general health must be built up by liberal diet and the use of stimulants and tonics. BOILS, STYES, CARBUNCLES, WHITLOW A boil or furuncle is an acute local inflammation of a hair-follicle or sebaceous gland, usually due to local infec- tion by a pus-producing organism (Chap. XII). Where suppuration does not occur, the lesion is known as a blind boil. A boil may be an isolated occurrence. More fre- quently, boils tend to occur in groups and to recur at intervals. The condition is favored by a debilitated state of health, and especially by the presence of chronic debili- tating diseases, such as diabetes and nephritis. Suppuration is hastened by the use of hot compresses or counterirritants, such as ichthyol ointment. As soon as the local abscess has formed, the boil is incised. In the center will be formed a small lump of necrosed tissue. The little cavity is irrigated, lightly packed, and dressed with a simple aseptic dressing or some astringent ointment. The application of a caustic, such as crude carbolic, to the cavity is sometimes recommended. The surrounding parts should be carefully cleansed with an antiseptic solu- tion, to protect other hair-follicles from infection. Recurrent boils may be due to the state of health, to infection from the existing boil, owing to scratching or careless dressing, or to lack of cleanliness in the clothing. The care of the general health and the removal of any debilitating cause are important parts of the treatment. A stye is a small furuncle occurring on the margin of an eyelid, involving a hair-follicle. The usual treatment is to apply hot boric compresses until a small point of suppu- ration is seen round an eyelash; on pulling out the eyelash a channel of escape for the discharge is formed, and, after a few more applications of the hot boric compresses, the inflammation usually subsides. BOILS, STYES, CARBUNCLES, WHITLOW 661 A carbuncle is an acute inflammation attacking the skin and underlying tissues, also due to infection through a hair-follicle by one of the pus-producing organisms. The infection spreads through the subcutaneous tissue, involving a considerable area, and causing numerous local points of suppuration and necrosis. In appearance the skin over the area is red and brawny, and pitted with openings discharging pus. The necrosed areas increase, forming large, offensive sloughs, attended with copious discharge. The condition is accompanied by the physical symptoms of sepsis, attacks of shivering, fever, and great prostration. Patients are usually in middle age, and fre- quently are sufferers from some chronic debilitating dis- ease, especially diabetes. From a neglected carbuncle general septicemia may result. The usual sites of a carbuncle are the nape of the neck or the back, between the shoulders; more rarely they occur on the buttocks. The surgical treatment consists in free cross incision, so as fully to expose the necrosed areas and allow for drainage. The sinuses are usually cureted, or applica- tions of crude carbolic are used. Hot antiseptic compresses are employed to hasten the separation of the sloughs. A thorough dressing is given at least once daily. The area may be syringed with peroxid of hydrogen, and freely irri- gated with a mild antiseptic. On account of the exten- sive surface, strong antiseptics are not used. The deeper pockets and sinuses are lightly packed, and sloughs are cut away as soon as possible. The possibility of hemor- rhage on the separation of the slough should not be for- gotten, and the means of controlling it kept on hand. The cure of a carbuncle is long and tedious. The care of the physical condition forms an equally important part of the treatment. Rest in bed, good hygiene, and a liberal, nourishing diet are essential. Stimulants are generally given freely, and tonics, especially iron, arsenic, and quinin. As in all septic conditions, elimination should be active. A felon, whitlow, or paronychia is a local infection occur- ring near or under a nail. It is frequently the result of leaving exposed the small wound caused by a pin-prick. 662 NURSING IN ACCIDENTS AND EMERGENCIES The inflammation is accompanied by acute pain, owing to the tension caused by the limited area for expansion, due to the proximity of the bone. If not relieved, the infection is liable to spread along the lymphatics and cause painful enlargement of the glands in front of the elbow and in the axilla. Local suppuration usually occurs rapidly. The usual treatment is to apply hot antiseptic com- presses, followed by incision as soon as suppuration has taken place. If the patient can be persuaded to keep the finger in a hot antiseptic bath (carbolic, 1 : 40, or bichlorid of mercury, 1 : 2000), either continually or for a couple of hours at a time, suppuration may frequently be averted. The incision must be made with the same strict asep- tic precautions observed in larger operations. The open- ing of a small infected area with a non-sterile needle, etc., is a frequent cause of general septic infection. If the discharge is imprisoned by the nail, it becomes necessary to cut away a portion of the nail to allow a channel of escape. It is a painful operation, and is generally done under a local anesthetic, such as freezing the surface with ethyl chlorid. The small cavity is usually cureted, or, instead, an appli- cation of crude carbolic may be preferred, after which a small drain of gauze is inserted and a dressing applied. As from the locality of the wound the smallest tension causes acute pain, a wet dressing is usually preferred, which favors the escape of discharge. Voung nurses often show a disposition toward repeated small infections of this nature. The general health should be attended to, the bowels regulated, the appetite encour- aged, and a certain amount of time spent daily in the open air. Tonics, especially the iodid of iron or the elixir of iron, strychnin, and quinin, are frequently prescribed. Nurses should be taught to cover all pricks and scratches at once. The application of a light collodion dressing is sufficient to protect from infection. If a felon is neglected, the suppuration may spread to the deeper tissues involving the periosteum, and possibly lead to the destruction of a portion of the bone. The whole finger is inflamed and acutely painful. The usual treat- CONVULSIONS 663 ment is free and deep incision, without delay. The wound is kept open by a drain of gauze, etc., over which a wet antiseptic dressing is applied. If a sequestrum forms, the wound will not heal until the fragment of bone has sepa- rated and been removed. In such a condition the physical symptoms are usually severe. Shivering, fever, and the general disturbances of a. septic condition are present. They are treated with free purging, rest in bed, and a liquid diet as long as the fever lasts, after which a liberal diet, the use of tonics, and good hygiene are the general lines of treatment. CONVULSIONS By the term convulsion is understood a paroxysm in which the voluntary muscles are contracted involuntarily. The convulsion may be general or local; the muscular con- tractions continuous or intermittent. Continuous contractions are called tonic; intermittent, clonic. A convulsion usually begins abruptly and is of short duration. In a tonic convulsion the muscles are strongly contracted, the limbs forcibly extended, the head retracted, and the body held rigid in a forced position; the spine may be com- pletely arched (opisthotonos). A clonic convulsion is characterized by abrupt jerky movements of the affected part. The two forms may occur in the same seizure, and frequently follow each other. Convulsions are considered in two principal groups: those in which consciousness is lost and those in which, if present, it is retained. The first group is known as epileptiform, the second as tetanic; epileptiform convulsions are, in common tongue, spoken of as fits. Epileptiform convulsions occur in epilepsy; in conditions causing pressure to the brain, as apoplexy, fractured skull, brain tumor; in meningitis, uremia, alcoholism, and in poisoning by certain drugs. In young children epilepti- form convulsions are common as the result of reflex irri- tation in many conditions; common causes are gastric disturbances, intestinal worms, teething, the onset of an 664 NURSING IN ACCIDENTS AND EMERGENCIES acute illness, especially of the infectious fevers, and in any other condition associated with rise of temperature. In an epileptiform convulsion there is usually a compar- atively short tonic contraction, followed by a longer period of clonic contractions. A characteristic feature is the closing of the hand over the inverted thumb. The eyes squint and are turned upward; the sphincters are re- laxed, urine and frequently also the bowel movements are passed unconsciously; there is usually foaming at the mouth; the face is flushed, or may be first violently flushed, then pale. Tetanic convulsions, as the name shows, are character- istic of tetanus, or look-jaw. They occur also in poisoning by strychnin, in the condition known as tetany, and are the usual form of the hysteric convulsion. The contractions may be clonic or tonic. Prolonged tonic contractions are characteristic. In the general treatment of a convulsion the patient should be placed where he cannot hurt himself; the clothing should be loosened, and a cork or small object placed between the teeth to prevent the tongue being bitten. The movements may be guided, but should not be re- strained. During a convulsion the patient must not be left. A message should be sent to summon medical aid; in the mean time close accurate observation of the symptoms may be an important aid to diagnosis. The chief points to be observed are as follows: 1. Whether the convulsions are tonic or clonic, or whether one condition follows the other. 2. The area affected—whether the whole body, one- half of the body, or confined to a localized area. 3. The point at which the movements are first manifested, and the order in which the other muscles become affected. 4. The length of duration. 5. Twitchings of the facial muscles and the side toward which they are drawn; squinting; contraction, dilatation, or irregularity of the pupils; frothing of saliva at the mouth. 6. Relaxation of the sphincters, causing involuntary voiding of urine or action of the bowels. CONVULSIONS 665 7. Changes in the pulse or respiration. 8. Lividity or flushing of the face. 9. Premonitory symptoms, such as sharp cry, great restlessness, apprehension, etc. Important points should be noted on the record chart, together with the hour of the occurrence of the attack. Special treatment is, of course, directed toward treat- ing the underlying cause and quieting the nerve-centers. In most conditions of epileptiform convulsions elimination is furthered by a quickly acting cathartic. Epilepsy.—True or idiopathic epilepsy is a chronic disease characterized by failing mentality and recurrent convulsions. The attack is preceded by a loud cry, and the patient falls heavily where he stands. Frequently there is decided premonition of the attack, accompanied by some one peculiar sensation, which is known as the aura. The convulsion involves the whole body; consciousness is recovered immediately the convulsion is over. After an attack the patient is induced to rest, and usually sleeps heavily. The bromids are generally prescribed, and the bowels purged. Where the convulsion is the result of injury to or acute disease of the brain, the treatment is the general treatment of the condition. The convulsions are generally confined to a definite locality, and sometimes only the face or one limb, at others one-half the body, may be involved. The convulsions are usually of the clonic variety. Conscious- ness is not recovered between the attacks, which are often prolonged indefinitely. The convulsions of alcoholism and uremia bear many points of resemblance. In both there is frequently noisy delirium, and the convulsions may at first be mistaken for violent voluntary movements. Later the convulsions of uremia are markedly epileptiform, with coma, more or less profound, between the attacks. To mistake the two conditions is an error that, should the case be one of uremia, might cost the patient his life. Both conditions are the result of poisons in the blood acting on the nerve-centers. In a case of alcoholism, the poison having been ingested by the natural means, it can 666 NURSING IN ACCIDENTS AND EMERGENCIES be withheld, and can be eliminated by the natural excre- tions of the body. Recovery is generally anticipated. In a case of uremia the poison is a natural product of the bodily activity, by far the larger proportion of which is excreted in the urine, but which, owing to the failure of the kidneys to perform their function, has found its way into the blood. As long as life is present this poison must con- tinue to be formed and to accumulate until the organs of elimination—the kidneys, the skin, and the bowels—can adequately fulfil their function. Uremia is a very grave condition, and not infrequently fatal. It occurs in condi- tions of nephritis, either due to disease or other causes. The marked smell of alcohol on the breath in one case, and of a urinous odor on the other, will suggest the con- dition; on the other hand, it must be remembered that the first treatment of any abnormal condition among bystanders is usually to give alcohol; the odor may be, therefore, misleading. The prominent characteristic symptom of uremia is the state of the urine. It is either scanty or entirely sup- pressed. What there is is loaded with albumin. In alco- holism the urine will probably be passed freely. Two other points may be noticed. In uremia the coma is profound: in alcoholism the patient can generally be roused by shouting or violence. In uremia the pupils are usually contracted: in alcoholism they are dilated. In alcoholic seizure the pulse is full and quickened: in uremia it is usually slow and of high tension. In hospital work the nurse will obviously not have the responsibility of either the decision or the treatment. She should, however, always remember to save carefully any urine that can be obtained for examination, and to examine the clothing for evidence of urine recently passed. In pri- vate work it may occur that she is called upon to give first aid in such a case, and she should realize the possible gravity of the condition and see that medical aid is promptly secured. In alcoholic convulsions the treatment consists in ad- ministering an emetic or giving lavage, and in furthering eumination by a drastic purge, such as croton oil (1 to 3 CONVULSIONS 667 minims). The patient is prevented, by shouting, shaking, cold affusion, etc., from sinking into coma. Fresh cold air should be admitted freely. Cardiac stimulants are given if the pulse shows signs of heart failure. If there is much delirium, an enema containing bromid and chloral in full doses is frequently prescribed. The after-symptoms of nervousness are treated according to their severity with various narcotics. Acute gastritis is commonly present, and is treated with rest, light diet, and purgatives. In uremia the most urgent necessity is to produce active elimination. To induce the skin to act the patient is usually placed promptly in a sweat-bath or a hot pack (see Chap. II); at the same time pilocarpin (| grain) is given hypodermically, and a drastic purge, such as croton oil (1 to 3 minims) or elaterium (£ grain), is administered by mouth. The sweat-baths or packs are continued until profuse sweating is produced, and repeated at intervals of two to four hours. The greatest care must be taken not to chill the surface of the skin by exposure while giving the treatment. If possible, such cases are best treated in a small room or ward, where the remperature can be evenly maintained at 70° to 80° F. At the same time, it is of the first importance that the air be fresh, and not allowed to become exhausted and the means of further poisoning. During the convulsions inhalations of chloroform are given, or chloral in full doses is prescribed by enema. In robust patients venesection is frequently performed, and from half a pint to a pint of blood removed, followed by the injection into the veins of one to two pints of water or of normal salt solution. The same is also given by hypo- dermoclysis or by rectum, with the object of diluting the toxin in the blood. Dry cupping over the loins is also a treatment frequently prescribed. If cyanosis is marked, inhalations of oxygen are necessary, but it should be re- membered that the condition may be due to the exhausted atmosphere of the room, and fresh air admitted may improve the condition. Between the convulsions the patient may be partially conscious, wildly delirious, or sink into a profound coma. If conscious, he may complain of headache, vertigo, or total blindness. The attacks fol- 668 NURSING IN ACCIDENTS AND EMERGENCIES low each other with more or less rapidity. Sometimes hardly any pause is perceptible between the convulsions. Such a state is described as the status epilepticus. If the patient recovers, the treatment consists in rest in bed, a diet chiefly of milk and farinaceous foods, and the use of sweat-baths until the albumin has disappeared from the urine, and free purging, usually with salines. Headache, vertigo, and disturbances of vision are symp- toms that are persistent. There may be temporary total blindness. The patients are usually extremely anemic, and require tonics, such as iron, and plenty of fresh air and sunlight. Uremia may occur as a complication in pregnancy, labor, or during the puerperium. It is then known as eclampsia. Correctly speaking, the term eclampsia may be employed in any convulsive seizure from a temporary cause, as, for example, the reflex convulsions of children. Generally, the use of the term is restricted to the above condition. Where the case is serious, abortion is generally produced, or the actual labor hastened by artificial dila- tation and the use of forceps. After delivery the symptoms usually quickly improve. In other respects the treatment is the same as described above. Convulsions in children signify less than the same condition in adults; their nervous centers, being in a less stable condition, are easily upset by minor causes. The gravity of the condition depends on the cause (see above). In excitable children violent emotion may be sufficient cause. The customary treatment during the convulsion is immersion in a hot tub-bath (100° F., rising to 105° F.), with, at the same time, the application of cold to the head. The bath is usually prolonged until relaxation is complete, and repeated if the convulsions recur (p. 669). An enema is generally given at once, followed by a purgative, com- monly castor oil or calomel, the dose according to the age. The convulsions are apt to recur at intervals until the con- dition has been relieved, or, if ushering in an acute illness, until the period of invasion is over. The temperature is generally raised, sometimes very high; the pulse is full and CONVULSIONS 669 rapid. If a child is very restless or delirious, a hot pack in which he can remain for an hour or more is often more efficacious than the hot tub. Convulsions of Tetanus.—Tetanic convulsions, so called, are chiefly tonic in character, and accompanied by extreme pain. The convulsion is aggravated by any small disturb- ance, such' as a touch or a sudden noise. A leading char- acteristic is the stiffening of the muscles of the jaw, finally causing lockjaw {trismus). As we have already seen, tetanus occurs only from infec- tion by the tetanus bacillus, introduced through a wound by direct inoculation, and most commonly developing in punctured wounds contaminated by soil or other dirt. The first symptom is a difficulty in swallowing, with a feeling of stiffness about the jaws. The first suggestion of such a symptom must be promptly reported. The stiffness gradually extends to the neck, the shoulders, the back (which becomes completely arched), the abdomen, and extremities; not infrequently the arms remain free. The contractions are almost entirely tonic. The muscles remain rigid between the convulsions; consciousness is not lost during the attacks. The seizure is usually accom- panied by profuse sweating and fluctuations of tempera- ture. In a mild form of tetanus the spasm is confined to the head and shoulders, and the jaw is not completely locked. Where the larger part of the body is involved and the jaw completely locked, the condition is very frequently fatal. (See also p. 647.) Convulsions from strychnin poisoning closely resemble those of tetanus. The first symptom is, usually, some mental exaltation, with sharpening of the special senses, especially that of hearing; the spasms begin in the extremities, with twitchings (clonic contractions) of the fingers and toes. Tonic contractions follow, extending over the whole body, and involving the jaw last. As in tetanus, in acute cases the back is completely arched. The muscles are relaxed between the convulsions; conscious- ness is not lost. The pain is frequently agonizing. (See Poisons, p. 351.) During the course of spinal meningitis rigidity and tonic 670 NURSING IN ACCIDENTS AND EMERGENCIES contractions of the muscles of the back and shoulders, associated with local tenderness and pain, are character- istic symptoms. The paroxysms occur at intervals. During a paroxysm the back may be so completely arched that the soles of the feet rest on the back of the head. The treatment is, of course, that of the underlying dis- ease. Tetany, a disease seen usually in rickety children, is also characterized by tonic contractions of the legs and arms, usually occurring in paroxysms. The limbs are contracted toward the median line of the body, the feet being turned in until the soles meet. Hot baths are sometimes used to favor relaxation, but the chief treatment is directed toward the underlying cause and the reestablishment of health. A hysteric convulsion may simulate any of the above forms. It is a characteristic symptom that, as a rule, no one group of symptoms is followed exactly. The patient is not unconscious, but keeps the eyes persistently closed, and resists attempts to open them. He can generally be roused by sharp pressure on the supra-orbital notch. The sphincters are not relaxed, the pupils react to light, the pulse remains unchanged, and the face is neither pallid nor deeply flushed. If the patient falls, it is in a position where he will not hurt himself. He may be noisy, and simulate delirium or mania, or perfectly quiet, as though comatose. Opinions and practice vary greatly as to the treatment of hysteria. To some extent the treatment is always one of suggestion. If a nurse is with such a case, she must realize that only by perfect control herself can she control or help her patient. Scolding and punishments rarely obtain desired results. Nurses must frequently be warned against treating hysteria as though it were a mere display of childish temper. For the time the patient is in an ab- normal condition. Where possible, pains should be taken to get at, either through the friends or from the patient, the underlying cause of the attack. It may be mental, the result of shock, grief, or worry, or physical, due to alcohol- ism or possibly some debilitating disease. In nervously constituted patients, especially women, minor causes, REMOVAL OF FOREIGN BODIES 671 such as constipation or the monthly period, may induce hysteric outbursts. In every case possible the removal of the cause is the first step in successful treatment. REMOVAL OF FOREIGN BODIES A foreign body in the eye causes pain and local irrita- tion, shown by the increased secretion of tears and con- gestion of the blood-vessels of the conjunctiva. If this condition is unrelieved, serious inflammation may result. The patient should first be directed to keep the eyelid closed, and refrain from rubbing the eye, which may embed Fig. 207.—Eversion of the upper lid (Manhattan Eye, Ear, Nose and Throat nursing book). the particle in the eyeball. Allowing a few seconds for the tears to collect, the nose is smartly blown, and the particles will, in many cases, be found to be washed by the tears down the lacrymal canal into the nose. A second method is to take the upper lid by the lashes and pull it well over the under lid, by which movement the particle may be swept on to the cheek. Failing these means, the lids should be everted. The lower part of the con- junctival sac is freely exposed by pulling the under lid 672 NURSING IN ACCIDENTS AND EMERGENCIES down toward the cheek bone, and directing the patient to look upward. The upper lid is taken by the lashes and turned upward and backward. The movement is made easier by placing a probe, a knitting-needle, etc., on the lid, over which it is turned. At the same time the patient should be told to move the eyeball freely about, so that the surface may be examined. The fragment is removed by a gentle wiping movement, using a camel's-hair brush, a feather, or some soft clean material. No force must be used. If the eye is irritated and painful after the removal, a warm boric douche may be given, and a little white vaselin or a few drops of sweet or castor oil be laid between the lids and a pad and bandage applied for a short time. Fig. 208.—The upper eyelid everted (Pyle). Should the fragment not be perceptible, a douche of warm boric solution should be given, or the eye held open in a basin of warm water and the lids shut and opened rapidly. If the fragment is seen to be embedded in the eye- ball or fails to be removed by the simple means described, surgical assistance should be at once obtained. In all cases of injury to the eye prompt treatment is an urgent neces- sity. In some cases the fragment may be so small as to be imperceptible without a lens. In others, especially with fragments of metal from machinery, the fragment may be driven deep into the tissues of the eyeball. Foreign Body in the Ear.—In the case of children a foreign body in the ear is usually a pea or some small object REMOVAL OF FOREIGN BODIES 673 poked in in mischief. Occasionally an insect crawls in the ear and, by the noise of its movements, causes acute discomfort. No attempt should be made to remove the body with a probe, a pair of forceps, a hair-pin, or other object. To do so will almost certainly push the object further in, and may injure the tissues. The patient is laid on the side, the affected ear uppermost. The ear is then filled with a little warm sweet oil dropped from a pipet; the object will probably float to the top, and is easily removed. To remove an insect the same method may be used, or a plug of cotton saturated with vinegar or with strong salt and water can be inserted in the ear. Over the plug a pad is held firmly and the patient directed to lie on the affected side. On removal after a short time the insect will generally be found on the plug. Syringing, unless done by experienced hands, is liable to wash the object further in. Vegetable substances (as a pea) should not be moistened, as they swell and become more difficult to remove. A small hard substance that will not float may require gentle syringing. (See Ear Douche, p. 135.) A foreign body in the nose is also generally the result of mischievous poking. Small objects may sometimes be dislodged by violent sneezing excited by pepper or snuff or by blowing hard down the affected nostril while the other is held compressed. If these means fail, a nasal douche may be gently given through the unaffected nostril (see Nasal Douche), unless the substance is one that will swell with moisture. If the object is immovable, surgical aid must be sought. If this is not procurable, an attempt may be made to snare the object with a small loop made of a piece of clean wire. If the tissues are at all scratched, the removal should be followed by a warm boric douche. Foreign Body in the Throat.—Small substances, such as particles of food, are frequently dislodged by drinking water or swallowing a morsel of well-chewed bread. A larger substance may lodge near the top of the esophagus 43 674 NURSING IN ACCIDENTS AND EMERGENCIES and cause acute pain, choking, and possibly asphyxia, from pressure on the windpipe. The esophagus is an elastic tube. Near the top, how- ever, its expansion is restricted by the one complete cartilaginous ring in the formation of the trachea. It is at this point that hard substances are liable to stick. A sharp slap between the shoulders will frequently dislodge the substance, sending it into the mouth or below the point of obstruction, when it can readily pass into the stomach. To be more effectual, a child may be held inverted, or a larger person directed to lean forward over the back of a chair. If this does not avail, water or bread may be swal- lowed or vomiting induced by pushing the finger down the back of the throat. If the patient is quiet, it is often quite easy to reach the object with the finger and remove it or force it beyond the obstruction. A fish-bone or other sharp substance embedded in the tissue of the throat, if it can be seen, is generally easily removed by a pair of forceps, the patient holding his throat open in a good light, and the tongue held down with a spoon or other suitable object. If it cannot be seen, the patient should be taken to a doctor, who will remove it with an instrument known as the horsehair probang. A probang is an instrument used in esophageal treatment, resembling a bougie, and usually made of gum elastic. For ordinary treatments a small sponge is attached to one end. The horsehair probang has, near the point, an inter- ruption filled with a skein of fine stiff hairs. On pulling on a wire inserted in the probang, the point is pulled toward the operator and the hairs stick out all round, very much like an open umbrella. The foreign body becomes enmeshed in the hairs, and is thus removed. Where more solid objects, such as coins or buttons, are lodged in the esophagus, a special probang, called the coin- catcher, is used. In this, the tip of the bougie is provided with small flat pockets. It is inserted beyond the object, and when withdrawn may, if the object is movable, catch it in one of the pockets. A coin permanently lodged in the esophagus is not an uncommon accident with children; it causes partial stricture, shown in the inability to swallow REMOVAL OF FOREIGN BODIES 675 solid foods. Should the coin-catcher fail to recover the object, it is located by means of an x-ray photograph and removed by a surgical operation. If a sharp substance, such as a fruit-stone, fish-bone, pin, or a small toy, has been swallowed, means must be taken to prevent injury to the mucous membrane of the alimentary canal. Purgatives should not be given at first. The patient should eat liberally of cereal or new bread, sub- Fig. 209.—Esophageal instruments: A, B, Forceps; C, horsehair probang; D, coin-catcher; E, esophageal bougie (DaCosta). stances in which the object may become embedded. A couple of hours after he should be given a meal of figs, prunes, or cooked apples, which will act as a gentle purga- tive. The stool should be examined for the missing object. Foreign bodies in the larynx or trachea consist usually of fluid or food-particles lodged there as the result of choking, vomiting, or in consequence of paralysis of the soft palate. Their presence causes dyspnea and coughing, which may result in the ejection of the irritating substance. In 676 NURSING IN ACCIDENTS AND EMERGENCIES this circumstance a blow on the back will only deprive the patient further of breath and make matters worse. If the patient becomes asphyxiated, artificial respira- tion should at once be begun, and surgical aid secured. Laryngotomy or tracheotomy may be necessary in order to remove the foreign body and to enable the patient to breathe. A fluid in the larynx, while producing symptoms less immediately alarming than those caused by a solid sub- stance, is nevertheless more difficult to remove entirely. Some portion will almost certainly escape down the trachea; in the lungs it becomes decomposed, and is frequently the cause of septic pneumonia. Where paralysis of the soft palate exists, fluids should not be given except by a nasal or stomach-tube. Solids or semisolids are less dangepous, as the muscular action of the cheeks and the tongue passes the bolus to the back of the throat. ARTIFICIAL RESPIRATION Artificial respiration is necessary when, for any cause, the mechanical act of respiration ceases while life is not de- stroyed. Arrested respiration produces the condition known as asphyxia, of which the accompanying symptoms are lividity, cyanosis, and loss of consciousness. Causes.—Asphyxia may result from the following causes: Mechanical obstruction, as in drowning or edema of the lungs, where the lungs are filled with water; the lodging of a foreign body in the trachea; edema of the glottis; inflammation or morbid growths of the larynx; pressure of a tumor on the trachea or bronchi; a foreign body, such as a bone, in the esophagus, pressing forcibly on the trachea. Convulsive spasm, as in whooping-cough or croup. Paralysis involving the muscles of respiration, as in shock from lightning or electricity, and in injuries to the upper part of the spinal column. The inhalation of poisonous gases. The administration of a general anesthetic, especially ether. In the new-born, from failure of the lungs to expand. ARTIFICIAL RESPIRATION 577 Where it is possible to remove the obstruction, this is obviously the first step in the treatment of asphyxia. In any other case artificial respiration should be begun without a moment's delay. Where there are fluids to be expelled from the lungs and bronchi, the patient is placed on his face, the head hanging so that the mouth is lower than the trunk. In other circumstances he lies on his back, a thick pad under the shoulders, and the head thrown back lower than the chest. In this position the throat is extended and the muscles of the chest-wall are allowed free play. The tongue is grasped with a handkerchief or by a pair of forceps, and pulled forward and to one side, to prevent its falling back and mechanically closing the larynx; a small object is placed between the teeth, to keep the mouth open. In case of vomiting the head should be kept turned to one side. The clothes are loosened round the throat, chest, and abdomen. Any collection of mucus in the nose or throat must be quickly wiped away. There are several methods of giving artificial respiration, of which the most commonly employed are known as the Sylvester method and the Marshall Hall method. The Sylvester Method.—The patient is placed on his back, as just described, the tongue drawn out and to one side. Seizing the arms just above the elbow, they are slowly abducted, extended at right angles to the body, and brought together above and behind the head. By these movements the chest-wall is slowly expanded, as in the natural act of inspiration. The throat being extended and the tongue drawn out, the air-passages are held open. The arms are held together above the head for three or four seconds. The movements are then slowly reversed, and the arms pressed forcibly against the sides of the chest for about three seconds, causing the act of expiration. The movements are continued rhythmically. They must not be hurried: 12 or 14 times a minute, somewhat lower than the normal respiration, is sufficient. The Marshall Hall Method.—The patient is laid on his side, a thick roll of blankets or pillows under the chest, and the arms placed above the head. The head is low, the 678 NURSING IN ACCIDENTS AND EMERGENCIES throat extended, and tongue drawn out, as in the Sylvester method. The patient is turned alternately on his face, to compress the chest (expiration), and on his back, to allow Fig. 210.—Artificial respiration: first movement, inspiration (Murray). the chest to expand (inspiration). While on his face, ex- piration is further aided by pressure on the ribs from behind. Again, the movements must be continued "hythmically, and not more than 12 to 14 times a minute. Fig. 211.—Artificial respiration: second movement, expiration (Murray). Drowning.—In asphyxia caused by drowning the lungs and air-passages must be freed from water. To do this, the patient must be placed in such a position that the head ARTIFICIAL RESPIRATION 679 and shoulders hang low, when the water will naturally escape by the mouth and nose. A child may be held by the legs head downward, or placed across the knees, face downward, the abdomen over the knees, and the head and shoulders hanging low. A larger patient may be laid in the same way across a table, a barrel, the seat of a boat, a bale of goods, or anything available that can be rolled into a bundle sufficiently large so that pressure comes on the lower part of the chest and the abdomen, and the head and shoulders can hang down. The tongue is pulled out and held to one side.- At the same time the ribs are pressed at the sides and back to help in emptying the lungs. Arti- Fig. 212.—Expressing water from the stomach and lungs (Murray). ficial respiration, as described above, is then promptly begun. It should be continued as long as there is any sign of action of the heart. Recovery may occur after several hours. While artificial respiration is being carried out, no time should be lost in making every effort to restore the circulation and stimulate the heart. Bystanders should be directed to remove the wet clothing and cover the body with warm blankets, etc., and to apply friction, under cover, to the extremities. Stimulants, especially atropin (tIo to ^ grain) and strychnin {-fa to TVgrain), are given by hypodermic; whisky or brandy may be given by rectum. Counterirritants in the shape of a sinapism or poultice may be applied over the heart; cold water may be dashed over 680 NURSING IN ACCIDENTS AND EMERGENCIES the chest, or, if available, a current of electricity may be applied. Fluids, such as normal salt solution by enema or hypodermoclysis, are avoided. On recovery, the usual reaction from shock may be present, especially in nervous patients. Until completely recovered, patients should be kept in bed and quiet. Asphyxia of the New-born.—In the new-born, failure of the lungs to expand may be due to—(1) Blocking of the air-passages with secretions; (2) delayed reflex action; or (3) lack of vitality. In the first two conditions the baby is cyanosed (blue asphyxia); in the third, the skin and mucous membranes are livid (white asphyxia), and the baby shows no sign of vitality. Fig. 213.—Schultze's method of artificial respiration (Hirst). The first step in the treatment is to wipe the nose and mouth free of secretion. If the skin is cyanosed, the baby should be slapped smartly on the back, which is often sufficient to excite respiration as a reflex action, or the ribs may be compressed several times in succession. If these means fail, two methods of artificial respiration are usually employed in preference to either described above, although the Sylvester method is also frequently used. The Schultze Method.—The baby is held at arm's length, suspended by each axilla, the back turned toward the operator. The hands of the operator are held with an index-finger in each axilla, the thumbs over the clavicle, ARTIFICIAL RESPIRATION 681 and the palms and remaining fingers against the back, on either side of the spine. In this position the baby is swung forward and upward, so that the lower half of the body is doubled over the upper and the abdomen corn- Fig. 214.—Byrd's method of artificial respiration: first position (Dorland). pressed against the chest. After one or two seconds the movement is reversed. The movements are repeated about 14 to 18 times a minute. The Byrd Method.—The baby is taken in both hands. The right is placed behind the shoulders, the thumb and Fig. 215.—Byrd's method of artificial respiration: full inspiration (Dorland). index-finger brought over the clavicles, on either side the neck. The left hand grasps the buttocks. Between the hands the body is then doubled, using, gentle force, and the 682 NURSING IN ACCIDENTS AND EMERGENCIES abdomen compressed against the chest; by the reverse movement the body is extended until the spine is arched. The movements must be done slowly, and repeated about 14 to 18 times a minute. In the condition of white asphyxia the baby is usually placed in a hot bath (100° F., increased to 105° F.). Under these circumstances the sides of the chest may be taken between the hands, and gentle, forcible pressure made and relaxed from 14 to 18 times a minute. The chin must be kept up and forward, and the tongue drawn out and to the side. Fig. 216.—Byrd's method of artificial respiration: full expiration (Dorland). The gums and lips at the same time may be rubbed with brandy and water. Examination of a new-born infant may show that the chest-wall has expanded unequally, although the baby may appear to be breathing comfortably. In this circumstance also artificial respiration must be practised until the con- dition is rectified. FAINTING OR SYNCOPE Fainting is a condition involving temporary loss of consciousness, either partial or complete, the result of a change in the force of the action of the heart. The heart's action is controlled both by the central nervous system and by the sympathetic nervous system. Conditions that affect either system may cause a temporary suspension of the activity of the heart and produce syn- CEREBRAL CONCUSSION, HEAT-STROKE, STARVATION 683 cope. Causes affecting the central nervous system are anemia of the brain, as in cases of hemorrhage, an insuffi- cient supply of oxygen in the atmosphere, exposure to heat, and poisoning by certain drugs, especially the car- diac depressants. Causes acting through the sympathetic nervous system may be emotional, such as fear, joy, appre- hension, an offensive sight, or poisoning by a drug that acts on the inhibitory nerves of the heart (sympathetic), such as digitalis. Premonitory symptoms of an attack are: a sensation of weakness, giddiness, and inability to stand; ringing in the ears; the sense of blindness; a clammy skin or profuse sweating. During the attack the patient loses conscious- ness and sinks to the ground; the muscles are completely relaxed, the pulse is small and weak, the breathing shallow, the face and lips pale, and the eyes closed. The treatment is to lay the patient flat, with the head and shoulders lower than the rest of the body, to loosen the clothing about the throat, chest, and waist, and admit fresh air freely. When consciousness is regained, water or aromatic spirits of ammonia (60 minims in \ ounce of water) should be given. If the attack is prolonged, the respiration may be stimulated by smelling salts or burning feathers, the hands and face sponged with cold water and briskly rubbed, or reflex action may be encouraged by slapping the chest smartly above the heart. After an attack of syncope the patient should lie still and not attempt to sit up or walk until fully recovered, or the attack may recur. CEREBRAL CONCUSSION, HEAT-STROKE, STARVATION Concussion, or cerebral shock, is the effect on the brain of a fall or direct violence, where there is no lesion of the brain substance. The function of the brain is temporarily arrested or stunned. Usually there is a short interval of insensibility, with symptoms of syncope, pallor, and small, feeble pulse; the respirations are quiet, whereas, in conditions of brain injury, stertorous breathing is an early symptom; as con- sciousness returns there are sensations of dizziness, head- 684 NURSING IN ACCIDENTS AND EMERGENCIES ache, and nausea; vomiting is frequentty present, and the mental faculties may be confused. After resting, the symptoms may pass away entirely. In more severe cases a semicomatose condition persists for some days. The patient lies with eyes closed, indiffer- ent to all that passes, but can be roused by talking or shouting. The mind is generally clear, but not infrequently there is no memory for events immediately preceding the accident. Rest in bed with the light shaded, the administration of a purgative, and a liquid diet until the symptoms disap- pear are usually all the treatment necessary. Persistent headache is relieved by the application of an ice-bag. Heat-stroke, thermic fever, insolation, sunstroke, are names used to describe a condition resulting from undue exposure to heat or to the direct rays of the sun. There are two distinct varieties, heat exhaustion or prostration, and heat-stroke proper. Heat Exhaustion.—The symptoms are exhaustion, sensation of great weakness, clammy skin, cold extremi- ties, small, feeble pulse, and shallow respirations. As a rule, consciousness is not lost, but syncope may occur. The patient must be moved out of the sun and placed in the recumbent position, with the head low; the clothing must be loosened, fresh air admitted, and external warmth, such as blankets and hot-water bags, applied; cardiac stimulants, especially aromatic spirits of ammonia (60 minims) or strychnin (^ to ^ grain), are given, and water or hot tea or coffee to drink. The patient should rest until entirely recovered. As a rule, there are no after-effects. For some days the action of the heart may remain weak. Usually rest and avoidance of exertion is all the treat- ment necessary. Heat-stroke is a condition of great gravity, and if un- relieved is quickly fatal. Some cases terminate fatally in less than an hour. The usual patients are men that have been doing hard physical labor in a high temperature. There may be premonitory symptoms of vomiting and acute headache. The patient rapidly becomes unconscious, the surface of the skin is deeply flushed and cyanosed, the CEREBRAL CONCUSSION, HEAT-STROKE, STARVATION 685 eyes bloodshot, the pupils contracted, perspiration is arrested, the temperature rises rapidly to from 105° to 110° F., the pulse is rapid and small, the respirations either stertorous or rapid and shallow. Convulsions or delir- ium may be present. In the treatment not a moment must be lost. The patient is moved out of the sun, the clothes stripped, and cold in the most immediately available form applied to the whole body. The water-hose, cold bath, ice rub, or the cold pack, frequently changed, are the usual means employed; plenty of fresh air must be available. Cold rectal irrigation is also frequently used. The treatment must be carried out constantly until the temperature drops and the patient perspires naturally. The pulse must be closely watched and cardiac stimulants given if necessary. In patients of robust appearance, venesection (J to 1 pint), followed by infusion of hot normal salt solution, is some- times prescribed. On recovery, the patient is put to bed in a darkened room with plenty of fresh air. A purge is given and the action of the skin and kidneys encouraged by drinking water freely. An ice-bag should be kept on the head. In severe cases convalescence is slow and is treated with prolonged rest and quiet, and careful attention to diet and to the condition of the bowels and kidneys. Exposure to the sun must be avoided. Where prompt treatment is available, recovery may be looked for. After-effects frequently met with are impair- ment of the memory, failure of mental power, a tendency to severe headache, and inability to bear exposure to heat or to the direct rays of the sun. One attack predisposes to another. In tropical countries exposure to the sun has been known to cause acute meningitis. In Animals.—It is humane to remember that animals, particularly horses and dogs, leading the artificial life of the cities, are also liable to heat-stroke. In dogs it is often shown by an attack of wildness and extreme excit- ability, ending in convulsive seizures, from which they usually recover. 686 NURSING IN ACCIDENTS AND EMERGENCIES The condition may often be averted by keeping animals out of the sun and supplying them with sufficient drinking- water. Horses, if obliged to work, should be kept as much as possible in the shade, should not be hurried, and should have their mouths and nostrils frequently sponged with cold water. Starvation as an emergency is usually complicated by exposure. The condition is one of general collapse, frequently accompanied by coma. The patient should be put to bed, external warmth applied, and the extremities briskly rubbed. Food in fluid form is given in very small quantities, gradually increased at regular intervals. Hot normal salt solution is given by rectum or by hypo- dermoclysis. Cardiac stimulants are generally given by hypodermic injection. Reflex vomiting may occur as the nerve-centers react to treatment, and it may be necessary for a time to give the nourishment by rectum. Con- valescence is usually rapid unless complicated by the consequences of exposure, such as pneumonia, inflamma- tory rheumatism, etc CHAPTER XX SYMPTOMS AND CONDITIONS FREQUENTLY MET WITH Pain—Delirium—Delusion—Illusion—Hallucination—Coma— Coma Vigil—Insomnia—Paralysis—Hemiplegia—Paraplegia— Edema—Dropsy—Vomiting—Hiccup—Constipation — Diarrhea— Rigor—Sweating—Sudamina—Fever: Causes; Varieties; Course; Incubation—Eruptions: Some Other Skin Eruptions. PAIN Pain is a subjective symptom (p. 180), and as such should be described in the words of the patient. At the same time the condition is commonly accompanied by certain objective symptoms, which must be carefully noted. The chief causes of pain are inflammation, injury, pressure, as from a tumor, a collection of fluid in a circum- scribed area, or an obstructive body, such as gall-stone; and acute irritation of a nerve, as in facial neuralgia. The subjective symptoms of pain include the character of the pain, its location, and its duration. Varieties.—Pain is described as dull or sharp. A dull pain may be aching or boring; a sharp pain may be cutting, shooting, throbbing, or griping. A sharp shooting pain is sometimes described as lancinating. Throbbing pain is due to local congestion, and frequently associated with the formation of pus. Boring pain is usually caused by persistent pressure, as from a tumor. It is a characteristic symptom, for example, of thoracic aneurysm. Pain is always more or less localized; in some conditions it may involve a very large proportion of the body. Thus in some infectious conditions (smallpox, influenza, diph- theria) we have acute pain in the back, lower extremities, and head. In acute inflammatory rheumatism and in pyemia we have pain attacking many of the joints simul- 687 688 SYMPTOMS AND CONDITIONS FREQUENTLY MET taneously, and disappearing from one part of the body, to reappear immediately in another. Pain may be continuous, intermittent, or occur in par- oxysms. Neuralgic pain has a tendency to recur in parox- ysms at regular intervals. The onset of pain may be sudden or gradual, and it may also disappear suddenly or gradually. Sudden relief from acute local pain usually suggests the removal of pressure or of an obstruction; thus in the sudden relief of toothache we have an escape of fluid into the soft tissues; an abrupt cessation of pain in an attack of renal or hepatic colic in- dicates the escape of an obstruction into a less constricted passage. Objective symptoms to be noticed in reference to pain are: Changes in the pulse or respiration; the existence of swelling, discoloration, deformity, or local tenderness; the expression of the face, whether drawn and pinched, or worn and apathetic; moaning or crying; the attitude as- sumed, and whether pain appears to be increased by moving or touching. In acute abdominal pain the tendency is to draw the knees up, in order to relax the abdominal muscles; in pleurisy the patient lies on the affected side, in order to restrict the painful movement during respiration; in colicky pain the body is sharply doubled to relieve the contractions. Remedies used for the relief of pain are called anodynes or analgesics. They may be systemic, acting through the nervous system, or local. Of the systemic anodynes, the most important is opium, especially its principal salt, morphin. Others are bella- donna, cannabis indica, hyoscyamus, antipyrin, acetanilid, phenacetin, and many others. Local anodynes are heat, especially moist heat, cold, the different forms of counterirritation, and several drugs,— belladonna, camphor, chloroform, etc.,—usually applied in the form of liniments or plasters. A condition in which pain when afflicted is not felt is known as anesthesia. Unless produced by the action of a general anesthetic, it is due to paralysis of the sensory nerves. It may be strictly local, as in the facial paralysis DELIRIUM 689 often temporarily following a mastoid operation, or as produced by a local anesthetic; or it may involve half of the whole body, as in paraplegia. Hyperesthesia is an abnormal sensitiveness to touch, and is most commonly found associated with neurasthenia or hysteria. Absence of pain may sometimes be a grave symptom. Thus in accidents to the spine no pain is felt below the seat of injury, owing to total paralysis caused by pressure on the spinal cord; in a deep burn pain is absent, owing to the destruction of the nerve-endings; in cases of severe shock, pain is frequently not experienced, even in violent injuries. DELIRIUM Delirium is an acute disorder of the mental faculties, due, commonly, to disease. Two types are recognized, low muttering delirium and wild delirium. The low muttering delirium is characterized by dis- connected, irrational speech, restless impulses, and im- paired will and motor power. Disturbing dreams and attacks of weeping or excitement are common. In mild cases the delirium is intermittent and the patient can fre- quently be roused to answer questions sensibly. In more severe cases the muttering is constant, the patient appears insensible to his surroundings, and fails to show any recog- nition of his friends. The stools and urine are passed involuntarily. Plucking at the bed-clothes, or carphology, is a frequent symptom. Low muttering delirium is com- mon in all the acute infectious fevers. In typhoid fever it is to some extent almost invariably present. Where restlessness is a feature, the patient continually tries to get out of bed, and not infrequently to escape by the window. Low muttering delirium is commonly treated by hydro- therapeutic measures, especially the cold tub-bath or the wet pack. Either of these measures almost invariably relieves the symptoms for a time. Wild delirium is a condition of maniacal excitement. It is usually associated with toxic conditions not due to bacterial infection. The deliriums of uremia, alcoholism, 44 690 SYMPTOMS AND CONDITIONS FREQUENTLY MET and of poisoning by a certain class of drugs are examples. The drugs which induce delirium are known as deliriants; such are belladonna, stramonium, hyoscyamus, and others. Patients of alcoholic habit frequently develop wild mania in the course of an acute infectious disease. The patient is noisy, violent in his actions, insensible to his surround- ings, and difficult to control. The eyes are wide open and staring, and usually dilated; the face is flushed; the speech is incoherent and rapid. The condition is generally con- trolled by the use of sedatives or narcotics, and the patient's general health is carefully supported by regular nourish- ment. In alcoholic cases a certain amount of stimulation is usually necessary. The treatment includes the means for eliminating or neutralizing the poison. Enforced physical restraint may be necessary. Delirious patients require watching, even when the - symptoms seem mild. The character of the delirium may change abruptly, and the patient escape by the window or do himself other injury. In wild delirium a homicidal mania may develop. The means for quick restraint should always be at hand. The fact should be borne in mind that delirium may develop suddenly in any condi- tion associated with high temperature, and such patients should constantly be under close supervision. Delirium due to great exhaustion is frequently associated with the end of a long illness or conditions of low vitality, such as following shock or profuse hemorrhage. The chief treatment is in the support of the patient's strength by regular nourishment, stimulation, hypodermoclysis, or in- travenous infusion of normal salt solution, and so forth. The wild delirium associated with acute alcoholism is known as delirium tremens, from the tremors (subsultus) which characterize the condition. DELUSION, ILLUSION, HALLUCINATION Delusion is the persistent possession, by the mind, of a false belief, sufficiently strong to influence the actions; for example, the fixed conviction that the life is threatened. Illusion is a false conception concerning some actual COMA 691 material object; for example, the mistaking of a piece of furniture for a wild beast. Hallucination is a perception of objects or sounds that have no demonstrable existence; for example, the hearing of voices or the seeing of imaginary persons or animals. COMA Coma is a condition of complete unconsciousness. The appearance is that of deep sleep; in certain conditions it may be accompanied by delirium. Coma may occur in any condition associated with pro- found exhaustion, such as the end of a long illness, severe shock, or following profuse hemorrhage; in toxic conditions, as the infectious fevers, uremia, alcoholism, and the aceto- nuria of diabetes, and in poisoning by many of the func- tional poisons. It is a symptom in many diseases of the brain, and one of the early evidences of brain pressure. In this condition it is accompanied by changes in the respira- tion, most commonly stertorous breathing. The coma due to a toxin may be relieved by means to eliminate or neutralize the poison. In the coma due to alcoholism, opium poison, and like causes, efforts are made to rouse the patient by talking, shouting, enforced move- ments, cold affusions, etc. Diabetic coma is regarded as a fatal condition, though the patient may linger a few days. Coma accompanying a condition of profoundly lowered vitality is treated by prompt stimulation, external heat, infusion or hypodermoclysis of normal salt solution, and other means described under Shock or Collapse. In the large majority of cases death is preceded by a period of coma of short or long duration. Stimulation of the vital centers by atropin, strychnin, camphor, etc. or the injection of normal salt solution, may prolong the condition and in some cases induce a temporary return of consciousness. In many conditions this form of coma is accompanied by Cheyne-Stokes' respiration. Coma vigil is the name given to a state of unconscious- ness where the eyes, the pupils dilated, remain open, with an intensely watchful gaze. The condition may be accom- panied by delirium. It is seen in conditions of extremely 692 SYMPTOMS AND CONDITIONS FREQUENTLY MET lowered vitality, and is always a grave symptom, generally signifying approaching death. Other conditions of unconsciousness, usually attributed to hysteria or disturbed mental conditions, are—trance or simulated death, catalepsy, in which the patient, ap- parently insensible, will remain for a long period in any fixed position, and ecstasy, an exalted condition frequently accompanied by extravagant movements, such as dancing, during which the patient is apparently insensible to his surroundings. INSOMNIA Insomnia, or inability to sleep, is a common occurrence in most disturbed physical conditions, and especially so in conditions associated with fever, with pain, or following a severe physical or mental strain, such as an accident or an important operation. In the acute fevers there is little or no natural sleep during the fastigium, or febrile stage. The return of natural sleep is a favorable symptom; it is frequently a feature of the crisis. Acute insomnia in persons of alcoholic habit is generally a preliminary symptom of delirium tremens, and for this reason is always promptly treated. In middle age and elderly people, occurring especially after a shock or a long exhausting illness, insomnia is not infrequently the first sign of insanity. In the acute fevers, insomnia, unless associated with great restlessness, is not usually specially treated. A tepid or hot-water sponging, an ice-bag to the head, attention to comfort and quiet, will predispose to as much sleep as is possible. In these conditions patients are indifferent to the passing of time, and loss of sleep is rarely complained of. In loss of sleep due directly to pain, anodynes are com- monly given, of which the most potent is opium in some form, usually morphin, given hypodermically. Where acute pain is not a feature, milder drugs, such as antipyrin, phenacetin, sulphonal, veronal, and many others, should always be preferred to morphin; they have less constitu- tional effect, and there is not the same risk of forming a habit. INSOMNIA 693 In giving drugs to relieve incidental insomnia, much judgment must be exercised by those to whom the giving is intrusted. Other means to induce sleep should be tried first. Evening visitors and excitement should be forbidden: quiet occupation or reading aloud substituted, and the patient's attention diverted from his own condition; his comfort should be carefully attended to, and disturbing noises prevented as far as possible. A warm tub-bath, when practical, or a sponge-bath, an alcohol rub, a hot- water bag to the feet and cold applications to the head, or massage of the spine and forehead, may often prove effi- cacious. If the administration of the drug becomes necessary, it must be given after every other duty connected with the patient or the sick-room is finished. It seems hardly neces- sary to add that a sleeping patient must not be roused for a sleeping draft; but in intrusting the administration of medicines to a pupil, she must at least be carefully in- structed as to which medicine is for hypnotic purposes, and given orders not to administer it unless necessary. The giving of a placebo, in the shape of a sugar capsule or sterile water hypodermic, is sometimes resorted to when other means of breaking the patient of the use of a narcotic have failed. To decide upon doing so is not the nurse's function. The most difficult patient to break is the one whose insomnia has been the result of pain. His dread of its recurrence will often lead him to feign pain in order to procure what will prevent its return. A patient's own account of his sleep should neither be disregarded nor receive implicit credence; nor should his own account ever be contradicted in a report given in the patient's hearing. Great pains should be taken to measure both sleeping and waking intervals by the clock, and to record both accurately on the chart. Broken sleep is not restful. On a report, for example, " sleep, four hours " should mean only four hours' consecutive sleep. If the four hours is the total sum of many short sleeps, with rest- less intervals between, the record chart should state the fact clearly. Chronic insomnia occurring in health is one of the most 694 SYMPTOMS AND CONDITIONS FREQUENTLY MET intractable of conditions to cure. It is most commonly due to mental conditions, such as brain fatigue or persist- ent worry; it may result from injudicious use of tea or coffee, the alcohol habit, deficient hygiene, sedentary habits, or lack of outdoor exercise. Many cases are referred directly to eye-strain. Insomnia is a frequent accompaniment to habitual constipation. Where the cause is known, the first step is to remove or alleviate the cause. In many cases, however, the habit once formed tends to persist. The general health should receive close attention, and the habits regulated to in- clude fresh air and a reasonable amount of exercise. Coffee and tea should be given up or taken only in the early hours of the day, and the use of alcohol restricted or forbidden. Frequently, stopping all brain work, even pleasurable brain work, at an early hour in the afternoon has a beneficial result. The effect of a light meal in place of the heavier dinner at night should be tried. At bedtime means are used which have for their object the reduction of the blood-supply in the brain. An anemic brain will sleep. Heat to the extremities and cold to the head are the usual means. A hot tub-bath or hot foot-bath, hot-water bags to the feet or over the abdomen, with an ice-bag or bag of ice water to the head, are simple means. The cold bag should be placed at the back of the neck and side of the head. A light meal, a cup of warm milk, or hot whisky toddy may, in milder cases, be sufficient to divert the blood from the head to the stomach and induce sleep. Other means are massage, either gen- eral or to the spine and head, and the wet pack. In very overwrought conditions the wet pack is usually the best immediate treatment. Acute insomnia in health is frequently seen as the result of abnormal mental effort or .acute business worry. The best treatment is complete change of scene and occupation. When this is impossible, the amount of mental work should be reduced to a minimum, and the health and habits carefully regulated; of the means of immediate treatment, the wet pack is generally the most beneficial. Insomnia in a child is usually due to a mental condition, PARALYSIS 695 and always an important symptom. Women are more prone to insomnia than men. Aged people are wakeful, but, as a rule, they do not suffer from the effects of loss of sleep. When it becomes necessary to employ drugs for insom- nia, the ease with which the narcotic habit is formed should never be lost sight of. It should never be begun without medical advice nor continued away from medical super- vision. The excitable temperament most liable to in- somnia is liable to be deficient in self-control. PARALYSIS By paralysis we usually understand a loss of the power of movement, usually also accompanied by loss of sensa- tion, not due to local impairment, but to disturbance of the nerve-centers that govern movement. This disturb- ance may be due to disease, to direct injury, or to pressure. With our complex nervous system, the varieties of par- alysis are numerous. We find a special lesion in some special part of the brain or spinal cord, followed by special symptoms of impairment of power and nutrition in special groups of muscles. In many cases the group of symptoms are classed as a disease and known by the name of the observer or authority who originally called attention to the special manifestations. A large number of these forms of paralysis are the result of changes due to incurable disease and develop very slowly. Paralysis may affect one entire side of the body (hemi- plegia), or the whole body below a certain point in the spine {paraplegia); paralysis may also be strictly local, affecting one limb or a special group of muscles, as in facial paralysis. Hemiplegia.—In hemiplegia the lesion is in the brain, in paraplegia the spinal cord is the seat of injury. Hemiplegia is most commonly the result of an apoplexy or cerebral hemorrhage, and begins with an acute condition of unconsciousness, stertorous breathing, etc.; it may also result from disease of the brain tissue, embolism, or press- ure on the brain from a tumor or depressed fracture of the skull (p. 624). 696 SYMPTOMS AND CONDITIONS FREQUENTLY MET In a typical case of apoplexy, the patient falls to the ground in an unconscious condition, the respirations are stertorous, the pulse full and slow, the face congested and somewhat cyanosed; the eyes are half open and the pupils do not react to light. There may be twitching of the muscles or epileptiform convulsions. The temperature is first subnormal and later usually raised. As the acute symptoms subside, the patient is found to have no power on one side of his body. In some conditions sensation is not lost, in others there is either complete or partial anesthesia. With some rare exceptions the paraly- sis is on the opposite side to the injury, owing to the fact that the nerves cross at the part of the brain known as the pons, so that the nerve-center that governs the move- ment of a muscle is situated in a portion of the brain on the opposite side from the muscle it governs. In hemi- plegia of the right side of the body the organ of speech is usually affected. Recovery in hemiplegia follows removal of pressure, in some conditions from surgical intervention, usually from gradual absorption of the blood-clot. Where the hemor- rhage has been due to arterial degeneration, apoplexy is very liable to recur, and eventually to prove fatal. After several attacks, or where the injury has been extensive, hemiplegia usually results in impairment of the mental faculties: loss of memory, mental sluggishness, and aphasia are common effects. Paraplegia, or paralysis of the lower extremities and lower part of the trunk, is the result of injury or disease involving the spinal cord. Occurring suddenly, the most frequent cause is fracture or dislocation of the spine (p. 629). The motor and the sensory nerves are both paral- yzed, and the bladder and rectum involved. Unless the injury has also caused concussion or other brain condition, the mind is clear. Paralysis occurs below the seat of lesion; when this is so high as to involve the muscles of respiration, death occurs from asphyxia. Cases of mild injury recover com- pletely, others live years with the body paralyzed from the waist downward. Severe injuries are usually fatal: the EDEMA 697 patient lingers a few months and finally dies of exhaus- tion or one or other of the complications of the condi- tion. Special forms of paralysis frequently met with are in- fantile paralysis and facial paralysis. Infantile paralysis, acute anterior poliomyelitis, affects certain groups of mus- cles in the lower extremities, and is due to alterations in a minute portion of the spinal cord. Facial paralysis ' i is an affection of the nerve-endings, generally due to in- flammation of the periphery, sometimes from such a trifling cause as sleeping in a draught. The condition may also be the result of pressure on some part of the nerve, from which reason it is sometimes present as a temporary condition after operations on the mastoid. EDEMA Edema is a swelling due to the accumulation of fluid in the tissues. It may be caused by local inflammation, as in contused wounds. When it is a simple infiltration of fluid from the blood-vessels, unattended by inflammation, it is known as dropsy. Dropsy.—The characteristic appearance of dropsy is a puffy, colorless swelling which pits on pressure. That is to say, if the finger is pressed over the surface a depression is made which persists for an appreciable time. The skin has a waxy hue, and when the dropsy is excessive, a stretched, shiny appearance. The fluid in dropsy is derived directly from the circula- tion. It may be forced out through the walls of the capil- laries by the pressure of a venous obstruction, or may result from changes in the capillary vessels themselves, or from alteration in the composition of the blood. The most common conditions associated with dropsy are nephritis, chronic valvular heart disease, and anemia. A local dropsy, i. e., confined to one limb, is most commonly the result of a thrombus. It may also be produced by any condition causing pressure, such as a tumor, or prolonged mechanical constriction, as in tight bandaging. The dropsy in nephritis first appears about the eyes, and is most noticeable on first waking, and on the side on which 698 SYMPTOMS AND CONDITIONS FREQUENTLY MET the patient has been lying. In heart disease the dropsy first appears about the feet and ankles, and gradually ascends. The dropsy of anemia is usually confined to a puffiness of the feet and ankles, observed at the end of the day and improved by the night's rest. The term dropsy is also used for accumulations of fluid in the cavities of the body, as, for example, the pericar- dium or the abdomen. The fluid is confined to the cavity and does not infiltrate the tissues in the vicinity. Fluid in the abdomen is called ascites; a condition of general dropsy is called anasarca. The condition of dropsy is treated principally through the underlying cause of the dropsy. Active elimination by the bowels and kidneys, and, where the kidneys are im- paired, increased elimination by the skin are the principal points of general treatment. In conditions of extensive dropsy saline purgatives are frequently ordered in strongly concentrated solutions. As a rule, fluids are restricted in the diet, but this depends on the underlying cause. (See Salt-free Diet, Chap. XXIII.) For the local treatment of dropsy, see Paracentesis, p. 518. Where drugs with accumulative properties are being taken by dropsical patients, it should be borne in mind that a sudden withdrawal of the fluid may be followed by symptoms of overdose of such drugs (p. 306). The drug, to a large extent, it is considered, has been held in suspen- sion in the excessive fluid, and becomes suddenly set free in the system. This is especially the case with digitalis, which, both as a heart tonic and as a diuretic, is largely used in the treatment of heart disease and nephritis. VOMITING OR EMESIS This is a forcible ejection of the contents of the stomach. The causes of vomiting may be local or remote. Local causes are those that arise from disturbance of the function of the stomach. The most common are indigestion, catarrh or disease of the stomach, the action of certain irritants, such as mustard or zinc, known as emetics; the VOMITING OR EMESIS 699 action of corrosive and irritant poisons, and obstruction at some part of the alimentary tract. Remote causes are those that produce vomiting by irritation, direct or reflex, of the central nervous system. Vomiting due to nerve irritation is described as central vomiting. Common causes of central vomiting are: dis- ease of the brain, pressure on the brain from a tumor or injury; the presence of toxins in the blood as in uremia, the invasion of the system by an acute infection; the ac- tion of certain drugs, such as apomorphin or ipecacuanha, known as central emetics, the toxic action of many drugs, especially nerve depressants; violent swinging, as in sea- sickness; and reflex irritation, as in pregnancy, worms, etc. Reflex vomiting may be excited by tickling the back of the throat or by strong unpleasant odors and tastes. Central vomiting occurring in conditions of shock shows a return of vitality in the nerve-centers, and is considered a favor- able sign. Regurgitation is the simplest form of vomiting. It consists in the rejection of some of the contents of the stomach before digestion has taken place. It occurs com- monly in infants, from too rapid feeding. Occurring as a constant symptom after small quantities only have been taken, it is frequently caused by stricture of the esophagus. The appearance and odor of regurgitated food are not changed. An attack of vomiting is usually preceded by headache, nausea, and local discomfort, either pain or distention, and accompanied by retching and eructation of gas. If the stomach is loaded, the contents are vomited in a partially digested condition. If the stomach is empty, as after a previous attack of vomiting, the vomitus is usually small in quantity, greenish yellow, viscid, and with a bitter taste, owing to the presence of bile. This is ihe ordinary attack of vomiting, due to a large variety of causes— gastric disturbances, the so-called bilious attack, sea-sick- ness, intestinal obstruction, the after-effects of an anes- thetic, etc The attack is followed by a sensation of relief and relaxation. Treatment.—If a patient is unconscious, it is important 700 SYMPTOMS AND CONDITIONS FREQUENTLY MET to keep the head turned to one side, so that the vomitus does not enter the larynx. A patient in an extreme con- dition of exhaustion should not be allowed to sit up or raise the head; the vomitus should be received on a towel or in a shallow vessel. Persistent vomiting is difficult to control. All food should be withheld, the recumbent position maintained, and bright light or moving objects excluded. Counter- irritants, such as a mustard plaster, hot fomentations, or a small blister, over the stomach, together with an ice-bag to the head, may have the desired effect; or an ice-bag may be applied over the stomach. In many cases lavage gives relief. The lavage may be of plain warm water, or contain bicarbonate of soda, to counteract the acidity of the stomach. The drinking of one or two pints of warm water will usually act as lavage without the necessity of passing the stomach-tube. In some cases the inhalation of vinegar gives relief. As a rule, the head should be kept low; in a few instances elevation of the head of the bed has had a beneficial result. When the cause is an error in diet, lavage, followed by a purge, such as castor oil, is often the quickest remedy. Where the castor oil cannot be retained, an enema may be given. Cracked ice to suck or brandy or champagne poured over crushed ice and given in sips are usually acceptable remedies. Drugs frequently prescribed for the condition are morphin by hypodermic {^ to | grain), opium, usually by suppository (^ to 1 grain), cocain (& grain), astringents, such as bismuth subnitrate (10 grains), cerium oxalate (5 grains, given dry on the tongue), hydrochloric acid diluted (5 to 10 minims), and others. In some instances obstinate vomiting has been checked by 1-minim doses of carbolic acid in water. If sleep can be induced, the attack frequently passes off. A cleansing, non-nauseating mouth-wash should be given to rinse the mouth. Vomiting occurring regularly on rising in the morning is a common symptom during the early months of preg- nancy. It is unaccompanied by nausea, headache, or HICCUP; SINGULTUS 701 retching. The vomitus usually consists of a little mucus. It may often be prevented by drinking a cup of tea before moving. Mucous vomiting on rising is also a common symptom in chronic alcoholic gastritis. For abnormal constituents in the vomitus, see Chap. VII. HICCUP; SINGULTUS The spasmodic inspirations known as hiccup are caused by a spasm of the diaphragm accompanied at the same time by spasm of the glottis. In health an attack of hiccup is the result of minor causes, such as slight gastric disturbance from overacidity, from bolting the food, or from energetic exercise too soon after eating. The spasms may usually be overcome by drinking water, either alone or with a little sugar or bicar- bonate of soda, or by holding the breath and so keeping the diaphragm and glottis immovable for a time. Attacks of hiccup occurring in the course of disease are usually significant and often difficult to treat. When associated with conditions of shock or collapse, hiccup is a symptom of serious exhaustion. In certain conditions attacks of hiccup occur from reflex irritation, these may be: disease of any part of the alimentary tract, pressure from an aneurysm, toxic conditions, such as uremia, nervous disorders, and in conditions caused by pressure on the brain; intractable hiccup is not infrequently met with in hysteria. The spasm if long continued is extremely exhausting. The usual remedies tried are hot applications or counter- irritants applied over the abdomen; hot whisky and water by mouth; or emptying the stomach by an emetic or lavage. Antispasmodics may be effective; those usually prescribed are musk, Hoffmann's anodyne, or camphor. Sedatives or narcotics are given to induce sleep; chloroform inhala- tions and morphin are used in extreme cases. Frequently no treatment has any lasting effect. A special movement in massage is sometimes followed by good results. The fingers are placed over the ribs on 702 SYMPTOMS AND CONDITIONS FREQUENTLY MET either side, so that the thumbs meet at the sternum. Rhythmic strokes are then made with the thumbs from the sternum downward and toward the sides, following the line of the margin of the ribs. The treatment is chiefly valuable in hysterical hiccup. CONSTIPATION Constipation is the most common of minor disorders, either in health or disease. It may be acute or chronic. Acute constipation is usually due to an error in diet, sudden alteration in normal habits, or changes of climate. It is generally most quickly relieved by a dose of castor oil, or a course of calomel followed by sulphate of magnesia, and subsequent attention to diet and hygiene. The tendency to chronic constipation is frequently hereditary. It may be acquired by careless habits, seden- tary occupations, or injudicious diet. Other causes are nervous strain, overfatigue, and the alcohol habit. Physical symptoms that accompany constipation are headache, loss of appetite, nervous irritability, and slug- gishness of mind and body. If allowed to become habitual, constipation is liable to result in the formation of hemor- rhoids, anal fissures, or in intestinal obstruction from fecal impaction. Treatment.—The condition should be regarded as a menace to health and not allowed to continue. The formation of a punctual habit, combined with tonic measures, such as cold bathing and regular exercise, will frequently, if persevered in, cure even obstinate cases. The diet should be studied to ascertain the food best suited to the individual. Whole wheat bread, oatmeal, and fruit, particularly cooked fruit, are mildly laxative (Chap. XXIII). The meals should be taken at regular hours and eating between meals discouraged. Water, either hot or cold, should be drunk regularly, and is especially beneficial taken at bedtime or on first rising. A general tonic, such as strychnin, will frequently benefit the condition. Good hygiene and warm clothing, especially woolen wear next the abdomen and for the feet, are important factors, and particularly so with children. DIARRHEA 703 The constipation may be largely due to weak muscular action, and chiefly affect the lower bowel. In these cases a simple enema or a suppository of soap or glycerin are generally effective, and their use for a short time may help to establish a regular habit, especially in young children. Their persistent use, however, has an irritating effect on the local mucous membranes, and may lead to the formation of fissures. When drugs become necessary, they must be used with caution, and discontinued as soon as possible, as the sys- tem quickly comes to rely on them. Mild drugs are to be preferred to drastic purges. Many cases of obstinate constipation are benefited by regular abdominal massage. It should be given punctually at the same hour every day. When an expert masseuse is not procurable, the massage may be efficiently performed with a cricket ball or base- ball. Placed over the lower part of the abdomen to the right, the ball is carried slowly upward, with a rotatory movement of the palm of the hand, then across the abdo- men, and, finally, down on the left side, the movements following the direction of the colon. The pressure should be firm and even, but not forcible; the process is usually prescribed for about ten minutes at some time when the intestines are at rest, preferably in the morning. Constipation is a common accompaniment to many diseases, especially those that interfere with the process of nutrition or, from whatever cause, obstruct the secre- tion of the digestive juices. It is present in many forms of gastritis, enteritis, cancer of the stomach and intestines, jaundice, and pancreatic disease; in brain affections and nervous conditions; in anemia; and commonly in the acute infectious fevers. In many of these conditions the stools have a characteristic appearance. (See Excreta.) DIARRHEA By diarrhea is understood an abnormal frequency of the stools, with a change in their character and consistency. (See Excreta.) Commonly, it is an acute condition associated with in- flammation of some part of the alimentary tract. It is 704 SYMPTOMS AND CONDITIONS FREQUENTLY MET symptomatic of the water-borne infections, typhoid fever, dysentery, and cholera; it is common in all forms oLgas- tritis or enteritis, both acute and chronic, and may be associated with chronic constipation; it accompanies acutely septic conditions, and is usually a symptom at the close of long, wasting illnesses; an attack of diarrhea is also a common accompaniment of the crisis of an infectious fever, such as pneumonia. The chronic form of diarrhea is commonly associated with chronic dyspepsia. Persons who have suffered formerly from typhoid fever or dysentery are subject to attacks of diarrhea from trifling causes or in any low- ered condition of health. In nervous persons acute diarrhea may result from ex- citement or strong emotion. Physical symptoms that accompany an acute attack of diarrhea are nausea, frequently vomiting, abdominal cramps, distention, straining (tenesmus), loss of appetite, and thirst; slight fever is not uncommon; on the other hand, the temperature may be subnormal. The first treatment of an acute attack, not associated with a specific disease, is to clear the alimentary tract by a quickly acting purgative, in order to get rid of the source of irritation. Castor oil is usually preferred. If not effectual in two or three hours, it is followed by a simple enema. After one or two actions from the castor oil, the diarrhea, in favorable cases, is checked; if not, astringents, such as bismuth subnitrate (10 to 20 grains), are usually ordered, repeated every three or four hours until effectual, or opium in some form may be given (usu- ally paregoric, 2 to 4 drams, or tincture of opium, 10 to 20 minims; the dose may be repeated once). Brandy, taken raw (1 to 2 drams), has frequently a beneficial effect. Meantime solid food should not be taken. The after- treatment of the condition is chiefly dietary. (See Chap. XXIII.) Fatigue and exposure to cold, damp, or to sudden changes of temperature must be avoided; fre- quently a short time in bed is the quickest remedy. Diarrhea in infants is always an important symptom, and may quickly become a very serious condition. It may RIGOR 705 result from injudicious feeding, sour or impure milk, dirty feeding bottles, from cold or wet feet, or from exposure to high atmospheric temperature. It is a common dis- order in the summer months, particularly with bottle-fed babies. It is also the accompaniment of all acute infec- tions of the alimentary tract to which infants, especially neglected and bottle-fed infants, are liable. Unless treatment is prompt, the condition may be fatal. The first treatment aims at removing the irritating cause, usually with a purge (unless in infectious conditions, where special treatment is necessary), following which the treat- ment is largely dietary (Chap. XXIII). If the condition persists, astringent enteroclysis is frequently ordered. RIGOR An acute paroxysm of shivering is known as a rigor or chill. In severe cases the shivering is accompanied by the sensation of intense cold, especially referred to the back and spine; the surface is cold to the touch, the teeth chatter, the features are blue and pinched, the pulse is small, hard, and rapid, and the vitality greatly depressed. The par- oxysm may be so violent that the bed on which the patient lies is actually shaken. The temperature for a short time is subnormal, but rapidly rises. The attack lasts from a few minutes to half an hour or more. In cases of malaria the characteristic rigor frequently lasts an hour. A short time after the shivering has stopped, a rigor is followed by a hot stage, the characteristic symptoms of which are high temperature, full, bounding pulse, headache, a hot dry skin, and other evidences of fever. A rigor always has a definite signification. It is the usual accompaniment of the onset of all infectious fevers that begin abruptly, such as pneumonia, erysipelas, etc.; of all septic conditions, especially when accompanied by suppuration, and is the characteristic symptom of the first stage of an attack of malaria. Occurring in connec- tion with an open wound, as after an operation, or in the course of an acute illness, a rigor indicates some suppura- tive process. In all intermittent fevers (see Fever) the rise of temperature is usually accompanied by rigors of 45 706 SYMPTOMS AND CONDITIONS FREQUENTLY MET more or less severity. In these cases the hot stage, which may last but a short time or for several hours, is followed by a stage of sweating in which the temperature again falls. Not infrequently prolonged or difficult catheterization is followed by a rigor and rise in temperature. The rigor may be purely nervous in its origin, in which case the tem- perature does not remain high and the acute symptoms quickly subside. More often the rigor indicates infection from a non-sterile catheter, unclean hands, etc., and ushers in an attack of septic cystitis. A nervous chill may follow an accident or severe strain. Although frequently quite severe, it is not followed by any marked rise in tem- perature or other symptoms of fever. As a rule, children do not have rigors. Conditions that in an adult would be associated with rigor, in a child are usually accompanied by convulsions. The treatment of a rigor is the application of warmth— warm coverings, hot-water bottle, and hot drinks. Fre- quently stimulation, such as hot whisky and water, is ordered. The patient should be kept in bed and carefully protected from draughts. The hot stage is treated with light covering, an ice-bag to the head, and plenty of water to drink. The pulse, and, where practical, the temperature, should be taken at the beginning of a rigor, immediately after, and again in half an hour's time. The duration of the rigor, the pulse and temperature, and any other prom- inent symptoms should be carefully recorded on the chart. SWEATING An attack or profuse sweating, or diaphoresis, is the com- mon feature of any crisis following a period of high tem- perature. (See Crisis.) In such condition it is a favorable sign, and is accompanied by a fall of temperature and a general condition of improvement. A typical example of a favorable diaphoresis is the profuse sweating in the third stage of a malarial paroxysm. Accompanying a condition of profoundly lowered vital- ity or general collapse, with clammy skin, cold extremities, and small feeble pulse, sweating is an unfavorable symp- tom. It may be associated with a high or a subnormal tern- SWEATING 707 perature. Such a condition is frequently seen shortly before death. Severe sweating, usually occurring at night, is a common feature of enfeebled conditions associated with hectic fever, such as the later stages of tuberculosis and septicemia. Periodic attacks of sweating are a common symptom in acute inflammatory rheumatism; the sweat is peculiarly acid and has a characteristic sour smell. Attacks of sweating are also a characteristic accompaniment of the convulsions of tetanus. Sweating may also be produced by great pain or by emotion, especially fear. In the latter case it is preceded by the creeping sensation known as goose-flesh, due to the contraction of the minute muscles attached to the roots of the hair. Sweating may be induced artificially by the applica- tion of external heat, such as the sweat-bath, hot pack, etc. (Chap. II). and by the action of certain drugs known as diaphoretics. The treatment of sweating lies in keeping the patient warm, dry, and protected from exposure to chill or drafts. While the sweating continues, he should be closely covered, preferably with material that will absorb the sweat, such as flannel or blankets. If a cotton shirt is worn, it is best to remove it at once, as when wet it has a chilling effect. When the sweating ceases, the skin should be quickly dried with hot towels, and the wet clothing changed, the whole process being carried out strictly under cover. A brisk alcohol rub may be added where practical, and will help to check a continuance of the sweating. The sweating of tuberculosis is reduced by methods that reduce the fever, especially sleeping and living in the open air. To some extent tepid or astringent sponging, such as vinegar and water, has a beneficial effect on the sweating of feverish conditions. The bed-coverings should not be heavy; if necessary, warmth may be supplied by the hot- water bag or the use of woolen socks. The sweating of rheumatic fever is frequently indirectly treated by hydrotherapeutic measures, such as cold bath- ing or sponging. The patient should sleep between blan- 708 SYMPTOMS AND CONDITIONS FREQUENTLY MET kets and wear a flannel shirt. To remove the disagree- able odor of the sour perspiration, sponging with hot water or hot water and vinegar is generally practised. It must not be begun until the diaphoresis is completely over. Certain drugs have the property of checking sweating (anhydrotics); that in most general use is belladonna, with its alkaloid, atropin. Unilateral sweating, or sweating confined to one side of the face, is a phenomenon that occurs from pressure on certain nerves of the sympathetic system, either from a thoracic aneurysm or other tumor. Sudamen.—A peculiarly pretty eruption of minute, pearly vesicles is known as sudamen. It consists of fine beads of perspiration that have become imprisoned in the upper layer of the skin. It is usually seen in connection with free perspiration. The condition requires no treat- ment; the vesicles dry up, leaving a superficial desquama- tion. FEVER A condition in which the body temperature is raised above 100° F. is said to be one of fever. A raised tempera- ture is a common feature of many physical disturbances (see Temperature). By the term fever in its more re- stricted sense we understand a condition in which the tem- perature is persistently raised for certain defined periods, the rise being associated with a group of characteristic physical symptoms. The cause of fever in the majority of cases is attributed to the presence in the blood of toxins or poisons (Chap. XI), usually the production of bacterial activity. These are the so-called infectious fevers, such as typhoid fever, smallpox, malaria, and others. In other cases the toxins are sub- stances produced by the natural activity of the body, which, owing to defective elimination, have entered the circula- tion. Such are the toxins in uremia or in auto-intoxica- tion. A fever not due to infection, but the result of overfatigue, gastric disturbances, exposure to heat, etc., is known as simple continued fever. Conditions in which the FEVER 709 secretions of the body are abruptly checked are also associ- ated with fever. A mild example is the fever attending the common " cold "; a grave example, the high fever of heat- stroke. The physical symptoms that accompany fever are— malaise, chilliness, headache, nausea, loss of appetite, thirst, constipation (or, less frequently, diarrhea), and coated tongue. The pulse is full and bounding; both pulse and respiration are quickened in proportion to the rise of temperature (see Temperature). The skin is hot and dry, the face flushed, the mouth parched, the urine scanty and concentrated, and frequently albuminous; the patient is restless and sleep is disturbed. When fever begins abruptly, the chilliness may be severe and takes the form of rigors. As already said, in children convulsions usually take the place of rigors. An abrupt onset in chil- dren is usually also characterized by a sudden attack of vomiting. As the fever progresses, further symptoms are prostration, emaciation, and nervous symptoms—insomnia, startling dreams, and, in severe cases, delirium or coma. The coated tongue has a tendency to become heavily furred, dry, and fissured. The symptoms that mark the beginning of a fever are called prodromes. The most common are malaise, chilli- ness, headache, loss of appetite, gastric disturbance and restlessness, and, in children, vomiting. It is to the pro- dromes we refer when we talk of a person " sickening " for an illness. In many of the specific fevers there are characteristic prodromes. For example, in measles there is a characteristic coryza; in scarlet fever, soreness of the throat; in smallpox, agonizing pain in the back and limbs. Course.—A fever is divided into three periods: the invasion or onset, the fastigium, also called the stadium, and the decline (p. 157). In the specific fevers the average length of duration of each period varies within the different infections. During the invasion period the temperature rises and the characteristic symptoms gradually develop; during the fastigium the temperature remains at or near its highest point, with certain variations in each twenty-four 710 SYMPTOMS AND CONDITIONS FREQUENTLY MET hours; the symptoms are intensified, especially the ner- vous symptoms, and emaciation, which progresses rapidly. During the period of decline the temperature falls until the normal is regained; in favorable cases all the symptoms improve. The skin begins to act naturally, the urine is increased in quantity, the bowels are less constipated, some diarrhea is frequently present, sleep is natural, the tongue becomes moist and clean, and the mental condition improves. During the decline, prostration is a prominent symptom; it is especially at this time that, unless carefully supported, the overtaxed heart may fail. In some fevers the invasion is abrupt, the temperature rising rapidly in a few hours to a considerable height, in others the rise is slow, the temperature rising and falling from day to day, but each daily scale of temperature being higher than that of the preceeding twenty-four hours. The invasion is then described as gradual. A decline occurring abruptly is called a crisis; occurring gradually, a lysis. Only a few fevers commonly terminate by crisis. They are pneumonia, measles, typhus fever, erysipelas, malaria, relapsing fever, and, frequently, influenza. A crisis is accompanied by marked characteristic symp- toms. They are profuse perspiration, a large increase in the quantity of urine, frequently diarrhea, sensations of chilliness or shivering, unless the body is well protected. Some prostration is always present, and there is risk of sudden cardiac failure. In favorable cases the patient falls into a natural sleep and awakens refreshed. At the end of the decline convalescence is established. Daily variations in the temperature are known as remissions (see Temperature). Where the remissions are slight, not more than a degree to a degree and a half, the fever is said to be continued. Where the remissions are greater, but where the whole scale of temperatures is entirely above normal, that is to say, fever is always present, the fever is said to be remittent. A few characteristic paroxysms of high temperature followed by remissions, in which the temperature falls to normal or subnormal, is described as intermittent; that is to say, in an intermittent fever there is a period in which there is no fever. This period may be FEVER 711 a daily remission, lasting a few hours, as in many forms of septicemia, or it may occur after a short, acute access of fever and last for one or more days, as in the different forms of malaria; or again, a period of continued fever, lasting sev- eral days, may be followed by an intermission of several days, as in relapsing fever. In intermittent fever the characteristic symptoms of invasion, fastigium, and decline are present in an aggravated form and follow each other with great rapidity. Then, as the fever rises, we have an acute attack of shivering, followed quickly by the flushed face, hot skin, full pulse, high temperature, and other symptoms of the fastigium. The decline occurs as a crisis, with profuse sweating, increased urine, exhaustion, and a disposition to sleep. The fever, during a gradual invasion and toward the end of a lysis, is commonly remittent. During the fastigium it is generally continued. In fevers beginning abruptly and ending by crisis, such as pneumonia or typhus fever, the fever is continuous during the whole course of the disease. In typhoid fever, as a rule, the fever is remittent not only during the invasion and lysis, but also during the fastigium. Remittent fever lasting three weeks is one of the diagnostic symptoms of the disease. In acutely septic conditions, associated with the formation of pus, intermittent fever is common. Fevers that do not belong definitely to either class, but may evince in their course the characteristics of two or all three, are described as irregular. The fever in tetanus, and frequently in diphtheria, is irregular. Long, protracted fever is sometimes called hectic; as a rule, it is of the intermittent variety. It is common in septic conditions and generally accompanies the last stages of tuberculosis. Incubation Period.—In the specific infectious fevers the period occurring between the exposure to infection and the beginning of the invasion is known as the incubation period. Duration of Periods.—The table on p. 712 gives the average duration of the different periods in the more com- mon infectious fevers. Chicken-pox. Diphtheria. . Erysipelas German measles. Influenza. Measles. . Mumps......... Pneumonia, lobar Scarlet fever..... Septicemia. Smallpox. . Tetanus...... Typhoid fever. Typhus fever. Incubation. Invasion. About two weeks. A day to a week. Three days to a week. About two weeKs. A few days to a week. Usually two weeks. Two to three weeks. A few hours to one week. Usually three days. Ten days to two weeks. A few days to three or four weeks. Two to three weeks. A few hours to two weeks. Abrupt. Usually gradual or moderately abrupt. Usually abrupt. Gradual; one or two days. Abrupt. Gradual; about four days. Gradual; one or two days. Abrupt. Abrupt. Abrupt. Abrupt. Gradual. Gradual; seven to ten days. Abrupt. Fastigium. One to three days. Variable. Variable. Favorable cases a week to ten days. One to three days. Two to four days. Two to four days. Three to six days. Five, seven, or nine days; occasionally fourteen days. Two to four days. Indefinite. About eighteen days. Variable. A few days to several weeks. One to two weeks. Twelve to fourteen days. Lysis generally rapid. Lysis. Crisis. Lysis; rapid; a few days. Lysis or crisis. Crisis. Lysis; a few days. Crisis. Lysis. Lysis. Lysis. Lysis; a week or ten days. Crisis. Lysis; four to six days. s FEVER 713 ERUPTIVE FEVERS Certain acute infectious fevers are characterized by the presence of a skin eruption or rash; they are classed as the eruptive or exanthematous fevers. In each case the rash presents a characteristic appearance. It is usually first observed over some special area, appears on a certain day of the disease, and is followed by a more or less extensive shedding of the upper layer of the skin, a process known as desquamation. The shed particles should be regarded as infectious. Desquamation is described as branny (a powdery shedding of the surface skin), or may occur in scales, flakes, or crusts. The first day of disease is taken as the first day of abnor- mal symptoms, such as shivering, vomiting, malaise, and rise of temperature. Varicella, or Chicken-pox.—Rash appears on the first day of the disease. Character.—Rose-red papules which, except in mild cases, rapidly become vesicular. Intense itching is usually present. Distribution.—The rash appears simultaneously all over the body, coming out in groups. The vesicles are superficial, become pustules, and dry up in two or three days. The cuticle is shed in the form of thin crusts, con- sidered moderately infectious. Infection is considered to last until the crusts have all been removed and the skin is entirely healed. Scarlet Fever.—Rash appears on the second day of the disease, that is to say, between twenty-four and forty- eight hours. Character.—Diffuse, scarlet (erythematous), punctiform eruption, effaced by pressure. A quick stroke with the finger across the rash will leave a white line lasting several moments. Distribution.—The rash appears first on the chest and neck and rapidly covers the whole body. The whole face is involved, except an area round the nose and mouth, which remains pallid; the rash lasts from five to seven days, gradually fading, and followed by profuse flaky desquama- 714 SYMPTOMS AND CONDITIONS FREQUENTLY MET tion, the particles of which are considered extremely infectious. Infection lasts until the desquamation has entirely ceased—usually from six to eight weeks. Infection will last beyond this period if there should be discharges from nose, ears, or suppurating glands. The scarlet-fever rash is typical of many other rashes caused by accidental conditions (Chap. VI); the expres- sion scarlatinous rash is frequently used to describe them. The association of scarlet fever with special physical symp- toms, in particular with acute sore throat, and a char- acteristic appearance of the tongue, known as the straw- berry tongue, and the characteristic distribution of the rash confirms the diagnosis. Smallpox.—Rash appears on the third day of the disease. Character.—Small, round, red papules, feeling like shot beneath the skin, which develop into vesicles and finally become pustular. Papules, vesicles, and pustules (p. 206 may be seen together on small areas. As the rash appears the temperature usually falls somewhat and rises again as the rash becomes pustular, about the eighth day. When the eruption is so copious that the papules run together, the rash is said to be confluent. Distribution.—The eruption occurs first on the forehead, face, and wrists, finally involving the whole body. Desquamation occurs in scales with a peculiar offensive odor, each scab leaving behind a pit or pock which remains for a long time after the spot is healed and may be per- manent. Infection is considered to continue until the skin is entirely healed. Measles (Rubeola).—Rash appears on the fourth day of the disease. Character.—Macular and papular spots (p. 206), dark red in color, and usually occurring in groups forming a crescent. Distribution.—The rash appears first on the face, usually the forehead, and spreads rapidly over the body. It fades in from three to four days, followed by branny des- quamation. Itching is a frequent symptom. A few small, FEVER 715 bluish-white specks, scattered on the mucous membrane of the cheeks and lips, may frequently be observed before the rash develops. They are known as Koplik's spots. The acute catarrhal condition of the nose and eyes which accompanies the onset of the disease confirms the diagnosis. Infection lasts until the skin is quite free from desquama- tion or until all discharge from the ears or nose has stopped. German Measles (Rubella or Roseola).—Rash appears on the first or second day of the disease. Character.—It may resemble either the papular rash of measles or the diffuse, bright-red rash of scarlet fever. Distribution.—It appears first on the face or behind the ears, and rapidly spreads over the body. It fades very quickly, leaving a slight branny desquamation. It is distinguished from scarlet fever or measles by the slight physical symptoms and the rapidity with which the rash fades and convalescence is established. Typhus Fever.—Rash appears between the fourth and eighth days. Character.—Petechial rash (p. 207). The spots are first rose colored, then fade to a purplish hue known as mulberry rash. Distribution.—The rash occurs on the body, and is slight or diffuse, as the attack is mild or severe. Typhoid Fever.!—Rash appears in successive crops from the seventh to the fourteenth day. Character.—Rose-colored, isolated, lenticular (p. 206) papules, which disappear on pressure; frequently called typhoid spots. Distribution.—The papules most frequently appear in groups of two or three spots on the abdomen, but they may develop on the chest, back, or, more rarely, on the extrem- ities. Frequently the rash is entirely absent or repre- sented by one or two spots. Each spot forms for two or three days, and then fades. Very slight local desquama- tion may follow. Other physical symptoms of typhoid are usually so marked that the rash, in many instances, is of slight diagnostic importance. 716 SYMPTOMS AND CONDITIONS FREQUENTLY MET OTHER SKIN ERUPTIONS Erysipelas.—Erysipelas is classed as one of the exan- thematous fevers. The rash is, however, more an acute local inflammation of the skin. Rash appears on the first day of the disease. Character.—The area is swollen, hard, and bright red or crimson in color, with a well-defined margin, frequently raised, beyond which the skin has its normal color. The affected surface has a glossy, polished appearance; later vesicles and blebs form, and in some cases suppuration occurs. The tissues in the vicinity are edematous. Distribution.—It occurs at a spot in the vicinity of, though somewhat remote from, the wound through which the microbe has gained entrance. For example: in infec- tion through a wound on the body the rash may appear on one of the extremities. In facial erysipelas the rash begins about the nose, and spreads until the whole face is in- volved, usually stopping short at the roots of the hair and the neck. The rash in erysipelas lasts for four or five days, then fades, and the inflammation subsides; the desquamation may be branny or occur in flakes. Infection is considered to continue as long as there is any desquamation. Syphihs.—The different stages of syphilis are marked by varieties of skin eruptions, usually occurring in local- ized areas. In the earlier stages (secondary syphilis) the rash is commonly macular or papular, and has a char- acteristic dark-red color, described as ham color or cop- pery; subsequently the rash may become pustular and lead to superficial ulceration, or break down into moist papules or mucous patches. This occurs usually in warm, moist areas, such as beneath the breasts, under the arms, round the mouth, etc. Pustules either become reabsorbed or lead to the formation of characteristic ulcers. In the later stages of syphilis (tertiary syphilis) tubercles (p. 206), gummatous nodules, and blebs filled with purulent fluid are common. A gummatous nodule is one that be- comes soft or gummy in character. The eruption may dry up and become absorbed. Commonly they produce ulcera- FEVER 717 tion and leave behind the typical syphilitic ulcer, which has a punched-out surface, covered with thick, offensive dis- charge. In dressing these ulcers the greatest care must be taken or the dresser may become inoculated through any small abrasion on his own hands. From the above it will be seen that the date of the appear- ance, the character and distribution of the rash, and the subsequent desquamation are all points of diagnostic importance and must be accurately noted. Accidental Rashes.—Many conditions of acute gastric irritation, especially in children, are accompanied by a scarlatinous or erythematous rash. The physical symp- toms are pronounced and the fever high. Frequently distribution of the rash begins in the vicinity of the abdo- men, and the absence of acute sore throat or strawberry tongue distinguishes it from scarlet fever. An erythe- matous rash may also follow exposure to cold. Other accidental rashes are caused by poisoning by certain drugs. Atropin or belladonna produces an erythematous rash resembling scarlet fever, but on close examination the punctiform character is absent. Salicylic compounds and quinin also frequently produce an erythematous rash. Poisonings by many of the coal-tar products, such as anti- pyrin, may frequently cause a papular rash. The irritant poisons, such as arsenic, may produce either an erythe- matous or a papular rash. An acne rash (see below) is a characteristic symptom of bromidism and iodism. The continued use of chloral may be followed by an erythe- matous rash. A transitory diffuse rash, caused by the di- latation of the superficial blood-vessels, frequently appears about the neck and chest during the administration of ether. The more common skin eruptions not associated with skin diseases are as follows: Herpes {fever-blister, cold sore) appears in small groups of minute vesicles, usually about the lips. It is common in many catarrhal and feverish conditions. It is nearly always present in lobar pneumonia. The vesicles are usually treated with a simple ointment, such as oxid of zinc, and dry up and diasappear in from three to five days. 718 SYMPTOMS AND CONDITIONS FREQUENTLY MET Herpes Zoster {Shingles).—The vesicles are distributed over the course of a superficial nerve, more commonly over one side of the body or about the face, round the eyes; the eye itself may be involved, causing intense pain. The condition is usually associated with acute neuralgic pain which is most intense before the eruption appears. Herpes zoster is generally considered to be of nervous origin, though it may result from exposure to wet and cold, usually from wearing wet garments next the skin. A dressing of simple ointment is first applied, and the general health attended to. The neuralgic pain is fre- quently relieved by phenacetin. Urticaria {Hives, Nettle-rash).—The rash usually ap- pears in successive crops, either as rose-colored papules or as white wheals on a red surface. Each crop lasts a few hours and causes intense itching. Urticaria is fre- quently a result of mild poisoning from shell-fish, certain acid fruits, especially strawberries, or from poisoning by poison-ivy or similar weeds. Some persons are pecu- liarly susceptible to the condition. To allay the itching the surface may be sponged with a solution of carbolic acid (2 per cent.) or with equal parts of alcohol and water. If due to a gastric condition, a purgative is usually ad- ministered. Erythema Simplex, or Stomach Rash.—A simple, diffuse scarlatinous rash, not caused by a specific disease, is des- cribed as simple erythema. It may be due to gastric disturbances or poisoning by certain drugs, as mentioned above; to exposure to heat or cold, especially to sudden changes of temperature from excessive cold to excessive heat, and, not infrequently, to the effects of antitoxin. Erythema Nodosum.—The rash appears in circum- scribed, slightly raised, irregular, rose-colored patches, usually over the front of the legs. The condition is accom- panied by general malaise, some fever, and rheumatic pains in the joints. It may be associated with rheuma- tism, gastric disorders, and malnutrition. The condition is more common in childhood. In fading, the patches change color, turning yellow, blue, and green, like a bruise. FEVER 719 Local applications of lead-water or lead-water and laud- anum are usually applied, and the general health is attended to, the patient remaining in bed. The condition lasts a few weeks. Erythema Intertrigo (Chafing).—A local inflammation, occurring where two surfaces of the skin rub together, as in the groins, under the breasts, and between the buttocks. Cleanliness and care in keeping the places dry prevent this condition. The affected part appears first red, then moist, and, if the condition is allowed to continue, will become macerated. The surfaces should be kept apart, and a simple dressing, such as zinc ointment, applied. Acne Rash.—An eruption of small papules frequently developing into pustules is common about the face, shoul- ders, and chest, especially in young girls about the age of puberty. Generally it is associated with physical debility or menstrual or gastric disorders. Small blackheads are usually present, due to occlusion of some of the sweat- ducts. In most cases the condition is due to a parasite. The scalp should be examined, as in many instances the skin is infected from dandruff falling on the body when the hair is brushed. The use of special antiseptic ointments and lotions is usually prescribed, and attention to good hygiene and the improvement of the general health. The various forms of skin disease are accompanied by characteristic eruptions, to recognize all of which involves a special study of the subject. The various forms of eczema are described as papular, pustulous, or squamous, according to the characteristics of the eruption. The fol- lowing skin affections, however, may frequently be met with, especially in an out-patient department or in dis- trict work, and it is of importance that their characteristic appearance should early be recognized. Scabies Itch.—Scabies is caused by an animal parasite, the female of which burrows under the skin in order to deposit her eggs. The line of burrowing and deposition of the eggs is marked by short, red, slightly raised dotted lines, about one-half inch in length. The accompanying line of eruption is papular, the papules frequently forming 720 SYMPTOMS AND CONDITIONS FREQUENTLY MET vesicles or minute pustules. The itching is severe. The condition is highly contagious, especially through the clothing, towels, etc Nurses in out-patient departments may frequently be exposed to this contagion. If the infection is contracted, a doctor should be consulted at once, and the greatest care exercised in disinfecting sheets, towels, etc., before sending them to the general laundry. The treatment usually advised is a hot tub- bath at bedtime, following which an ointment, generally sulphur, is well rubbed into the affected area. The doctor should be seen every few days, as the treatment itself might cause irritation to the skin. A non-infectious eruption of red papules, intensely itching, is common in agricultural districts about harvest time. It is also due to an insect that deposits its eggs under the skin. The itching may be relieved by sponging with carbolic and water (2 per cent.) or alcohol and water (equal parts). Pediculosis.—The bite of a louse, an insect that, in filthy conditions, inhabits the human hair, either on the head, pubes, or about the body, produces an intense itch- ing and an appearance as of red papular rash. The dis- covery of the lice, and of small translucent bodies clinging to a separate hair, which are their eggs, determines the cause (p. 44). On close examination the bite of the insect can be seen in the individual papule. Ringworm.—Tinea Tricophytina.—The eruption may occur on the head {tinea tonsurans), on the beard {tinea sycosis), or on the body {tinea circinata), and is caused by a vegetable parasite which attacks the roots of the hair. The form most commonly met with is the scalp ringworm among children. This ringworm consists of round, red, elevated patches; the patches at first are slightly raised, with the hair-follicles prominent; later they are grayish and scaly, and the hairs of the roots involved are dry, discolored, brittle, and easily pulled out. The center of the patch clears first, leaving the characteristic ring; the condition is highly contagious, the infection being readily carried by clothing, etc., or direct contact with the hair by another child. FEVER 721 The treatment usually consists in keeping the head clean by daily washing, following which the diseased hairs are pulled out and an ointment, usually of sulphur or of mercury, rubbed into the affected part. The hair of the affected parts should be either cropped close or kept closely braided to avoid coming in contact with the ring- worm. Ringworms of the body are round, scaly, reddened patches, covered with minute vesicles. The inflammation disappears first from the center, leaving the ring formation. An ointment containing mercury or sulphur is usually applied, and the clothes should be carefully disinfected and strict cleanliness observed. Tinea favosa (favus) is a severe form of ringworm due to another form of parasite. It involves large areas of the scalp. The infected portion is covered with cup-shaped crusts, presenting an appearance somewhat like a honey- comb. The hairs are dry, brittle, and broken off short. The crusts have an offensive, musty odor. Usually the crusts are softened by poulticing or the application of warm oil, after which they are removed by washing. The treatment consists in the removal of each hair by forceps, and the daily application of an ointment con- taining usually sulphur or mercury. The treatment takes many weeks, but should be persevered in, or the hair may be permanently destroyed. Impetigo Contagiosa.—An acute contagious disease of short duration, characterized by an eruption of vesicles and blebs which quickly become pustular. In a few days the blebs dry up, forming thin crusts which, on separating, leave light scars. Impetigo usually attacks young and weakly children. The eruption commonly occurs on the extremities or the face. The contagion may be carried by clothing, towels, etc., and the patient may reinfect himself by scratching. The treatment consists in the removal of the crusts by bathing and the application of an ointment, usually of ammoniated mercury. The health is reinforced by suit- able diet, good hygiene, etc. The above are descriptions of symptoms, conditions, 46 722 SYMPTOMS AND CONDITIONS FREQUENTLY MET and appearances associated frequently with different forms of disease, all of which are of important signifi- cance, and will be met with constantly by the nurse in her work. It is important that she should be able to recognize these conditions, to understand their general significance, and be familiar with the ordinary lines on which they are treated. To attempt further to describe the symptoms and treatment of even the most frequently encountered of the many varieties of disease the nurse will meet with is beyond the scope of a practical manual of nursing, and, moreover, is obviously the work of those es- pecially qualified to write on the subject. CHAPTER XXI FOOD Chemical Composition—Varieties of Food-stuffs—Water—Protein —Carbohydrates—Fats—Mineral Salts—Vegetable Acids—Vita- mins—Condiments—Summary—Caloric Value of Foods—Calories in Diet—Value of a Mixed Diet—Digestibility of Food-stuffs— Process of Digestion—Digestive Juices and Their Action on Food- stuffs—Mechanical Process of Digestion—Absorption. A practical knowledge of cooking is really an essen- tial part of a nurse's training if she is to do private nursing, and to all nurses it is an important part of their equip- ment, since, should she remain in hospital work, a nurse must sooner or later be prepared to superintend the choice of diets and the cooking of food-supplies for a number of people, both sick and well. To do so effectively she must understand the basis on which foods are selected, their individual value, their economic use, and, especially in consideration of the diet of the sick, the various ways in which food can be prepared to increase its digestibility and palatableness, and to vary the monotony of a restricted diet. By foods we understand those substances which are taken into the body for its growth, development, and the repair of its tissues. Food also keeps up the tem- perature of the body, and furnishes the motor power, or energy, of its' activities. It is not too much to say that nothing makes so much difference to the average human being as the food he is given; from the patient's point of view certainly no one item of his treatment touches in importance his meat and drink: what it is, how it is cooked, and in what manner it is served. In selecting a diet a group of facts have to be con- sidered : . 723 724 FOOD 1. The chemical composition of the food-stuffs. 2. Their value as energy-producers, known as the " caloric " value. 3. Their digestibility. 4. The condition of the patient's digestion. The fourth consideration will include the patient's age, physi- cal condition, and habit of living. To this group other considerations may frequently be necessary to add, such as whether a food is in season, the market price of food, and climatic conditions, meat and fat, for example, being required in greater quantities in a cold climate, and so forth. In the case of certain diseases also special dieting becomes necessary. CHEMICAL COMPOSITION OF FOOD We know that all matter, however apparently solid, is capable of being reduced into various simple component parts, which we know as elements or bases. Sugar, to take a simple example, is composed of the three elements, oxygen, hydrogen, and carbon. The nature of an ele- ment, we remember, is that it cannot be reduced to a simpler substance, or decomposed by any known force. Complex though the body is, the cells of which it is composed are made up of various simple elements, of which the most important are oxygen, hydrogen, carbon, and nitrogen; other elements constantly present in the tissues of the body are sulphur, iron, chlorin, soda, mag- nesia, lime, phosphorus, etc—in all, the body represents from 15 to 20 different chemical elements. The mineral elements are present in the body as salts, that is to say, in combination with an acid; thus we have chlorid of soda, phosphate of lime, sulphate of magnesia, and so forth. The particular combination of these elements found in living tissues is described as organic combination. The body grows, develops, pursues countless activities, both functional and motor, and would, therefore, soon use up the stock of the necessary elements of which it is at birth composed; further, all activity causes some waste of the tissues. It becomes, therefore, necessary to fur* CHEMICAL COMPOSITION OF FOOD 725 nish the body with a continual supply of each of the above elements. This supply is obtained from the air we breathe and the food we consume. Value of Oxygen.—Of all the elements in the body, the most immediately important to life is oxygen. Deprived of oxygen, even for a few minutes, the body dies. Death from want of oxygen we call asphyxiation. Besides entering into the composition of the cell, oxygen is neces- sary to the body for two prime reasons: (1) Oxygen is necessary for the process by which the prepared food is split up into its elemental parts and used by the body-cell. This process is similar to the process by which fuel is consumed in burning, and for this reason is known as combustion. As the process cannot take place without oxygen (any more than fuel can burn without oxygen), it is often spoken of as oxidation. (2) By contact with the oxygen present in the air- cells of the lungs the blood gets rid of a poison, carbon dioxid, one of the products of oxidation, which, if left in the body, quickly causes death. For the body's supply of oxygen we depend on the vol- ume continually taken up from the atmospheric air by the blood circulating in the walls of the air-cells of the lungs. For all the other essential elements we depend upon our food-stuffs. It is obvious that food, as we see it, does not, except in a very few instances, such as water and common salt, sug- gest in its appearance the elements of which it is composed; in order, then, to supply the body with the elements it requires, and to supply them in their due proportion, it is necessary to learn what various food-stuffs contain these elements, in what proportion, and in what manner avail- able for the body's use. Classification.—For this purpose the food-stuffs have been classified, according to their chemical composition in five groups: 1. Water—hydrogen and oxygen. 2. Protein—carbon, hydrogen, oxygen, and nitrogen. 726 FOOD 3. Carbohydrates—carbon, hydrogen, and oxygen, the two last in the same proportion as in water. 4. Fat or hydrocarbon, also carbon, hydrogen, and oxy- gen, present as fatty acids (oleic, palmitic, stearic), in com- bination with glycerin as a base. 5. Mineral salts—lime, phosphate, sodium, iron, etc., as above. Water.—We derive water to the greatest extent from our drinking-water, and from beverages, soups, and milk. It is also present to some extent in solid foods, as in the juice of meat, fruit, and vegetables. As an essential to the life of the body water ranks next in importance to oxygen. Without food, but sufficiently supplied with oxygen and water and artificially protected from loss of heat, the body has been kept alive for days and even weeks at a time. Water forms about two-thirds of the entire weight of the body, and enters into the composition of every fluid and solid tissue in the body. The uses of water in the body are: 1. To regulate the body temperature. 2. To dissolve solid substances, as, for example, food- stuffs and solids in urine. 3. To dilute the blood and other fluids of the body; water is the chief part of all the secretions. 4. To dilute the poisonous products of oxidation and any accidental toxins, and to aid in their elimination. 5. It has a definite use in the process of oxidation, which cannot take place without it. Water does not itself undergo combustion, and, there- fore, does not, like other foods, supply energy. For these purposes, and especially as a solvent and diluent, water is more valuable in its pure state than modified as beverages, soups, etc. Protein.—Protein enters into the composition of all animal food, such as meat, fish, eggs, milk and its products, and many vegetable foods, especially the cereals (vege- tables of which we use the seeds as food, oatmeal, wheat, etc.) and legumes (vegetables of which we use the pods, as peas and beans). Such foods are often described as CHEMICAL COMPOSITION OF FOOD 727 proteins, or, from the fact that nitrogen is obtainable only from protein, as the nitrogenous foods. Protein is divided as follows: Albumin, found in white of egg. Myosin, " lean meat. Legumen, " legumes. Albuminoids: i Gluten, " cereals. Vitellin, " yolk of egg. Caseinogen and \ ,< •„ . Lactalbumin / mllk> Gelatinoids: \ Collagen, found in skin and tendons. t Ossein, " bones. The gelatinoids are of less value in the human economy than the albuminoids. They are not so readily digested, and a large proportion passes from the body unchanged. Nitrogenous foods also contain certain bodies known as extractives, which impart flavor to the foods and stimulate the appetite and the digestive secretions. They are with- out nutritive value. The most important use of protein is for the repair of the tissues. It is the only food substance that has this property: we, therefore, conclude that some form of nitrogenous food is an absolute necessity to the body. Whatever protein is not used for the repair of the tissues goes, in common with the other food-stuffs, to supply energy, in the form of heat and muscular power. The carbohydrates are derived, for the greater part, from the vegetable foods, such as the cereals (wheat, oatmeal, etc.), the legumes (peas and beans), the tubers (potatoes, etc), and the pith of certain plants (sago, etc.). Carbo- hydrate is present in milk as milk-sugar, and in the form of animal starch in oysters and other mollusks. The carbohydrates are divided into the starches or amyloses and the sugars. The amyloses include glycogen, or animal starch, certain soluble gummy substances, of which dextrin is the most important, and cellulose, a vegetable carbohydrate, the structural base of all plants, which cannot be utilized by the human body. 728 FOOD The sugars in food are divided into sucroses, or cane- sugars, and glucoses, or grape-sugars. Both sucroses and amyloses must be converted into glucose by the action of the diges'tive ferments before they can be utilized by the body. The glucoses can be absorbed without alteration. The sucroses include— Cane-sugar. Beet-sugar. Maple-sugar. Malt-sugar (maltose). Milk-sugar (lactose). The glucoses include— Grape-sugar (dextrose). Fruit-sugar (levulose or fructose). A mixture of equal parts of grape-sugar and fruit-sugar is called invert sugar. Honey is a form of invert sugar. Sugar as food is taken in the form of the different sugars of commerce, sweet fruits, certain vegetables, such as the tomato and cucumber, and in milk (lactose). The carbohydrates are non-nitrogenous foods, and cannot, therefore, be used in the repair of tissue in place of the proteins. Their special use is the production of energy, especially in the form of muscular power. What is not used for this purpose is converted into fat, and, as such, stored in the body. The carbohydrates are also stored in the body in the form of glycogen, or animal starch. It is prepared from digested carbohydrates by the liver, and stored in that organ for subsequent use. Some of the glycogen is continuously given out in the form of dextrose between the meals to the body, thus keeping up its supply of heat and energy. A reserve supply is also stored in the liver for use in an emergency when the body is deprived of food. Fats or Hydrocarbons.—Fats are obtained both from the animal and the vegetable kingdoms. There are three varieties of fat, i. e., solid fat {stearin), semisolid {palmitin), and liquid fat or oil {olein). Animal fat is found in meat, CHEMICAL COMPOSITION OF FOOD 729 certain fish (salmon, mackerel, herrings, and cod livers), the yolk of eggs, cream, and butter; vegetable fat in the form of oils (olive oil, cotton-seed oil), in nuts, in cocoa, and in chocolate, and, to a small extent, in the cereals and some other vegetables. Like the carbohydrates, with which, as foods, the fats are to some extent interchangeable, their use is to produce heat and muscular power and to supply the body with fat or adipose tissue. Except in the extreme north, where whale fat is one of the principal articles of diet, the carbohydrates are more largely used. They are a less expensive variety of food, and, as a rule, presented in more digestible forms. For example, nuts, while containing a highly nutritious oil, contain, at the same time, so much vegetable cellulose that they are not an easily digested food. Fat, however, is considered peculiarly necessary for the development of young tissues, where, from the natural activity of young things, and their comparatively rapid growth and development, a large proportion of protein goes actually into the repair of the tissues. The best and most easily digested form in which fat can be taken is as cream or as bacon fat. Taken bulk for bulk, fat will produce twice the amount of energy that can be obtained from carbohydrates. Fat is also stored in the body in the form of fat, for use in emergency. In cases of starvation the body can consume its own adipose tissue, obtaining heat and muscular power from its combustion. Mineral Salts.—The salts of the various minerals are found distributed through all the food-stuffs, both animal and vegetable. Certain food-stuffs, such as the green vegetables, are valuable almost solely for their mineral salts and contain little else of nutritive value. Some green vegetables are rich in special minerals, such as spinach, which contains an appreciable quantity of iron. The minerals help in the building up of the tissues; certain of them, such as iron and common salt (chlorid of soda), are continually present in the blood. Lime, in the form of phosphate of lime, is the basis of all bony tissue; salt is found in all the tissues of the body, fluid and solid; 730 FOOD from salt the stomach prepares the hydrochloric acid of the gastric juice, thus aiding digestion. So important is this mineral to the body that, where much is lost in the cooking of food, more is added, and, in addition, salt is taken as a condiment (see below) with all heavy meals. The mineral salts found in living material are known as organic salts; they are usually more easily assimilated than the inorganic salts. The importance of the minerals in the human economy is appreciated when we observe the effects of a deficiency of one or other of the more important. Thus, when there is a deficiency of iron, we get the condition known as anemia, with its attendant symptoms; a deficiency of phosphate of lime causes the bones to be easily bent and deformed, the condition known as rickets, and so forth. Vegetable Acids.—In connection with the mineral salts we must also consider certain vegetable acids, which, in combination with potassium, forming the salts of potash, have a very marked influence on nutrition. They are found in fruit, fresh vegetables, and in milk that has not been sterilized or evaporated (condensed milk). Deprived entirely for any length of time of food contain- ing one or other of these acids, a group of symptoms known as " scurvy " develops, which yields to treatment only when these acids are in some form replaced in the diet. The important acids are as follows: Lactic acid, found in milk. Citric acid, found in lemons, oranges, limes, tomatoes, etc. Tartaric acid, found in grapes, pineapples, etc. Oxalic acid, found in strawberries, rhubarb, etc. Malic acid, found in apples, pears, apricots, gooseberries, etc. Acetic acid, found in vinegar and wine. Some fruits contain more than one acid: Strawberries, for example, contain both oxalic and citric acid. The flavor of both meat and vegetable foods is due to the extractives already mentioned, which serve as a stim- ulant to the appetite and to the digestive secretions. Artificially, the flavor of food is altered or increased by the use of certain adjuncts, known as condiments. Pepper, salt, mustard, vinegar, spices, and essences are familiar CHEMICAL COMPOSITION OF FOOD 731 examples of condiments constantly used to make food more palatable. Many of them (salt, mustard) also stimulate the gastric secretions, thus aiding digestion. Vitamins.—Mineral salts and vegetable acids are classed as accessory food substances. Other important accessory food substances, recently recognized, and at present much under consideration, are known as vitamins. Vitamins are chemical bodies found in minute quantities in a large variety of food substances, which are proved to have a direct effect on metabolism, and especially on the growth and repair of animal tissue. Experiments show that a young animal deprived of vitamins ceases to grow; when vitamins are again introduced into the diet growth recommences. A diet deficient in vitamins disposes to nutritional disorders such as marasmus, scurvy, rickets, forms of neuritis, etc, and is considered one if not the pri- mary cause of the tropical diseases of beriberi and pellagra. Vitamins may be destroyed by exposure to high tempera- ture; food, therefore, prepared by processes involving high temperature are probably deprived of vitamins. Such are pasteurization, sterilization, canning, preserving, drying, desiccation, and evaporation; frequently also cooking. Vitamins are also mechanically removed in the milling of certain grains—as in polished rice, patent white flour, and cornmeal. In many proprietary baby foods the vitamins are absent. The disease of beriberi is common in districts where the inhabitants live on a diet principally of polished rice. Milk is the most important source of vitamins in the diet of a young child. If unavoidably the child must be fed on sterilized milk or largely on some proprietary food the vitamins should be restored in the form of orange juice. An ordinary diet of fresh food provides all the vitamins necessary for normal needs. Should circum- stances necessitate the use of dried rations, or a large proportion of canned foods, fresh fruit—such as oranges, lemons—and vegetables—such as potatoes, onions, cab- bage, and squash, all of which can be stored—should be added to the diet. 732 FOOD Proteins or Nitrogenous Foods: Chemicalcomposition: Hydrogen, oxygen, carbon, nitrogen; with various salts, sulphur, iron, phos- phorus, etc. Carbohydrates: Chemicalcomposition: Oxygen and hydro- gen (H20) and car- bon. Fats and Oils: Hydrocarbons: Same as carbohydrates. Fatty acida (oleic, palmitic, and stearic) and glyc- erin. Minerals: Examples: Magnesia,' soda, lime, sulphur, etc., in the form of soluble salts. Organic Acids: Examples: Acetic, citric, tartaric, malic, oxalic, and lactic, in combina- tion with potash. Water: Chemicalcomposition: Hydrogen and oxy- gen (HX>). SUMMARY Obtained from— Animal: Meat, fish, milk, cheese, eggs. Vegetable: Especially cereals and legumes. Starch: Cereals, leg- umes, tubers, pith of plants (sago). Glyco- gen (animal starch), from oysters and other mollusks. Sugars: Sugar, fruit, honey, some vegeta- bles (tomatoes, etc.), and milk (lactose). Animal: Fat of meats, cream, butter, eggs (yolk). Vegetable: Oils, nuts, cocoa, and choco- late. In all animal and vege- table foods: A suffi- cient quantity of all salts except sodium chlorid, or common salt, is supplied in an ordinary mixed diet. Common salt is added to all cooked foods. Fresh green vegetables and fruit; milk that has not been sub- jected to high tem- perature; vinegar. Drinking-water, milk, soups, beverages; the juice of meats, fruits, and vegeta- bles. Uses. Repair of tissues. Supply energy in the form of heat and muscular power. Supply energy, es- pecially muscular power; excess converted into fat and stored as such; also glyco- gen, stored in the liver. Can be used as spaiers of protein or fats. Same as carbohy- drates, valuing bulk for bulk twice as much. Stored as fat in the tissues. Help in the build- ing up and pre- serving of the tissues. Aid in digestion. Necessary to nutri- tion. Regulates body- temperature. Di- lutes all fluid tissues. Dilutes poisonous prod- ucts of oxida- tion and other toxins. Aids in elimination. Is necessary to me- tabolism. CALORIC VALUE OF FOOD 733 CALORIC VALUE OF FOOD We see that not only are food-stuffs required for the repair of tissue, but that on them the body relies for the production of the energy necessary for its activities. By the energy of the body we understand its heat and its mus- cular or motor power. Above, we said that the process by which the food- stuffs, prepared by digestion, were split up into their chem- ical elements and assimilated by the body-cells, were similar to the process by which fuel was consumed in burning. In the body this process is called combustion or oxidation. The relative value of fuels depends on the amount of heat engendered by their combustion and the length of time their heat can be sustained. A further value is reached when we use fuel not only to produce heat, but the heat to produce activity or power, as when heat is used as the motor power of machinery. To understand what we mean by the caloric value of any food substance we shall regard it as the fuel used to provide the motor power of an engine. The energy of the body is expressed in every one of its activities; the action of the muscles in all the simple or complicated acts of movement, the action of the central nervous system in controlling all the activities of the body, of each separate organ in fulfiling its own functional activity, of each body-cell in assimilating from the food-stuffs just the element it requires for its repair and development, and, lastly, the activity of that force we know as the mind or intellect, which works through the medium of the body. Just as the different fuels have different values as heat and power producers, so, too, the different foods vary on this point. Some foods represent slow combustion, giving out a steady supply of heat and energy over lengthened periods; such foods we value for their sustaining qualities; other foods are more rapidly oxidized, and resemble a fuel that flares up quickly, giving out a high degree of heat, and as quickly dying down again; the effect of such foods is to stimulate the body for a short time. The proteins are more slowly oxidized than the starches, and again starch is more slowly oxidized than sugar, unless it has been par- 734 FOOD tially dextrinized by cooking. Sugar is the most rapidly oxidized of food-stuffs, and the heat and energy produced by its combustion are, in comparison, transitory. Alcohol produced by the fermentation of sugar is more rapidly and more completely oxidized than any other form of food; it is, therefore, of great value where immediate stimulation is necessary. Fat is a " concentrated fuel food," and, as has been said above, appears to be particularly necessary for the growth and development of young tissues. Where we have combustion we have also a certain amount of waste, shown in the residue or ash remaining after the complete combustion of any fuel. In the same way the oxidation ol food-substances produces certain waste- products in the body. The ash, or residue, of protein foods is known as urea; it is excreted by the kidneys and eliminated from the body in the urine. To a much less extent it is also excreted by the skin in the sweat. Where the kidneys fail in this function, the body becomes rapidly poisoned by the accumulation of urea in the tissues. A chronic, imperfect elimination of urea causes such condi- tions as gout, certain forms of rheumatism, etc. The acute condition,i where no urea, or a very small amount, is eliminated is known as uremia, and is rapidly fatal if unrelieved. The waste-products of carbohydrate combustion form carbon monoxid. If allowed to accumulate in the tissues, this poisons the body more rapidly than urea, less than five minutes producing death. On contact with the oxygen in the lungs carbon monoxid leaves the body in the form of carbon dioxid, or carbonic acid gas. The structural changes which take place in the body-cells as the result of combus- tion are spoken of as metabolism. Of late years the question of the economic value of the different food elements as producers of heat and energy has received a great deal of attention. It has been made practical by means of an instrument known as the bomb calorimeter, to estimate the amount of heat and power produced by the various food-stuffs assimilated by the body. The amount of heat and power produced by the complete combustion of any one food-stuff is spoken of a.s CALORIC VALUE QF FOOD 735 its potential energy. In the scale used for the comparison of the potential energy of different foods the unit or base of measurement has been named a calorie, or heat unit. One calorie represents the amount of heat necessary to raise the temperature of one kilogram of water one degree centigrade; this amount of heat represents in motor force sufficient power to lift one ton 1.54 feet. In compar- ing the potential energy of different foods, we speak of them as valuing so many calories. The proteins and carbohy- drates have, weight for weight, the same caloric value, the fats rather more than twice as much. Water and or- ganic salts, neither of which undergo combustion, have no caloric value. Professor Atwater estimates the caloric value of food- stuffs as follows: 1 gm. protein (15| grains) = 4.0 calories. 1 gm. carbohydrate = 4.0 " 1 gm. fat = 8.9 " Rubner's scale is slightly higher: 1 gm. protein = 4.1 calories. 1 gm. carbohydrate = 4.1 1 gm. fat = 9.3 " Both scales are in use. The caloric value of food will, therefore, depend, not on the bulk, but on the proportion in which the above chemical elements are present. For example, the white of one egg, which weighs about one ounce, is composed al- most entirely of albumin and water, the latter in the pro- portion of 86.2 per cent.; its caloric value is 14; the yolk, which weighs about half an ounce, contains less water, more protein, and about 33 per cent, fat, and represents a caloric value of 58. A tablespoonful of olive oil, which is almost entirely hydrocarbon, furnishes 135 calories. Calories in Diet.—The caloric value of food is an impor- tant factor in preparing dietaries, either for the individual patient or for large numbers. It is estimated that a healthy man of average weight, between 130 and 150 pounds or 65 to 75 kilograms (1 kilo = 2.2 pounds), 736 FOOD requires for his daily consumption a diet that will furnish about 3000 calories, generally divided as follows: 125 gm. protein furnishing 500 calories. 500 gm. carbohydrate " 2000 " 50 gm. fat " 445 " 2945 " ' Obviously, the amount of food will be influenced by many conditions, such as the size and weight of the indi- vidual, his state of health, etc., his age, and occupation. Less food is required if the life is sedentary, more if there is great muscular activity. A woman is considered to re- quire about four-fifths the quantity of food required by a man, and children less in proportion to their age, i. e., between the ages of six and nine about half as much, and so forth. In old age combustion takes place slowly, the body is less active, and, therefore, less food is required. As a rule, in health the appetite is the best indication of the amount of food required. It is, however, important to see that, in the bulk desired, the proteins, carbohydrates, and fats are in the required proportion. An ordinary meal of meat, vegetables, bread, and dessert represents the right proportions very fairly. Where dietaries have to be made out for large numbers, the caloric values of the foods used should be given full consideration, in order to provide meals of good nutritive value, or, in other words, to get the largest results with a minimum of outlay. Those that have the arranging and ordering of such diets will find a good dietary computer, of which there are several on the market, an immense help. One should be chosen in which the chemical composition of the foods and their caloric value are clearly stated. In dieting the sick at the present day the caloric vaiue of the foods is given as much consideration as their digest- ibility. In acute illnesses accompanied by much tissue waste and active heat-production, as in many fevers, an increased number of calories may be necessary, and, if dieting is intelligently understood, may be administered without increasing the bulk of the food to be taken. Such a diet is spoken of as a high caloric diet. In other CALORIC VALUE OF FOOD 737 conditions, such as gout, arteriosclerosis, etc., it may be necessary to reduce the calories while giving the ordinary amount of food-stuffs, and a low caloric diet is selected. In these circumstances the patient is usually weighed daily, and a certain number of calories given for each kilogram of the patient's weight. The food must be weighed and measured with strict accuracy. The metric system is gaining so much in favor that it is as well to accustom the pupils to its use in weighing and measuring. In hospitals where the most modern methods obtain it is now the custom to order the individual patient's diet in the form of a prescription calling for so many calories of carbohydrate, protein, or fat; the prescriptions are worked out in the diet kitchen, attention being given to order the required amount of food with variety from day to day, and due consideration for individual preference. Some contrivance of box or small covered tray carries each diet from the diet kitchen directly to the patient. The patient benefits by having the diet most suited to his indi- vidual needs and tastes, and for the pupil nurses nothing can be better training. Not only must they realize the importance of food in the human economy, whether in health or in sickness, but they learn from practical ex- perience the relative values of the different food-stuffs, and how and in what variety of ways to combine them so as to produce appetizing meals with the necessary chemical elements in proper proportion. A diet kitchen, where such methods are carried out and proper instruction given, will obviously be in charge of a trained dietitian, an expense that many of the smaller hospitals feel a serious addition to their salary budget. At the same time, in treating disease, no one item is at the present day receiving more attention than dieting, and a nurse is certainly handicapped if she is not familiar with the routine work of computing diets in what is obviously a more scientific and intelligent manner than merely order- ing a diet from a given list of permitted food-stuffs. Such instruction can hardly be left out of a nurse's education, so surely will she in private work meet with doctors who ex- pect such knowledge from her. Tables giving the caloric 47 738 FOOD value of food-stuffs are available and there is no real diffi- culty in teaching each class of nurses their use, the instruc- tion being given in connection with their practical work in the diet kitchen. A bulletin, giving the chemical compo- sition and caloric value of every substance in use in Amer- ica, is issued by the United States Department of Agricul- ture, and may be had by sending ten cents in coin to Superintendent of Documents, Washington, D. C. (Bul- letin 28, Chemical Composition of American Food Mate- rials) . From this, or any other comprehensive computation table, charts of the food substances in use in the hospital dietaries may be made out, giving the quantity of each required to yield 100 calories. This will be found more readily retained by the memory than tables of more vary- ing numbers. The pupils will become familiar with the amount both by weight and by appearance required to give the necessary calories of the various chemical ele- ments, and find that such a method of computing dietaries presents no real obstacle. Pupils may be given as an exercise to find the caloric value of a meal or of the whole diet of a day, and to remove the process by ordering a meal or meal to contain a given number of the required calories. In the modern treatment of certain diseases, such as dia- betes, familiarity with such methods is essential, and is taught not only to nurses but to the patients themselves. (See Diabetes.) Books that will be of value in starting such classes for nurses are Food Values, by Edwin A. Locke; Laboratory Handbook for Dietetics, by Mary Schwartz Rose; Ele- ments of the Science of Nutrition, by Graham Lusk. The tendency in many institutions, and in families where expense is a serious consideration, is to use an excess of the cheaper carbohydrate foods in the place of the proteins and fats. On account of their bulk, these foods satisfy the appetite. For economic considerations experiments have been made on a large scale to determine the value or disadvantages of a purely vegetable diet. The outcome of such experiments goes to prove the value of a mixed diet. A purely vegetable diet gradually produces a con- DIGESTIBILITY OF FOOD 739 dition of mental and physical inertia, and a lessening of the powers of resistance, and is, therefore, inappropriate where either physical or mental work is to be done. The protein contained in vegetable foods is present in much smaller proportion than in animal food, and is of a variety less soluble and more difficult of digestion. To obtain a sufficient supply of protein for the needs of the body, where active work is required, from vegetable foods, either alone or supplemented by milk and eggs, the bulk of food required would quickly cause disorders of the digestion. Other experiments have been carried out, eliminating the carbohydrates from the diet. The results show a decrease in muscular power, since muscular energy is obtained from these foods; the physical endurance is, how- ever, found to be greater on a protein diet than on a vege- table one. An excess of protein in the diet leads to the formation of a larger proportion of urea. Where elimination is not active, this creates a tendency to those disorders associated with uric acid, such as gout and rheumatism. In mature life, where the body is less active and less repair of the tissues is required, and in people of sedentary habits, the proportion of protein in the diet should be dimin- ished. DIGESTIBILITY OF FOOD A further highly important consideration in estimating the comparative value of different food substances in a diet is the digestibility of the various foods, since, to quote an old saying, " we live not on what we eat, but on what we digest." Process of Digestion.—The work of splitting up food- stuffs into their chemical elements and changing them into soluble forms, so that they may be absorbed by the lymphat- ics and the blood, and finally assimilated by the individual body cell, is accomplished by the process we know as digestion, whichtakes place in the mouth, the stomach, and the small intestine. As a first step, solid foods must be dissolved. This 740 FOOD process is already accomplished in liquid foods, for which reason liquid foods are a valuable form of diet in condi- tions of enfeebled digestion. In order to be used by the body, food must further undergo the following changes: 1. Proteins (nitrogenous foods) must be converted into soluble peptones. 2. Carbohydrates must be converted into dextrose. 3. Fats must be either emulsified or split up into fatty acids and glycerin. They are not digested in the sense of either proteins or carbohydrates. The above changes are brought about by the action of the digestive juices, of which there are three, each contain- ing one or more active agents, known as enzymes or fer- ments. The digestive juice in the mouth is the saliva, and con- tains the ferment ptyalin. The function of ptyalin is to begin the digestion of the carbohydrates. The starches, except such as have already been dextrinized (see below), are converted into maltose before their final change into dextrose. Substances soluble in water, such as salt and sugar, are dissolved in the mouth. The saliva has no effect on pro- teins or fats. Food stays such a short time in the mouth that the action of the saliva is restricted. The digestive juice in the stomach is the gastric juice. It contains hydrochloric acid (about 0.2 per cent.) and two ferments, pepsin and rennin. The hydrochloric acid provides the acid medium neces- sary for the gastric ferments to act, and prepares the protein for the action of the ferments; pepsin converts pro- tein of every variety into soluble peptones; rennin coagu- lates the casein in milk, converting it into solid curds, which are then digested in the same manner as other protein foods. During the digestion of milk a ferment (lactic acid) is also elaborated from the milk itself, which aids in the process of digestion. Fats are melted and set free, but not otherwise acted upon. The carbohydrates remain unchanged. Food leaves the stomach in the form of a thick, milky fluid known as chyme. DIGESTIBILITY OF FOOD 741 In the small intestine food is acted upon by the pan- creatic juice, the bile, and the intestinal juice. By far the greatest part of all digestion is carried out in the small intestine. The pancreatic juice excreted by the pancreas contains three ferments—amylopsin, trypsin, and steapsin. Amylopsin completes the conversion of the starches into maltose. Trypsin completes the digestion of the proteins. Steapsin splits up fats into fatty acids and glycerin, and emulsifies fats. The bile excreted by the liver contains certain salts which also act on the fats, emulsifying them and splitting them up into fatty acids and glycerin, in which forms they can be absorbed. The bile is also considered to act as an in- testinal disinfectant, preserving the contents of the in- testines from putrefaction, and has further the property of preparing the walls of the intestines for the absorption of the emulsified fat. The intestinal juice, or succus entericus, excreted in the walls of the small intestine, acts as a diluent to the intesti- nal contents, and contains a ferment {invertin), which it is considered causes the change of the maltoses (prepared from starch by the ptyalin and the amylopsin) and the sucroses into dextrose, in which form only it can be taken up by the blood. The change, it is supposed, takes place during absorption through the intestinal walls. Each of the above ferments acts only in that part of the digestive tract in which it is produced. Ptyalin can act only in an alkaline medium, such as the saliva, its action is, therefore, checked by the acidity of the gastric juice; pep- sin and rennin are only active in an acid medium, such as the gastric juice; their action is, therefore, checked by the alkalinity of the digestive juices in the intestines. The ferments further require that the medium should be at blood-heat; iced drinks, therefore, and ice-cream, etc, by temporarily lowering the temperature of the gastric juice, delay digestion somewhat. The large intestine secretes no digestive juices, but offers a large surface from which water and food-stuffs in the 742 FOOD soluble forms in which they can be used by the body may readily be absorbed. As the digestive juices continue their action on the intestinal contents in the large intestine, digestion may, to this extent, be said to take place in the large intestine. There are no digestive juices in the large intestine, however, to digest food-stuffs introduced into the alimentary tract by the rectum. The work of pre- paring the food-stuffs must, therefore, in rectal feeding, be performed outside the body; the process is known as predigestion or peptonizing. The undigested and indigestible portion of the food-stuffs are passed out of the body as the feces. Mechanical Aids.—Digestion is also aided by certain mechanical processes. In the mouth food is masticated, that is to say, crushed and chewed and thoroughly mixed with the saliva. It is then passed into the stomach by the action of swallowing. In the stomach food is churned by the mechanical action of the stomach-walls, and passed forward, a small quantity at a time, to the intestines by a wave-like, muscular move- ment of the stomach-walls, known as peristalsis. The peristaltic action is continued in the intestine, and the food thereby forced gradually forward in the direction of the anus. The presence of bile is considered to help in this peristaltic movement; if the liver is sluggish and little bile poured out, the peristaltic action is likely to be weak. This is one of the commonest causes of consti- pation. Stimulation of Juices.—The digestive juices are stimu- lated by the presence of food. Recent research has also shown that both the quantity and the quality of the juices are affected by the different kinds of food-stuffs and by the individual liking for the food taken. Thus, food eaten with an appetite is considered to be more easily digested than the same food taken unwillingly or with indifference. This is an important point for nurses to remember, since the appetite may be tempted by dainty service, quiet and pleasant surroundings, and by offering just the right quan- tity at the right time. Slovenly service, disorderly sur- roundings, unpunctuality, or an overheaped plate may ABSORPTION OF FOOD 743 affect even a healthy appetite. Where possible, the individual taste should be consulted, and, even where the diet is restricted, pains should be taken to vary it as much as possible. The fact that the quantity and quality of the digestive juices varies with the different varieties of food-stuffs demonstrates further the value of a well-balanced, mixed diet. The supply of all secretion depends largely on the demand, and the same holds true of the secretion of the digestive juices. If, for example, there is but little demand for protein digestion, less gastric juice is secreted, and the proportion of the composition is somewhat altered. This should be remembered in adding to a patient's diet any food-stuffs that have been withheld, as, for instance, in reintroducing protein foods after a patient has been kept for a time exclusively on carbohydrate foods; the change should always be effected gradually. The sight and smell of food, when pleasant to the appe- tite, stimulate the flow of the saliva, and probably of the other digestive juices. That this fact is widely accepted we know from the homely saying that good food makes the mouth water. The temperature of the food affects the secretion of the gastric juice. The presence of food in the stomach causes the dilatation of the blood-vessels in the walls of the stom- ach, and a large increase in the quantity of blood. It is estimated that nine times the ordinary amount of blood is present in the walls of the stomach during digestion. Hot fluids help in the dilatation of the vessels, and so stim- ulate digestion; ice-cold drinks and foods, by contracting the more superficial vessels, are considered to delay digestion somewhat, as well as by arresting the activity of the ferments, as noticed above. On the other hand, cold is held to stimulate the peristaltic action of the stomach. ABSORPTION OF FOOD The absorptive powers of the different parts of the diges- tive tract vary considerably. A very small amount of converted carbohydrates, alcohol, and common salt may be absorbed in the mouth; in the stomach the same, to- 744 FOOD gether with a small proportion of peptones and mineral salts, are absorbed without undergoing intestinal digestion. In the small intestines foods of every sort are absorbed, especially the emulsified and saponified fats, which are taken up by the lymphatics in the walls of the small in- testine (the lacteals); lastly, the large intestine acts as a reservoir from which the remainder of the food-stuffs and water is absorbed. With the exception of the fats taken up by the intestinal lymphatics, the food-stuffs are collected from the super- ficial blood-vessels of the alimentary tract by the portal vein, and carried directly to the liver; thence to the vena cava, and so finally distributed through the whole arterial system. The liver, besides taking from the blood what is necessary for the use of the individual cells of the liver itself, also stores up a certain amount of the digested carbohydrates, which it converts into glycogen, or animal starch. As glycogen is insoluble, it is converted back into dextrose, when it is given back to the blood. The fats absorbed by the lacteals also finally reach the general circulation through the thoracic duct, a lymphatic vessel which collects the contents of the intestinal lymph- atics and passes them into the general circulation at the junction of the left subclavian and left internal jugular veins. The comparative digestibility of the various food-stuffs is, for convenience, reckoned by the length of time that the foods take completely to leave the stomach. A full meal of mixed ingredients takes about four hours to leave the stomach. A light meal of, for example, tea or coffee, bread, and eggs, should have left the stomach in from one and a half to two hours. Tables may be found in most books on dietetics giving the comparative digestibility of the common varieties of foods. Conditions Disturbing Digestion.—Many conditions disturb the digestion to a greater or less extent. A meal should not be taken immediately after prolonged physical exertion, nor should exercise be taken immediately after a meal. On the other hand, exercise an hour or two after a meal promotes absorption. Very violent exercise im- ABSORPTION OF FOOD 745 mediately after a meal arrests digestion altogether, causing severe headache, vomiting, and sometimes cardiac failure. Nervous irritation, excitement, or strong emotion will materially upset the digestion, while congenial company and pleasant surroundings actually promote digestion. Bathing disturbs digestion by diverting the necessary blood-supply from the stomach, and should not be prac- tised after a meal. Digestion during sleep is continued slowly; the last meal of the day should, therefore, be given time to digest before bedtime. The stomach should be allowed to rest for a time before each meal; for this reason the habit of eating between meals is pernicious. SUMMARY OF THE DIGESTIVE PROCESSES Mouth Stomach. Intestines. Saliva: Alkaline. Gastric juice: Acid. Pancreatic juice: Alkaline. Intestinal juice: Alkaline. Bile: Alkaline. Ptyalin: Converts starches into maltose (sugar and salt, etc., are dis- solved) . Pepsin: Converts proteins into soluble peptones. Rennin: Coagulates casein, forming curds. (Fats are set free and melted.) Amylop- Completes digestion of sin: starches; dissolves cellulose. Trypsin: Completes digestion of proteins. Splits fats into fatty acids and glycerin. Emulsifies fats. Changes sucroses into dextrose. Emulsify fats. Pre- pare the walls of the intestines for absorp- tion of fats. Avert putrefaction. Steap- sin: Invert- ase: Bile salts: CHAPTER XXII THE PREPARATION OF FOOD Effect of Cooking on Proteins—Carbohydrates—Fats—Milk- Cream—Skimmed Milk—Whey—Curds—Dilution—Fermentation- Heating—Predigestion—Flavoring—Milk as Infants' Food—Modi- fication—Signs of Indigestion of Milk—Eggs—Gruels—Meat Broths and Extracts—Water—Beverages. The process of digestion is materially helped by the manner in which raw food-stuffs are prepared and cooked. To take the most obvious example, we do not use the cereals as food in the form of oats and wheat, as we find them growing. The grain is first removed from the husk, then ground and rolled, thus producing flour and meals, which are easy to cook, and when cooked, are readily acted upon by the digestive ferments, and contain com- paratively little material that cannot be used by the body. The objects of the processes we know as cooking are, by the exposure of food-stuffs to certain temperatures, by the chemical action of various alkalis and acids, and by combination with other food-stuffs, extractives, or con- diments, to render food more palatable and more easily digested and absorbed by the body. Exposure of raw food-stuffs to heat is the simplest form of cooking; heat, combined with moisture, has the general effect of softening hard or tough tissues, such as meat fiber and the indigestible cellulose of plants, and making them more readily broken up and dissolved by the digestive processes. On the different varieties of food-stuffs heat and moisture produce important chemical changes, on the understanding of which the whole principles of cooking are based. 746 PROTEINS—CARBOHYDRATES 747 PROTEINS The albuminoids are dissolved in cold water and coag- ulated by heat or acids. For example: If the white of an egg (egg-albumen) is stirred in cold water, it is dissolved; if it is dropped into hot water, it becomes coagulated and solid; casein, the principal albumin of milk, is changed into a solid curd on the addition of an acid, such as rennet. The albumins of meat are affected in the same way. If raw meat is placed in cold water, the albumins are dis- solved and the juices drawn out into the water; if plunged into hot water, the albumins are coagulated and seal up the blood-vessels, thus, keeping the juices in the meat. Thus, if, we want nourishing broths or stews we put the meat in cold water and heat it slowly; if the meat itself is to be the nourishing part, we expose it at once to a high temperature, as in roasting, broiling, or baking. The fibrin of meat is not soluble either in cold or hot water. We, therefore, eliminate fibrin entirely where the digestion is weak, or divide it up very finely, as in minces. The gelatinoids are drawn from bone, skin, and tendon by prolonged boiling, and are not soluble in cold water. Although not valuable as food in the same sense as albu- mins, soups made from bone-stock in this way are rich in minerals, especially phosphate of lime, which is found principally in bone. Raw meat is insipid and flavorless. Exposure to heat brings out the distinctive flavor of meats, as does also the addition of common salt. It is for this reason that the beef-juice of slightly cooked meat is more palatable than that expressed from raw beef, and still more so if salt is added. CARBOHYDRATES The starch in vegetable foods is inclosed in a capsule of cellulose, which must be broken down before the starch can be acted upon by the digestive ferments. Exposure to heat causes the starch-grains to swell, so that the cellu- lose is burst and the grains of starch set free, to be acted upon by the digestive ferments. Soaking in cold water will separate the starch grains and thus prevent lumping while they are cooking. ^1 5 « o o o Fig. 217.—A class in dietetics, Presbyterian Hospital, New York (Aikens* " Hospital Management"). FATS 749 We saw above that starch must be converted into dextrose before it is used by the body. This process can be partially accomplished in cooking, either by prolonged exposure to heat, or by the addition of certain ferments, such as diastase of malt, which have the property of dextrinizing starch. Farinaceous foods, Mellin's food, and other proprietary foods owe their value to this process. Cane-sugar {sucrose) is changed to grape-sugar {dextrose, one of the glucoses) by prolonged exposure to heat. As grape-sugar is only half as sweet as cane-sugar, much of the sweet taste is thus lost. For this reason sweetening is usually added to dishes toward the end of cooking. Cereals are cooked in a large proportion of boiling water, with the addition of salt, which brings out the flavor. Where the meal is fine or flour is used, the grains should always be separated by being mixed first in cold water to prevent lumping. Cereals should be cooked slowly and very thoroughly. Vegetables.—" All plants used for food except grains and fruit" (Farmer). One of the chief objects in cooking vegetables is to break down and soften the cellulose, which is the structural base of all plants. Although cellulose is not used by the body, it is valuable as supplying bulk. Green vegetables are cooked in boiling water to which salt is added. Salt brings out flavors and coagulates the legumen in peas, beans, and lentils. Ground vegetables (potato, turnip, etc.), which require more time to soften than green vegetables, are best placed in cold water and gradually brought to boiling-point. Salt is added at the end of cooking, as it to some extent hardens the water and delays the process of softening. FATS Cooking has very little effect on the digestibility of fats and oils. Certain acids are set free which, when the fats meet with the digestive juices, produce a finer emulsion than is the case with uncooked fats. This is of importance where patients do not assimilate fats. In such cases, for example, boiled bacon may be substituted for butter, cream, etc. In good cooking the valuable mineral salts are preserved; 750 THE PREPARATION OF FOOD in careless and unintelligent cooking they are frequently lost, and some of the nutritive value of the food is thus wasted. On the above facts the principles which govern the cook- ing of foods, the temperature necessary, the time required, etc., are based. To carry these principles further and study their effects in the preparation of all the various food-stuffs we consume is beyond the scope of a general text-book, and belongs rather to a full course in cooking. Certain simple forms of food it is, however, from the begin- ning of her training, part of a nurse's duties to prepare and administer. It seems essential that she should un- derstand the comparative importance of these foods, their value in the human economy, and the different forms of preparation by which they may be made appetizing and most readily digestible. In the large majority of illnesses the digestive processes are deranged, and it becomes necessary to provide the body with food in those forms in which it can be most readily digested. It is essential that the diet should in- clude all five food elements in a proper proportion. At the same time, as with rest in bed the body has no motor activ- ity to perform, a much smaller quantity of food is required. To give an ordinary quantity of solid food to a patient confined to bed is likely to cause some of the disorders of deficient elimination. The simple forms of food to which we shall confine ourselves are milk, eggs, beverages, soups, and gruels, foods which constitute the entire diet of the majority of acute cases. MLLK Of all the various food-stuffs, milk is the most valuable to man, and for the following reasons: 1. It contains all five food elements in their proper proportion; for this reason it is often called the perfect food. 2. It is generally procurable. 3. It is comparatively inexpensive. 4. Usually it is easily digested. In many of the large agricultural districts of the world milk is the principal article of diet, and with cheese and MILK 751 eggs the only animal food taken; it is also, as we know, the natural and sole food of infants and all young mam- mals, and an important article in the diet of children dur- ing the years of their most rapid development. Milk as a sole article of diet is not suitable for people leading active lives; to obtain from milk alone the quantity of protein necessary for a man in active work as much as four quarts of milk would be required, at the same time he would be taking too much fat and too small an amount of carbohydrates. The consequence of such a diet would be an undue accumulation of adipose tissue and a decrease in muscular energy. In the agricultural districts just mentioned the extra protein is taken chiefly in the form of cheese, and the carbohydrates as potatoes and bread. In the diet of the sick an increase of proteins, if desired, is usually given in the form of eggs, especially the easily digested whites of eggs, arid meat broths, and the carbohydrates in the forms of gruels, barley water, or simple farinaceous foods. The chemical composition of cows' milk is, on an average: Fat, 4 per cent.; carbohydrates, 4.5 per cent.; protein, 4 per cent.; mineral salts, 0.7 per cent.; and water, about 87 per cent. The proportion in which the fats, proteins, and carbohydrates are required in the diet of an adult doing active work are as fat, 2; protein, 4, and carbohydrates, 18. Oysters and similar shell-fish are the only other food- substances which contain the five elements in something the same proportion as milk. For this reason they are, when taken raw, on account of their easy digestion, a valu- able food in the sick-room. They cannot, however, be taken in sufficient quantity to take the place of milk, even if their price did not make them a much more expensive food. The chemical composition of an oyster is, on an average: Fat, 1.1 per cent.; carbohydrates, in the form of animal starch or glycogen, 3.3 per cent.; protein, 6.1 per cent.; mineral salts, 0.9 per cent., and water, 88.3 per cent. Indigestibility of Milk.—A very little experience is needed to show that milk, as obtained from the cow, can- not be digested by infants or by a large proportion of sick or convalescent persons. An exclusive diet of milk 752 THE PREPARATION OF FOOD is apt to produce gastric irritation, a coated tongue, nausea, constipation, and biliousness, or, less frequently, diarrhea; often the milk cannot be taken in sufficient quantities for purposes of nutrition. Many persons also who, when in health, drink milk freely, when ill dislike the taste. At the same time there is no perfect substitute. An important part of our work is then to find out in what way the disadvantages of milk as a diet for the sick can be overcome. The principal cause of the indigestibility of milk is the protein caseinogen, which, by action of the ferment rennin, is converted in the stomach into solid curds. Where the digestion is enfeebled, these curds are frequently found impossible of digestion. The biliousness, which is an occasional symptom where the diet is exclusively of milk, is commonly caused by the large proportion of fat. These disadvantages may be mitigated in several ways: 1. Milk may be split up, and the parts that disagree with digestion either altered or left out. Cream.—If we take the cream alone, we obtain, in the same bulk, a higher proportion of fat (from 10 to 30 per cent., instead of 4 per cent.), while the proteins, carbohydrates, and salts remain about the same. Cream, therefore, is used with advantage where emaciation makes the use of an excess of fat necessary, 1 ounce of rich cream containing as much fat as 6 or 8 ounces of whole milk. Rich cream, being largely pure fat, has consequently a very high caloric valve. This makes it a valuable food where the greatest results are desired, with the least amount of work for the digestive organs. Skimmed or Fat-free Milk.—Skimmed milk is milk with the fat removed, the protein, carbohydrates, and salts re- maining. It is, therefore, well borne in many cases of intestinal indigestion, and in jaundice, where the bile is decreased or absent, in which condition the fats are not well borne (Chap. XXI). Whey.—Whey is milk—as a rule, skimmed milk—from which the casein has been removed, usually by the action of rennet. It contains no fat or casein, 1 per cent, protein MILK 753 in the form of lactalbumin, and the full proportion of carbohydrates and salts. The lactalbumin is the same as the albumin found in the blood, and, therefore, readily assimilated. Whey is often of great value where the diges- tion is seriously impaired, especially in the feeding of young, feeble infants. The curds obtained by this process, which contain the casein, together with carbohydrates and salts, form an agreeable change in an exclusive milk diet, but are not suitable where the digestion of proteins is difficult. Buttermilk.—Buttermilk is the sour, acid fluid sepa- arated from sour milk or cream by churning, by which proc- ess the fat is removed in the form of butter. In chemical composition buttermilk closely resembles skimmed milk, and is, for the same reasons, useful in cases of intestinal disorders. The sour taste is due to the bacterial activity that has caused the souring or ripening of the milk. It is often appreciated where sweet milk is disliked. Butter- milk has a decided laxative effect, and is, therefore, not suitable in conditions where diarrhea exists, and is, on the other hand, peculiarly serviceable in conditions accompanied by biliousness or obstinate constipation. 2. The dilution of milk with hot water or with one of the carbonated table waters (Apollinaris, Vichy, seltzer, etc.) is frequently the simplest means of increasing the digesti- bility of milk. The latter not only give to the milk a re- freshing, agreeable taste, but have the effect of separating the particles of casein, which consequently solidifies in less dense curds. Milk may also be diluted by being mixed with thin gruels, toast, bread-crumbs, or crackers. This increases the nutritive value of the diet, and has also the effect of causing the casein to form in lighter curds. Gruels should not be given where there is any tendency to diarrhea. 3. Lessening Acidity.—Substances may be added to the milk to increase its digestibility. An alkali, such as lime-water or bicarbonate of soda, by lessening the acidity of the medium, restricts the curdling action of the rennin on the casein, and causes the curds to form in much smaller, lighter masses, resembling more the curds of natural human milk. Lime-water is usually 48 754 THE PREPARATION OF FOOD added in the proportion of 1 part lime-water to from 6 to 12 parts of milk; bicarbonate of soda, in the proportion of about 1 grain to the ounce. The latter is used largely in infant feeding. The addition of common salt is frequently observed to aid in the digestibility of milk. We saw that the stomach uses common salt in the manufacture of the hydrochloric acid of the gastric juice: patients who are kept for long on an exclusively milk diet frequently suffer from lack of the salt. 4. Fermentation.—Fermentation is the disorganization and oxidation of the carbohydrates (Gould). Among the primitive races of the East the process of fermentation has been known for ages as a means of pre- serving milk and increasing its digestibility. At the present day fermented milk is found invaluable in many severe gastric disorders, especially in chronic varieties, and rarely fails to be retained. • Koumiss, matzoon, and kefir (see Recipes) are the forms of fermented milk in use; they differ but slightly from each other in composition. In the East mares' or asses' milk were commonly used; in this country cows' milk is pre- ferred, and is more readily attainable. 5. Heating.—Hot milk frequently appears more easily digested than cold, probably from the stimulating effect of hot fluids on the gastric secretions. Care must be taken not to bring the milk to a higher temperature than 155° F., or the albumins will be coagulated and rendered less easy of digestion. (See Pasteurization and Sterilization.) 6. Predigestion.—By the addition of a ferment resem- bling the pepsin of the gastric juice, proteins may be con- verted into soluble peptones. The process is frequently used for the predigestion of the protein in milk, in cases where the digestion is greatly impaired, and for rectal feed- ing. Several preparations for the predigestion or pepton- izing of milk, etc., are on the market (see Recipes), all having for their object the conversion of proteins into sol- uble peptones. If milk is completely peptonized, it has a peculiarly bitter taste; this is objectionable except occasionally, in special cases, such as acute catarrhal jaundice, where MILK 755 the patient frequently craves bitter-tasting foods. The digestive process can be arrested at the desired point, either by placing the milk on ice or by bringing it quickly to the boiling-point. Like the ferments in the digestive juices, the artificial peptonizing agents can act only at certain temperatures, and in a medium of a certain degree of acidity or alkalinity. To obtain accuracy on these points the directions which accompany the various pepton- izing preparations must be carried out exactly. 7. Flavoring.—Quite frequently the taste of milk is objected to; the difficulty may be overcome by flavoring the milk with weak freshly made tea or coffee, cocoa, chocolate, etc.; with the two latter the nutritive value of milk is increased. Milk may also be given in solid form, as junket, blanc- mange, or as milk jelly (see Recipes). These forms are frequently prescribed in cases of paralysis of the soft palate (a common sequela of diphtheria), as solids are then more readily swallowed than fluids. Ice-cream is also valuable, flavored with simple essences or fresh fruit. It is too rich in fat, however, to be taken in large quantities. Where a milk diet is continued over long periods, as, for example, in cases of acute nephritis, much ingenuity is required to prevent the food becoming hopelessly monot- onous. It may be altered in any of the ways just sug- gested, and the form varied at the different hours of nourishment. Example of a milk diet for the day: 7 a. m. Cup of milk flavored with hot weak tea or coffee. 10 a. m. Glass of milk with Vichy, etc. 1 p. m. Dish of curds and whey with cream. Varied with blanc-mange or ice-cream. 4 p. m. Cup of milk flavored with cocoa. " 7 P. M. Glass of warm milk or milk and hot water. Frequently a light carbohydrate diet is combined with the milk diet, and milk-toast, gruels, and farinaceous puddings may be used to give variety, and light cakes, such as lady-fingers or simple crackers, added as dainties. Another method of flavoring milk or cream is to serve it as a soup, flavored with a small amount of some well- cooked vegetable, choosing those which are least rich in 756 THE PREPARATION OF FOOD proteins, such as tomatoes, asparagus, spinach, or onions, and season with butter and salt. Pepper must be avoided where the kidneys are irritated or the digestive organs impaired. Where milk is given as an additional nourishment with a mixed diet, it should not be taken with a heavy protein meal, since the casein in itself taxes the digestion con- siderably. It is best taken with a cereal or a farinaceous pudding, or by itself with a cracker, as a light luncheon between meals. Milk-punches or white wine whey are also favorable ways of taking milk where alcohol is added to the diet. (See Recipe.) MILK AS A FOOD FOR INFANTS To use cows' milk as a food for infants it is necessary to alter or modify it so as to bring its chemical composition to resemble more closely that of human milk, the natural food of infants. Human milk contains a smaller proportion of fats, proteins, and mineral salts than cows' milk, and a larger proportion of sugar. The proportion of water is about the same in either. Cows' Milk. Human Milk. Fats................ 4.0 per cent. 3 to 4 per cent. Sugar (lactose)...... 4.5 " 6 to 7 " Protein............. 4.0 " 1 to 2 " Salts................ 0.7 " 0.2 " Water.........about 87.0 " about 87.0 " The protein of milk is composed of casein and lactalbu- min. Casein, as we have seen above, is difficult of diges- tion, while lactalbumin is soluble and readily absorbed. In cows' milk the proportion of casein is greatly in excess of the lactalbumin; in human milk there are nearly three parts of lactalbumin to one of casein; the protein of human milk is, therefore, more easily digested than that of cows' milk. The curds formed during the digestion of cows' milk are hard and dense; those of human milk are lighter, soft, and flocculent. Cows' milk has a slightly acid reac- tion; that of human milk is slightly alkaline. Human milk, as the infant receives it, is free from any external MILK 757 contamination, either from bacteria or dirt, and is at the natural temperature of the body; cows' milk, on the other hand, must necessarily be handled, can only by the most scrupulous care be kept from contamination, and is sub- ject to several changes of temperature before it is given to the infant. Another important point is that human milk, to some extent, changes with the development of the child, in order to meet the demands of its growth. From the above it will be seen that cows' milk cannot be a perfect substitute for human milk. Very frequently, however, it is the best food available. In these circum- stances we do our best to imitate as closely as possible the human milk as the infants receive it. The process of alter- ation is known as modification. To modify cows' milk we first ascertain the total quan- tity in ounces required for a given number of feedings. We then take as a basis cream of a known percentage, say, for example, 16 per cent.; this will supply us with fats in the proportion of 16 per cent, to 4 per cent, protein and 4.5 per cent, of sugar. If we dilute the fats with water down to the required proportion (3 to 4 per cent.), we shall also reduce the proteins and the sugar, and we already have too small a percentage of sugar to start with. We must, therefore, increase these ingredients. To increase the protein of the mixture, we add skimmed milk, which is free of fat, but contains 4 per cent, protein and 4.5 per cent, sugar; the sugar we increase by simply adding a sufficient quantity of dry sugar of milk. Finally, when we have, by mixing cream, skimmed milk, and sugar, obtained the full amount of fat, sugar, and pro- tein required in the total feedings, we take a sufficient quantity of water to make up the necessary bulk, and divide the whole amount equally into the number of feed- ings required. To make the above calculation is obviously a somewhat complicated arithmetic problem. Several formulas, how- ever, have been devised to simplify the process, by means of any one of which the required foods may be quickly pre- pared. 758 THE PREPARATION OF FOOD One in common use in hospital work is by Dr. Baner, It will be found simple to use, and is sufficiently accurate for practical purposes. Dr. Baner's Formula for the Modification of Milk. Given: The quantity desired in ounces. The desired percentage of fat. The desired percentage of sugar. The desired percentage of protein. To find in ounces cream, milk, water, and sugar of milk: p Quantity X (Fats — Proteins) Percentage of cream — 4. Milk = (Q^ntity X Proteins^ _ Cream Water = Quantity — (Cream + Milk). „ = (Sugar — Protein) X Quantity ougai 10Q To work out an example, let us take a formula requiring a percentage of fats 3, sugar 6, proteins 1—about the aver- age composition of human milk. We will use a cream with a fat percentage of 16, and estimate the quantity required at 20 ounces. To find the cream required: Q. 20 X (F. 3 - P. 1) = 40 -f- (percentage of cream 16 - 4) = 3 J (cream in ounces). To find the milk required: Q. 20 X P. 1 = 20 -h 4 = 5 - Cream 3.33 = If (milk in ounces) To find the water required: Q. 20 - (Cream 3£ + Milk If) = 15 (water in ounces). To find the sugar required: (S. 6 - P. 1) x Q. 20 = 100 -i- 100 = 1 (sugar in ounces). MILK 759 Thus, to modify ordinary cows' milk so as to obtain 20 ounces, in which the percentage of fats, sugar, and proteins shall be 3, 6, 1, we require: Cream (16 per cent.)...................... 3f ounces. Milk (skimmed).......................... If « Water.................................. 15 « 20 ounces. Sugar of milk 1 ounce (dissolved in the whole quantity). In hospital work the percentage of fat in the cream is readily ascertained in the laboratory. Where this is not practical, it is usual to use the tops of milk bottles, calcu- lating the fat in the following manner: Upper 10 ounces, 10 per cent. " 8 ounces, 12 per cent. " 6 ounces, 20 per cent. Cream that is left to rise and not separated artificially is known as gravity cream. It is usually easier to teach the pupils to carry out the calculation in decimal fractions rather than in vulgar fractions. In estimating the quantity in ounces (where the metric system is not used throughout) the ounce may, to facilitate calculation, be taken as 500 (480 minims), which makes each ^ part to represent 50 minims instead of the 8 parts of 60 minims each. To the prepared mixture an alkaline is frequently added to aid in the digestion of the protein, since in modifying we do not change the proportion of casein and lactalbumin in the protein, and the casein is still in excess. To help in the digestion of the casein bicar- bonate of soda (J grain to each ounce) is frequently used, or lime-water, from Jj to f part. If lime- water is used, a correspondingly smaller proportion of plain water will be required. The formula to find the water will then read: Water = Quantity — (Cream + Milk + Lime-water). Milk is one of the best media for the cultivation of germs, and it becomes a question in what way we can best re- produce the sterile quality of human milk. Sterilization.—At one time it was considered best to 760 THE PREPARATION OF FOOD sterilize the cows' milk by subjecting the prepared food to a temperature of 212° F. for thirty minutes. By this process, however, much of the nutritive value of the milk is lost in the skin which collects on boiled milk and is very difficult to reincorporate. Fat, coagulated albumin, and some of the salts of milk, all parts of high nutritive value, are contained in the skin. Milk also appears less easily digested after it has been boiled. A continued diet of boiled milk quite commonly causes constipation from insufficiency of fat. It is con- sidered that the exclusive use of sterilized milk may also be a cause of infantile scurvy, probably from the loss of vitamin destroyed by the high temperature. Where sterilized milk is considered necessary, many doctors add to the diet the white of an egg (| to 1 in the day) and a small quantity of" orange-juice daily. They are given in water (separately) between the milk feedings. Orange- juice is not usually ordered until after the sixth month. At the present time pasteurization is preferred to com- plete sterilization. In pasteurizing milk the prepared food is subjected to a temperature of from 155° to 167° F. for thirty minutes. (See Recipe.) At this temperature pathogenic bacteria (disease-producing micro-organisms) and also the non-pathogenic micro-organisms that cause the souring of milk are destroyed. Spores (p. 359) are, however, not destroyed by this process, and if allowed time and exposed to a suitable temperature, may develop. Pasteurization is not considered to affect materially the nutritive value of milk, and is, for practical purposes, accepted today as the best method of insuring uncon- taminated milk. Some authorities, however, consider that the vitamins in milk are destroyed by pasteurization. Keeping Milk Pure.—Where the milk can be brought straight from the cow to the consumer, under strictly hygienic conditions, kept during the transit at a tempera- ture not above 45° F., and used before it is many hours old, most doctors consider the milk is best digested and most nutritious if neither pasteurized nor sterilized. It then becomes doubly necessary to preserve the milk from contamination or from changes due to temperature while storing and preparing the mixture. The whole MILK 761 process is carried out under strict aseptic precautions. The bottles, spoons, etc., used are sterilized previously by boiling, and laid out conveniently on a clean sterile towel. Rinsing during the process must be done with sterile water, wiping with a sterile towel. The nurse's hands should be scrubbed as for an operation, and kept clean throughout. As a further precaution, a sterile gown is generally worn over the uniform during the process. The simple implements required are the feeding-bottles, a graduated glass for measuring, a funnel, a spoon, a pitcher (containing sterile water), and sterile non-absorb- ent cotton. The milk and cream are taken direct from the bottle in which they are delivered. The bottles should be kept in the ice-box until required, and the mix- tures replaced in the ice-box as soon as they are prepared. The feeding-bottles each contain one entire feeding only, a sufficient number for the day's feeding being prepared at a time; they are corked with sterile cotton and clearly marked with the baby's name or number. At the hour of feeding the bottle is placed in a bowl of hot water until it is the required temperature, and a clean nipple substituted for the cotton. The bottles used should have the nipple directly attached to the bottle. Rubber tubing is im- possible to keep clean, and should never be allowed. As soon as the bottle is finished, it should be rinsed in cold water, washed in hot suds, rinsed, and set aside clean, to be sterilized with all the other bottles before being used again. This may be done by boiling for half an hour, or by placing for fifteen minutes in the autoclave. The nipples should be rinsed inside and out under run- ning cold water, then washed in hot suds, rinsed, and boiled for five minutes, after which they may be put away dry in a clean sterile towel or placed in a jar of boric-acid solution until required. Every baby should keep its own nipple. To keep the nipples from floating on the top of the antiseptic solution, they may be loosely tied in small squares of gauze, to a bunch of which, for weight, a pair of forceps is clipped, otherwise they will only float. Whey, buttermilk, barley-water, and thin gruels may also have their place in the baby's dietary and take the 762 THE PREPARATION OF FOOD place of water in diluting the food. (See Recipe.) When barley-water or gruel is used, less sugar will be necessary, since they are already rich in carbohydrates. Starchy foods are not usually ordered before the eighth month. In giving any form of starch to a baby, it is necessary to remember that, at first, there is no ptyalin in the saliva, and that, even after the saliva flows freely, the percentage of ptyalin is small. Starches must, therefore, be dextrin- ized, either by prolonged exposure to heat or by the addi- tion of a dextrinizing agent. (See Recipe.) After the tenth month beef-juice is sometimes used for feeble in- fants. The capacity of a baby's stomach is small, and the amount of food given at a time must be regulated accord- ingly. As the child grows, the capacity of the stomach in- creases and the food may be given in increased quantities at longer intervals. Capacity of the Stomach At birth.......................... 1 ounce. At 4 weeks....................... 2| ounces. At 8 " ....................... 3| At 3 months...................... 4 At 5 " ...................... 5| At 9 " ...................... 7i At 1 year......................... 9 The feedings are usually ordered in the following quantities, gradually increased. It must be remembered that the weighing scales are a more accurate guide to the baby's requirements than its age. Day (6-10) Night (10-6) First week (after first two days). . 6 drams every 2 hours. Every 1\ hours. Four weeks...... 2 ounces every 2| hours. Twice at night. Three months.... 3 ounces every 3 hours. Once at night. Five months......4| ounces every 3 hours. No night feeding. Nine months.....6 ounces every 4 hours. " " " One year......... 8 ounces—4 feedings. " " " The strength of the food is gradually increased at the same time, beginning, during the first week, with a weak formula, such as 2, 5.50, 0.60, and increasing as the diges- EGGS 763 tion will bear it, until, at one year, the child can take cows' milk undiluted. If the child is tranquil, gains stead- ily in weight, and has well-digested stools, the food is agreeing with it and requires no alteration. If the weight is not increasing sufficiently, usually a stronger formula is prescribed, or a formula with a larger proportion of sugar. After the ninth month starchy foods may be ordered. Proprietary foods should, however, be looked upon with suspicion; as a rule, they are deficient in fats, which are a prime necessity for the infant. Indigestion may be shown by colic, vomiting, or by ab- normal stools, all of which are important points to observe. Regurgitation and vomiting may also be caused by feeding too quickly, or in overlarge quantities. Protein indigestion is shown by colic, vomiting, diarrhea or constipation, and the presence of curds in the stools. Carbohydrate indigestion is shown by colic and thin, green-, acid stools that " scald " the buttocks. Too much fat causes vomiting toward the end of diges- tion, and frequent stools, either of normal appearance or containing fat. Too little fat is the commonest cause of constipation. EGGS Eggs rank next to milk in forming a nourishing, easily digested food for the sick. They contain all the food ele- ments except the carbohydrates, and are rich in mineral salts. The salts are present in " organic combination," which make them readily assimilated by the body. The white of egg is almost pure albumin and water, and is more easily digested than the yolk, which is a highly complex food-substance, containing fat, protein, and a large number of the mineral salts. The presence of sul- phur is detected easily when an egg begins to decompose. The white or yolk may be used separately or together, and either raw or cooked, measured by bulk. Eggs contain a much larger amount of nourishment than milk. Where the digestion is feeble, the white of an egg dissolved in cold water is one of the simplest forms of nourishment, and generally well borne. (See Recipes.) 764 THE PREPARATION OF FOOD The first quality of an egg is that it should be fresh, and especially so when taken raw. To be perfectly fresh, an egg should not be more than twenty-four hours old; in hospital work, however, it is commonly impractical to obtain eggs the day they are laid. The freshness may be maintained for a considerably longer time if eggs are properly cared for. The egg-shell is porous, and in course of time some of the water in the egg evaporates through the shell, the place of which is taken by air from outside. We see the effect of this in the little air-space at the top of a boiled egg. If the egg is new laid, the space is very small; in an older egg it is considerably larger. The entrance of the air, which may also mean the entrance of bacteria, is the cause of the decomposition. Air may be excluded in several ways, but it must be remembered that the material used will readily impart the taste to the egg. To keep eggs for immediate use as fresh as possible the shells should be clean, and they should be kept at a low temperature in the larder or ice-chest, away from all strong-smelling foods, such as cooked meat or vegetables. When used, each egg should be broken separately in a cup, as one turned egg will cause a whole dish to be spoiled. The albumin of eggs coagulates at a temperature of 134° F. If exposed to high temperature, the albumin is tough and leathery, less palatable, and more difficult of digestion. They should, therefore, in most cases be cooked slowly at a comparatively low temperature (134° to 167° F.). The yolk will cook at a lower temperature than the white. The digestibility of eggs is also increased by beating; this ruptures the fine capsule which incloses the particles of albumin, setting the albumin free to be acted upon by the gastric juice. (See Recipe.) GRUELS Gruels, when combined with milk, are rich in nutritive value, and form usually a much-appreciated variety in the monotony of a restricted diet. Oatmeal, wheat-meal, bar- MEAT BROTHS AND EXTRACTS 765 ley-meal, rice, and other prepared cereals may be used. Oatmeal gruel has a laxative effect, and is, therefore, pre- ferred where active elimination is desirable. Barley gruel and rice gruel have astringent properties, and are preferred in cases of intestinal irritation. In cooking cereals it must be borne in mind that long exposure to heat is necessary, in order thoroughly to rup- ture the cellulose inclosing the starch-grains, and for the purpose of partially dextrinizing the starch. Patent invalid foods are frequently used instead of the cereals in the preparation of gruels. In them the starch is usually already dextrinized, and less time is, therefore, required for the cooking. We have seen that long exposure to heat destroys some of the nutritive value of milk; milk or cream, therefore, is usually added at the end of cooking. Since heat also converts cane-sugar into glucose, thus losing much of the sweet taste, if sugar is desired, it should be added on serving. The cereals are, however, rich in carbohydrates, and sugar should not be required. Salt should be used for seasoning, and will aid in diges- tion. Gruels must be served hot; they should be sufficiently thin to be drawn through the feeding-tube. MEAT BROTHS AND EXTRACTS Beef-tea, beef-juice, chicken-tea, and mutton broth are frequent additions to a liquid diet. They contain some soluble albumin, mineral salts, a little fat and meat extractives, and a large proportion of water. The nutritive value of meat-teas .is not high, but the meat extractives act as stimulants to the gastric juice, and contain, besides, act- ive principles, much like the alkaloids of vegetable drugs, which have a stimulating effect on the nervous system. Both as a general stimulant, therefore, and as a stimulant to the appetite, meat-teas and extracts are of value. They furnish, besides, an acceptable change in a monotonous, restricted diet. The nutritive value is increased by the addition of toast, croutons, crackers, or well-boiled rice. 766 THE PREPARATION OF FOOD It is on account of the stimulating effect of the meat ext rac- tives on the gastric juice that a hot meat soup is usually the first course of a heavy meal. In preparing beef-tea or beef-juice the lean meat from the round of beef is used; for mutton broth, lean meat is cut from the forequarter of lamb or tender mutton, the skin and fat removed, and the meat cooked with the bones; for chicken broth the whole chicken is used, with the skin and fat removed. Where the digestion is delicate, fat, especially meat fat, will often cause digestive disorders, and should, therefore, be avoided. In order to extract all the nourishing properties of the meat-juices, meat to be used for broths or teas should be cut up in small pieces and placed in cold water, which is then slowly brought to the temperature necessary for cooking. (See Recipe.) WATER The value of water in a dietary must not be overlooked. As a solvent, a diluent, and as an aid to elimination no food-stuffs can take its place, and although it is consid- ered that water does not undergo combustion, but passes out from the body still as water, it is certain it has an influ- ence, probably nearly as important as that of oxygen, on metabolism. On an average, from four to six pints of fluids should be taken daily in the form of drinking-water, beverages, soups, and milk. In disease, where the ordinary processes of nutrition are impaired, a certain amount of water should be given daily over and above that represented by the liquid diet, remembering that water in a pure state fulfils its own purpose in the body better than when combined with food-stuffs. The supply should not be left to chance, and given only when the patient complains of thirst, but be entered as part of the diet and given at regular hours. Conditions where water should be pushed are: deficient elimination, either of bowel or kidney, toxic conditions, fevers, in rheumatism, gout, and other conditions associ- ated with excess of uric acid, where much fluid has been lost to the body, as after severe hemorrhages, when the bleed- ing point has been secured. BEVERAGES 767 Water is restricted where dropsy is present, in effusions of pleura or pericardium, and in conditions where it is desirable to promote the clotting of the blood, as in aortic aneurysm or hemorrhages, where the local lesion cannot be reached. Fluid is also restricted in the condition of dilated stomach. Besides its general purposes, water may be used as an aid to digestion. Hot water acts as a stimulant to the gastric juice, and is a useful aid to deficient elimination, especially in bilious conditions. A glass of hot water ten minutes before meals is fre- quently prescribed in conditions of chronic gastritis. It washes the stomach free of mucous secretion, and promotes the secretion of the gastric juice. Cold water has the important effect of exciting peris- talsis, and for this reason is often ordered night and morn- ing in the treatment of constipation. Either boiling hot water or iced water (or ice) in small sips is useful in relieving nausea and vomiting; hot water is most valuable in nausea after an operation, as it also allays thirst, which ice or ice water frequently appears to increase. The carbonated waters—soda-water, seltzer, Vichy, etc, —are often preferred by patients to ordinary drinking- water, and are, as has been said, especially useful in the dilution of milk. Soda-water is often found useful in checking vomiting. Their only disadvantage over plain Water is that they tend to produce flatulence. Many of the natural mineral waters are useful for special properties in the aid of elimination, and are not used as beverages; such are Hunyadi water, Apenta, and others. Others, such as lithia water, are valuable in conditions associated with uric acid, and may be taken more freely. BEVERAGES Where it is difficult to induce a patient to take a sufficient amount of fluid, he may often be induced to do so by offer- ing it in the form of a beverage with an agreeable flavor or appearance. 768 THE PREPARATION OF FOOD The beverages most universally used and constantly craved by patients are hot tea and coffee. Both are re- freshing, stimulating, and cheering, and to some extent both diuretic and diaphoretic. Taken at night, they cause wakefulness, and the abuse of either induces a con- dition of nervousness not unlike the abuse of alcohol and tobacco. Unfortunately, both tea and coffee are apt to produce disorders of digestion, and are, therefore, not usually in- cluded in the diet of very sick persons or invalids of weak digestion. Tea.—The indigestibility of tea is due to the tannin. Tea may be prepared with a minimum amount of tannin in the following manner: Place two teaspoons of tea in a small pot, previously well heated; add just sufficient boiling water to cover the leaves, cover, and let stand for three minutes; pour off the tea into a heated cup, and add sufficient boiling water to dilute; sugar and cream or lemon may be added. By this method the thein (the active principle of tea), which is readily dissolved, is extracted and forms a satu- rated solution which will not pick up the more slowly dis- solved tannin. In any case the longer the water stands on the leaves, the more tannin will be extracted. Freshly made tea that does not stand more than three minutes before being poured off the leaves should be the rule in the sick-room. The tannin in tea checks digestion; strong tea is, therefore, an unsuitable beverage to take with a heavy meal, and its use in this respect is a common cause of dyspepsia. Coffee, if taken in excess, is apt to produce nervousness, insomnia, and biliousness. It contains an oil which is the cause of its bilious effect, but also produces a slightly laxative action on susceptible people. Black coffee is a good general stimulant, and useful in cases of lowered vitality; it is frequently given by enema in conditions of shock and collapse. A small quantity of black coffee at the end of a meal is considered to aid digestion. The best coffee is made by the drip method, from freshly BEVERAGES JQQ ground beans. The flavor is spoiled if it is allowed to boil. Coffee for the sick-room should be freshly made. Coffee and tea have no food value, except in so far as milk, cream, or sugar may be served with them. Chocolate and cocoa are rather foods than beverages, since they contain carbohydrates, fats, and proteins^ besides a stimulating principle, theobromin, and represent considerable nutritive value. Beverages made from fresh fruits and fruit syrups are refreshing and easily made. The sugar and the vegetable acids they contain give a small proportion of food value. Starchy beverages are frequently ordered in cases of intestinal irritation; the most important are barley-water and rice-water. They have a slightly astringent effect on the mucous membrane of the intestines. The value of alcoholic drinks in illness is largely a matter of opinion, and is governed by many considerations: the previous habits of the patient, the necessity for stimulation, the state of the digestion, and so forth. They belong to the physician rather than to the dietitian, and in illness are practically medicines. Hot alcoholic drinks, such as whisky toddy, have a quick diaphoretic effect and are useful in the breaking up of a cold. They are also valu- able where much of the body heat has been lost from exposure or fatigue. 49 CHAPTER XXIII DIETS AND DIETING General Division of Diets—Selection of Diet—Liquids—Eggs, Meats, Fish, Vegetables, Fats, Carbohydrates—Some General Points—Diet in Special Diseases: Fevers, Typhoid Fever, Acute Gastric and Intestinal Disorders, Gastric Ulcer, Diarrhea, Infantile Diarrhea, Chronic Dyspepsia, Dilated Stomach, Obstruction of Bile- ducts, Chronic Constipation, Nephritis, Dropsy, Salt-free Diet, Dia- betes, Phthisis, Scurvy, Rickets, Anemia. GENERAL DIVISION OF DIETS In hospitals where the diets are not prescribed individu- ally by the calories required, as explained in the preceding chapter, the patient's food is usually ordered under the heading of certain standard diets, except in cases requiring special dieting. The usual divisions are milk diet, liquid diet, semisolid diet, house diet, house diet with care, and extra diet. The quantities are prescribed, and the nurse's chief responsibility is to see the patient gets the right amount, properly served. In private work a nurse may find herself left much more to her own resources, both as to the selection of food and the quantities in which they may be given. She may have no more precise orders than "a light, nourishing^ diet," or "keep him on liquids"; it is then very essential that she should know the average quantities necessary, and the forms in which foods are most easily digested. If she has been taught thoroughly the chemical compo- sition of food-stuffs and their caloric values, she will ob- viously bring a trained intelligence to bear on the subject that will both aid her in her work and benefit her patient. A nurse is, in fact, not fully equipped without this knowl- edge. Liquid Diet.—This includes milk, buttermilk, whey, cocoa, chocolate, egg-albumen, broths, bouillons, barley 770 GENERAL DIVISION OF DIETS 771 and rice water, thin gruels, and beverages. From four to six pints are the average allowed. Where milk is taken, generally two-thirds of the diet should be milk; of the re- maining third, one-half should contain nourishment, as in broths, egg-albumen, and gruels, and one-half be pure water or beverages. Where milk is the only diet, the form in which the milk is given should be varied. Few patients can take more than three or four pints of milk in the day. Extra liquid to relieve thirst should be given as water or beverages without food-stuffs. The whole quantity should be divided into feedings, and given at regular intervals. In a sick diet not more than 5 ounces of plain milk should be given at a time; of diluted milk, broths, etc., not more than 10 ounces; thin gruels, from 5 to 8 ounces; beef-juice, | to 1 ounce. Whole milk may be diluted with carbonated waters, lime-water, etc., as above. The most digestible forms of milk are whey, buttermilk, and fermented milks (koumiss, etc). Where cream is well borne, it is of great use on account of its high caloric value. Broths and bouillons made from beef are more irritating to the intestinal tract, on account of their extractives, than those made from mutton or chicken. They should be made from lean, tender meat, with all fat carefully removed. (See Recipe.) It must be remembered that broths, bouil- lons, and beef-extract preparations are valuable chiefly as stimulants to the digestion, and as affording variety to a monotonous diet, and contain little of nutritive value. Egg-albumen and gruels are foods and have distinct caloric value. As meat extractives are to some extent irritating to the alimentary tract, they are often useful in overcom- ing constipation, and are contraindicated, as a rule, in con- ditions associated with diarrhea. In any case of gastric or intestinal disorder liquids should be given cool: either very hot or very cold drinks tend to aggravate the trouble. Even a fluid diet may cause indigestion, the symptoms of which may include nausea, vomiting, flatulence, dis- tention, coated tongue, and diarrhea or constipation, the latter symptoms especially from an exclusive milk diet. Most commonly it is the proteins that cause digestive 772 DIETS AND DIETING troubles, especially the casein of milk. The milk may be altered or diluted, as already described; lime-water or bicarbonate of soda may be added, with the object of making the curds less heavy, or the protein may be pre- digested by a peptonizing agent. Another method of help- ing the enfeebled digestion is by giving regularly, in small doses, dilute hydrochloric acid (3 to 5 minims), or some preparation of pepsin, thus supplying the gastric juice arti- ficially with what, in a normal condition, is called forth by a mixed diet. The use of a small amount of table-salt in the milk is also a valuable aid to digestion. The return from a liquid to a solid diet must be gradual. A long continuance of fluid or bland food-stuffs renders the stomach unaccustomed to digest solids, and a short time must elapse before the gastric juice becomes reestablished in its normal condition. The diet should be increased first by easily digested foods, such as gruels, cocoa, soft-boiled eggs, junket, farinaceous puddings, baked potatoes, oysters, and so forth. The stools should be examined to insure that the food is being well digested. Eggs.—Eggs are most digestible if taken raw, either plain or as eggnog, or soft boiled. Taken with an or- dinary liquid diet, two to four are usually given in the twenty-four hours, except in cases of forced feeding. Fried eggs, or eggs cooked with butter, must be avoided in all disorders of the digestion. Meats.—The most digestible meats are those containing least fat or gristle; young meats are tenderer than meat from older animals, and white meat than dark meat. Red meats, especially beef, are irritating on account of the extractives, and are, therefore, not generally given where the digestion is feeble. Meat may be made more digestible by being finely divided, as in mincing or scrap- ing. The most digestible meats are sweetbreads, white meat of chicken, pigeon, and tripe. Where red meat is ordered, broiled lamb-chops or tenderloin steak are best to begin with. ' Meat is usually tenderest and most palatable if lightly broiled or roasted; boiling is permissible with chicken or mutton if it is impossible to get young meat. Fried meat GENERAL DIVISION OF DIETS 773 should never be given in the sick-room. Gravies and seas- oned sauces should also be avoided. Commonly speaking, meat is best given at the midday meal; if preferred at the evening meal, at least three hours should intervene before bedtime. Fish.—The fish to be avoided are those containing much fat—salmon, mackerel, herring, bluefish, and shad. White fish, such as whiting, flounder, carp, halibut, white-bait, and others, are suitable. They are more digest- ible boiled, broiled, or scalloped. If fried, all grease must be carefully removed. Oysters and clams may be eaten raw or stewed; in this way they are more digestible than if panned or fried. Vegetables.—The most digestible vegetables are those with the least amount of cellulose. Cabbage contains a large amount, and elaborates much gas during its digestion. Peas and beans tax the digestion considerably, both from the amount of cellulose they contain and also from the large percentage of protein. The vegetables must be very young and cooked until soft. Potatoes should be well cooked in order partially to dextrinize the starch; they are most digestible baked or thoroughly mashed. Coarse vegetables, cabbage, turnips, carrots, onions, and radishes should be avoided in the sick room. The most digestible green vegetables are asparagus-tops and the flower of cauliflower. They should be well boiled, and eaten with- out seasoning, except salt. Fruits are usually acceptable, and, although not nutritious, they are refreshing and please the appetite. On account of the acids they con- tain they should not, where the digestion is delicate, be taken with milk. Where the digestion is weak the juice only should be given. Grapes, orange-juice, and lemon- juice may usually be given freely. Peaches, pears, grape- fruit, and berries must be given with more discretion. All fruits must be thoroughly ripe and perfectly fresh. Carbohydrates.—In a liquid diet carbohydrates are given in the form of barley-water, rice-water, and thin gruels. Where more solid food is taken, bread, rusks, toast, well-cooked cereals, and farinaceous puddings are the usual means. All starchy food must be cooked slowly 774 DIETS AND DIETING and thoroughly, in order partially to dextrinize the starch and so spare digestion. Hot bread, hot buttered toast or cakes, and scones, etc., made with butter or served hot with butter, are diffi- cult to digest. The melted butter surrounds the starch grains, and prevents any action of the digestive ferments, until the fats have first been acted upon. Fat.- Where the diet is liquid, fat is given, either in whole milk or cream, and is an important part of most diets. To convalescents an increase of fat is best given as butter, with toast, bread, etc., and in the fat of cooked meats. Chocolate may also be ordered for the fat it con- tains. Speaking generally, fat should not be used in the cooking of meals in the sick room, either in the form of butter, dripping, or oil. SOME GENERAL POINTS A few working rules a nurse may bear in mind concern- ing the diet of her patients: See that the food is ready punctually, and served at regular intervals: the intervals should be sufficiently long for the stomach to have a period of rest, and not long enough for the patient to become in any degree exhausted for want of food. Insist that all solid food be properly chewed and eaten slowly. Remember that food is better digested if it is liked; tempt the patient's appetite with variety, small surprises, and dainty service. Worry, temper, and overexcitement affect the digestive processes: see that the atmosphere of the sick-room is pleasant during mealtime. Allow sufficient time for digestion between the last meal and bedtime, since the digestive processes are sluggish during sleep. Serve hot foods very hot and cold foods really cold; avoid either extreme of temperature, especially hot or ice-cold fluids, in all cases of gastric disorder, especially if associated with diarrhea or ulcerated conditions. Omit altogether, in the diet of the sick, spices, season- ings, rich gravies and sauces, and fried foods. DIET IN SPECIAL DISEASES 775 In giving liquids to patients in bed use either the feed- ing cup or, as is generally preferred, a glass tube bent to a convenient angle. If neither is procurable, pour a small quantity at a time into a tumbler, and raise the head slightly by passing the arm under the pillow. A patient in a stupor may be given liquid food with a spoon; the mouth is opened by pressing the chin down- ward or by pressing the cheek on either side against the back teeth, using the finger and thumb of the left hand. The food is passed to the back of the mouth, pressing the tongue gently down with the spoon, and will generally be swallowed. Where the patient cannot be induced to swallow, he may be fed through the nose with a medicine-dropper, passing the dropper into the nostril and directly backward. The liquid will trickle directly into the pharynx, and usually be swallowed. For patients in this condition gavage is generally preferred. A baby should be taken on the arm, or turned on its side in its cot, and given its bottle slowly, with a little pause from time to time. Many babies learn to bolt their food by being left to take their bottle alone; others, that are slow feeders, leave their bottles until they are cold, or neglect to take the whole amount. A young baby should never be left to take its bottle alone. DIET IN SPECIAL DISEASES At the present day the question of diet in the treatment of disease, and especially of the more chronic varieties, has assumed an immense importance. In many respects scientific dieting is still in the experimental stage, and nurses must be prepared to meet with contradictory opin- ions and varying methods. In the large majority of diseases we meet the need for some alteration in the normal diet. The diet may be altered to suit the requirement of a special organ, as when we decrease the proteins where the kidneys are diseased, or the carbohydrates in cases of diabetes All toxic condi- tions are accompanied by digestive disturbances; food must, therefore, be given in these circumstances in its 776 DIETS AND DIETING simplest and most digestive forms, and, at the same time, it must frequently be contrived so as to increase its caloric value. The most common condition in which strict dieting is a principal part of the treatment is in dis- orders and diseases of one or other part of the digestive tract. A diet is succeeding when it is bringing about the effect for which it is prescribed. If the kidneys are improving, there will be less albuminuria and fewer casts in the urine; under a strict diabetic diet the excretion of sugar in the urine is controlled, and so forth; for special conditions the nurse must watch special points for the results. For general purposes, a diet is agreeing with a patient when he increases in weight, or, at least, in an adult, does not lose weight, is placid in mind, digests his food, shows a reasonable appetite, and the excreta are normal. The consistence and appearance of the bowel movements are the most important indications of the satisfactory diges- tion of a diet; in cases of disordered digestion, from what- ever cause, and in any case of special dieting, their in- spection should never be left to inexperienced persons. It is only possible, in a book of this size, to take, as ex- amples of special dieting, the diseases most frequently met with, in which strict dieting is a prominent part of the treatment. Fevers.—The condition we know as fever most com- monly is the result of the presence of toxins in the body (Chap.XX); it is always associated with certain phenomena —raised temperature, prostration, waste of the tissues, loss of appetite, and derangement of the natural processes of digestion and metabolism. The diet to combat these Conditions must contain all the food elements, must be sufficient to combat to some extent the tissue waste, must be nourishing, easily digested and assimilated, and should include a large supply of water. Taken in sufficient quantity water acts as a diluent to the toxins, and also furthers their elimination by the natural excreta. It is given freely in all fever cases unless contraindicated by other conditions, such as general dropsy or effusion of one of the serous cavities, DIET IN SPECIAL DISEASES 777 A liquid diet is the most suitable for this condition, such as has been described. The diet may be exclusively of milk, or varied in the ways suggested. If diarrhea is a symptom, the milk may be ordered boiled, diluted with lime-water, or given with equal parts of barley-water. In certain conditions, to be described presently, milk may be withheld altogether. When constipation is present, milk may be given with a larger proportion of cream, or diluted with the natural waters or with thin oatmeal gruel; broths and bouillons may also aid in overcoming this condition by their stimu- lating effect on the alimentary canal. In the mild fevers that accompany, for example, the common cold, bronchial catarrh, etc, hot drinks and hot gruels may be added, with the object of encouraging sweating. Typhoid Fever.—Until very recent times typhoid fever was one of the most common diseases to be met in every medical ward, and the correct nursing of a typhoid patient was a classic ground for teaching certain important points in nursing, especially dieting, the handling of helpless patients, and the practice and principles of disinfection. At the present date this fever is rarely encountered in America; inoculation and other methods of prophylaxis apparently are succeeding in stamping it out as vaccina- tion, half a century ago, reduced the number of smallpox victims to a negligible amount. It is, however, too early to omit from a nurse's training instruction in the care of typhoid patients, almost the entire treatment of which lies in careful nursing. In typhoid fever we have some special conditions that must be taken into consideration in the dieting. We have an infection that develops slowly, produces a profound toxemia lasting over a considerable length of time, and is characterized by a rapid waste of the tissues and marked prostration. Further, typhoid fever is associated with ulceration of certain glands in the walls of the small intes- tines; in severe cases these ulcers burrow deeply into the wall of the intestine, and irritation of these parts from decomposition of food particles or distention of the walls 778 DIETS AND DIETING from gases so elaborated may result in rupture of a blood- vessel so exposed, or in perforation, where the walls of the vessel have been worn thin by the burrowing ulcer. In choosing the diet, we must have one that will counter- act the tissue waste, put the body in the best condition to resist the prolonged attack of the invading infection, and, at the same time, will not overtax the deranged digestion or leave an indigestible residue to irritate the intestinal ulcers. For many years the classic diet for all typhoid cases was a strict liquid diet, composed chiefly of milk, diluted with Vichy or lime-water, to which strained chicken and mut- ton broth and beef-tea were added, provided there was no diarrhea nor very acute toxic symptoms which would suggest extensive ulceration. The diet suited the gastric condition, but did little to combat the tissue waste or the prostration, which in themselves may be a menace to life. At the present day our ideas on diet have been much modified by the more definite knowledge available on the comparative value of the different food-stuffs as energy- producers, as we saw in a previous chapter. We saw (Chap. XXI) that the diet of a man of average weight in normal conditions should yield, roughly, between 35 and 40 calories for each kilogram of his body weight, which energy he uses up in functional and motor activity and in the repair of the tissues. In typhoid fever we have, although we keep the body at rest, a waste of tissue out of all proportion to what could be caused by any physical activity, and an abnormal heat- production due to the febrile condition. We have, there- fore, a condition in which an increased amount of energy is used up, and should be counterbalanced by an increased number of calories in the diet; at the same time we have an enfeebled digestion and an irritable alimentary tract. It is estimated that the average typhoid-fever patient re- quires an increase of 25 per cent, calories in his diet, in order to combat the tissue waste and the loss through the abnormal heat-production, and to increase his resistance to the infection. It is a condition, then, in which a high caloric diet is of special value; at the same time the diet must be DIET IN SPECIAL DISEASES 779 chosen to throw a minimum of work on the enfeebled digestion. In whatever school the nurse works at the present day she will probably find some scheme or schedule for the high caloric diet of fever patients, and the accurate adminis- tration of such is almost the most important part of her share in the care of the patient. The patient is weighed regularly, frequently daily, and every article of his diet must also be weighed and measured. As many fever patients display little appetite, much tact, discretion, and perseverance may be called for in inducing the patient to take the necessary amount. The number of calories prescribed depends on the weight of the patient; the average high caloric diet allows from 60 to 80 calories for each kilogram of the patient's weight, and in special cases an even higher number is given. If the diet is successful after the first week, the patient gains steadily in weight—often as much as three pounds and over in the week. In all the schedules cream, eggs, milk in some form, milk- sugar, and, usually, butter are the staple articles of diet. Eggs are most digestible if taken soft boiled; milk-sugar is used instead of cane-sugar, as, being only half as sweet, a much larger quantity can be given in the diet. The sweet taste is further lessened by cooking. If the sugar is to be added to uncooked foods, such as fruit-drinks, it may first be boiled in water for two minutes. The quantity of each of these foods necessary to furnish 100 calories is as follows: White of eggs........................ 5 Yolks............................... 2 Cream (20 per cent.).................. 45 c.c. Milk............................... 150 c.c. Whey............................... 180 c.c. Milk-sugar.......................... 45 gm. Butter.............................. 15 gm. To the above are added well-cooked cereals,—oatmeal, hominy, or wheatena,—corn-starch and tapioca puddings, custards, ice-cream, wine and fruit jellies, toast, stale bread or simple crackers, with which the patient is induced to eat as much butter as possible. Milk-sugar is used in 780 DIETS AND DIETING the cooking, as well as taken with the milk, cream, and other drinks. It is given in small quantities at first, not more than \ ounce, and gradually increased until from 4 to 6 ounces can be taken in half a pint of fluid. Cream is given pure or diluted with milk, etc., as well as served with various foods. Coffee or tea with cream and milk- sugar or cocoa is served with the morning meal. Some doctors add to this diet scraped beef, finely minced chicken, and boiled whitefish or beef-juice; others omit meat or meat-juice entirely during the acute stage. When the digestion is abnormally sensitive, the diet may be exclusively of cream, milk, and milk-sugar; usually, however, the more mixed diet is well borne. If the patient shows symptoms of indigestion, such as vomiting, diarrhea, or the presence of curds in the stools, he may be given peptonized milk for a short period, until the digestion is reestablished, when the diet is gradually resumed. Patients are usually given their three principal meals as breakfast, dinner, and supper, with additional feedings either every two or three hours, according to the amount of nourishment necessary and the quantity the patient can take at a time. At the beginning the quantity taken may be small, but should be increased perseveringly. During the night only liquid food is given. Water should also be taken, and may be given with fruit-juice, sweetened with milk-sugar, if there is difficulty in getting in the full amount of calories. A diet scheme in one of the leading hospitals gives, in the daily diet, an average of 1 to 2 pints of cream, 2 to 3 pints of milk, £ to 1 $ pounds of milk-sugar, from 3 to 6 eggs, and as much butter as the patient will eat with stale bread or toast. When the temperature falls, solids are added to the diet, beginning with baked potatoes, sweetbreads, finely minced chicken, and broiled squab, and, finally, broiled chop and tender steak as the digestion is accustomed to the increased diet. Throughout the whole course of the illness the stools should be inspected by an experienced person, to insure that the diet is being well digested. DIET IN SPECIAL DISEASES 781 Gastric and Intestinal Disorders.—No special rules or diet-lists can ^>e laid down for. the treatment of gastric or intestinal disorders which will cover all cases. It may be assumed that in no class of disease is it more necessary that the patient should seek the advice of a specialist on this point. Not only may the individual case vary greatly, but general symptoms, apparently similar, may proceed from opposite causes, and the diet that may benefit one will aggravate the trouble in another. Again, under treatment, the gastric conditions change from time to time, demanding that the effects of the diet should be carefully watched, and the diet itself modified accordingly. Many stomach specialists use certain diet-lists as a routine treatment in given conditions, and these are avail- able in various text-books. A nurse should be very careful not to encourage the use of such lists except under expert advice, since, without accurate knowledge of the condition, even careful dieting is merely hit or miss. To take a case in point: In gastric disorders the gastric juice is, to a greater or less extent, changed. There may be an increase of acid- ity, or there may be a decrease or even an absence of acidity (p. 218). The symptoms that are, however, ap- parent to the patient or the nurse may seem to be the same in either case. Obviously, the diet that will suit one case will not be best suited to the other. In the first case, since the use of the hydrochloric acid is in the digestion of the proteins, the excess of acid may be in some cases counter- acted by a diet in which the proteins are pushed at the expense of the carbohydrates; in the second, protein diges- tion is faulty; the protein foods are given sparingly, in the most digestible forms, and their place largely taken by carbohydrate foods and fats. In other cases it may be the muscular power of the stomach that is at fault, as in dilated stomach. In this condition the restriction of fluids is a most important part of the diet, and a diet, however digestible, in which broths and milk are given freely may simply increase the disorder. The object of a special diet in these conditions may be put briefly as a means of giving the body the amount of nourishment necessary, with the least possible work for 782 DIETS AND DIETING the faulty digestive organs; whatever part of the digestive tract is out of order, therefore, must be given the least amount of work. At the same time the five food-elements must be represented. Here again the importance of an estimation of the caloric value of a given diet is demonstrated, so that the best re- sults may be obtained with the least work for the diges- tion. Usually, 35 calories for each kilogram of the weight is allowed if the patient is confined to bed, or 40 if he is about doing light work. During the entire treatment the patient must be regularly weighed. In the acute stage of any gastric disorder the first aim is to give the digestive tract as little work as possible, fre- quently at the cost of temporarily starving the body. In chronic conditions, especially where the patient is about and leading an ordinary life, it is necessary that he should have the amount of food to keep up his body weight, which is the practical sign that the body is getting and using its due amount of nourishment. Acute Digestive Disorders.—In any acute gastric or intestinal condition we begin, probably, with a period of starvation, following which food in its most digestible form is given, i. e., milk and milk preparations, broths, and egg- albumin, and finally, solid foods are gradually added as they can be borne. The choice of diet is governed by local symptoms. Thus, if diarrhea is present, foods with a constipating quality are necessary until the condition is arrested. Such are boiled milk, milk with lime-water, corn flour or arrowroot gruels, barley-water or rice-water —the two latter for their mildly astringent action. If constipation is present, buttermilk or whey is preferred to milk; and, as a rule, fats in some form will be ordered, probably as cream. Gastric or Duodenal Ulcer.—In nursing these cases there are two standard forms of treatment with which a nurse should be familiar, as they form the basis of most present-day treatment. They are known respectively as the Lenhartz diet and the Sippy diet. The latter is the more recent method and at the present day is probably the accepted standard of treatment in America. DIET IN SPECIAL DISEASES 783 In the true Lenhartz diet the patient is given food by mouth from the beginning even where there is hemor- rhage. In America it is more usual to begin by a short period of starvation, perhaps forty-eight hours, during which small enemata of saline solution {\ to 1 pint) are ordered every four or six hours. Some doctors also give rectal feeding of predigested food in conjunction with the mouth-feeding until the patient is taking sufficient nourishment. In the Lenhartz treatment the stomach is never entirely empty except at night, the theory being that the gastric juices are less irritating if in conjunction with bland food-stuffs. The Lenhartz treatment is carried over a period of two weeks. Beginning with a minimum quantity of raw egg and milk, one raw egg and 100 c.c. of milk are added daily until 12 eggs and 1000 c.c of milk are taken. To this diet sugar, scraped beef, boiled rice, soft toast, ham (or chicken) minced, and, lastly, butter are added on regular days, each beginning with a minimum portion gradually increased. The following table, taken from the dietary of the Peter Bent Brigham Hospital, Boston, explains the way this diet is carried out. In some minor respects it differs from the original Lenhartz diet scale. p Eggs. Milk. Sugar. Scraped Beef. Rice. Toast. Ham. Butter. Calories. C.c. Gm. Gm. Gm. Gm. Gm. Gm. 1 1 200 212.45, 2 2 200 286.05 3 3 300 429.75 4 4 400 20 653.00 5 5 500 20 796.25 6 6 600 30 979.05 7 7 700 30 35 1185.04 8 8 800 40 70 100 1541.00 9 9 900 40 70 100 20 1768.71 10 10 1000 50 70 200 40 2146.12 11 11 1000 50 70 200 40 50 20 2515.17 12 12 1000 30 70 300 60 50 40 2857.18 The food each day is divided into so many equal por- tions. For example, for the first day the raw egg is beaten and divided into six portions and placed in separate 784 DIETS AND DIETING medicine measures on ice; the milk for the day is also measured and kept on ice. The feedings of milk and eggs alternate. The patient is spoon fed and allowed to make no exertion whatever for himself. The first days the eggs may be salted to taste; when the sugar is added it is given (also divided in equal portions) with the egg feedings. From the eighth day four of the eggs are taken soft boiled. Scraped beef and rice are each divided in three feedings and may be taken together; the toast is given first at two feedings then at four, and from the twelfth day at each feeding. The butter may be taken with the toast or with the boiled rice. The chopped ham (other hospitals use chopped chicken) is given in two portions, one in the middle of the morning and one at 5 p. m. It is usual in hospital work to prepare a set of cards covering the "diet days; the card is placed with the patient's chart and order sheet and changed daily. The following is a sample of such a diet card for the first and twelfth days of the above diet: Day 1: Food. Amount. Protein. Gms. 6.7 6.6 Fat. Gms. 5.25 8.00 Carbohy-drates. Calories. lEgg........ Milk......... 50 gms. 200 c.c. Gms. 10 74.05 138.04 Total...... 13.3 13.25 10 212.09 Day 12: 12 Eggs..... Milk........ Sugar....... Scraped beef. Rice........ Toast....... Ham........ Butter....... 600 gms. 80.04 63.00 889.68 1000 c.c. 33.00 40.00 50.00 692.00 30 gms. 30.00 120.00 70 " 14.62 7.42 125.03 300 " 8.04 .03 73.02 329.01 60 " 5.88 5.94' 44.01 253.38 50 " 10.01 11.02 141.02 40 " .04 34.00 307.06 Total 151.63 161.41 197.03 2857.18 By the fourteenth day the patient is ready for a con- valescent diet, beginning with milk, soft-boiled eggs, soft toast or milk toast, purees of peas, potatoes or beans, jelly, custard or farinaceous puddings, and introducing DIET IN SPECIAL DISEASES 785 gradually boiled white fish, broiled chop or rare steak, roast or boiled chicken, and strained apple sauce1, until an ordinary diet can be taken. Fried food is to be avoided, also coarse vegetables, gravies and condiments, and either ice-cold or very hot foods or drinks. The amount of food necessary to give the patient the right number of calories will be divided between the three principal meals, with a luncheon in the middle of the morning, between dinner and supper, and a little before bedtime. The Sippy diet table for gastric ulcer following is from that in use in the Pennsylvania University Hospital: The period of strict dieting lasts from eight to ten weeks. First four days: From 7 a. m. to 7 p. m. give every hour 1| ounces of milk with 1| ounces of cream. Fifth day: Continue the same diet, but substitute for one feeding 6 ounces of some semisolid—cereal, cocoa, custard, cream soup, junket, egg-nog, or soft-cooked egg. Each following day replace one more milk feeding by another 6-ounce meal of semisolid diet. As the patient shows tolerance gradually introduce solids into the diet, beginning with mashed potato, white meat of chicken finely divided, stewed fruits, well-cooked spinach, asparagus, and squash; raw fruits and vegetables and bread are avoided throughout the treatment. The number of feedings are gradually reduced from every hour to every two hours, and finally to every three hours. In connection with the Sippy diet table an alkaline is given at the half-hour between each feeding from 7.30 a. m. to 7.30 p. m. and every half-hour from 7.30 to 10 p. m. In the Pennsylvania University Hospital sodium bicarbonate, gr. xx, and bismuth subcarbonate, gr. x, is given alternately with sodium bicarbonate, gr. x, and magnesium oxid, gr. x. In cases of chronic gastric ulcer the patient may be ad- vised to restrict his diet entirely for ten days or so to milk, cream, and soft-boiled eggs. Following this, tapioca or corn-starch puddings are added for three or four days, after which the convalescent diet given above is suitable. 50 786 DIETS AND DIETING Diarrhea, Dysentery (Acute).— Before any diet is begun, the patient is purged and starved twenty-four hours; sips of tepid water may be given to allay the thirst, or ice may be slowly sucked, but even water should be as re- stricted as possible. At the present day milk in any form is avoided during the acute stage, i. e., as long as there is any pain, tenesmus, or rise of temperature. Albumin water and strained chicken or mutton broth are given—two pints in all in the twenty- four hours. Some doctors order tender, lightly broiled lean meat or scraped beef at an early stage. As the con- dition improves, well-cooked barley or rice or dry toast is added to the broths, skimmed milk, or whey; later, far- inaceous puddings, tapioca, rice, etc.; soft-boiled eggs and rusks. When all symptoms have disappeared, butter and cream are added with caution, and the ordinary diet is gradually resumed, beginning with lean, finely divided meats in small quantities, and avoiding coarse vegetables, fried or seasoned foods, and extremes of temperature, es- pecially in drinks. Diarrhea in Infancy.—Diarrhea in young children is always an important symptom, even when slight; in its severe form, accompanied by high fever, acute colic, and rapid waste of the tissues, with profound prostration, it is one of the most fatal disorders of infancy. The treat- ment is largely dietetic. Castor oil is usually given first as a purge, and all food withheld for twenty-four hours. Sips of tepid water may be given if there is no vomiting; if vomiting is present and thirst is excessive, the mouth is washed with weak lemon- juice and water, or shavings of ice are placed in the mouth. Lavage and enteroclysis of sterile water arc also often ordered, or, if collapse is threatened, hypodermoclysis of normal salt solution. Milk is avoided entirely—indeed, is looked on as actually poisonous. After twenty-four hours egg-albumen is added to the water, beginning with half an egg in twenty-four hours and increasing to two eggs if well borne. Small feedings (\ to 2 ounces) of well-cooked barley-water or rice-water are added as the condition improves. Of the next step DIET IN SPECIAL DISEASES 787 there are a variety of opinions: at present predigested foods in some form are in favor, such as malted milk, cereo- barley, Benger's or Mellin's food, and panopeptone in water. Milk is usually reintroduced first as whey, one feeding in the twenty-four hours. Peptonized milk with equal parts of barley-water is favored by some. Chicken and veal tea, with all fat carefully removed, are frequently ordered. Fat, in the form of cream, is not added until all symptoms have disappeared and convalescence is estab- lished. Many doctors withhold milk entirely for some weeks; others begin with a weak modified milk as soon as convalescence has set in, and gradually build up until the usual diet is resumed. In older children the return to solid diet is made with chicken or veal tea, thickened with well-cooked barley or rice, or eaten with dry toast, soft-boiled eggs, and farina- ceous puddings. Milk may be given, first boiled with rusks or toast. Fruit, vegetables, and cereals are with- held until the child is perfectly well, and butter used spar- ingly. In all these cases very accurate records of the diet taken should be kept and charted with the records of the tem- perature, etc., the bowel movements, and the weight. The child is usually weighed daily. Every stool must be carefully inspected. Chronic Digestive Disorders.—As has been said, it is impossible to lay down any rules for the diet of the large variety of chronic gastric or intestinal disorders. The ob- ject of dieting is to give food that will cause least trouble to the damaged part of the digestive tract, that will not aggravate existing trouble, and that, with a minimum amount of work for the digestive organs, the required amount of energy should be gained. At the same time, in order to get the digestion into perfect working order, it is probably necessary to tone the damaged part with light work, gradually increasing the work as the condition im- proves. It may be necessary to begin with predigested foods, either proprietary foods or peptonized milk, broths, or gruels. As a rule, these are dispensed with as soon as possible, in order to stimulate the natural secretions with a more normal diet. 788 DIETS AND DIETING The choice of food depends on the local condition, on the digestibility of the food, and on its caloric value. Practice may be given nurses in class, in making out for such cases varied diets of the most digestible food-stuffs containing the necessary calories. Where hyperacidity is present, protein foods are usually ordered in excess to counteract the condition. All forms of lean, tender meat are given, eggs, and cereals and vege- tables with a high protein percentage, such as oatmeal, and cornmeal, mashed potatoes, and purees of peas, beans, and lentils. Toast and rusks are the most digestible form in which white bread can be taken. In cases of deficient gastric secretion the proteins are given sparingly and in the most digestible forms. The meats preferred are broiled sweetbread, broiled tenderloin steak, and white meat of young chicken, all in small quan- tities. The best cereals are wheat and rice, in which the percentage of protein is low; mashed potatoes and well- cooked asparagus-tips or cauliflower (flower only) are generally the vegetables preferred. Milk is valuable in either condition, and pains should be taken to find the form in which it is most digestible. it should be taken between the heavier meals, with nothing more solid than a biscuit. Tea and coffee are frequently forbidden; if allowed, they should be weak, freshly made, and allowed to cool before they are taken. They should only be allowed with the light meals. Water is usually ordered between meals, and drinking altogether forbidden at the more solid meals. Fat in some form is a necessary part of the diet. It is given as butter or cream, or sometimes as chocolate, but should be used very sparingly in the preparation of the food. In these conditions the appetite is not a guide to the amount of food. Some patients loathe their food, others are ravenous and overload the digestion. The food should be carefully weighed and measured, and the patient gradually accustomed to the required amount. The usual rule is to give small meals at frequent inter- vals, with the heaviest meal in the middle of the day. DIET IN SPECIAL DISEASES 789 Patients should eat slowly, masticate thoroughly, and rest for a short time after each meal. Obstruction of the Bile-ducts.—In these conditions, as from gall-stones, inflammation, or organic disease, the bile may be greatly diminished in quantity or entirely absent from the digestive tract. In the diet for such a condition the fats are omitted, since, as we remember, the bile plays an important part in the digestion and absorption of fats. Peptonized milk, buttermilk, whey, or skimmed milk diluted with natural mineral waters, are given during an acute attack. Hot water should be given freely; it helps to purge the alimentary tract, and counteract the consti- pation due to the absence of bile, and aggravated by the lack of fats. When solids can be borne, lean broiled meats, sweetbreads, whitefish, baked potato, crackers, and toasted bread are gradually added; fats, butter and cream, or fried dishes, should not be allowed until the patient is completely recovered. ChrOnic Constipation.—The dietary causes of constipa- tion are insufficient proportion of fluids, lack of fats and oils or organic salts, excessive use of alcohol, or the use of foods that are almost entirely digested (such as milk and eggs), and leave no residue to act as irritants to the intes- tinal walls and induce peristalsis. Water should be taken freely between meals, and especially at bedtime and before breakfast, cold water being preferred, as it excites peris- talsis. The diet should include foods that leave some indigestible residue, such as oatmeal, cornmeal, whole- wheat and bran bread, coarse vegetables, berries, and figs; bland, non-exciting food, such as milk and eggs, should be restricted. To some people milk is constipating; on others it has a laxative effect, especially if rich in cream. Its use must be governed by the individual effects. Olive oil taken regularly, a dessertspoonful three or four times a day, is often successful in relieving constipa- tion, and almost all fruits are beneficial, especially apples and prunes. They are most efficacious if taken first thing in the morning. Alcohol should be given up. Tea may cause constipation, on account of the tannin it contains; 790 DIETS AND DIETINC on the other hand, the amount of fluid ingested is helpful: coffee is preferable as a morning beverage, as it contains an essential oil. Buttermilk may be used as a beverage with good effect, as it usually acts as a mild laxative. Molasses and honey are also considered laxative, and may be given with whole-wheat breads. Nephritis (Inflammation of the Kidneys).—As the excre- tion of urea and its elimination from the body is the func- tion of the kidneys, it is not effectually performed where1 the kidneys are not in a normal condition of activity. If we give an ordinary amount of protein food in such conditions, we may cause the system to become overloaded with urea (which we remember is the residue of protein combustion), and we also further overtax the diseaseel kidneys. In all conditions associated with irritation or disease of the kid- neys it is usual to give a minimum supply of protein food, in order both to rest the kidneys and to diminish the1 amount of urea formed in the body. In acute cases of nephritis an exclusive milk diet is generally ordered; when itbeconie-s necessary to reinforce this, carbohydrate food is added in the form of gruels, bread and butter, rice, and farinaceous foods. This is continued until the urine is normal, and shows, on examina- tion, no trace of albumin. (Se>e Urine.) In chronic cases of nephritis it is not practical to reduce the protein foods permanently, and a more varied diet is necessary. Foods which must be restricted or eliminated are red meat, eggs, and dishes cooked with egg; spices, condi- ments, and rich sauces are forbidden absolutely. The1 diet may contain fish, poultry (both preferably boiled), potatoes, and most vegetables except asparagus, celery, garlic, and leeks; fruit fresh and cooked; milk in any form, cream, and butter; cereals, bread, and cakes maele without eggs, and simple desserts also without eggs. Tea, cocoa, simple beverages, and bland drinks are allowed, but the amount of fluid taken is strictly regulated and given under the doctor's direction. Headache, vertigo, and disturbances of vision are some of the indications of an accumulation of urea, and when noticed the diet shoulel be altered accordingly. DIET IN SPECIAL DISEASES 791 Diets for Testing the Kidney Functions.—Of recent years the use of test-diets in determining the functional powers of the kidney have come into use; by their means a diet is contrived in accordance with the degree of renal impairment shown in the individual case. Most of the renal test-diets in use are adaptations from those of Drs. Hedinger and Schlayer; the one in most common use in American hospitals and in private practice is that adapted by Dr. Mosenthal for use in the Johns Hopkins Hospital. The diet consists of three meals, each contrived from food substances known to be diuretic in character. All food is salt free and with each meal from 2 to 3 grams of common salt is served. Every item served is weighed or measured with great care, and any food fluid or salt not consumed is weighed or measured and noted. The meals are served at 8 a. m., noon, and 5 p. m. No other food or fluid is taken in the twenty-four hours required for the test. The Mosenthal diet table for the "two-hour test for renal function" is as follows: Breakfast, 8 a.m.: Boiled oatmeal.............. 100 gm. Sugar, 1 to 2 teaspoons. Milk....................... 30 c.c. Bread, 2 slices.............. 30 gm. each Butter..................... 20 gm. Coffee 160 c.c., milk 40 c.c, sugar 1 teaspoon.......... 200 c.c. Dinner, Noon: Meat soup.................. 180 c.c. Beefsteak.................. 100 gm. Potatoes boiled, mashed, or baked.................... 130 gm. Green vegetables as desired. Bread, 2 slices............... 30 gm. each Butter..................... 20 gm. Tea 180 c.c, sugar 1 teaspoon, milk 20 c.c................ 200 c.c. Water..................... 250 c.c. Pudding, tapioca or rice...... 110 gm. Supper, 5 v. m. : Eggs (2) cooked as preferred. Toast, 2 slices............... 30 gm. each Butter..................... 20 gm. Tea 180 c.c. milk 20 c.c, sugar 1 teaspoon........... 200 c.c. Fruit stewed or fresh........ 1 portion Water..................... 300 c.c 792 DILI'S AND DIETINe; The1 bladder is emptieel at 8 a. m. before the first me'al is served, and every two hours after till (and including) S p. m. Each specimen is put up separately—the hour, the quantity, and the specific gravity noted on the label. The night urine after the 8 p. m. voiding to 8 a. m. is e-e>l- lce'ted as one specimen. Dry Diet.—A eliet in which the fluiels are restricted! and reduced to the minimum is known as a dry diet. If is favored by some doctors in the treatment of vascular heart disease, of chronic kidney disease, and for dilated stomach. The objects to be attained are different in each case. In heart disease the restriction of fluids is followed by a lowering of the blood-pressure; in kidney disease the work thrown upon that organ is directly diminished, since the amount of water excreted by the kidneys is in proportion to the amount taken into the system. In cases of dilatation of the stomach the restriction of fluiels is, for a local reason, an important part of the treat- ment. In this disorder the cavity is dilated usually at the lower (and greater) curvature; below, that is, the pyloric valve, through which the gastric contents are passed on into the intestines. In consequence residues of food substance's are apt to become lodged in the stomach, unavailable for nutrition, and giving rise to fermentation. Water, which is non-nutritious, fills up the stomach to no purpose, ag- gravating this condition and further weakening the lax action of the distended muscular walls. For these reasems restriction of fluids by mouth is the special feature in the diet of patients with dilated stomach. The food is given in small quantities of highly nourishing food substances at comparatively frequent intervals, the heaviest meal in the middle of the day, as in all cases of gastric disorders. The distress caused by the restriction of fluid in the system is, in these cases, often relieved by rectal infusion of plain water. In many cases lavage is a routine part of the treatment. Salt-free Diet.—Salt, chlorid of sodium, is the one inor- ganic substane-e' that is necessary to man. Not only is it an aid to digestion, but it has a elefinite and important effeert on metabolism, especially in the absen-ption of fluids by the DIET IN SPECIAL DISEASES 793 tissues. In certain conditions a diet restricting, or elimi- nating for a time, salt from the food is a common form of treatment. In epilepsy, chlorid of sodium may be re- stricted in order to push the bromids, bromin and chlorin having the property of displacing one another in the tissues. Other diseases in which a salt-free diet may be prescribed are those associated with dropsy, or accumula- tion of fluid, in one or other of the cavities of the body, as pericarditis, pleurisy, or tuberculous peritonitis; in glau- coma; in interstitial nephritis; and in disorders associated with oversecretion, such as coryza, hay-fever, and eczema. In ordering a salt-free diet it is obviously necessary to know the amount of sodium chlorid represented in the various food-stuffs, and to be able to control the manner in which it is cooked. The strict salt-free diet commonly ordered consists of the following articles: Bread baked without salt and eaten with fresh, salt-free butter or clotted cream. Rice, barley, tapioca, or sago, well cooked and eaten with cream and sugar or molasses, mashed potatoes without salt, eaten with fresh butter, eggs, two to four per diem, usually soft-boiled and eaten without salt. A small amount of certain fruits, orange, grape-fruit, or grapes, is allowed daily. Not more than one pint of liquids is taken daily—gen- erally milk diluted with Vichy or lime-water. The quantities are prescribed to suit the case. Where a more liberal diet is permissible, as in chronic cardiac affections, meats cooked without salt, fresh-water fish, vegetables, salads, and fruits, both raw and cooked, all without salt, are added, with salt-free cheese and simple desserts. The food must be given in its most digestible form, since in omitting salt we omit one of the aids to di- gestion. Oxaluria (calcium oxalate in the urine) is a symptom associated with gout, certain forms of rheumatism, and many nervous disorders. Acid fruits and vegetables ag- gravate the condition. The diet exclueles tomatoes, rhubarb, plums, and all berries, either raw or cooked; spinach, cauliflower, green beans, and potatoes; cocoa 794 DIETS AND DIETING anel chocolate. Tea, coffee, and alcohol are either forbid- den or their use strictly limited. The food must be simply cooked, avoiding rich dishes, spices, and seasonings. Diabetes Mellitus.—No disease depends for its treat- ment so entirely on diet as diabetes, which is e-harae-te^ized by the persistent presence of grape-sugar (dextrose, one of the glucoses) in the urine, and the passing of large quantities of urine of a high specific gravity. No condition has been more benefited by the advance in scientific knowledge of food values, and by the appli- cation of such knowledge to special dieting. The treatment known as Dr. Allen's starvation diet, in- troduced in quite recent years, may be said to have revo- lutionized the treatment of diabetic cases. Under this treatment a patient is kept "sugar free," thus preventing the serious waste which is the chief symptom of the disease; he is given a varied diet, suited to his individual newels, and based upon his individual tolerance for carbohydrate and protein, and also one in which the amount of food taken, reckoned in calories, is in direct relationship te> the energy he expends. The main points brought out in the treatment are: 1. Diabetic patients can be starved without risk e>f coma or other ill effects; that during starvation the sugar excreted rapidly diminishes and shortly disappears. 2. Protein in excess also produces glycosuria; it is, therefore, as important to control the protein intake as the carbohydrate intake. 3. It is possible by careful dieting and regulation of the activities of the individual to keep a patient "sugar free" on a mixed diet. To describe the dietetic treatment briefly: The treat- ment begins with a period of starvation, averaging forty- eight hours, at the end of which the tested urine specimen shows no sugar. During the starvation period the patient remains in bed and is given water freely and clear meat broth, tea, or coffee without milk or sugar. A little weight is lost during the time, but where the patient is obese this is consielered an advantage. In severe cases the patient is preparer I for starvation by reducing his diet first over a DIET IN SPECIAL DISEASES 795 period of several days; in others starvation periods alter- nate with one or more days of restricted feeding. Once the urine is sugar free, a carefully graduated diet is begun, in- troducing first carbohydrate, then protein, then fat into the diet, until the patient reaches a mixed diet from which he can derive the necessary amount of calories. The different food elements are introduced in minimum quantities, increased very slowly so as to test the patient's tolerance accurately, the carbohydrate and protein foods being added to at first on alternate days. Every article of food given must be strictly weighed or measured, its chemical composition clearly understood, and its caloric value estimated. Such a diet is, of course, always undertaken by a doctor's orders and under supervision. The urine is examined daily, the patient's weight noted, and his exercise regulated, so that he may not use up more energy than he is taking in according to the caloric value of his food. After the urine has been sugar free for twenty-four hours the diet scale is begun. Carbohydrate is the first food element given. The first day after starvation the patient is given 150 grams of vege- tables which contain only 5 per cent, carbohydrate. Roughly speaking, these are all the green vegetables (except peas, lima beans, and shell beans). After cooking the available carbohydrate is reduced about one-half. If the vegetables are boiled in three different waters (kept at boiling-point), rather more than 4 per cent, carbohy- drate is lost. By this means patients may be given bulk with a minimum amount of carbohydrate. In many hospitals thrice boiled 5 per cent, vegetables is the first food ordered after the starvation period. A little butter is often allowed with them. The second day 10 per cent, vegetables are added to the 5 per cent., sufficient to add 5 grams carbohydrate. Roughly speaking, 10 per cent, vegetables include the ground vegetables, except artichokes and parsnips which contain 15 per cent, carbohydrate, and potatoes which have 20 per cent. After the first day 5 grams carbohydrate is added daily up to 20 grams, and then 5 grams on alter- 796 DIETS AND DIETlNei nate days until sugar appears or the tolerance' reae-hes 3 grams C. per kilogram of the body weight. The carbo- hydrate foods are taken successively up from the 5, 10, and 15 per cent, vegetables and 5 and 10 per cent, fruits to potato, oatmeal, and bread. Protein.—When the patient has been sugar free1 for two days, protein is introduced usually in the form of three eggs, representing 20 grams protein (approximately, as eggs differ in weight). On the following days 15 grams protein are added daily in the form of lean meat until the1 patient is getting 1 gram protein for each kilogram of his body weight. Fat is added when the protein taken reae'hes 1 gram per kile>gram weight, and adele'el at the rate of 25 grams daily until the patient is taking not more than 40 calories per kilogram weight. Fat is taken in the form of butter, cream, milk, fat of meat, etc. If sugar reappears the patient again fasts until sugar free; the- diet scale is then begun again, but increased twice as rapidly as in the initial test. Only half the amount e>f carbohydrate tolerated is given till the urine has been sugar free two weeks, and it is then increased not more than 5 grams a week. The above test-scale, taken by permission from the instructions issued to the patients in Dr. E. P. Joslin's diabetic clinic, the Deaconesses' Hospital, Boston, varies in some respects in different hospitals and with individual practitioners. The tendency of the present day is to re- serve the initial strict starvation for acute cases. Patients under a strict diabetic regime are usually re- quired to fast once a week. Where the carbohydrate tol- erance is low, a complete fast is required like the initial fast; where the tolerance is greater, it is modified accord- ingly. It is important that the urine should be examined once a week, and this patients can be taught to do for themselves, using Benedict's test (p. 242). Patients should also be taught to select their own diet, computing the amount of calories of carbohydrate, protein, and fat repre- sented. A short table of the permitted foods with their chemical composition and caloric value is usually issued DIET IN SPECIAL DISEASES 797 to hospital patients, and they are given practice under supervision in computing their diets. In this way a patient is made self-reliant and can be trusted intelligently to carry on his own treatment. A set of very comprehensive diabetic diet charts compiled by Dr. Mosenthal of Johns Hopkins Hospital are on the market, published by Paul B. Hoche, 67-69 S. 59th Street, New York. The charts are widely used at the present day in private practice, and will be found by nurses a very great help in com- puting varied diets while following a strict diabetic regime. The charts comprise: 1, starch-free diet; 2, ac- cessory diet for foods rich in carbohydrates; 3, minimal fat starch-free diet (measured); 4, ditto (weighed); 5, low fat starch-free diet (measured); 6, ditto (weighed). By careful tests with the calorimeter (p. 734), the amount of energy the patient may expend in proportion to the calories he is able to take in is ascertained, and the habits, avocations, and exercise regulated accordingly. A patient "at rest" is considered to require 25 calories for each kilogram of his body weight. This provides no sur- plus energy for work or exercise; where a larger proportion of calories is tolerated, i. e., can be assimilated without pro- ducing glycosuria, the amount of exercise taken, or work permitted, is regulated accordingly. No food is prohibited provided the patient can tolerate it and that it can fit into the required proportion of his diet. Oatmeal and white bread are exceptionally high in carbohydrate and can only be taken where the carbo- hydrate tolerance is high, and then only in small quantities, which reduces the bulk of the food-stuffs. Patent flours are on the market with a very low carbo- hydrate percentage from which rolls and muffins can be made. Such are Lyster flour, Hepso flour, and others. A Lyster roll contains C. 0.23 grams; P. 71.5 grams; F. 5.87 grams, and represents 83.20 calories. As the diabetic tolerance of carbohydrate is lower than normal the neces- sary calories are made up by fats, which produce the same kind of energy in the human economy as the carbohydrates, and give, as we saw in Chapter XXI, bulk for bulk, ap- proximately twice the number of calories. Where the 798 DIETS AND DIETING appetite is large the diet can be made to include foods which give a large amount of bulk in proportion to the caloric value, as in the green vegetables; where the appe1- tite is small the reverse will be indicated. Acidosis, a disorder characterized by decreased alka- linity of the blood and the presence of acetone and diacel ic acid in the urine (test, see p. 244), is a condition at present receiving much consideration, though, so far, imperfectly understood. The acute attack is a severe form of intoxica- tion and the patient will be invariably in the doctor's hands. Children with a disposition toward acidosis must have their diet carefully regulated, and nurses should understand the principles underlying the selection of such a diet. The condition is considered to be due to an impair- ment in the metabolism of fat in the body, due most fre- quently to some form of starvation for which there may be a variety of causes. A carefully regulated diet is the chief prophylaxis in keeping a child disposed to acidosis free from an attae-k. The1 dangerous food elements are the fats and the foods in which the acid-forming elements predominate. The aim in dieting must be to contrive a well-balanced diet that will be well borne by the patient, and this can only be1 arrived at by testing the individual tolerance. Fats (butter, cream or whole milk, and fat of meat) are elimi- nated entirely during an attack, however slight, but as fats are necessary to the growth of the body they must on recovery be very gradually added, the child's toler- ance being tested day by day. Meat, eggs, and certain cereals, oatmeal, rice, wheat and corn, rhubarb, straw- berries, and all sour fruits are foods in which the acid- forming elements are in excess; their use must be guided by individual tolerance. Vegetables, especially potatoes, turnips, peas, and beans, and cooked fruits, such as prunes and apples, are foods in which the building-up elements predominate and should form a staple part of all such diets. With the exception of the cereals mentioned the diet is largely carbohydrate and can without much diffi- culty be made appetizing to most children. With the DIET IN SPECIAL DISEASES 799 above facts in mind a varied and sufficient diet can readily be computed. Phthisis.—At the present day most people realize that a prominent part of the treatment of all forms of tuberculosis consists in a well-balanced dietary of easily digested foods. A larger amount of food than is necessary in the normal condition is required to increase the resistance of the body to the disease and to repair the tissue waste. A well- mixed diet of a somewhat raised caloric value is usually prescribed. To avoid indigestion, this is given in easily digested and concentrated forms. The most valuable artiedes in a consumptive's diet are milk, cream, and eggs. Milk is taken between the meals, and with the lighter meal —either breakfast or supper; eggs, as a rule, are taken raw. In this way they are not actually so easily digested as when lightly boiled, but as the patient tires less easily of them, more can be taken over a greater length of time. From 8 to 18 are often consumed daily without causing indigestion. Fats and oils are also of value, and in the phthisis dietary largely replace carbohydrates. They are more highly concentrated, have, bulk for bulk, twice the caloric value, and, further, they help to correct the constipation that commonly results from anj' large consumption of milk and eggs. Fats are given in the form of cream, bacon-fat, olive oil, and the fat of various meats. Scurvy.—Scurvy is directly due to a deficiency of cer- tain food substances, notably the vegetable acids and the vitamins referred to in the previous chapter, and results from a diet in which milk, fresh meat, vegetables, anel fruit have not been included. In adults, fresh meat, vegetables, milk, and the juice of oranges and lemons are ordered. When sailors have to be long away from supplies of fresh food, lemon-juice, onions, and vinegar are taken as preventives. In infants, scurvy is most frequently the result of using sterilized milk, condensed milk, or some of the proprietary infant's foods. A diet of fresh milk, beef-juice (1 dram to 1 ounce daily), and orange-juice (1 ounce to 4 ounces daily) is usually sufficient to correct the condition. Beef- 800 DIETS AND DIETING juice is not given until after the tenth month, and is con- traindicated if the intestines are in an irritates! e-emelition. Rickets.—Rickets is a disease' of young life, the result of a deficiency of lime salts, in consequence1 of which the bones become soft and deformed. It is generally causeel by a diet containing too little protein and fat and too large a proportion of carbohydrates, as is frequently the1 fault in proprietary foods. A liberal diet, including fresh milk, egg-albumen, and beef-juice, broths, or fresh meat, if the1 child is old enough, is necessary. At the same time fresh air and good hygiene are equally important. Fat in the form of cream, butter, and bacon-fat shoulel be given. Cod-liver oil is often ordered, and usually some preparation of the phosphates, such as the syrup of the hypophosphites (5 to 15 minims). In anemia the quality and composition of the blood is altered, and there is a marked deficiency of the red color- ing-matter or hemoglobin and of the red cells. The diet must be liberal, nourishing, and digestible. It should include concentrated nourishing foods, especially eggs, beef-juice, or, if the digestion permits, rare tender beef-steak and other meats; milk, cream, butter, bacon- fat, and well-cooked cereals. Nourishing soups are also given, and vegetables, especially green vegetables, on ac- count of their mineral salts. Spinach, which contains iron, is particularly suitable. Anemic girls have often very capricious appetites and abnormal cravings for such articles as chalk, earth, etc. Others enlist sympathy by pretending to be unable to eat, and satisfy their appetites in secret. In these1 cases the patient may require close watching, and the right diet, may have to be foireel. CHAPTER XXIV THE HEAD NURSE AND WARD MANAGEMENT Division of Duties—Orderly—Ward-maid—Time-table—Report- ing—Stock-book and Inventories—Linen Supply—Blankets—Pa- tients' Effects—Special Duties of a Head Nurse—Patients' Visitors— Domestic Work: Sweeping, Mopping, Scrubbing, Polishing, Dust- ing, Care of Enamelware, Glass, Porcelain, Marble, Polished Furni- ture, Stains on Wood, Saucepans and Kitchenware, Ice-chest, Brass and Copper—Beds and Bedding- Ward Ventilation and Tempera- ture—The Visiting Rounds. An essential quality of a successful head nurse is execu- tive ability. While in a well-organized hospital the lines are already set in which the work must run, most days will bring fresh circumstances which alter conditions so mate- rially that, unless rules and orders are promptly adapted to meet them, confusion, rushed work, and overwork of the most willing are the result. On her shoulders falls the responsibility of carrying on the daily work adequately and without friction; of ad- ministering the domestic side of ward work; of insuring the proper fulfilment of all orders for treatment; of preserv- ing the equipment, instruments, etc., in her charge in good condition; of keeping up supplies and preventing waste in their use; of the physical and mental well-being of the patients under her care. At the present day she is not often held responsible for the actual instruction of the pupil nurses, but, as a matter of practical experience, we know no teaching impresses itself more forcefully on the pupil than that gleaned from the practice and example of a ward head nurse, from her manner and attitude toward patients, workers, doctors, and visitors to the standards of work required by her from each pupil working under her. "As the twig is bent so the tree is inclined"; a nurse's work will carry through life something of the impress of the first wards in which she practised her duties, 51 801 S02 THE HEAD NUKKE AND WAK!> MANAGEMENT In the present chapter we' should like briefly to suggest, from our personal experiene'e1, some methods in which the practical work of a head nurse can be so ordeivel as to be both simplified for herself ami of wide-reaching use1 anel comfort to others. DIVISION OF LABOR From the early days of her training the pupil nurse1 should be given some responsibility, and that one eluty, however small, be used as a training-ground in thorough- ness, punctuality, and in observation, as well as in the1 acquiring of a sense of responsibility, without which she will never be a reliable worker. In arranging a schedule of work among several nurse's the1 duties are graded according to the progress of the1 indi- vidual training, the more responsible forms of treatment being given to the senior, and the simplest duties to the1 newest comers. At the same time many duties shoulel be common to all, and others of monotonous routine may, with advantage, be interchangeable from week to week. It is ne> uncommon thing, where nurses are left to divide their own minor duties, to find the youngest worker passing her entire time in an accumulation of monotonous and profit- less routine duties, tiring1 to body and spirit, while the senior nurse performs not the smallest minor duty and usually ends by considering such duties beneath her dignitj'. While the nursing of the patient is the most important part of our work, to make such distinctions in any neces- sary duty connected with the care of the sick shows a lack of common sense and results in harm. Is it not the- first step toward that attitude that makes people say, too often justly, " A nurse wants so much waiting upon." No definite lines can be laid down as to the division of work, since it must depend on the amount of the work, the kind of the work, whether medical, surgical, children's, or special nursing, whether in a general ward or private rooms, and must always be modified by the hospital construction or the number of workers. A sug- gested outline may, however, be helpful. In some wards each nurse is given a certain number of DIVISION OF LABOR 803 " beds," and the absolute charge of those patients, making their beds, attending to all their wants, giving them their meals, their medicines, and carrying out all their treatment. When the patients are in single rooms, as with private patients, this is almost necessary, and in children's nursing the system also works well, as all children, whether very sick or convalescent, require a great deal of individual care and attention. In general ward work the patients should be so divided, to a certain extent, that is to say, for their bed-making, washing, and routine treatment (such as douching, etc.), to avoid the discomfort for the patient of constant change; at the same time, in an open ward, all the nurses are familiar, and for one nurse to take his temperature and another to give his medicine or his food does not mean for a ward patient a perpetual fresh face, as it would for one in a pri- vate room. When possible, the patients in a nurse's immediate charge should be grouped together, in order to save her steps, and that she may readily be within call of each; she should then be held responsible for the neatness and cleanliness of that particular division of the ward, with the lockers, bed- tables, and personal effects of her patients. Where the cases are acute, a smaller number should be given to a nurse than where the cases are mild or convalescent. It is usually a mistake to give a junior nurse only conva- lescent cases. If she is in earnest over her work, a few weeks will teach a nurse the actual handling of a sick patient, and such responsibility as observation of symp- toms or the carrying out of more difficult treatment is always, in ward work, shared by those over her. Nothing will deepen the sense of responsibility, quicken the powers of observation, resource, and helpfulness, or put an end to a frivolous or flippant attitude toward the work like contact with acute1 illness early in the training. If, however, the duties are otherwise arranged, a point must be made that the junior nurses help the seniors with the acute cases. Dusting and Cleaning.—The daily dusting anel cleaning of a ward ought certainly to be divided between all the nurses, 804 THE HEAD NLRSE AND WARD MANAGEMENT for the rease>n already stated. Usually the work can be grouped, as, for example, one side of the ward with certain tables, dressing-stands, etc.; the other side, with bath-room, corridor, or equivalent; the service-room and lavatories, and so forth, according to the hospital construction. It matters little how, if the adjustment is fair, and if each nurse knows exactly what her own work is. In this respect the senior nurse's duties may be lighter than the others, since she will probably have certain other duties which cannot be shared. In the same way the closets, drawers, and supply-boxes should also be divided between the nurses, and each held responsible for keeping her share in perfect order and fully supplied. Thus the medicine cupboard would be in charge of one, the surgical supply closet of another, the clothes- closet, linen-e'loset, milk-chest, refrigerator, and china closet all divided out. Besides the daily care, it should be a rule that each closet, etc, be thoroughly cleaned, over- looked 1, and the supplies brought up-to-date once a week regularly. If such work is left merely to the convenient moment, it is never done. Duties that-may be interchangeable are, for example, the giving of the regular medicines; the preparing and dis- tributing of lunche-s and extra nourishment; minor dress- ings, fomentations and poultices; the taking of the regular temperatures; the counting of soiled clothes for the laundry, and distribution of daily clean towels, etc These duties may often, with advantage, be taken by the nurses in turn for a week at a time, a regular order of rotation being maintained. There must, however, never be any doubt as to who is responsible for each duty. A rule that admits of no exception should be that each nurse cleans whatever she herself has used, and returns it to its place as soon as it is done with. The habit of making younger nurses fetch and carry and clean up for the older ones may be good discipline for the junior, but is altogether wrong from any other point of view. If any one requires special help, it is the less experienced junior. The night nurse, although exempt from the work of meals and the busy rush of the doctor's visits, still, if the THE WARD-MAID 805 patients are sick, has her hands too full to give much time to the domestic ward work, nor can she be given duties that keep her out of the wards, even in the diet kitchen or ser- vice-room. There are periods, however, especially in sur- gical wards, where there may be a considerable amount of idle time while the patients sleep. It is always best to leave definite work for these hours, otherwise novels, letters, or fancy work will creep in and open the way for wasting time that belongs to the patient. If the hours on duty of the night nurse overlap those of the day nurse, it is usual to give some special duties for this time, since she is no longer wanted exclusively in the wards, such, for example, as counting out the laundry, cleansing and disinfecting the lavatory crockery. With more common-sensible ideas, however, on the uselessness of unnecessarily prolonging hours of duty, the hours of a night nurse are generally curtailed as much as possible. THE ORDERLY In a male ward the orderly has very definite duties. He gives the baths to all except the very sick, attends to bed- pans and urinals, enemas, and similar treatment, assists the doctors with the screen cases, and helps in other minor duties, such as feeding helpless cases, and so forth. Usu- ally the domestic work given to him is the care of the lavatory crockery, including the spittoons, and the polish- ing of the ward " brights," such as taps, gas-brackets, etc Where hi6 duties are light, some general cleaning is often given, too—window cleaning, for example, or cleaning walls. When it can be avoided, however, the orderlies will generally be found to give more satisfactory work if they are kept to duties that immediately concern the patients. THE WARD-MAID Next to a good head nurse, a good ward-maid is probably the most important item for the general comfort of a ward. Her duties vary considerably in different hospitals. In some she is merely the scrubber, occupied entirely with floors, grates, where such exist, and washing up dishes; in others, besides these duties, she sets the trays for meals, 806 THE HEAD NURSE AND WARD MANAGEMENT helps in serving them, anel does a fair share1 e>f the warei dusting and cleaning. I think me>st experience'd nurses will agree it is a mistake to have her do even minor duties about the patients. Whatever her duties, the-v should be well defined, and the daily duties performed always in the same order, and as nearly as possible at the same time, the weekly cleaning in a certain order of rotation. It is a good system to have the ward-maiels' duties written down and hung where they can be readily referreel to. At the same time, it is better to avoid needless de- tails or a schedule written out with fresh duties opposite every half-hour. You will find these long and minute schedules are never read and rarely referred to. A schedule prepared in the following order is generally prac- tical: Ward-maid—Ward A. f Breakfast ■J Dinner ( Supper J Morning \ Evening ^ ( Breakfast Hours of patients meals :\ Dinner Hours of meals: Hours of duty: to to Before breakfast: After breakfast, until some specified hour: A specified hour: A specified hour: After dinner: Before supper: After supper: (. Supper Daily Work. Set breakfast trays; prepare and help to serve patients' breakfast. f Wash breakfast things, sweep wards, scrub lavatories, clean kitchen, ice- ■{ box, etc. (including the routine work in the order in which it is most con- ' veniently performed). Begin weekly cleaning. Set patients' dinner trays, etc. (enum- erate the special duties entailed). Wash patients' dinner things. Tidy kitchen, etc. Finish the weekly cleaning before the time off duty. Set patients' supper trays, etc. Wash patients' supper things. Tidy the kitchen, etc.' Weekly Cleaning. Monday: Scrub...... Thursday: Scrub ...... Tuesday: Scrub...... Friday: Scrub ...... Wednesday: Clean closets, etc. Saturday: Sweep walls. Clean Turn out china closet. knives and spoons, etc. HOURS OFF DUTY 807 It is human nature to work better if we feel a certain responsibility and possession in our work, and it is time well spent to stimulate this feeling in our ward-maid. Give her also some one thing in which she can take a special pride; for example, give her the charge of the china-closet, and take time yourself to go over a working inventory of its contents with her on specified dates. You will hardly find one who will not respond to this treatment, and do all her work better for the little personal notice this entails. HOURS OFF DUTY The length of the hours on duty is not determined by the ward head nurse, but with her usually rests the arrange- ment of the hours of the specified time off duty. In the hands of a good organizer the practice acts well, but we have all realized its shortcomings in the hands of a woman incapable of looking forward beyond the immediate needs of the hour. In hospitals for private patients, where the doctors change constantly and their visiting hours with them, and in similar conditions, the nurse's time-table may require readjusting daily, but there seems to the writer little excuse in the general wards of general hospitals for not preparing a schedule of time off duty that will be practical at least from week to week. We are never tired preaching to our pupils the uses of recreation and the value of keeping up their outside interests, but we make it very difficult for them to do so if they can make no engagement even a day ahead, and feel secure they can keep it. As a matter of fact, we can foresee the work much more than we think. Certain events, such as the meals and all the details of routine work, occur at the same hour every day. In a medical ward there are certain hours in which the pressure of work will be greatest, such as the hours in which temperature, baths, packs, or sponges are prescribed, anel other quieter hours, in which the work usually will not be beyond the attainments of a junior nurse, while, espec- ially in a teaching school, the hour at which the visiting doctor arrives with his students is generally known and fixed. In a surgical ward the hours for dressings, the sur- 808 THE HEAD NURSE AND WARD MANAGEMENT geon's visit, even the operating elays and hours, are prac- tically unchanged year in and year out. Is it not, then, quite practical to decide at what hour, you are most likely to be sure to reepiire your senior nurse or to be able to manage with the juniors? To know definitely when she is to be " off " and when " on " is a real source of contentment and pleasure to a pupil, and should not be denied merely for want of the will to take some pains in the matter anel look sufficiently far ahead. The hours may then be printed or written up in some convenient place for ready reference, thus: Mon. Tues. Wed. Thurs. Fri. Sat. Senior......... Second nurse . . . Third nurse .... Probationer, etc. with some simply worded notice that sudden emergencies and other special conditions may call for a temporary re- arrangement of the hours. The Sunday hours are usually arranged specially, that each nurse may have a larger portion of the day to herself and sufficient time to attend her own chuivh. The specified hours may be taken in rotation, se) that each may know beforehand what time she can count upon. Punctuality, both in leaving the wards and in returning to duty, should be exacted. At the same time our patients are considerably more than our mere duty, and any service begun for a patient should, as a rule, be finished by the same nurse, to avoid the changes so trying to the average patient. The habit of consideration for the patient's feelings cannot be too strongly insisted upon as the most important point of view, in spite of conflicting interests. REPORTING As a matter of routine, every nurse on going off duty or on returning should report verbally to her head nurse or to the nurse taking the head nurse's place. This habit REPORTING 809 keeps the head nurse in touch with the individual worker, gives an opportunity for communicating facts, orders, etc., which might otherwise be overlooked, and insures punc- tuality. At the same time, every detail in the treatment of a patient should be written down in a form that can be read- ily available for quick reference. The system of report- ing can be so complicated as greatly to increase the day's labor; the aim should be to supply accurate information in the simplest manner possible. Report Book.—A system of report books, one for day duty and one for night, arranged after the following ex- ample, has been found practical and convenient: Example: John Jones. Temperature, pulse, respiration....... 8—12—4—8 Milk, 5 ounces; Vichy, 2 ounces...... 10— 1—4—7 Water, 5 ounces.................... 9—12—3 —6 Medicine.......................... 10—2- 6 Whisky, 2 drams.................... 9—12—3—6 Sponge at 70° F. for twenty minutes for temperature over 102.4° F......... 8—12—4—8 Where the card system for giving medicine is used (p. 315), it will not be necessary to write down the medicine. As each detail of the treatment is carried out a pencil mark is crossed through the hour. At a glance, then, the nurse in charge can ascertain what treatment has been done and what omitted. If purposely omitted as not necessary, or for some other reason, a circle may be drawn round the hour or some similar distinctive mark made. For example: Sponge at 102.4° F., etc J? y£ ®X A mark without either cross or circle would indicate that the treatment had been forgotten. Such a book is both order and report book. Its dis- advantage lies in the considerable amount of writing entailed morning and evening. This may be mitigated by using copy-books with the sheet a convenient size to be ruled off into several spaces, each representing a day. Where no changes in the orders have been made, the space will merely indicate " as before," the hours alone requiring 810 THE HEAD NURSE AND WARD MANAGEMENT to be written again. The writing of the orders should be the duty of the head nurse. The doctor's orders, from which the above reports are1 compiled, should, without any exception, be in writing, and no change in treatment should be permittee 1 except on receipt of a written order. The doctor's orders, including diet, direction for treatment, and medical prescriptions, are in some hospitals entered directly in a ward day-book; in others, on bed-boards or prescription sheets hung over the patient's bed, side by side with his temperature chart and his history notes. Either practice has its advantages and some drawbacks. It may, for example, frequently be a disadvantage for a patient or his friends to have sue-h easy access to all information concerning his treatment. If the bed-board system is used, it is a rule that, as soon as an order is written, the board is laid on the table until the order has been entered in the " report " book. The temperatures, pulse, and respirations, together with the record of the excreta, are entered in a separate copy- book from which the temperature charts are compiled. Unusual symptoms, such as rigors, vomiting, etc., must obviously be reported instantly to the head nurse, and by her to the doctor, but as a further safeguard against over- sight the fact and the hour of occurrence shoulel be noted on a slip of paper and placed on a file on the record table. The night report should be reinforced by a written sum- mary from the night nurse with reference to the sleep, special symptoms, fresh orders, and treatment of the patients under her charge during the night. Verbal reports are also important, especially as a training to the pupils for their future work. It is not really an easy thing for the average nurse to collect her thoughts at a moment's notice and remember all necessary facts about an individual patient, or many patients, and few without practice have the faculty of stating the facts accurately and briefly without the help of leading questions. And yet, either as head nurses or in private work, such reporting is constantly required of them. The pupils should be taught a certain routine form, beginning with routine facts, REPORTING 811 such as temperature, record of excreta, sleep, appetite1, etc., and finish with abnormal symptoms. As a rule, such a report should be received from each day nurse before finally leaving the ward for the night, and from the night nurse when she has finished her work in the morning. After receiving the night nurse's report and reading the order book, etc., the head nurse should call the day nurses together and go briefly over the changes in the order of treatment and the report of special symptoms, etc., that have occurred during the night. It may be pertinent to add that there is often a tendency to allow reporting to degenerate into gossiping or chatter on irrelevant subjects. Young head nurses in particular should be careful to guard against such a habit. Insist always that all reports are given in a busitiess-like attitude, and in concise, business-like terms, the reporting nurse standing upright, her hands crossed in front of her, in an attitude of drill. Nurses giving their reports either lolling over the table or standing, their hands easily on their hips, is not a matter that actually affects the well-being of the patient, but certainly suggests a lack of finish in the training that will probably also have other more import- ant manifestations. Charts.—From the above " reports " the daily records are compiled in the form of charts, some of which form a per- manent part'of the patient's history, and all of which are preserved for reference during the whole course of the patient's illness (Chap. V). A special sheet should also be kept recording the diet of each patient, for quick reference at the serving of meals. Diet-sheets.—In all hospitals the different diets are classified under such headings as liquid diet, house diet, e'xtra diet, etc. (p. 770). A printed table is generally kept, with a list of the items included under such headings. Extras are ordered by item, such as oysters, fruit, game, beef-juice, extra eggs, or milk, etc. The diet-sheets should give the names of the patients under the different diets, and be corrected from day to day. 812 THE HEAD NURSE AND WARD MANAGEMENT STOCK-BOOKS AND INVENTORIES Stock-books.—The care of the equipment is again one of the important responsibilities of a head nurse. Left entirely to such casual care as the individual worker may think of bestowing, we have invariably, as the result, a spectacle of loss, waste, and destruction of property that positively seems wanton, and accounts, year by year, for considerable sums of money that would otherwise be avail- able for other purposes. To guard against such a condi- tion, a system of methodical and scrupulously honest stock- keeping, coupled with persevering anel constant vigilance, is necessary. The former should not be left to the initia- tive of young head nurses. A gooel and simple system should be thought out by the hospital authorities, and carried on in e>ve«y department with similar care, whether wards, ope'rating-rooms, laundry, kitchens, library, or any other department. Every article given to a ward (since' we are at present discussing ward work), from the weekly allowance1 of soap or safety-pins to bed-linen, surgical instruments, or new furniture, shoulel be entered in writing. This may be- done e-laborate'ly by a system of carel cataloging, always in the long run a convenience, or more simply by keeping a set of requisition books and checking carefully the articles received. For example, one book would be reserved for household supplies, another for ward crockery, a third for linen and ward furnishing, and a fourth for surgical instru- ments and supplies. These books are thus in the nature of receipts, and should, therefore, not be* destroy eel when complete until a given time has elapsed. This, however, constitutes but the first step in the neces- sary care. The next is to minimize the risk of loss. The best way yet devised is to take regular, and, one may add, honest, inventories. How often the inventories should be taken may be a matter of opinion, obviously, the more frequently they are done, the more easily will they be accomplished. Inventories.—The inventory for the ward china, glass, knives, and spoons, etc., may be conveniently kept in the form of a sheet or «ard ruled into weeks anei fastened up STOCK-BOOKS AND INVENTORIES 813 inside the china-closet. The complete number of articles in stock should be entered at the beginning of the list, and a regular day set aside for the counting. It is a good rule to do the counting each week on the day on which the china-closet is scrubbed, and an excellent plan to do it with the ward-maid. She soon comes to feel responsible for not allowing the articles to stray, and after a few weeks of encouragement on the subject will invariably take a pride in keeping her things together. FORM OF INVENTORY 30 cups. 30 saucers . 60 plates... 30 glasses. . 60 spoons. . 30 knives . 30 forks, etc February. 7 30 14 21 28 30 60 30 60 30 30 The same form of inventory may ke kept for surgical instruments and supplies, for lavatory supplies, including bed-pans, urinals, sputum-cups, rectal tubes, catheters, douche-cans, etc., and for medical supplies, including pneu- monia jackets, stupe flannels, poultice binders, and so forth. These inventories are usually most conveniently kept in small separate copy-books. They also should be taken at regular and frequent intervals—once a week is not too often—and gone over personally with the nurse in whose charge they for the time are. When these duties are changed, the inventory should be again carefully checked, that the nurse taking up the duty may know exactly what she is responsible for. The furniture inventory (beds, mattresses, lockers, etc.) is frequently not left in the charge of the head nurse, but kept and taken from time to time by the hospital author- ities. The linen inventory is perhaps the most important of all, since, of all ward equipment, this alone leaves the ward 814 THE HEAD NURSE AND WARD MANAGEMENT and is handled, both for washing and for repair, by persons outside the ward. As the linen represents a very large item of expenditure, it should be closely looked after. Besides the regular inventory, the care of the linen entails a carefully kept laundry book and a repair book. Printed laundry books with duplicate slips which are' sent to the laundry with the soileel clothes are usually provided. From the duplicate slips the clothes can be recheckeel in the laundry, and by comparing the return laundry with the list in the book, losses can, to some extent, be at once1 detected. Where the laundry sorting-room is well organ- ized, linen for repair is usually se*nt straight from the1 sort- ing-room to the linen-room; in other cases it should be' a special eluty of one or other of the nurses to sort out the clean linen and set on one siele all that require1 repair. In either case1 the article's should be enumerated in a book kept for the purpose, which may conveniently be arranged as follows: Example: Items. Received. 3 sheets March 8th Returned. 2, March 12th Condemned. 1 All condemned articles are replaced by new ones either immediately or, more conveniently, on a certain day, say, once a month, thus keeping up the full supply of linen. The linen inventories have a more official appearance, and are generally more carefully kept, if printed forms are used in place of the ruled copy-books, which are quite suffi- cient for china lists and surgical supplies, etc. They can be bound inexpensively in the form of small books. The first page should state the standard number of the' different articles required. Some losses are almost certain to take place from month to month, at least until the inventory system is well established, and the full amount will from time to time, perhaps twice a year, require to be made up. STOCK-BOOKS AND INVENTORIES 815 A practical linen inventory may be arranges! in the following manner: ............Ward. No. of Beds........ Date.............. A' u tuber pre- ceding month. He mi: Con- demned. Number per bed. Signed......................Head Nurse. New articles are given only in place of those condemned. " Unaccounted for " may indicate actual loss or merely that the articles have strayed to another department, to be recovered subsequently. One of the most satisfactory results in keeping careful inventories is observed in the steady decrease in the numbers under this heading as the practice of taking the inventory becomes confirmed. By placing on the left of the list the number of the pre- ceding month (or last inventory), and not the standard numbers, the date of any loss is clearly shown. The amount of linen required by a ward depends on the activity of its service and its laundry facilities. Thus, if the linen sent down daily is returned on the following day, a smaller amount will be necessary than if the linen is returned from the laundry only twice a week. The following list includes the average amount per bed usually considered necessary: Sheets.......................... 6 to 10 per bed. Draw-sheets..................... 4 to 6 Pillow-cases..................... 6 to 10 Blankets........................ 2 to 3 Spreads......................... 1? to Patients' towels.................. 4 Diet towels...................... 4 Roller towels....................12 Hand towels for doctors..........36 Dish-towels, and all other small towels, etc., of each............ 6 to 12 2 to 6 to 6 to 24 to 72 816 THE HEAD NURSE AND WARD MANAGEMENT If night-shirts are provided, the supply can hardly be too ge'nerous; in man}' lmspitals, henvever, the1 patients supply their own shirts, a ce'rtain numbe'r e'specially made for bed cases only being supplied by the hospital. CARE OF LINEN The care of the linen is, however, only begun with the taking of the inventory, and a head nurse will find herself obliged to exercise constant vigilance in its use. Insist, in the first place, that linen is used only for the purpose for which each piece is provided, otherwise pillow- cases will serve for sand-bag covers, crumpled sheets for draw-sheets, and all small towels for dusters, all of which implies an increase1 of wear and tear on an unnecessarily good class of material. Stains which result from careless- ness or inevitably from the kind of work should be treated as soon as they occur, and before, if possible, they have time to dry. Blood-stains should be soaked in cold water, and not allowed to dry before they are washed. They should be washed with Ivory soap in cold water. Small stains on mattresse's or pillow-ticking can be completely effaced with peroxid of hydrogen. This, however, is an expensive method, only permissible where it is impractical to wash the articles in question. Shee'ts and diapers soiled with fecal matter should be taken at once to the lavatory hopper and under running cold water brushed as clean as possible with a long-handled hard brush. The custom of sending badly soiled sheets or infants' diapers to the laundry without such treatment, to wait possibly twenty-four hours before they are washed, is obviously objectionable, and especially so in hospital work. Ink-stains should not be exposed to light or treated with hot water, sine-e either will blacken the nitrate of silver all inks contain. In the Boston Cooking School Cook-book Miss Farmer recommends washing in a solution of hydrochloric acid, rinsing immediately after in ammonia water (to arrest CARE OF LINEN 817 the1 action of the aciel); the1 stain is then wet with warm water, rubbed over with Sapolio, and gently rubbed be- tween the hands. Small spots may be covered with salt and rubbed with a piece of lemon. Stains from iron-rust are still more difficult to remove, but may yield to the same treatment as that for ink-stains. Whenever an acid is used in bleaching, the1 material must be rinsed in an alkali to check the action of the acid, which will otherwise cause holes. Iodin stains when fresh may be removed by washing; olel stains are treated with a paste of starch and alcohol, or, if trifling, by sponging with ammonia-water or with alcohol. Tea and coffee stains are easily removed if washed at once; if there is milk or cream in the stain, it must first be washed in cold water. Fruit-stains, especially those from peaches and pears, are very intractable and are indelible if the linen is washed before removal. Hydrochloric acid or oxalic acid may be used exactly on the spot, rinsing immediately in ammonia water, and then washing with Ivory soap and cold water. Stains from oil or grease must also be removed before the linen is washeei. Ether, benzin, or gasoline may be used. As these are highly inflammable, care must be taken to keep them away from an exposed light. When the stain is small, Ivory soap and cold water may be sufficient to remove it. Bichlorid of mercury turns linen an ugly gray color after it is exposed to the heat of washing, and shoulel, therefore, not be used for disinfection. If stains occur, they may be removed by soaking the linen in a cold solution of chlorinated lime and carbonate of soda (Labarraque's) for several hours. They must then be at once rinsed and washed, as the soda is injurious to the linen. Linen torn in any way or wanting tapes or buttons should be set aside for repair, and not, as is too often the case, used again and again until a small tear has become one wanting several hours' work. Disinfection of Linen.—See Disinfectants, Chap. XII. 52 818 THE HEAD NURSE AND WARD MANAGEMENT BLANKETS The most careful washing in time causes blankets to shrink and invariably spoils their appearance. With the more expensive varieties, such as provided for the private rooms, it is an economy, in the long run, to send the^n to the dry cleaners rather than wash them. From the elry cleaner they return as good as new, and with reasonable care will last many years. Nurses should take a pride in keeping their blankets clean. Finger-marks and spots can be minimized by doubling the end of the spread over the tops of the blankets before turning back the sheet. If stains occur, they should be sponged aff at once in cold water, after which place the portion to be washed over a board, and with a piece of flannel wash off the spot with a lather of Ivory soap and tepid water; rinse only partially, rub with a dry cloth, and finish drying in the air and sun. A less expensive variety of blanket is more practical for use in the general wards. Here, besides the purpose for which blankets are originally intended, we find them put to various uses: soaked in boiling hot water for hot packs; elampened with steam from the sweat-bath, wrapped round a patient dripping with perspiration, and so forth; add to which the nature of the cases compels us to have the ward blankets continually in the wash-tub. We all know the forlorn aspect of the average ward blanket after it has been but a few weeks in use—its diminished size, the curious frilled appearance caused by the unequal shrinking of its gay borders, the lighter weight, the harsh feeling of the wool. Except in using for their original purpose, a full- sized blanket is an unwieldly article. For the uses just enumerated old blankets, the shrunk margins cut off and bound with strips of stout muslin, are much more practical, and if provided, their use should be rigorously insisted on. Unless the old blankets are adapted in some such way, there will always be a difference of opinion as to which blanket is old and risk of a good one being spoilt. Some hospitals provide crib blankets of a light weight, made without margins for all extraneous uses—a plan that certainly con- tributes to the longer life of the more expensive article. In washing, tepid water and white soap without soda PATIENTS' EFFECTS 819 are used. After washing and rinsing, a bucket of tepid suds should be thrown over the blankets and only partially wrung out. The soap helps to keep the blanket soft and replaces, to some extent, the natural oil of the wool lost in frequent washing. With the first hot weather all spare blankets should be put up in moth-balls, and moth-balls also laid between the fold of those left on the shelves. Where special chests or closets are not provided, the blankets, well packed with moth-balls, may be wrapped in several thicknesses of newspaper. Moths apparently dislike printers' ink, and newspaper wrappings, it is found, are never eaten through, as frequently occurs with wrappings of cotton, etc. PATIENTS' EFFECTS The personal effects of patients in the general wards become an item of constant trouble unless their loss is controlled by some methodical system. Wherever possible, the clothes should be returned to the friends, since clothes that have been worn are undesirable articles to pack away in closets. Frequently, however, this is not practicable. In these cases, as soon as the patient is undressed the clothing should be gone over and the items carefully listed, the list entered in a book kept for that pur- pose and signed by the nurse who has taken the list. The clothing is then made into a bundle and clearly marked with the patient's name, the ward, and the date of admis- sion. All small articles in the pocket, with the money, railway tickets, etc., should be made into a separate packet, also carefully listed, preferably in a separate book, and kept under lock and key until returned to the patient. For these articles a receipt is usually made out and given to the patient, and it should be a rule that such a packet is opened only by the patient himself or in his presence. Should it be necessary to send any personal clothing to the hospital laundry, they must temporarily be marked with the name of the ward, otherwise, being unfamiliar to the laundry staff, they may easily be lost. Clothing badly infested with insects is best burned. The list is still necessary, however, as the equivalent must 820 THE HEAD NURSE AND WARD MANAGEMENT be given to the patient in their place. If this is impractical, they should be first fumigated with sulphur to destroy the animal life, then further disinfected, either in the auto- clave or by subjection to live steam and finally washed. (See Disinfection, Chap. XII.) SPECIAL DUTIES OF A HEAD NURSE As a head nurse must, in her daily work, meet many conflicting interests, it is very necessary that she should arrange her various eluties in as methodical a manner as possible in order to give to each the necessary time and attention. Her first work will be to receive the report of the night nurse and, following that, to interview the day nurses and see that they understand their orders. Next in order, she should make a point of seeing and speaking to each patient under her care. However excellent a system of reponting, however we'll trained and disciplined the nurses actually engaged in the nursing duties may be, nothing can make up for a lack of individual interest on the part of the head nurse, and this interest must be shown if it is to be realized. It would seem a curious point to insist upon, but the writer must own that she has met not one but several head nurse's who did almost all their work from the ward office. They were certainly fully informeel as to all that happened in their ward, but they literally hardly ever saw a patient exe'ept when accompanying the eloctors in their visiting rounds, unless some abnormal condition had been reported. One felt there was a want somewhere. Either the head nurse was overoccupied with clerical work, reports, records, and so forth, so that actually time was wanting, or she had never realized the privileges of her position. When the domestic work for the morning is finished, a thorough round of inspection should be made daily, in- cluding closets, lavatories, milk-boxes, refrigerator, etc. The work of the ward-maid and orderlies should also re- ceive methodical inspection. Just how much of the actual nursing it is best for a head SPECIAL DUTIES OF A HEAD NURSE 821 nurse to do it is impe>ssible to say on general principles; it will partly be determined by the' amount of work to be done, the nature of the work, and the powers of the pupil nurses. A head nurse is a captain, not a soldier, and while we may at times feel it easier to do a piece of work ourselves than to get as good results through a pupil, this is weak organ- ization, and not fair to the pupil, who is there to learn her work. At the same time nothing is worse than for a head nurse to cheapen any of our various duties by taking the attitude that some are beneath her. A good head nurse should do everything, from dusting upward, just a little better than anyone else in the ward, anel she should realize that her example, whether negative or positive, is bounel to have its influence on her pupils. Whenever possible, the heael nurse shoulel superintend herself the serving of the meals anel ascertain whether they have been eaten anel en joy eel or not. In her absence it should be the work of the senior on duty. Meals left to the junior nurses and the ward-maid, while the senior's diet eluties are confined to administering the tonics, although seemingly illogical, is really not an uncommon division of duties. That it results in bad service, cold food, and a general attitude of indifference toward the meals is not an unnatural sequence. Any deterioration in the quality or cooking of the food shoulel be methodically reported in the proper quarter. In some hospitals one of the senior nurses is put in charge of the ward diets, her eluties including ordering the supplies, distributing the food, anel superintending the service of the meals. It must be remembered, however, that the nurse is only learning her work, and that training will be as necessary in this particular as in any other. All the various details of nursing duties must, if they are to be properly done as regards the patient, and be made of full value in the nurse's training, be subject to constant inspection and comment, nor should the head nurse ever feel that her responsibilities end when she has relegated the duties to the various nurses. To the last day of her training a nurse's duties are part of her training, and it is 822 THE HEAD NURSE AND WARD MANAGEMENT due to her that the best quality of work should be taught and exact eel. In going off duty for her recreation hour the head nurse will naturally choose the time in which there are likely to be least demands made upon her. Wherever possible it ought to be arranged that she can be entirely free from any calls at such times. In her absence the senior nurse takes her place, superintends the work in the wards, attends any visiting round, takes all orders, and receives any new patients that may be admitted. THE PATD2NTS' VISITORS One weak point in the management of many wards is the attitude of the nursing staff toward the patients' friends. They forget that what is a common event to them is to the'se people an unusual experience, and they are naturally upset and anxious and often a little aggressively on the watch that their patient should not be defrauded of any of his rights. To treat them peremptorily, or even in a business-like, unsympathetic way, only confirms their suspicions. One can say from experience that most hos- pitals where good nursing standards are maintained bear investigation, and the more these methods are known, the more confidence will the public feel. At the same time this confidence cannot be taken for granted and is easily destroyed by want of a little kindly tact. Nowhere are good manners more a sheer necessity than in our relation- ships with the public in just these circumstances, and to err in this particular is a serious shortcoming, however sure we may be that as soon as the patient is left in our charge we shall give him the most devoted care. Let us realize that to his friends this is not a foregone conclusion. At the risk of sermonizing, might one suggest that this is specially necessary where mothers are bringing their children to hospitals. We do not realize that probably only the pressure of bitter circumstances induces a mother of the very poor classes to leave her child in a place that she really believes to be a place of torture or, at best, of unsympathetic neglect. Why not reassure her by showing something of the genuine interest and pleasure most of DOMESTIC WORK 823 us take in our child patients ? Let her realize that her child is among friends, and she will go away with one bur- den less on her heart. And in her weekly visits take the trouble to talk to her and gain her confidence; it is quite as easy to do as to leave her to gain a false impression if you allow her to feel she is an interloper whose visits are a trouble. To take the other side, however, in our " visitors," especially in the general wards, we have a class little likely to appreciate the wisdom of many of our rules. Unless close watch is kept, indigestible food, unwholesome candy, and alcoholic drinks will certainly be smuggled in. It is best to allow a list of wholesome dainties, fresh eggs, fresh fruit, simple cakes, plain ice-cream, and so forth, where the patient's condition admits of such food. It is natural to dislike to visit a patient in a hospital empty handed, and the time of sickness is often the one time in the lives of our patients that they may allow themselves such sim- ple luxuries. In the evening the head nurse should again visit each patient before going off for the night and giving over the responsibility of the ward to her night nurse. However carefully the reports are made out, there will be some individual details about the patients to be mentioned. The verbal report between the head nurse and night nurse should always be regarded as an important part of the day's routine. Where practical it is always a good thing for the head nurse to see the night superintendent. In a large hospital, however, this is often not possible without keeping-the head nurse unnecessarily long on duty. DOMESTIC WORK The routine care necessary for each patient has been discussed at length in the chapters on Practical Methods. The domestic routine care will require, equally, method in its management and punctuality in the way it is carried out. A ward, where dusting is done here and there all the morning, or not at all in a rush of work; where the baths and other routine details are fitted in anywhere, is an uncomfortable one for the patients and a very tiring 824 THE HEAD NURSE AND WARD MANAGEMENT one for the nursing staff. There should be an hour at which the domestic work should, as a rule, be finished, an hour for beginning the evening work, definite time, as far as possible, for all the routine details. Certain work that is not required daily should have its special day for being done. It may be1 of some assistance to go over briefly some accepted methods of carrying out the domestic work of a ward. The sweeping of polished floors must be done with a hair broom. After the dust has been swept up, the broom may be put in a bag of washeel flannelette, or other soft material, and the floor gone over thoroughly with a regular polishing movement. For scrubbed wood floor, as well as those of stone and concrete, the ordinary corn broom is quite efficacious and more economical. Moistened bran or used tea leaves well washed in cold water may be used with ad- vantage as dust collectors, and prevent the dust from flying about. From time to time brooms should be washed and thoroughly drieel in the open air. When not in use, they should be hung or stood within, the broom end uppermost. Mopping is not a good substitute for scrubbing, either for stone or wooden floors, but where labor is inadequate, it is frequently used as an alternative. The water must be changed frequently or the floor will show streaky black marks. Each time after use the mop should be washed in hot water with soda or soap powder and dried in the open air before being put away. Scrubbing is the only way of really cleaning stone or woodwork. The secret of good scrubbing is hard rubbing, thorough rinsing, and frequent changing of the water. Either soft soap, a good scrubbing soap, or soap powder in very hot water serves to loosen and dissolve the dirt; if not carefully rinsed off, however, they discolor wooden floors, turning them yellow or black. When sand can be procured, it forms an admirable and inexpensive means of cleaning wooden floors, kitchen tables, etc. A small amount of soap is necessary at the same time if the wood is really dirty. The sand is well sprinkled on the boards and then thoroughly rubbed into DOMESTIC WORK 825 the grain of the wood with a hard scrubbing-brush and hot water. Unglazed tiles, whether white or colored, should be scrubbed with a good sand-soap and plenty of clean hot water, and will require to be scrubbed daily to present a good appearance. If they get discolored and streaky from the soap, they may be gone over with dilute muriatic acid. Two details in the interest of economy should be ob- served—first, the soap must not be left standing in the water; second, scrubbing-brushes and floor cloths should invariably be washed after use, well rinsed, and thoroughly dried before being put away. The bucket also should be rinsed and dried. If these details are attended to, a housemaid's closet will not present the damp, dirty, dis- couraging appearance so commonly seen, but will look as trim and neat as any other part of the ward equipment. Any kneeling work may cause inflammation of the bursa in front of the knee—what is known as housemaid's knee. Kneelers should, therefore, be provided with a suitable mat or an old blanket folded to several thicknesses to avert this risk. Polishing.—Many hospitals now have polished wooden floors in the wards. They have the advantage of being less absorbent than scrubbed floors, warmer, and less tiring to the feet than any form of stone floor; the polished surface is also considered to make them less likely to harbor germs. At the same time, they require a considerable amount of time spent on them if they are to present a good appear- ance, since every spill, etc., spots the floor. Many floor polishes are on the market, but none are better than a mixture of beeswax and turpentine, in the proportion of one part beeswax to two of turpentine. The beeswax is cut up in small lumps; when thoroughly dissolved, it forms a yellowish, thick fluid, about the con- sistence of cream. A very small amount is rubbed directly on the floor, a few yards of the surface at a time, and pol- ished until perfectly dry with a special weighted brush with a long handle. The brush is weighted with lead, and weighs about thirty pounds. It is wrapped in a piece of thick soft flannel or blanket. If the floor is left sticky, it will 826 THE HEAD NURSE AND WARD MANAGEMENT catch the dirt and dust. Any such accumulations must be removed with turpentine before repolishing the floor. In many hospitals floors are colored, varnished, or shel- lacked previous to polishing. This is labor-saving in the be- ginning, but costly, since if accidents occur which remove the polish,—and they are almost unavoidable,—there is either an unsightly patch, or the whole floor must be scraped and repolished. Where nothing but the beeswax and turpentine mixture is used, any patch can be quickly rubbed up to look like the rest of the floor. The weighted polisher must be used daily, and, as a rule, once a week is sufficient for a fresh coating of polish. Only hardwood floors, oak, teak, maple, etc., are capable of taking a good polish. If desired, when first laid, the boards may be darkened with linseed oil before polishing. At first, when beeswax and turpentine alone are used, a considerable amount of labor is necessary before the polished boards present a good appearance; once well polished, however, they are easily kept at comparatively small cost. In the weekly polishing two should work together—one kneeling to apply the polish, and the other using the polisher. With a little practice the polisher can be used without much exertion, since the handle is on a hinge anel the weighted brush can be pushed backward and forward with a swinging movement not difficult to acquire. Floors covered with cork carpet, linoleum, etc., may either be scrubbed or polished in the same way. Dusting is usually the first of the domestic duties assigned to the nurses. After sweeping, a short time should elapse to allow any dust that has been raised to settle before the dusting is begun. The dusters should be dampened with clean water, in order that the dust may more readily adhere. The use of a disinfectant is an unnecessary' expense, since it cannot be used in sufficient strength to do any practical good. For polished surfaces, dry, soft dusters should be used. Dusting must be taught, so slovenly and inaelequate are the average ideas on the subject. Every corner of the ward, including any ledges above the level of the head DOMESTIC WORK 827 and the top of the skirting boards, should be thoroughly gone over daily. At the present day ward furniture is especially contrived so that it can be readily cleaned, a large part of it being white enamel ironware and glass, so that there is no excuse for anything less than spotless clean- liness. It is an excellent rule that each nurse should wash out her own duster in hot soap and water daily, immediately after use. Enamel Ironware.—Finger-marks and most stains are easily removed by washing in soap and water. Soaps containing pumice or sand (Sapolio) should not be used, as they scratch the polished surface and loosen the enamel. Acids and strong disinfectants also destroy the polished surface. Intractable stains are best removed with Labarraque's solution. The only disadvantage of enameleel iron is the readiness with which it is chipped—a tendency that is apparently increased if subjected to high tempera- ture, as in the autoclave. Enameled iron is the popular ware for kitchenware and lavatory utensils, and is largely used for bath-tubs and sinks. Glass.—Soap and hot water are quite sufficient to clean glass, and the use of expensive drugs, such as ammonia, alcohol, liquor potassae, etc., to save labor, is an extrava- gant habit that should never be countenanced. Am- monia in time will destroy the polished surface of glass. Cheese-cloth or flannelette rags or a soft chamois-skin should be used to rub up the surface after washing. Where glassware has become badly soiled and scrubbing in soap and water fails to remove the stains, a paste of whiting moistened with water, or, if the stains are very bad, with a little ammonia, may be used. Marble becomes discolored with ordinary soaps and stained with grease and many of the commonly used dis- infectants. To clean marble a paste of whiting and ammonia may be made, spread over the surface, and left overnight; in the morning it should be rubbed away with a dry cloth. The process is repeated until the marble is clean. The polish of marble is destroyed by acids, a great disadvantage where, in the form of terrazzo, it is used for 828 THE HEAD NURSE AND WARD MANAGEMENT the flooring of operating-rooms anel out-patient elepart- ments. If any acid is spilled, it shoulel immeeliate'ly be neutralized with an alkali, such as aqua ammonia, washing- soda, etc. The porcelain and enameled iron used for bath-tubs, basins, and sinks is frequently wantonly ele>stroyed by strong alkalis or aciels, or even by the use of soaps contain- ing pumice or sand or strong alkalis. The1 smooth sur- faces become roughened, unsightly, and difficult to clean. If it is necessary to soak any article in a strong alkali or acid, a zinc bucket or unpainted wooden tub should be used. In cleaning tubs, etc., grease' stains that have been allowed to dry are difficult to remove with ordinary soap- and-water washing. A cloth moistene'el with very little1 turpentine or coal-oil may be permitted. Stains from bichlorid of mercury, permanganate' of potash, ete\, will generally yiedel to Labarraque's solution. Rust-marks, or marks from dripping of hard or impure water, are' diffie-ult to remove, and may require an application of one of the patent se>ap powders, Porcella, or Bon-ami. These are, however, proportionally high priceel, and should be used only when " edbow grease " and gooel scrubbing or an ap- plication of Labarraque's solution have failed. Stains in lavatory sinks and wate'r-closets should be treated by prevention. They do not occur if the basins are well brushed down every day, and always well rinses 1 after use. Labarraque's solution, or Bon-ami, or Porcella will usually remove all sueth marks. Iodin stains may usually be removed by a paste of starch and alcohol, which should be applied at once. Polished Furniture.—In the private room of a hospital tables and bureau of highly polished woods are often met with. Like all furniture in eionstant use, they are liable to become dirty. Greasy stains, etc., may be removeel by washing with a soft cloth in warm (not hot) soapsuds. The surface should be dried and rubbed up with soft, dry cloths. If the polish is dimmed, a very little furniture polish may be rubbed on with a flannel and rubbed up until bright. A polish of equal parts of sweet oil, turpentine, and DOMESTIC WORK 829 alcohol is serviceable and less expensive than patent polishes. White marks on polished surfaces are removed by rub- bing quickly with a flannel soaked with a small quantity of camphor or soap liniment. Another method is to place a sponge wrung out of boiling hot water exactly on the spot; repeat the treatment until the spot is effaced, and then rub up with furniture polish. If the surface has been entirely lost, as by carelessly placing very hot articles (such as a can of hot water) directly on the polished wood, it is generally necessary to send the furniture to a dealer to be repolished. Olive oil applied with very small absorbent cotton pledgets and lightly rubbed into the wood may restore the polish, but the process is tedious and really requires expert practice. Experience shows it is necessary to teach nurses not to place hot articles on polished wood. Alcohol spilled on polished wood will also remove the polish. Olive or cottonseed oil should be poured imme- diately over alcohol accidentally spilled, to neutralize the effect. Stains on Scrubbed Wood.—Bad grease stains are very difficult to remove entirely. An acid—oxalic acid or hydrochloric acid—may be used to cut the grease, fol- lowing which the stain should be well scrubbed with cold water and ammonia and sand or a sand-soap. Ink, if spilled, should be sopped up with flour at once, and may then be treated in the same way with an acid, followed by ammonia and sand-soap. Small spots may be covered with common salt and rubbed until they disappear with a squeezed lemon. Blood-stains on absorbent surfaces are apt to leave discolored marks. They should be washed in cold water before they become dry, in order, as far as possible, to dissolve the albumin. Small spots on wood (as on linen, etc.) may be completely removed with peroxid of hydrogen, but this is, obviously, a costly method. . Iodin should be treated with a paste of starch and am- monia or alcohol, left on for some time, and washed off with ammonia and water and finally thoroughly rinsed. 830 THE HEAD NURSE AND WARD MANAGEMENT Cleaning of Brass, Copper, and Other Metals.—Labor can be materially saved by having metal work coated with lacquer, a process carried out by furniture-dealers. This is usually done for brass bedsteads and vessels, etc., not in constant use, but is unsuitable otherwise, as washing or exposure to heat destroys the lacquer. The usual metal polishes also destroy lacquer, and nurses and ward-maiels may require to be reminded not to polish lacquered metals. One or other of the patent pastes and fluids on the market for polishing brass, copper, and zinc are commonly used in hospital work. As they are expensive, they must not be1 used extravagantly. When the article can be first washed in hot soda and water, a smaller quantity of the polish will be necessary. If metal work is polished daily, it take's but little time to make it bright or clean. Brass or copper that has become very dirty is best cleaned with a strong solution of oxalic acid, which should be removed with a little coal-oil. The coal-oil is used to arrest the action of the oxalic acid, which, if continued, would destroy the metal, and helps to give the article a brighter polish. White metals, silver, nickel, or pewter^ are most eco- nomically cleaned with a paste of whiting and water, or, if very dirty, of whiting moistened with ammonia. The secret of well-kept brights, however, lies chiefly in clean, dry polishing rags and thorough rubbing. Saucepans and Kitchen Crockery.—Saucepans, tea- kettles, and such homely articles in enamelware are short- lived, indeed, unless a special point is made of their care. Milk, gruels, cocoa, and foods of like nature, which readily burn, should invariably be cooked in double boilers. The saucepan is then easily cleaned with hot water and a little soda, whereas if burned, the violent rubbing and use of Sapolio and such soaps are apt to chip the enamel and make further burning inevitable. If burning has taken place, and the marks do not readily come away, they can generally be removed with a little salt just moistened and rubbed on the' spot with the tips of the fingers. If this is not sufficient, an application of Labarraque's solution will usually be effectual. DOMESTIC WejRK 831 A kettle will last forever if not put on the stove empty. Nurses should be trained invariably to replace whatever water they take from a kettle. Each saucepan should be cleaned immediately by the nurse who has used it, and the inspection of the saucepans should be a routine part of the daily round. The Ice-chest.—The shelves of an ice-chest should be removed daily, and the whole interior wiped with a clean, damp cloth. Any spills must be removed at once. Once a week the whole chest should be well scrubbed with strong soda water and thoroughly dried. The drain-pipe must be flushed at the same time with boiling hot soda water, to prevent it becoming clogged. Milk, butter, and eggs should not be kept in the same compartment as other foods. Milk and butter absorb odors, and pure air at a low temperature is essential to keep eggs fresh. If there is only one ice-chest, these articles must be closely covered. Sinks and Hoppers.—To keep sinks and hoppers free of grease, boiling soda water should be poured down the soil-pipe twice a week. A fine wire-basket strainer kept in each sink prevents the too frequent blocking of the soil- pipe by lost articles, fluff from the mops, etc. A not infrequent accident with taps and spigots is the sudden giving way of a neglected washer, followed by a flood of water that cannot be checked. Every nurse should know the points at which the water-supply in her department can be temporarily cut off. The Walls.—Except, perhaps, in perfect mechanical ventilation, the walls of a ward quickly become covered with dust, which, if undisturbed, is not long in collecting cobwebs. The condition is minimized by the use of highly varnished, painted, or tiled surfaces, but to some extent dust on the walls is inevitable. As dust in a ward forms a resting-place for germs, it is necessary that the dust should be removed. Each week the walls should be swept down with a soft broom tied in a bag of cheese-cloth or flannelette. At longer intervals the walls may be washed, using a large sea-sponge or soft rags and plenty of clean tepid water. Bad stains, such as over the radiators, may require a little 832 THE HEAD NURSE AND WARD MANAGEMENT soap. The polished surface's must be well dried and rubbed with soft, dry cloths to prevent sine'aring. Greasy marks from fingers, heads, etc., on highly var- nished paint are best removed by rubbing with stale breael. Beds and Bedding.—At the present day the enameh'el iron bedstead has practically replaceel all other kinds for hospital use." Fitted with a chain or wire mattivss, it is comfortable, easy to clean and handle, and with e'are1 in preventing chipping of the enamel, wears we'll. It has one great advantage over the old wooden or painted iron bedsteads, that it does not harbor bedbugs. After each patient goes out, the enamel part of the bed- stead should be washed in warm water anel soap. Stains may be removetl by the processes already described for other enameled ironware. The use of a disinfectant is no material advantage, since it cannot remain sufficiently long in contact with the iron to be in any sense an active agent. The mattre'ss is one of the most abused of articles in hospital equipment. Wherever necessary, the mattress should be protecteel by a heavy rubber sheet under the linen one', covering the entire mattress. This rubber should constantly be inspected, as if cracked or worn, it is no longer waterproof, and no longer of any use. A slip- cover of unbleached cotton, which can be changed anel washed, should always be used to keep the mattress clean. Patients with chronic incontinence are frequently nursed on mattresses filled with straw or dried grass, or the mattress is dispensed with and replaced with old soft blankets covered with a rubber sheet, which can be' washed when necessary. After a patient's discharge, the mattress should be taken in the open air, thoroughly brushed with a hard whisk, and left in the sun for about six hours. Before being used again it should be carefully examined and sent at once to the repair room if there is the smallest tear. Disinfection can properly be done only by exposure to high temperature, as in an autoclave. Where this is not available, exposure to the fumes of fprmalin is considered suitable for most cases. This is not usually considered VENTILATION AND TEMPERATURE 833 sufficient if the case has been one where the infection is spread by the fomites, as in smallpox or scarlet fever. Stains are difficult to remove, as rinsing in water will injure the hair or flock with which the mattress is stuffed. Blood-stains can be removed with peroxid of hydrogen. Other stains may yield to washing with ammonia and water; the part washed should be rubbed as dry as pos- sible and instantly exposed to sun and air until quite dry. Mattresses may become infested with bedbugs. To kill these nothing is so efficacious as the fumes of sulphur. (See Disinfection.) Sulphur, however, will not destroy the eggs; in bad cases the mattress may have to be de- stroyed; in milder cases, the hair may be cleaned at an upholsterer's and sewn into fresh ticking. Pillows, either of hair or feathers, should be, where necessary, protected from soiling or wetting (as from an ice-bag) by slip-cases of rubber. These should not be retained unnecessarily, as they are heating to the head. If the ticking becomes stained, it is best to remove the stuffing and have the soiled ticking washed in the laundry. Surgical Supplies.—The care of rubber goods, instru- ments, and special surgical appliances is discussed in Chap. XIII. VENTILATION AND TEMPERATURE The necessity for a constant supply of fresh air and its special importance in the hospital ward or sick- room cannot be too constantly enforced. It is a point that should never be lost sight of, and will require, unless the building is mechanically ventilated, constant personal attention. All sources of impurity, bed-pans, soiled dressings, etc, should be quickly removed from the ward; if any odor is perceptible, the adjacent window should be opened for a short time. Garbage-cans and dressing-cans are a source of impurity unless kept closely covered and emptied and thoroughly cleaned at least once a day. The galvanized iron cans with closely fitting covers commonly used are the most san- itary available. The temperature of the ward is another subject re- 53 834 THE HEAD NURSE AND WARD MANAGEMENT quiring constant vigilance'. Wards and sie-k-roenns should be kept as nearly as possible at an equal temperature1, with little variation in the twenty-four hours. The self-regis- tering thermometer is the' most accurate' means of ascer- taining the variations of temperature. Whe're the or- dinary wall thermometer is used, the temperature of the- warei shoulel be' recorded every four hours. The' record may be kopt in the form of a chart, like a clinical chart, or noted in a small copy-book conveniently ruled for the purpose. The chart or record book must be inspected daity by the head nurse, and from time to time checked by her, to insure its aceurae'y. THE VISITING ROUNDS One of the important elutie's e>f a head nurse is to ace'om- pany the visiting doctors or the1 ivsielents on then rounds. She must make a point of being fully informed as to every detail e'oncerning her patients. Few things are more trying than the head nurse who either eliscovers or " re>- members " facts after the visit is over. In the usual eti- quette of the round of the visiting chief, he obtains his information concerning the patients from the resident, anel the heael nurse is required to report only if directly askeel. If there1 should be1 some information to report which she' has not yet been able to communicate to the resident, she shoulel make an opportunity of telling him privately of the facts, so that he may include them in his report. All record charts, report books, and the elay-book should be readily available, and the convalese'ent patients each seated by his own bed. Obviously, talking or noise of any sort is out of place during a round. One nurse (either the senior or, preferably, the nurse in charge of the' cases) should accompany the head nurse, her first duty being to arrange the patients for examination and to sel tie them comfortably afterward. The other nurses should continue their work quietly; it is usually considered etiquette, however, that they should not be seated during the round unless with permission. In a surgical ward dressings should be placed in readi- ness by any case that the surgeon may be- e'xpe-cted to look THE VISITING ROUNDS 835 at, unless, as is now happily often the case, dressings are done1 in a room especially reserved for the purpose, and not in the ward. Lotions and water should be alreaely heated, anel the instruments sterilized, and placed ready for use in a sterile towel. By such forethought a great eleal of time may be saved. In a medical ward a large square of flannelette or some thin, soft material shoulel be at hand for each patient when the chest is examined. Failing this, an ordinary towel may be substituted. To the nurse is intrusted the care1 of the patients' com- fort eluring the' round. It should not be left to the eloctor to suggest closing a winelow during a dressing or examina- tion, or placing a scre>en to obtain privacy. For all ex- aminations and dressings, however slight, a screen should be placed round the bed. This is both in the interest of the individual patient and for the sake of his fellows in the ward, to most of whom the sight of a dressing is naturally repulsive. This, however, is a point on which both nurses and doctors are apt to become careless, and it is for the head nurse to see that the screens are used when necessary. In touching on the above points of ward management and the duties and responsibilities of a head nurse, the subject is obviously far from exhausted. Even the con- struction of the hospital may alter many details and entail an arrangement of duties, etc., different to those suggested. The fundamental fact, however, of the gravity of the re- sponsibilities of each head nurse, and the immense import- ance of her influence on others, whether for good or ill, will be the same under whatever conditions she under takes her work. APPENDIX RECIPES Except where the recipes have been taken from private sources, the quantities, time, etc., are those recommended by Miss Fanner, in her book on invalid cooking, all of which have been frequently tested. MILK Milk is pasteurized by being kept at a temperature of 155° to 167° F. (66°-75° C.) for thirty minutes. A double boiler must be used, to lessen the risk of the temperature rising too high or of the milk scorching. In pasteurizing milk for infants' food, the amount for the twenty- four hours is divided, and each feeding placed in a freshly sterilized nursing-bottle. The bottles are arranged most conveniently in a bottle-rack, and are placed together in a boiler or kettle of suitable size, filled with sufficient cold water to rise halfway up the bottles. When a rack is not used, the bottles should stand on a folded towel or a tray, raised a little from the bottom of the kettle. After ex- posure to the required temperature for half an hour, the bottles are rapidly coolecl and placed on ice until required. To warm the feedings, the bottle is placed in a basin of hot water. To cool quickly, without breaking the bottles, remove them from the kettle and place in a pan of warm water, set the pan under the water-tap and let it run over the bottles first warm, and, as the bot- tles cool cooler, until the water in the pan is quite cold; then place the bottle at once on ice. There are many patent pasteurizers on the market, by the use of which the process may be carried out with greater exactitude. Where the process has to be entrusted to the mothers in poor homes, the following method is simple and reliable: Fill a soup kettle half full of boiling water; place the bottles, with the feedings measured, in the kettle; cover closely and set in a mod- erately warm place (an average room-temperature) on a wooden table for half an hour; remove, cool the bottles quickly, and place in the coldest place available, on ice if possible, or in a pan of cold water. Wood being a non-conductor, helps to maintain the water at an even temperature. To Sterilize Milk.—The milk is kept at a temperature of 212° F. (100° C), i. e., at boiling-point, for thirty minutes, otherwise the process is the same as in pasteurizing. The scum which forms on the milk is of high nutritive value and should be reincorporated by beating with an egg whisk. If lime-water is used with either pasteurized or sterilized milk in making up infants' food, it must be added after the process is com- 836 RECIPES 837 plete. The action of lime-water on sugar at a high temperature con- verts the sugar into caramel, giving the mixture too sweet a taste and a brown, uninviting appearance. To Peptonize Milk.—Various preparations are in use for the peptonizing or predigestion of milk, each of which is accompanied by full directions for their use. Fairchild's peptonizing powders (extract of pancreas, 5 grains; bicarbonate of soda, 15 grains) are one of the most convenient methods, and are generally used in hospital work. Dissolve one powder in 4 ounces of cold water. Add, when dissolved, to 12 ounces of fresh milk. Set in a pan of water at a temperature of 105° F. (25° C), and keep at that temperature for fifteen minutes. In order to arrest the further process of predigestion, the mixture is then either brought quickly to boiling-point or immediately cooked (as described) and placed on ice until required. Fully peptonized milk is extremely bitter, and is practically used only for rectal feeding or gavage. In peptonizing infants' food, dissolve the powder in 4 ounces of water, and use half an ounce of the peptonizing fluid to every two ounces of the feeding. Koumiss.—Two or three methods, the following recommended by Miss Farmer: 1 quart milk. £ yeast cake. 1^ tablespoons sugar. 1 tablespoon lukewarm water. Heat the milk to 75° F. (24° C), add sugar and yeast cake dis- solved in warm water. Fill sterilized bottles to within one and a half inches of the top, cork tightly, wiring, if necessary, and shake. Place the bottles, upside down, in a temperature of about 70° F. (21° C.) for ten hours. Keep for forty-eight hours in a cold place, shaking well from time to time. Clabber, or Milk-jelly.—Set one quart of milk in a covered bowl on the back of the kitchen stove until the milk begins to turn; remove to a moderately warm place, such as a wooden shelf in the kitchen, until firmly set, which will take from twelve to twenty-four hours. Serve with cream and sugar if desired. Clabber, like koumiss, is usually found easy of digestion and is generally retained. Milk-curds, or Junket.—To one pint of sweet milk, at a tempera- ture of about 100° F. (43.3° C), add two teaspoons of liquid rennet or one-quarter of a junket tablet, dissolved in a little cold water. Stand on a wooden shelf in a moderately warm place until set, then place on ice. Sprinkle with powdered cinnamon, and serve with cream and sugar. Whey.—To extract all the whey from junket, proceed as described. When the curd is well set, break it up thoroughly with a silver fork and strain through cheese-cloth. One quart of milk yields about a pint and a half of whey. Whey is frequently used in infant-feeding, combined with cream, or used instead of water in a modified milk formula. Before mixing with cream or milk, the whey and the milk mixture must be heated separately to a temperature of 150° F. (71° C), and then mixed, otherwise the fermentative action of the rennin will curdle the fresh cream or milk. White Wine Whey.—As above, one gill of sherry to a pint of 838 APPENDIX milk in place of rennet. Strain and serve hot, with a little sugar if preferred. Milk-punch.—Warm half a pint of milk, with a small pinch of salt and sugar to taste; add one tablespoon of whisky, brandy, or rum. Buttermilk.—Strain the fluid left after making butter into a sterile vessel. Keep on ice until required. EGGS The albumin of white of egg is soluble in cold water and coagulates in water at a temperature of 134° F. (5(44° C). If it is exposed to a high temperature, it becomes tough, leathery, and less easy of diges- tion. In cooking eggs for the sick-room care should be exercised on this point, and eggs should be cooked slowly, at a moderate temper- ature. A soft-boiled egg is the most easily digested form in which eggs can be offered. The white should be creamy and the yolk about tIn- consistency of jelly. To get this result the water in which it is cooked shoulel not be above 175° F. Soft-boiled Eggs.—Place in a covered vessel in hot water (about 175° F.) sufficient to cover the eggs, and stand where the temperature will not be rapidly cooled from seven to ten minutes. Where many eggs are cooked together, the water should be of a higher temperature to start with (185° F.), as the eggs will cool it considerably. The eggs should be tied loosely in a net, so that they may all be placeel in the water and taken out at the same time. Hard-boiled eggs are indigestible unless cooked sufficiently long that when removed from the shell the yolk is easily powdered. In this condition they are as easily digested as when soft boiled. They should be placed in water at about 175° F. and kept at that temperature for forty-five minutes. A hard-boiled egg may be chopped finely, mixed with a little butter, seasoned with pepper and salt, and served as a sandwich with thin bread and butter. Chopped parsley or anchovy paste may be added as relishes. Scrambled Egg.—Break one egg in a bowl, and with a spoon stir in a tablespoonful of milk and a pinch of salt. Melt half a tablespoonful of butter in a small frying-pan, add the mixture, holding the pan well above the flame, so that it cooks slowly. When it begins to set, break up with a fork and serve hot on a piece of crisp toast. Where permissible, the toast may be spread with a savory paste, such as anchovy. Poached Egg.—Slip an egg out of the shell into a cup or large spoon lightly greased with a little butter, place it in a saucepan with hot water (about 175° F.) sufficiently deep to cover the egg; cook until the white is set. Season with salt and pe;pper and serve on a small piece of buttered toast and garnish with a sprig of parsley. Coddled Egg.—Break an egg in a cup with a spoon, add 5 ounces of hot milk (about 165° F.), cook in a double saucepan, stirring con- stantly. Season with salt and pepper and serve on a piece of toast. Shirred Egg.—Use an egg-shirrer or a small custard cup. Mix a spoonful of crumbs with a little butter; grease the cup lightly with butter and sprinkle with bread-crumbs; slip the egg into the cup, add a sprinkling of salt, and cover with the remaining crumbs. Bake in a RECIPES 839 moderate oven until the white is set; garnish with a sprig of parsley, and serve in the cup in which it is cooked. Albumin-water.—The white is the most easily digested portion of the egg; being soluble in cold water, it may frequently be given in beverages. Break the albumin up by stirring with a spoon; add slowly, while still stirring, half a pint of cold water and a small pinch of salt. If desired, the albumin-water may be flavored with a little fruit syrup or the juice of fresh fruit. Egg-albumen may also be given in sweet milk or in whey, instead of in water. Wine and Egg-albumen.—Beat the white of one egg stiff with a knife, adding gradually about two teaspoons of powdered sugar; add, still heating, a wineglass of sherry, port, claret, or other still wine; serve in wide wineglass on crushed ice with a spoon. Meringues.—Beat the whites of two eggs until stiff with a knife, and folel in half an ounce of powdered sugar; drop from a teaspoon in small heaps on to a wet board; bake in a quick oven until lightly colored. Served with cream, either plain or ice-cream, they form a tempting desert in a restricted diet. Eggnog.—Beat one egg, adding gradually half a tablespoon of powdered sugar, a pinch of salt, and one tablespoon of brandy or three of sherry; when well mixed, add ice-cold milk to eight ounces. If preferred, the white may be beaten separately until stiff, and added on the top of the glass containing the eggnog. Eggnog with Coffee, Tea, or Cocoa.—Break the egg with a spoon, adding sugar and a pinch of salt. Stir into a little cold milk, and add to a cup of coffee, tea, or cocoa. GRUELS Oatmeal Gruel.—Into a pint of boiling water run through the fingers two heaped tablespoons of oatmeal and a pinch of salt, stirring all the time; allow to boil briskly for two minutes, then cook slowly m a double saucepan for one hour, stirring from time to time; strain, thin to required consistence with hot (not boiled) milk, and serve very hot. Cream may be added when desirable. Barley Gruel.—Make one tablespoon of barley flour into a paste with a little cold water; add to one pint of boiling water while stirring, and boil fifteen minutes; strain, add hot milk, allow to reheat to- gether and serve hot. Arrow-root.—Dissolve two teaspoons of arrow-root in a little cold water, place in a double saucepan, and add half a pint of hot milk and a pinch of salt; stir over the fire until it thickens; then allow to cook slowly for ten minutes; serve hot with sugar to taste; sprinkle, if desireel, with a little nutmeg or cinnamon. Cracker-gruel.—Crush a couple of plain crackers into crumbs and bake in a slow oven until quite brown, in order to dextrinize the starch; add to half a pint of hot milk with a pinch of salt, and cook in a clouble saucepan about five minutes. Rice-gruel.—Wash one tablespoon of rice and stand for about two hours in cold water; pour off water; add rice to cold milk, and cook in a double saucepan for an hour and a half; strain, add salt, and serve either hot or cold. Rice-flour Gruel.—Make one tablespoon rice flour into a paste with a little cold water and add to a pint of hot milk with a pinch 840 APPENDIX of salt. Cook in a double saucepan for fifteen minutes. Add sugar to taste, and flavor, if desired, with cinnamon or nutmeg. Apple-gruel.—Pare, core, and cut up a large apple; cover with one pint of boiling water, and simmer slowly until reduced to a pulp; then strain. Mix one tablespoon of arrow-root \vith cold water, and stir into the hot apple water until it boils. Boil two minutes, then cook slowly in a double saucepan for three minutes; flavor, if desiml, with a little lemon-juice. Sugar should be used sparingly. Flour-gruel (Pap).-—Make two tablespoons of flour or corn-starch into a paste with cold water and add to a pint of hot milk. Add a pinch of salt and cook for twenty minutes in a double saucepan. Add sugar to taste, and flavor with nutmeg or cinnamon, if desired. In making the above gruel and other farinaceous foods patent starch preparations are frequently used instead of the raw articles, and require less time for cooking, as the starch is already partially dextrinized. Directions for their use accompany each package. Robinson's patent foods are always reliable. Oatmeal Jelly.—Set two ounces of oatmeal in one quart of cold water and allow to soak about twelve hours; bring to the boil, and cook slowly down to one pint; strain while hot, and leave in a cold place to set. Barley Jelly.—Wash one ounce of pearl barley in cold water until clean; add to one quart of cold water, and boil slowly down to one pint; strain while hot, and leave in a cold place to set. Dextrinized Flour With Buttermilk (For Infant-feeding).— Wheat flour, 4 ounces (by measure); cold water, one pint. Mix the flour to a smooth paste in a little of the water; put the remainder on the fire in a double saucepan. When boiling, stir in the flour and allow to boil twenty-five minutes, stirring occasionally to keep smooth. Take from fire; cool down to between 140° and 160° F. Then add two teaspoons of "Cereo" (a patent preparation); stir for ten minutes, keeping the mixture at an even temperature. To each ounce of the mixture add half an ounce of cane-sugar, stirring until dis- solved. Strain through cheese cloth and put on ice. Add to fresh buttermilk just before feeding, in the proportion of half a dram of Cereo-sugar mixture to each ounce of buttermilk. Dextrinized Barley-gruel (For Infant-feeding).—Barley flour, one heaping tablespoon; boiling water, one pint. Mix the flour to a paste with cold water; add to the boiling water, and boil for fifteen minutes, stirring occasionally. Cool as above, and add Cereo as in flour mixture. Add two ounces of cane-sugar to one pint of gruel. Strain, and keep on ice. Give with whey in the proportion of two parts gruel to one of whey. The two last recipes (from the Philadelphia Chil- dren's Hospital dietary) are valuable substitutes for milk in cases of protein indigestion. MEAT-TEAS, ETC. Beef-juice.—From half a pound of lean, tender steak remove all fat. Broil on both sides over a hot fire for four minutes, turning quickly at first to seal the juices. Cut into small pieces, and squeeze through a lemon-squeezer or meat-press into a warm cup. Stand the cup in water about 130° F. until the juice is warmed through, but not cooked, and season with salt. Serve at once. If to be kept, RECIPES 841 the juice is seasoned with salt and placed on ice, but not reheated until required. It may also be taken iced, or added to milk if desired. Beef-tea.—From one pound of lean, tender steak from the round remove all fat and cut up in small pieces; place in jar, add one pint of cold water, and cover closely. Stand the jar in a kettle of cold water also covered. The water in the kettle should be sufficient com- pletely to surround the contents of the jar; unless a double boiler is used, the jar should be raised from the bottom of the kettle on an inverted saucer, etc. Bring the water in the kettle slowly to a tem- perature of 130° F., and keep about that temperature for two hours; then raise to 170° F. until the beef-tea becomes brown, in order to remove the unpleasant raw taste. Remove the meat and season with salt. In warming before serving care must be taken not to boil any meat preparation. Chicken-tea.—Use a whole spring chicken; clean, disjoint, and remove the skin and fat. Put in a kettle of cold water, one pint to each pound, and bring slowly to boiling-point. Add salt and pepper and cook slowly until the meat is tender, skimming, when necessary. Strain and remove the fat. Serve with a little well-boiled rice and chopped parsley, heated with the broth; or, if preferred, with a beaten egg or thick cream, in the proportion of one egg or one table- spoon of cream to half a pint of broth. Mutton-broth.—Take three pounds of lamb or tender mutton from the forequarter; remove skin and fat, and cut up in small pieces; put in a kettle with three pints of cold water. Bring gradually to boiling- point; add salt, and cook slowly until meat is tender, skimming when necessary. Strain and remove fat. Serve with a little well-boiled rice or barley and chopped parsley. BEVERAGES Lemonade.—Squeeze the juice of one or two lemons with a lemon- squeezer; add powdered sugar to taste, and dilute with iced water, either plain or carbonated; serve with a slice of lemon or a cherry or whole strawberry. Drink through straw. Lemonade may also be made with hot water in the same way, and taken hot. In this way it induces sweating and is serviceable for breaking up colds, etc. The juice of oranges or the strained juice of crushed fresh strawberries, grapes, or currants may be used in the same way. Where a high caloric diet is being used, milk-sugar may be used in place of cane-sugar. In this case the milk-sugar is dissolved in a little cold water and boiled for two minutes (p. 799); the amount of the sugar solution added depends on the quantity of milk-sugar to which the patient has become accustomed. Imperial Drink.—To each pint of lemonade, made as above, add one heaped teaspoon of cream of tartar; stir until dissolved. Useful in conditions of deficient elimination, especially when the kidneys are affected, and may be taken freely. Barley-water.—Wash two tablespoons of pearl barley in cold water; place in half a pint of cold water, and bring to the boil; throw the water away, add two pints of cold water, bring to the boil, and allow to simmer gently until reduced to one pint; strain, and serve ice cold with a little lemon-juice and sugar. Barley-water 842 APPENDIX unflavored is frequently ordered in the place of water to dilute the milk for the infant-feedings, or as a substitute for milk in cases of intestinal irritation. Rice-water may be made in the same way, and is also useful in cases of intestinal irritation. In these conditions beverages are usu- ally ordered cold. Oatmeal water is also made in the same way (oatmeal, half an ounce, to one quart of water), and is ordered e-hiefly for rectal irri- gation in certain irritated conditions of the intestines. Rice-milk.—Wash two tablespoons of rice in cold water and soak in one pint of cold water half an hour; bring gradually to boiling- point and cook slowly until the rice is soft; strain and dilute with hot milk or cream; season with salt or sweeten with sugar, as preferred. Flaxseed-tea (Linseed-tea).—Wash one ounce of whole flaxseed and pour over it one quart of boiling water; simmer to half the quan- tity; strain and add the juice of one lemon and sugar to taste. Frequently ordered in inflammatory conditions of the kielney. As a soothing drink and mild expectorant in bronchial affections it is often ordered with the addition of a small quantity of licorice root (about two drams), cooked with the flaxseed. Without flavoring, flaxseed tea is also used as a rectal irrigation. Toast-water.—Toast two slices of bread crust and crumb to a dark brown; place in a deep dish and pour over it one quart of boiling water; cool and when cold, strain. Serve cold; flavor if desired with lemon-juice or serve with a slice of lemon. Toast-water is often effectual in relieving nausea. Ginger-tea.—Mix half a teaspoon of ginger in a tablespoonful of molasses, add a cup of boiling water, and allow to boil one minute. If preferred, half the quantity of water may be used and the amount made up with hot milk. Useful as a carminative in dyspeptic flat- ulence and to relieve abdominal cramps. Cocoa or Baker's Powdered Chocolate.—Mix a teaspoon of cocoa into a paste with a little cold water, add half a cup of boiling water, sufficient sugar to taste, and a very small pinch of salt; boil for one minute, stirring constantly; add, while still stirring, half a cup of scalded milk, and pour into a heated cup. A larger proportion of milk may be used if preferred, or a spoonful of whipped cream can be added. A few drops of essence of vanilla placed in the cup before the cocoa or chocolate is poured will give additional flavor. INDEX Abbe condenser, 363 Abbreviations, 309 A. B. and S. pills, 312 A. B. C. antiseptic douche, 132, 439 Abdomen, appearance of, as symptom, 181 dropsy of, paracentesis in, 515 many-tailed bandage of, 261 operations on, sterilization in, 150 Abdominal binder, 202 breathing, 172 restricted, 172 dressing, adhesive strapping of, 2S9 section, bowel movements after, 5(54 diet after, 562, 563 distention of intestine after, 565 drainage after, 563 hemorrhage after, 567. See also Hemorrhage after abdominal sec- tion. intestinal obstruction after, 565 position after, 562 postoperative care, 558 sepsis after, 569 shock after, 567 early, 567 tympanites after, 566 visitors after, 565 Abscess, 79, 416 Absorption of food, 743 Absorptive activity of stomach, deter- mining, 219 Accident wounds, cleansing, 637 Accidental rashes, 717 wounds, shock in, 636 treatment, 636 Accidents, 578 Acetanilid as antiseptic, 435 overdose of, treatment, 349 poisoning by, treatment, 349 Acetic acid in hemorrhage, 594 Acetone in urine, 244 test for, 244 Acid, boric, as antiseptic, 433 as ear douche, 135 as vaginal douche, 132 carbolic, as antiseptic, 431 color of urine from, 233 poisoning by, treatment, 339 definition of, 303 diacetic, in urine, 24 I test for, 244 dilute, dosage of, 309 from bacteria, 356 hippuric, in urine, 231 hydrocyanic, poisoning by, 341 muriatic, 311 nitric, poisoning by, 339 Acid, oxalic, poisoning bv, treatment, 339 phosphoric, in urine, 231 prussic, 312 salicylic, full doses, symptoms of, 352 in rheumatic fever, 409 stains for bacteria, 365 sulphuric, in urine, 231 poisoning by, 339 uric, in urine, 230 vegetable, 730 Acid-fast bacilli, Gram's stain for, 367 Ziehl-Neelson stain for, 366 Acidity of gastric juice, 229 Acidosis, diet in, 798 Acne rash, 717, 719 Aconite, overdose of, treatment, 34S poisoning by, treatment, 34S Acupressure in hemorrhage, 592 Acupuncture in external hemorrhage, 598 Acute anterior poliomyelitis, 697 Adhesive plaster, 111, 285 strapping, 285 in fracture of clavicle, 287 of ribs, 286 in sprains, 288 in ulcer of leg, 288 of abdominal dressing, 289 of ankle, 289 of wounds, 289 Adrenalin chlorid in epistaxis, 605 in hemorrhage, 594, 595 Adventitious sounds, 184 Aedes calopus, transmission of vellow fever by, 360 Aerobic bacteria, 355 Aerogenic bacteria, 356 Affusion, cold, 73 Agur-agar as culture-media, 371 Age, influence of, on dosage, 304 Agglutination of bacteria, 402 of typhoid bacillus, 368 Agglutinins, 402 Air, exposure to, in hemorrhage, 584 Air-bed, 40 Air-borne diseases, 387, 3S9 prophylaxis, 392 Air-hunger, 171 Air-pump, sterilization of, 458 Albumin in urine, 239 Esbach's albuminometer for esti- mating amount, 239 Heller's test for, 239 of meat, effect of cooking on, 74S Albuminoids, 727 effect of cooking on, 748 Albuminometer, Esbach's, 239, 240 St8 844 INDEX Albuminuria, 239. See also Albumir in urine. Albumin-water, 839 Alcohol as antiseptic, 434 dilute, for rubbing purposes, 434 in hemorrhage, 597 poisoning by, treatment, 348 time of administering, 307 Alcoholic drinks, 769 solution of bichlorid of mercury Harrington's, 438 Alcoholism, convulsions in, 665 Alexins, 402 Algid collapse, 152 Alkali, definition of, 303 Alkaline bath, 63 stupe, 97 urine, 232 Alkalis from bacteria, 356 Alkaloid, definition of, 303 of coca, poisoning by, treatment, 350 purtefactive, 374 Allen's starvation diet in diabetes, 794 carbohydrates in, 795 description, 794 fat in, 796 fasting in, 796 protein in, 796 Alum enema, 123 in hemorrhage, 594 Ameboid movements of leukocytes, 211 Ammonia, action of, 306 as vesicant, 109 carbonate as emetic in poisoning, 337 fumes, inhalation of, 330 Ammoniacal urine, 233 Amyl nitrite vapor, inhalation of, 330 Amylopsin, 741 Amyloses, 727 Anacidity, gastric, 219 Anaerobic bacteria, 355 Analgesic, definition of, 303 Analgesics, 688 Anasarca, 698 Anemia after hemorrhage, treatment, 598 color of skin in, 205 diet in, 800 dropsy in, 698 malignant, color of skin in, 205 pernicious, color of skin in, 205 Anesthesia, 321, 688 chloroform, 323 ether, 324, 554 closed method, 325 intratracheal, 326 open method, 326 primary, 328 profound, 328 semi-open method, 326 stages of, 328 surgical, 328 ethyl bromid, 329 chlorid, 329 examination before, 329 insufflation method, 326 local, 329 nitrous oxid, 322 oxid-oxvgen, 322 spinal, 330 Anesthetic, definition of, 303 Anesthetist's table, 527 Aneurysm needle, 456 Angular splint, 274 anterior, 275 internal, 274 Anhydrotics, 70S Animal, bite of, 657 rabid, bite of, 657 starch, 727 Animals, heat-stroke in, 685 Ankle, adhesive strapping of, 289 Ankylosis from fracture, 613 Ankylostomum duodenale, 361 Anodyne, 688 definition of, 303 Hoffman's, 311 plaster, 110, 111 Anopheles, transmission of malaria bv, 360 Antepartum hemorrhage, 606 Anthelmintic, definition of, 303 Anthrax bacillus 382 spore formation in, 360 Antidote, 335 chemical, 335 common salt as, 436 dosage of, 306 physiologic, 336 Antifebrin, overdose of, treatment, 349 poisoning by, treatment, 349 Antihydrotic, definition of, 303 Antimeningococcus serum, 381 Antimony, wine of, 312 Antiphlogistine, 112 Antipyretic, 153 definition of, 303 Antipyrin, overdose of, treatment, 349 poisoning by, treatment, 349 Antisepsis, 418 theory of, 376 Antiseptics, 419, 430 A. B. C. douche, 132, 439 acetanilid, 435 alcohol, 434 argyrol, 436 B. B. C. powder, 436 bichlorid of mercury, 430 blue stone, 436 boric acid, 433 carbolic acid, 431 chlorin, 437 chlorinated lime, 437 soda, 438 copper sulphate, 436 corrosive sublimate, 430 creolin, 433 formaldehyd, 438 formalin, 438 Harrington's alcoholic solution of bi- chlorid of mercury, 438 hydrargyrum chloridum corrosivum, 430 hydrogen peroxid, 433 iodin, tincture of, 435 iodoform, 435 lunar caustic, 436 lysol, 433 milk of lime, 437 normal salt solution, 436 permanganate of potash, 434 phenol, 431 precautions in using, 439 protargol, 436 salt solution, normal, 436 silver nitrate, 436 INDEX 845 Antiseptics, Thiersch's solution, 439 whitewash, 437 Antistreptococcus serum, 401 Antitoxin, 400 diphtheria, 401 immunity unit, 401 measurement of, 401 serums, injection of, 509 technic of producing, 401 tetanus, 401, 418 in tetanus, 647 prophylactic injection of, 647 Anuria, 234 Anus, 113 Aperient, definition of, 303 Apomorphin [as emetic in poisoning, 337 Apothecaries' fluid, 293 measures, 292 changing of, to metric, 300 measuring solutions by, 445 weight, 292 equivalent in metric system, 299 Appendix, 836 Apple-gruel, 840 Applicators, vaginal, 197 Aquae, dosage of, 308 Argvrol as antiseptic, 436 Arm bath, 57, 58 four-cornered bandage for, 264 handkerchief bandage of, 266 sling for support of, 266 support of, by hand, 250 three-cornered bandage for, 264 upper, fracture of, treatment, imme- diate, 618 Arms, patient's, position of, on operat- ing-table, 537 Arnold sterilizer, 424 Aromatic substances in urine, 231 Arranging patient in bed, 47 Arrow-root, 839 Arterial hemorrhage, 580 tension, 161 Arteries, common carotid, taking of pulse at, 160 Arteriosclerosis, 1"1 Artery, brachial, digital compression of, 584 facial, compression of, 589 taking of pulse at, 160 femoral, digital compression of, 588 taking pulse at, 160 radial, compression of, at wrist, 586 taking pulse at, 160 subclavian, compression of, 587 temporal, pressure of, 588 taking of pulse at, 160 ulnar, compression of, at wrist, 587 Artificial respiration, 676. See also Respiration, artificial. Asafetida enema, 123 compound, 123 in intestinal distention after abdomi- nal section, 566 plaster. 111 Ascites, 698 paracentesis in, 515 Asepsis, 421 Ash, 734 Asparagus, odor of urine from, 233 Asphyxia, 676 artificial respiration in, 676 Asphyxia caused by drowning, artificial respiration in, 678 causes of, 676 of newborn, 680 artificial respiration in, 680 Byrd's method, 681 Schultze's method, 680 white, of newborn, 682 Aspiration, 516 of chest wall, 521 of pericardium, 521 of peritoneal cavity, 517-519 of pleura, 520, 521 Aspirator, 517 Asthma, inhalation of saltpeter for, 330 Astringent, definition of, 303 enema, 124 enteroclysis, 127 in hemorrhage, 594 Atrophy, 208 Atropin, effect of, on eye, 200 in hemorrhage, 597 in pain after eye operations, 571 in poisoning by opium, 351 in respiratory failure in ether anes- thesia, 329 in shock, 579 after abdominal section, 567 Attenuated virus, inoculation with, 399 Atwater's estimation of caloric value of food, 735 Aura, 665 Auscultation, 184 Autoclave, 425, 426 Autogenous vaccines, 406 Auto-infusion in hemorrhage, 597 Avoirdupois weight, 293 equivalent in metric system, 299 Axilla, glands of, operations on, steriliza- tion in, 451 taking temperature in, 159 Bacillus, 356, 357, 358, 382 acid-fast, Gram's stain for, 367 Ziehl-Neelson stain for, 366 aerogenes capsulatus, 360, 418 anthracis, 382 spore formation in, 360 coli, 383 colon typhoid group, 383 comma, 386 diphtherias, 382 drumstick, 356, 358 dysenteriae, 383 fusiformis, 383 gas, 360, 418 hay, 359 influenza, 384 Klebs-Loffler, 358, 382 leprae, 385 Ziehl-Neelson stain for, 366 of Pfeiffer, 384 paratyphosus A and B, 383 potato, 359 pyocyaneus, 384 wound infection by, 642 spindle-shaped, 358 spore of, 358, 359 tetani, 385 in surgery, 417 spore formation in, 360 tubercle, 359 846 INDEX Bacillus tubercle, Ziehl-Noelson stain for, 366 tuberculosis, 3S5 typhoid, 359. 383, 38,4 agglutination of, 384 Widal reaction of, 367, 384 Back, care of, 35 splint, 273 Bacteria, 353, 354, 355 acids from, 356 aerobic, 355 aerogenic, 356 agglutination, 402 alkalis from, 357 anaerobic, 355 avenues of entrance, 373 chromogenie, 356 classification, 353 by characteristics, 356 by shape, 357 culture of, 368 instruments for making, 370 culture-media for, 368 examination of, 362 facultative, 355 fission of, 356, 359 food of, 355 hanging-drop method of examining, 367 in blood, obtaining of, for culture pur- poses, 504 in epithelium, 388 in feces, 229 in typhoid fever, 229 in lungs, 388 in mouth, 388 in nose, 388 in secretions, 388 in surgery, 415 in throat, 388 Koch's postulates for, 376, 378 modes of transmission, 387 morphology, 357 motility of, 359 non-pathogenic, 355 obligate, 355 oscillating movements, 359 pathogenic, 355 action of, 407 description of, 379 photogenic, 356 plating, 369 preparation of specimens for examina- tion, 364 pyogenic, 415 incubation period, 416 reproduction of, 359 vegetative, 359 smear-culture, 364 staining of, 364 precautions, 365 strict, 355 temperature favorable to growth, 356 transmission of, modes, 387 zymogenic, 356 Bacterial casts in urine, 236 toxins, kinds of, 374 Bacteriology, 353 surgical, 475 Bacteriolysis, 402 Bag, bran, 88 hot-water, 86 ice-, S3 Bag, Pulitzer's, 204 salt, SS Baker's powdered chocolate, S12 Baking, sterilization by, 123 Ball syringe, 115 Balsam, Friar's, 312 Bandage, 24S Barton's, 256 capeline, 257 crinolin, 2IS, 249 Esmarch rubber, 249 figure-of-8, 252 of both shoulders, 252 of breast, 257 of eve, 255, 256 of foot, 253 of hand, 254 of instep, 253 of jaw, 256 of nape of neck, 257 posterior, 252 lour-tailed, 260 of arm, 264 of jaw, 260 gauze, 249 handkerchief, 263 of arms, 265 of chest, 265 of foot, 265 of hand, 265 of head, 264 of hip, 265 of perineum and hip, 264 of shoulder, 265 of stump, 265 to prevent motion of arm, 26 many-tailed, 260 of abdomen, 261 of eye, 255 of fingers, 25 I of head, 257 recurrent, 258 of heel, 254 of jaw, 25ei of stump, 255 recurrent, 255 plaster-of-Paris, 266 interrupted, 267, 2(58 opening in, 267 technique of applying, 266 reverse spiral, 251 of lower extremity, 251 of upper extremity, 251 roller, 248 machine to roll, 249 rules for, 250 rubber, Esmarch, 249 Scultetus, 260 silicon, 270 spica, of groin, 253 of instep, 253 of pelvis, 253 of shoulder, 252, 253 of thumb, 254 spiral, reversed, 251 of lower extremity, 251 of upper extremity, 251 simple, 251 starch, 269 stiff, 266 T-, 259 three-cornered, for arm, 264 tortuous, 254 INDEX 847 Bandage, triangular, 263 Velpeau's, 258 water-glass, 270 wax, 270 Y-, 263, 264 Bandaging, 248 rests in, 249 position for, 249 rules for, 250 Baner's formula for modification of milk, 758 Barley-gruel, 839 dextrinized, 840 Barley-jelly, 840 Barley-meal, 765 Barley-water, 841 as infant food, 762 enteroclysis, 127 Barton's bandage, 256 Base, definition of, 303 Basham's mixture, 311 Basins in operating-room, 530 Bath, 50 alkaline, 63 arm, 57, 58 bed-, 28 bran, 63 Brandt, 158 symptoms of injurious effect, 60 cold, 50, 58 in nervous diseases, 62 in typhoid fever, 5S cyanosis and shivering after, 61 hemorrhage and perforation during, 62 symptoms of injurious effect, 60 constant immersion, 56, 57 foot-, hot, 56 hemorrhage and perforation during, 62 hot, 50 foot-, 56 for cleansing purposes, 52 sitz-, 55 to induce perspiration, 53 to relieve convulsions, 55 hot-air, 68 leg, 57, 58 local, 57 medicated, 63 mustard, 63 rules for, 51 salt-water, 62 sitz-, hot, 55 starch, 63 stimulating, 63 sulphur, 63 sweat-, 66 pilocarpin in conjunction with, 67 tank, 56 tub-, cold, 58. See also Cold bath. hot, 50. See also Hot bath. in bed, 64 medicated, 63 turpentine, 64 Bath-room, temperature of, 51 B. B. C. powder, 436 Bed, 17 air-, 40 arranging patient in, 47 ether, 555 preparation of, for collapse, 556 Bed, lifting patient from, 46 in, 45 making of, 21 medical, changing of, 23 raising patient to sitting posture in, 46 returning patient to, 47 surgical, changing of, 24, 25 top sheet of, turning, without expos- ing patient, 26 tub-bath in, 64 turning patient in, 45 ward, cleaning of, 832 water-, 40 method of placing patient on, 40 Bed-bath, 28 Bed-clothes, 20 picking at, 182 Bedding, ward, cleaning of, S32 Bed-making, 17, 21 Bed-pan, care of, 41 covering of, 41 method of giving, 40 Perfection, 41 varieties of, 41 washing of, 41 Bed-rest, 47 Bed-sores, 35 prevention of, 35 treatment of, 35 Bedsteads, wooden, 18 Beef-juice, 765, 772 as infant food, 762 Beef-tea, 765, 841 Belladonna and glycerin stupe, 96 overdose of, treatment, 349 plaster, 111 poisoning by, treatment, 349 Benedict's test for glycosuria, 242 Beverages, 767 recipes for, 841 starchy, 769 Bichlorid of mercviry as antiseptic, 430 as vaginal douche, 132 stain on linen, removal, SIT tablets, 431 Bile, 741 color of urine from, 232 in urine, 244 Bile-ducts, obstruction of, diet in, 78!) Bilious vomiting, 217 Binder, 261 abdominal, 262 breast-, 262 V-shaped, 263, 264 Bismuth subnitrate in. vomiting after operations, 7ti2 Bite of animal, 657 of rabid animal, 657 snake-, 658 Black stools, 227 wash, 312 Bladder, condition of, after operations, 559 examination of, 19S infection of, in catheterization, 143, 144 irrigation, 143 Blanc-mange, 755 Bland enema, 124 enteroclysis, 127 • Blankets, 21 ward, 818 Blaud's pill-, 312 848 INDEX Blebs, 206 in syphilis, 716 Bleeder's disease, 610 Blind boil, 660 Blister, 107, 206 fever-, 717 flving, 109 Blistering fluid, 107 Blood, altered, in vomitus, 217 bacteria in, obtaining of, for culture purposes, 504 casts in urine, 236 color of urine from, 232 culture, 213, 504 examination of, 208 fresh, in vomitus, 217 in stools, 225 in urine, 236, 240 %in vomitus, 217 transfusion of, 506. See also Trans- fusion. Blood-agar as culture-media, 372 Blood-corpuscles, counting, 209 red, 200 white, 210 Blood-count, 209 Blood-poisoning, 416 Blood-pressure, estimation of, 162, 163 Blood-red urine, 232 Blood-serum, Loffler's, as culture-media, 372 Blood-smear, 212 Blood-stains on linen, removal, 816 on scrubbed wood, removal, 829 Bloody sputum, 221 Blue pills, 312 pus, 642 stone, 312 as antiseptic, 436 stools, 227 Blueness of skin, 204 Boards, fracture, 284 Boas' test-meal, 218 Bodily strength as symptom, 180 Body, condition of, as symptom, 180 Boil, 416, 660 blind, 660 Boiling, disinfection of excreta by, 444 sterilization by, 423 urine, 238 Boldt's operating-table, 525 Bomb calorimeter, 734 Bond's splint, 276 Bony union in fractures, 616 Boric acid as antiseptic, 433 as ear douche, 135 in pain after eye operations, 671 vaginal douche, 132 Bottger's test for glycosuria, 243 Bottles, hot-water, 88 label on, reading, 314 nursing, care of, 761 Bougie, esophageal, 675 rubber, sterilization of, 462 silk, sterilization of, 462 Bouillon, nutrient, as culture-media, 371 Bowels, hemorrhage from, 226, 600. See also Enterorrhagia. movements after abdominal section, 564 Box-splint, 274 Brachial artery, digital compression of, 584 Bradford frame, 282, 283 Bradycardia, 165 Brain, concussion of, 683 operations on, sterilization in, 451 Bran bag, 88 bath, 63 Brandt bath, 58 cyanosis and shivering after, 61 hemorrhage and perforation during, 62 symptoms of injurious effect, 60 Brandy enema, 122 Branny desquamation, 713 Brass, cleaning of, 832 Brawny swellings, 207 Bread poultice, 93 Breaking down of tissue, 207 Breast, figure-of-8 bandage of, 257 operations on, sterilization in, 451 Y-shaped binder, 263 Breast-binder, 262 Breath, odor of, as symptom, 181 Breathing, 167. See also Respiration. Bricks, hot, 88 Bromids, full doses, symptoms of, 352 in vomiting after operations, 561 Bromism, 352 Bronchial rales, 185 Bronzing of skin, 205 Broths, meat, 765 Brown mixture, 311 Brushes, hand-, sterilization of, 477 Bubbling rales, 185 Bubonic plague, infection by, 390 Buck's extension apparatus, 280 Burns, 648 by electricity, 656 treatment, 657 by lightning, 656 carron oil in, 649, 652 complications of, 653 dressings for, 652 embolism in, 654 erysipelas in, 654 immersion treatment, 651 nephritis in, 643, 655 of eye, treatment, 651 of first degree, treatment, immediate local, 649 of second degree, treatment, imme- diate local, 650 of third degree, treatment, immediate local, 650 of throat, treatment, 651 open treatment, 650 picric acid in, 653 protection in dressing of, 489 scar tissue from, 653 scarlet fever in, 655 shock in, 654 treatment of, immediate local, 649 immersion, 651 open, 650 physical, 653 vaselin in, 652 Buttermilk, 753, 838 Byrd's method of artificial respiration, 838 Cabinet arranged for giving sweat- bath, 70 Calcium chlorid in enterorrhagia, 601 INDEX 849 Calcium chlorid in hemorrhage, 595 oxalate in urine, diet for, 793 Calculus, urinary, 231 Callus, 616 provisional, 616 Calomel, 311 Caloric value of food, 733 Calories, 735 in diet, 735 Calorimeter, bomb, 734 Camphor in shock, 579 after abdominal section, 567 Cane-sugar, effect of cooking on, 749 Cannulas, sterilization of, 457 Cantharidal cerate as vesicant, 108 collodion, 108 ointment as vesicant, 108 Cantharides, 107 plaster, 108 Capacity of baby's stomach, 762 Capeline bandage, 257 Capillary hemorrhage, 581 pulse, 166 Capsicum plaster, 111 Capsules, 303 Carbohydrates, 726, 727 diet of, 773 digestion of, 740 effect of cooking on, 748 in Allen's starvation diet, 795 Carbol-fuchsin solution, Ziehl's, 366 Carbolic acid as antiseptic, 431 color of urine from, 233 poisoning, treatment, 339 Carbon dioxid, 725 Carbonate of ammonia as emetic in poisoning, 337 Carbonated waters, 767 Carbuncle, 416, 661 Card system in giving medicines, 315 Cardiac embolism, 644 Carminative, definition of, 303 enema, 123 Carotid arteries, common, taking of pulse at, 160 Carphology, 182, 689 Carrel method for treatment of infected wounds, 490 apparatus for, 491 local treatment, 490 microscopical examination in, 496 procedures, 490 solution for, 495, 496 technic, 496 Carron oil, 312 in burns, 649, 652 Carrying patient in operation in private house, 549 on stretcher, 47 Casein, 752, 756 Caseinogen, 752 Castor-oil enema, 123 Casts, bacterial, in urine, 236 blood, in urine, 236 epithelial, in urine, 236 fatty, in urine, 236 granular, in urine, 236 hyaline, in urine, 235 in urine, 235 oily, in urine, 236 pus, in urine, 236 waxy, in urine, 235 54 Catalepsy, 692 Cataplasm, 89 Catgut, 467 chromicized, 470 cumol, 471 formalin, 469 iodized, 469, 472 plain, sterilization of, 468 sterilization of, 467 Catharsis before emergency operations, 552 operation, 551 Cathartic, definition of, 304 time of administering, 308 Catheter, 140 double, 144 eustachian, 203 filiform, sterilization of, 462 glass, 140 sterilization of, 462 guarded, 145 metal, sterilization of, 462 rubber, 140 sterilization of, 461 silver, sterilization of, 457 Catheterization, 140 after operations, 559 cystitis in, 144 in male, 145 infection of bladder in, 143, 144 of ureters, 198 position of patient, 141 Caustics, 109 Cauterization, 105 sterilization in, 453 Cautery, actual, as counterirritant, 105 in hemorrhage, 593 Paquelin, 105 in operations, 539 sterilization of, 457 Cavities, illumination of, 199 packing of, 488 Cellulitis, 642 Cellulose, 727 Centigrade thermometer, 158 converting to Fahrenheit scale, 158 Centimeter, 297 abbreviation for, 299 cubic, abbreviation for, 299 Ce tral vomiting, 699 Centrifuge, 235 Cereals, 764 cooking of, 749 Cerebral concussion, 683 embolism, 644 hemorrhage, 609 shock, 683 Cerium oxalate in vomiting after opera- tions, 561 Cervix dilators, 197 operations on, sterilization in, 451 Cestodes, 361 Chafing, 719 Charcoal poultice, 93 Charts, 174, 811 clinical, 174 special, 176 temperature, 174 in intermittent malaria, 156 of lobar pneumonia, 155 of typhoid fever, 156 Chemical antidote, 335 composition of food, 724 SoO INDEX Chemical composition of milk, 751 compound, definition. 303 disinfection of excreta, 444 examination of urine, 236 sterilization, 429 Chemotaxis, negative, 356 positive, 356 Chest, diminished expansion of, 172 examination of, 186 in children, 186 handkerchief bandage of, 265 wall, aspiration of, 521 Cheyne-Stokes' respiration, 171 Chicken-pox, nursing in, 413 rash in, 713 Chicken-tea, 765, 841 Childbirth, hemorrhage connected with, 606 Chill, 704 China, sterilization of, 463 Chloral, overdose of, treatment, 349 poisoning by, treatment, 349 Chlorin as antiseptic, 437 disinfection of room, 442 in urine, 231 Chlorinated lime as antiseptic, 437 soda as antiseptic, 438 Chloroform anesthesia, 323 as vesicant, 109 inhaler, Esmarch's, 322 Chlorophyl, 354 Chlorosis, color of skin in, 205 Chocolate, 769 Baker's powdered, 842 Cholagogue, definition of, 304 Cholera spirillum, 386 Chromicized catgut, 470 Chromogenic bacteria, 356 Chyle in urine, 242 Chyluria, 242, 244 Chyme, 740 Cinchonism, 352 Clabber, 837 Clavicle, fracture of, adhesive strap- ping in, 287 Sayre's dressing in, 2S7, 288 treatment, 623 immediate, 619 Clean nurse, 479. See also Sterile ninse. Cleaning and dusting of ward, 803 Cleansing accidental wounds, 637 bath, 52 patient before operation, 553 Clinical charts, 174 thermometer, 158 Clonic convulsion, 663 Closet for instruments, 45S Clothes, bed-, 20 Clothing, removal of, in fracture, 621 Cloudv urine, 237 Clove-hitch knot, 291 Clover inhaler, 324 Clyster, 113. See also Enema. Coaptation splinting, Gooch's, 280 Cocain hydrochlorid in vomiting after operations, 561 poisoning by, treatment, 350 hypodermic injection of, as local anesthetic, 317 Cocci, 356, 358, 379 Cocoa, 769, 842 Coddled egg, 838 Coffee, 768 Coffee enema, 121 stains on linen, removal, SI 7 Coffee-ground vomitus, 217 Coils, ice-, 84 Leiter's, 84 Coin-catcher, 674, 675 Cold affusion, 73 applications, 71, 81 bath, 50, 5S in nervous diseases, 62 in typhoid fever, 58 cyanosis and shivering after, ' 61 hemorrhage and perforation during, 62 symptoms of injurious effect, 60 dry, application of, S3 exposure to, 659 in expietaxis, 604 in fractures, 621 in hemorrhage, 594 in inflammation, 79 in subcutaneous hemorrhage, 599 moist, application of, SI pack, 75 sore, 717 sponge, 71 water in hemorrhage, 594 Cold-water coils, 84 Collagen, 467 Collapse, 152, 154, 578 algid, 152 dosage in, 306 preparation of ether bed for, 556 Colles' fracture, treatment, 622 Collodion, cantharidal, 107 dressing, 489 styptic, in hemorrhage, 59 I Colon bacillus, 383 flushing of, 128 typhoid group of bacilli, 383 Colony, 370 Coma, 691 diabetic, 691 glucose injection in, 501 vigil, 691 Combustion, 725, 733 Comma bacillus, 386 spirilla, 359 Comminuted fractures, 614 Common carotid arteries, taking of pulse at, 160 Complement-fixation test, 381 Compound asafetida enema, 123 purgative enema, 123 Compress,'hot, 97 ice, 81 Compressible pulse, 163 Compression in hemorrhage, 584. Sec also Pressure. Concealed hemorrhage, 581, 599, CilM) Concussion, cerebral, 683 Condenser, Abbe, 363 Condiments, 730 Cone, ether, 325, 326 Constipation, 702 acute, 702 chronic, 702 diet in, 789 consistence of stools in, 224 massage in, 703 symptoms of, physical, 702 INDEX 851 Constipation, treatment of, 702 Contagious diseases, 374 Continued fever, 710 Continuous fever, 155 rectal infusion, 128 Contused wound, treatment, 640 Contusion, 635 Convalescence in fever, 710 Convulsions, 182, 663 clonic, 663 continuous, 663 epileptiform, 663 general, 663 hot bath to relieve, 55 in alcoholism, 665 treatment, 666 in children, 668 in epilepsy, 665 in hysteria, 670 in spinal meningitis, 669 in strychnin-poisoning, 669 in tetanus, 664, 669 in tetany, 663, 664, 667, 670 in uremia, 665 treatment, 667 intermittent, 663 lo'cal, 663 tetanic, 663, 664 tonic, 663 treatment, 664 Cooking, 723, 746 effect of, on carbohydrates, 748 on fats, 749 on proteins, 748 of cereals, 749 of vegetables, 749 Copper, cleaning of, 830 sulphate as antiseptic, 436 test for glycosuria, 242 Corn, ground, poultice of, 93 Corpuscles, blood-, counting of, 2e)9 Corrigan's pulse, 166 Corrosive poisons, 337, 33S table of, 336 sublimate as disinfectant, 430 Corrosives, poisoning by, 338 convalescence from, 339 symptoms, 338 treatment, 338 Coryza, salt-free diet in, 793 Cotton jacket, 88 mattress, 18 styptic, in hemorrhage, 594 Counterirritants, 98 Counterirritation in inflammation, 80 Counting sponges in operations, 539 Cover-glass, 364 Cowpox, infection by, 390 Cracker-gruel, 839 Cracking rales, 185 Cradle, Sauter's, 285 Cradles, 285 ice-, 74 Cream, 752 of tartar, 311 Creatinin in urine, 231 Creolin as antiseptic, 433 Crepitant rales, 185 Crinolin bandages, 248, 249 Crisis, 154, 397 of fever, 710 unusual, 182 Crockery, kitchen, cleaning of, 830 Croton oil as vesicant, 109 Croup kettle, 69, 331 tent, 331 Crowing respiration, 171 Crude drug, mixing solutions from, 446 Crusts, 713 Crutches on operating-table, 526 Crystalline lens, 200 Crystals in urine, 236 Cube, definition of, 297 Cubic centimeter, abbreviation for, 299 Culture, blood-, 213, 504 from sterilized articles, 477 of bacteria, 368 instruments for making, 370 pure, 370 smear-, 364 taking of, 372 Culture-media, 368 agar-agar, 371 blood-agar as, 372 Loffler's blood-serum, 372 milk, 372 nutrient bouillon, 371 raw potato, 372 sugar as, 372 Cumol catgut, 471 Cupboards in operating-room, 529 Cupful, apothecaries' equivalent, 296 Cupping, dry, 99 wet, 100 sterilization in, 453 Cups, sputum-, 222 Curds of milk, 753 Cutaneous emphysema, 208 Cyanosis, 173, 204 after Brandt bath. 61 Cycle, Koch's, 376-378 Cystitis from catheterization, 144 Cysts, 361 hydatid, 361 Dakin's solution, 312 for treatment of infected wounds, 495, 496 Daturin, poisoning by, treatment, 351 Death-rattle, 184 Decay, 355 Deep respiration, 170 Deliriants, 690 Delirium, 689 low muttering, 689 tremens, 690 wild, 689 Delusion, 690 Density of urine, 231 Deodorants, 429 Depressed fractures, 614 Desquamation, 713 branny, 713 flaky, 713 Dessertspoon, apothecaries' equivalent, 296 Dextrin, 727 Dextrinized barley-gruel, 840 flour with buttermilk, 840 Dextrose, 728, 740, 749 in urine, 242. See also Glycosuria. Diabetes mellitus, diet in, 794 Allen's starvation, 794 patent flours for, 797 852 INDEX Diabetic coma, 691 glucose in 501 Diacetic acid in urine, 244 test for, 244 Diachylon plaster, 111 Diaphoresis, 154, 706 Diaphoretic, definition of, 304 Diaphoretics, 707 Diaphysis, fracture at, 612 Diarrhea, 703 acute, 703 diet in, 786 chronic, 704 consistence of stools in, 224 in infancy, 704 diet in, 786 symptoms of, physical, 704 treatment of, 704 Diazo-reaction, Ehrlich's, in typhoid fever, 245 Dicrotic pulse, 166 Diet, 770 after abdominal section, 562, 563 before operation 552 by prescription, 737 calories in, 735 carbohydrates, 773 dry, in dilated stomach, 792 eggs, 772 fat, 774 fish, 773 for testing kidney function, 791 general division of, 770 high caloric, 736 in acidosis, 798 in acute diarrhea, 786 digestive disorders, 782 dysentery, 786 gastric disorders, 782 intestinal disorders, 782 in anemia, 800 in chronic constipation, 789 digestive disorders, 787 gastric disorders, 782, 785, 787 intestinal disorders, 782, 787 in constipation, 789 in diabetes mellitus, 794 in diarrhea, 786 in infancy, 786 in diseases, 775 of intestines, 781 of stomach, 781 in dropsy, 793 in duodenal ulcer, 782 in dysentery, 786 in fevers, 776 in gastric disorders, 781 ulcer, 782 in inflammation of kidneys, 790 in intestinal disorders, 781 in nephritis, 790 in obstruction of bile-ducts, 789 in oxaluria, 793 in phthisis, 798 in rickets, 800 in scurvy, 798 in tuberculosis, 798 in typhoid fever, 777 kitchen, 737 Lenhartz, in gastric ulcer, 782 liquid, 770 low caloric, 737 meat, 772 Diet, milk, feces of, 224 points for, 774 salt-free, in epilepsy, 793 Sippy, in gastric ulcer, 782, 785 vegetable, 773 Dietetics, importance of knowledge of, 737 Dieting, 770 Dietitians for hospitals, 737 Diet-sheets, ward, 811 Digestibility of food, 739 Digestion, 739 conditions disturbing, 744 mechanical aids to, 742 of carbohydrates, 740 of fats, 740 of proteins, 740 time for, 744 Digestive disorders, acute, diet in, 782 chronic, diet in, 787 juices, 740 stimulation of, 742 Digestives, time of administering, 307 Digital pressure in hemorrhage, 589 of brachial artery, 584 of femoral artery, 588 Digitalin, hypodermic injection, 319 Digitaline, hypodermic injection, 319 Digitalis in hemorrhage, 597 in shock after abdominal section, 567 overdose of, treatment, 350 poisoning by, treatment, 350 poultice, 94 stupe, 97 Dilatation of stomach, dry diet in, 792 Dilators, cervix, 197 Diphtheria antitoxin, 401 bacillus, 382 nursing in, 410 Diplococci, 356, 357, 358, 380 intracellularis meningitidis, 381 pneumoniae, 380 Disease, gradual onset, 155 sudden onset, 155 Disinfectants, 430. See also Antiseptics. Disinfection, chemical, of excreta, 444 of excreta, 442 by boiling, 444 in country districts, 444 of feces, 444 of linen, 817 of room, 440 chlorin, 442 formaldehyd for, 440 preparation for, 442 sulphur, 441 of vessel containing infectious stool, 444 Dislocation, 631 closed, 631 complicated, 631 compound, 631, 632 of finger, treatment, 633 of lower jaw, treatment, 633 open, 631 reduction of, 631 simple, 631 symptoms of, 631 varieties, 631 Distention of intestine after abdominal sections, 565 Diuresis, 154, 233 Diuretic, 233 INDEX 853 Diuretic, definition of, 304 Domestic work, ward, 813 Dorsal position, 189 recumbent position, 189 Dosage, 304 in children, 304 in collapse, 306 in shock, 306 influence of age on, 304 of fasting on, 305 of idiosyncrasy on, 305 of individuality on, 305 of pain on, 306 of race on, 305 of sex on, 305 of antidote drug, 306 of aquae, 308 of dilute acids, 309 of fluidextracts, 308 of infusions, 308 of mixtures, 309 of spirits, 308 of syrups, 308 of tinctures, 308 Young's rule, 304 Doses, fractional, 295 Double catheter, 144 inclined plane, 280 Douche, 130 A. B. C. antiseptic, 132, 439 ear, 135 boric acid, 135 eye, 136 of infant, 138 intra-uterine, 132 nasal, 134 vaginal, 130 bichlorid of mercury, 132 boric acid, 132 position of patient in, 131 Dover's powder, 311 Down pillow, 19 Drainage after abdominal section, 563 of incised wound, 639 Dram, abbreviation for, 293 Draw-sheets, 20, 21 Dress, patient's, in operating-room, 532 Dressings, application of, 488 collodion, 489 for burns, 652 sterilization of, 474 surgical, 486 Drink, imperial, 841 Drop, 294 'Droplet infection, 388 Dropsy, 207, 697 diet in, 793 in anemia, 698 in heart disease, 698 in nephritis, 697 of abdomen, paracentesis in, 515 overdosing in, 306 treatment of, 698 Drowning, artificial respiration in, 678 Drugs, accumulation of, in system, 306 acting locally on stomach, time to ad- minister, 307 _ , action of, circumstances modifying, 305 administration of, 313 by fumigation, 334 by inhalation, 321 for stimulation, 330 Drugs, administration of, by inunction, 333 by mouth, 313 by rectum, 315 hypodermic, 315. See also Hypo- dermic injection. classification of, 300-302 crude, mixing solutions from, 446 dosage of, 304. See also Dosage. for hypodermic injection, 317 fractional doses of, 295 injury to teeth from, 314 irritating, time of administering, 308 names of, 300-302 odor of urine from, 233 physiologic limit, 335 time of administration, 307 required for effect, 306 tolerance to, 306 volatile, action of, 306 with specific action in infectious dis- eases, 409 Drumstick bacilli, 352, 354 Dry cold, application of, 83 cupping, 99 diet, 792 gangrene, 644 heat, application of, 86 sterilization by, 423 rales, 185 Duodenal ulcer, diet in, 782 Dupuytren's splint, 278 Dusting and cleaning of ward, 803 ward, 826 Dusting-powders, sterilization of, 472 Dysentery, acute, diet in, 786 bacillus, 383 Dyspnea, 170 Ear douche, 135 boric acid, 135 examination of, 201 foreign bodies in, removal of, 672 hemorrhage from, 606 operation on, sterilization in, 452 Ear-drum, 201 Earth-worm, 362 in stools, 228 Ecbolic, definition of,, 304 Ecchymosis, 207, 599 Eclampsia, 668 Ecstasy, 692 Eczema, papular, 719 pustulous, 719 rash in, 719 salt-free diet in, 793 squamous, 719 Edema, 207, 697 Eggnog, 839 with coffee, tea, or cocoa, 839 Eggs, 763 coddled, 838 diet of, 772 hard-boiled, 838 poached, 838 recipes for, 838 scrambled, 838 shirred, 838 soft-boiled, 838 Ehrlich's diazo-reaction in typhoid fever, 245 theory of immunity, 403 S54 INDEX Elbow, forced flexion of, 585 Electricity, burns by, 656 treatment, 657 in shock, 579 Element, definition of, 303 Elephantiasis, 208, 361 Elixir iron, quinin, and strychnin, 311 Embolism, 644 cardiac, 645 cerebral, 645 in burns, 655 pulmonary, 645 traumatic, 645 Embolus, 645 Emergencies, 57S Emergency operations, catharsis before, 552 duties of nurse in, 539 table, 528 Emesis, 698 Emetic, definition of, 304 Emetics, 698 in poisoning, 336 Emmenagogue, definition of, 304 Emollient enema, 124 Emphysema, cutaneous, 20s Emplastrum, 110 Enamel ironware, cleaning of, S23 Enamelware, sterilization of, 463 Endotoxins, 374 Enema, 113 alum, 113 asafetida, 123 compound, 123 astringent, 124 avoidance of injecting air, 115 bland, 124 brandy, 122 carminative, 121 castor-oil, 123 coffee, 121 compound asafetida, 123 purgative, 123 emollient, 124 gelatin, 123 glycerin, 124 high, 117 in infant, 118 low, 117 medicated, 122 purgative, 122 nutritive, 120 oil, 122 position of patient, 1 Hi quantity given by, 118 quassia, 124 rectal tubes for, 114 salt solution, 119, 121 salts, 122 simple, 119 soapsuds, 119 starch, 124 stimulating, 121 temperature of, 118 turpentine, 123 whisky, 122 Energy, 727, 728, 733 potential, of food, 735 Enteroclysis, 125 astringent, 125 barley-water, 127 bland, 127 flaxseed, 127 Enteroclysis, gruels, 127 nitrate of silver, 127 salt solution, 126 tannic acid, 127 Enterorrhagia, 600 calcium chlorid in, 601 ergot in, 601 from hemorrhoids, treatment, 602 gelatin in, 601 hypodermoclysis in, 601 morphin in, 601 salt solution in, 001 symptoms of, tSOl tarry stools after, 601 treatment of, 6t)l Enzymes, 740 Eosinophiles, 211 Epilepsy, convulsions in, 665 salt-free diet in, 794 Epileptiform convulsions, 663 Epiphysis, fracture at, 612 Epispastic, 98, 107 definition of, 304 Epistaxis, 603 adrenalin chlorid in, t>05 cold in, 605 in purpura, 290 in scurvy, 605 iron in, 606 plugging nares in, t>06 tannic acid in, 606 Epithelial casts in urine, 236 Epithelium, bacteria in, 3S,s Epsom salts, 312 Ergot in enterorrhagia, 601 in hemorrhage, 595 in postpartum hemorrhage, 607 Ergotin in hemorrhage, 595 in postpartum hemorrhage, 607 Eruptive fevers, 713 Erysipelas from wounds, 646 idiopathic, 646 in burns, 655 nursing in, 414 rash in, 716 traumatic, 647 Erythema, 205 intertrigo, 719 nodosum, 718 simplex, 718 Erythematous rash, 205, 717 Erythrocytes, 210 Esbach's albuminometer, 239, 240 Escharotics, 98, 109 Eserin in intestinal distention after ab- dominal section, 566 Esmarch bandage, rubber, 249 chloroform inhaler, 322 Esophageal bougie, 675 forceps, 675 Esophagus, foreign bodies in, 674 Ether anesthesia, 324 closed method, 325 intratracheal, 326 open method, 326 primary, 326 profound, 328 semi-open method, 326 stages, 326 surgical, 328 bed, 555 preparation of, for collapse, 556 cone, 324, 326 INDEX 855 Ether for removing fat and grease from skin, 434 in shock, 579 inhaler, Clover, 324 Etherization, 554 Ethyl bromid anesthesia, 329 chlorid anesthesia, 329 Ethylhydrocuprein, 409 Eucain, hypodermic injection of, as local anesthetic, 316 Eustachian catheter, 203 tubes, Politzer's bag for dilating, 204 Evacuations, involuntary, 182 Eversion in Pott's fracture, 622 Ewald's test-meal, 218 Exanthematous fevers, 713 Excreta, 224 condition of, 42 disinfection of, 442 by boiling, 443 chemical, 443 in country districts, 443 Exhaustion, heat, 684 theory of immunity, 402 Exotoxins, 374 Expansion, diminished, of chest, 172 Expectorant, definition of, 304 Exploration, 511 Exploratory puncture of pericardium, 512 Exposure to cold, 659 Extension, 280 apparatus, Buck's, 280 treatment of fractures, 621 vertical, 281 Extracellular toxins, 374 Extractives, 727 Extracts, meat, 765 Eye, appearance of, as symptom, 181 bandage of, 255 burns of, treatment, 651 douche, 136 of infant, 138 effect of atropin on, 200 of homatropin on, 201 examination of, 199 figure-of-8 bandage of, 255, 256 foreign bodies itf, removal of, 671 operations on, 570 care after, 571 pain after, 571 sterilization in, 452 Facial artery, compression of, 589 taking of pulse at, 160 expression as symptom. 181 paralysis, 697 Facultative bacteria, 355 Fahrenheit thermometer, 158 converting to Centigrade scale, 15S Fainting, 682 treatment of, 683 Fallopian tube, ruptured, hemorrhage from, 618 Familiar preparations, 311 Fastigium, 709 of fever, 157, 408 Fasting, influence of, on dosage, 30.) Fat, 726, 728 diet of, 174 digestion of, 740 effect of cooking on, 749 Fat in Allen's starvation diet, 796 in feces, 226 Fat-free milk, 752 Fatty casts in urine, 236 Favus, 721 Feather mattress, 18 pillow, 19 Fecal stains on linen, removal, 816 vomitus, 218 Feces, 224, 742 bacteria in, 229 in typhoid fever, 229 blood in, 225 blue, 227 color of, 227 absence, 227 black, 227 consistence of, in constipation, 224 in diarrhea, 224 disinfection of, 443 by boiling, 443 chemical, 443 disposal of, 444 earth-worm in, 228 examination of, 229 fat in, 226 foreign bodies in, 228 gall-stones in, 228 green, 227 greenish-yellow, 227 in infancy, 224 melanotic, 227 mucus in, 225 normal, 224 odor of, 226 of milk diet, 224 parasites in, 228 poisons in, 228 preparation of, for examination, 229 pus in, 226 red, 227 seat-worms in, 228 tape-worms in, 228 tarry, 226, 227 after enterorrhagia, 601 undigested, 224 watery, 225 worms in, 228 Feeding by nasal tube, 150 forced, 150 infant, 756. See also Infant feeding. nasal, 150 Fehling's test for glycosuria, 242 Fellow's svrup, 311 Felon, 661 treatment of, 662 Felt, poroplastic, 280 Femoral arterv, digital compression of, 588 taking pulse at, 160 Femur, fracture of, treatment, imme- diate, 618 Fermentation of milk, 754 Ferments, 740 Fetid sputum, 222 Fever, 152, 708 Brandt bath in. 58 causes of, 708 continuous, 155, 710 convalescence in, 710 course of, 709 crisis of, 154, 710 decline of, 408, 710 856 INDEX Fever, diet in, 776 duration of periods, 711, 712 eruptive, 713 exanthematous, 713 fastigium of, 157, 408, 709 gradual onset, 155 hectic, 157, 711 in phthisis, 157 incubation period, 711 infectious, 70S intermittent, 151, 155, 710 invasion period, 157, 709 abrupt, 709 gradual, 709 irregular, 711 lysis of, 154, 710 onset of, 157, 709 prodromes of, 709 remissions of temperature in, 710 remittent, 155, 710 stadium of, 157, 709 sudden onset, 155 symptoms of, physical, 709 Fever-blister, 717 Fibrous union of fractures, 617 Field tourniquet, 591 application of, 591 Figure-of-8 bandage, 252 of both shoulders, 252 of breast, 257 of eye, 255, 256 of foot, 253 of hand, 254 of instep, 253 of jaw, 256 of nape of neck, 257 posterior, 252 Filaria sanguinis hominis, 361 Filiform catheters, sterilization of, 462 Fingers, bandage of, 254 dislocation of, treatment, 633 Fish, diet of, 773 Fishing-gut, 464 Fission of bacteria, 354, 359 Fistula, 643 Fits, 663 Flagella, 359 Flaky desquamation, 713 Flame, actual, sterilization by, 423 Flavoring milk, 755 Flaxseed enteroclysis, 127 poultice, 89 addition of glycerin and belladonna to, 93 of opium to, 93 Flaxseed-tea, 842 Fleischl's hemoglobinometer, 213 Flexion, forced, of elbow, 585 of knee, 587 Flies as carriers of disease, 391 Floors, mopping of, in ward, 824 polishing of, in ward, 825 protection of, in operations in private houses, 547 scrubbing of, in ward, 824 sweeping of, in ward, 824 Flour, dextrinized, with buttermilk, 840 Flour-gruel, 840 Fluidextracts, dosage of, 308 Flushing of colon, 128 Flying blister, 109 Fomentation, 94. See also Stupe. Fomites, 487 Food, 723 absorption of, 743 caloric value, 733 chemical composition, 724 classification of, 725 cooking of, 723, 724. See also Cooking. digestibility of, 739 nitrogenous, 727 of bacteria, 355 potential energy, 735 preparation of, 745 proper care of, in prevention of infec- tion, 392 Foot, figure-of-8 bandage of, 253 handkerchief bandage of, 265 Foot-bath, hot, 56 Foot-sling, 48 Forced feeding, 150 Forceps, esophageal, 775 Forcible vomiting, 217 Forearm, fracture of, treatment, im- mediate, 618 Foreign bodies in ear, removal of, 672 in esophagus, 774 in eye, removal of, 671 in feces, 228 in larynx, 775 in nose, removal of, 673 in throat, removal of, 673 in trachea, 775 removal of, 671 proteins, skin tests for, 400 Formaldehyd as antiseptic, 438 disinfection of room, 440 fumigator, 440 Formalin as antiseptic, 438 catgut, 469 Four-tailed bandage, 260, 264 of jaw, 260 Fowler's solution, 311 test for urea in urine, 245 Foxglove poultice, 94 Fractional doses, 295 sterilization, 428, 474 Fracture, 612 ankylosis from, 613 at diaphysis, 612 at epiphysis, 612 boards, 284 callus in, 616 causes of, 612 classification of, 613 closed, 613 cold in, 621 Colles', treatment, 622 comminuted, 614 complicated, 614 complications from, 617 compound, 613 treatment, immediate, 619 depressed, 614 extension treatment, 621 extracapsular, 613 from muscular contraction, 612 from violence, direct, 612 indirect, 612 greenstick, 613 impacted, 614 intracapsular, 613 longitudinal, 612 massage in, 621 multiple, 614 oblique, 612 INDEX 857 Fracture of clavicle, adhesive strapping in, 287 Sayre's dressing in, 287, 288 treatment, 623 immediate, 619 of femur, treatment, immediate, 618 of forearm, treatment, immediate, 618 of knee, treatment, 623 of leg, treatment, immediate, 618 of lower jaw, treatment, 627 of orbit, treatment, 627 of patella, treatment, 623 of pelvis, treatment, 627 immediate, 620 of ribs, adhesive strapping in, 286 complications from, 624 treatment, 624 immediate, 619 of skull, of base, treatment, 626 of vault, complications from, 626 treatment, 625 treatment, 624 immediate, 619, 620 of spine, treatment, 629 immediate, 620 of upper arm, treatment, immediate, 618 open, 613 Pott's, treatment, 622 removal of clothing in, 619 repair of, 615 simple, 613 splints in, 610 symptoms of, 613, 615 transverse, 612 treatment of, 617 extension, 621 immediate, 617 surgical, 620 union of, 615 bony, 616 delayed, 617 fibrous, 617 varieties of, 612 Frame, Bradford, 282, 283 Freckles, 206 Fremitus, 184 friction, 184 French mustard, 99 Friar's balsam, 312 Friction fremitus, 184 Friction-sounds, 184, 185 Frost-bite, 659 Fructose, 728 Fruit-stains on linen, removal, 817 Fruit-sugar, 728 Fumigation, administering drugs by, 334 Function, interference with, from in- flammation, 78 Functional poisons, 338, 347 Fungi, 354 Fiirbringer's method of sterilization of hands, 448 Furniture inventory, 813 of operating-room, 523 polished, care of, 828 Furuncle, 660 Gabbett's solution, 366 Gait as symptom, 181 Galactagogue, definition of, 304 Gallic acid in hemorrhage, 595 Gallon, abbreviation for, 293 Gall-stones in feces, 228 Gallows, 268 Gangrene, 38, 643 dry, 644 moist, 644 traumatic, 644 treatment of, 644 Gangrenous sputum, 222 Gas bacillus, 360, 418 Gastric disorders, acute, diet in, 782 chronic, diet in, 782, 785, 787 diet in, 781 juice, 740 acidity, 219 ulcer, diet in, 782 Lenhartz, 782 Sippy, 782, 785 Gauze bandages, 249 iodoform, 474 sterilization of, 474 medicated, 474 sterilization of, 476 Gavage, 150 Gelatin enema, 124 in enterorrhagia, 601 in hemorrhage, 595 Gelatinoids, 727 effect of cooking on, 748 Genupectoral position, 191 German measles, nursing in, 413 rash in, 736 Germicides, 429 Germs, 354 Ginger-tea, 842 Glanders, infection by, 390 Glands of axilla, operations on, steriliza- tion in, 451 of neck, operations on, sterilization in, 451 Glass catheter, 140 sterilization of, 462 cleaning of, in ward, 827 sterilization of, 463 Glauber's salts, 312 Glaucoma, salt-free diet in, 793 (31oves, rubber, sterilization of, 460 Glucose, 728 injection in diabetic coma, 501 Glycerin enema, 122 sterilization of, 473 suppository, 129 Glycogen, 727 Glycosuria, 242 Allen's starvation diet in, 794 Bottger's test for, 243 copper test for, 242 diet in, 794 Fehling's test for, 242 quantitative test for, 243 Trommer's test for, 242 Gonococcus (micrococcus gonorrhese), 381 Gonorrhea, infection by, 390, 394 Gonorrheal ophthalmia, 381 Gooch's coaptation splinting, 280 Goose-flesh, 707 Goulard's extract, 312 Gowns in operating-room, 532 in operations in private houses, 548 Gramme, gram, 299 abbreviation for, 299 Gram's iodin solution, 367 858 INDEX Gram's stain for acid-fast bacilli, 367 Granny knot, 289, 290 Granular casts in urine, 236 Granulation, 635, 636 indolent, 636 redundant, 636 Granules of diphtheria bacillus, 382 (irape-sugar in urine, 242, 794. See also Glycosuria. Gravel in urine, 244 Gray powder, 311 Grease stains on hnen, removal, 817 on scrubbed wood, removal, 829 Green sickness, color of skin in, 205 stools, 227 Greenish-yellow stools, 227 Greenstick fracture, 613 Gregory powder, 311 Groin, spica of, 253 Gruels, 764 apple, 840 as infant food, 762 barley, 839 cracker, 839 enteroclysis, 127 flour, 840 oatmeal, 839 recipes for, 839 rice, 839 rice-flour, 839 Grunting respiration, 171 GuaiacoTand glycerin as vesicant, 109 Guarded catheter, 145 Gummatous nodules in syphilis, 716 Gums, condition of, as symptom, 181 Gunshot wounds, 641 tetanus from, 641 Gurgling rales, 185 Gutta, 294 Hair, care of, 12 mattress, 19 pediculi in, examination for, 44 treatment, 44 pillow, 19 washing of, 42 ' Hall's method of artificial respiration, 677 Hallucination, 691 Hand, figure-of-8 bandage of, 254 handkerchief bandage of, 265 Hand-brushes, sterilization of, 477 Handkerchief bandage, 263. See also Bandage, handkerchief. Hands, cleaning of, 484, 485 sterilization of, 447. See also Sterili- zation of hands. Hanging-drop method of examining bac- teria, 367 Haptophore, 404, 405 Hard pulse, 163 1 lard-boiled eggs, 838 Harrington's alcoholic solution of bi- chlorid of mercury, 438 Hay bacillus, 359 Hay-fever, salt-free diet in, 793 Head, bandage of, 257 recurrent, 258 handkerchief bandage of, 264 nurse, 801 special duties, 820 visiting rounds, 834 Head, pediculi in, 44 examination for, 44 treatment, 44 support of, by hand, 250 Headache, 82 ice compresses in, 82 Healing of wounds, 635 by first intention, 635 by granulation, 635, 636 by secondary intention, 635 primary, 635 Heart disease, dropsy in, 69S quick, 165 slow, 165 Heat, 727, 733 as rubefacient, 9S dry, application of, 86 sterilization by, 423 exhaustion, 684 in hemorrhage, 593 in inflammation, 79 moist, application of, 89 sterilization by, 424 of inflammation, 78 sterilization by, 422 unit, 735 Heating of milk, 754 Heat-stroke, 684 in animals, 685 treatment of, 685 Hectic fever, 157, 711 in phthisis, 157 Heel, bandage of, 254 Heller's test for albuminuria, 239 Hemameba malarias, 386 Hematemesis, 217, 602 Hematuria, 236, 240, 608 Hemic murmurs, 185 Hemiplegia, 695 Hemocytometer, Thoma-Zeiss, 209 Hemoglobin, 214 estimation of percentage, 211 Tallqvist's method for estimating, 214 Hemoglobinometer, von Fleischl's, 213 Hemolytic streptococci, 380 Hemophilia, e>09, 610 Hemoptysis, 602 morphin in, 603 treatment, 603 Hemorrhage, 580 acetic acid in, 594 actual cautery in, 593 acupressure in, 592 adrenalin chlorid in, 594, 595 after abdominal section, 567 external, 568 hypodermoclysis in, 569 internal, 568 morphin in, 568 salt solution in, 569 after-effects of, 599 alcohol in, 597 alum in, 594 anemia after, treatment, 598 antepartum, 606 arterial, 580 astringents in, 594 atropin in, 597 auto-infusion in, 597 calcium chlorid in, 595 capillary, 581 cerebral, 609 Hemorrhage, cold in, 594 water in, 594 concealed, 581, 599, 600 connected with childbirth, 606 digital pressure in, 589 digitalis in, 597 ergot in, 595 ergotin in, 595 exposure to air in, 584 external, 581, 598 acupuncture in, 598 treatment of, 598 from bowels, 226, 600. see aiS( Enterorrhagia. from ear, 606 from kidneys, 608 from lungs, 602. See also Hemoptysis from nose, 603. See also Epistaxis. from ruptured Fallopian tube, 608 from stomach, 602 from throat, 606 from urinary tract, 608 gallic acid in, 596 gelatin in, 596 heat in, 593 hemostatics in, 594 hot water in, 593 hypodermoclysis in, 597 in labor, 606 in pregnancy, 606 in purpura, 609 in scurvy, 609 in typhoid fever, 62 internal, 581, 599 cause of, 600 iron in, 594 ligature in, 595 means of controlling, 582 Monsell's solution in, 594 morphin in, 597 postpartum, 607. See a,so Post- partum hemorrhage. pressure in, 584 digital, 589 direct, 586 indirect, 586, 589 primary, 581 revealed, 581, 599 salt solution in, 597 secondary, 581 silver nitrate in, 594 spontaneous, 581, 598, fi09 strychnin in, 597 styptic collodion in, 594 cotton in, 594 styptics in, 594 subcutaneous, 581, 598 cold in, 599 treatment of, 599 symptoms of, 581 tannic acid in, 594 thirst after, treatment, 607 torsion in, 595, 596 tourniquet in, 590 traumatic, 581, 598 treatment of, 582 physical condition, 596 varieties of, 581, 598 venous, 580 vinegar in, 594 Hemorrhagic purpura, 609 Hemorrhoids, enterorrhagia from, treat- ment, 602 INDEX ' 859 Hemostatic, definition of, 304 in hemorrhage, 594 Herpes, 717 zoster, 71s Hiccough, 701 persistent, 182 High enema, 117 High-tension pulse, 161 Hip, handkerchief bandage for, 264, 265 splint, Thomas', 277 Hippuric acid in urine, 231 Hirudo, 102 History-taking, 214 Hives, 718 Hodgen's splint, 278 Hoffman's anodyne, 311 Homatropin, effect of, on eye, 201 Home, patient's, operations in, 541. See also Operations in patient's home. Hookworm, 361 Hopper, cleaning of, 831 sterilizing, 443 Horizontal position, 189 Horsehair probang, 674, 675 sutures, 466 sterilization of, 466 Hospitals, dietitians for, 737 Host, 360 Hot applications, 86 bath, 50 for cleansing purposes, 52 to induce perspiration, 52 to relieve convulsions, 55 bricks, 88 compresses, 97 dry pack, 67 foot-bath, 56 pack, 66 dry, 67 sitz-bath, 55 water in hemorrhage, 593 Hot-air bath, 68 Hot-water bag, 87 after operations, 557 bottles, 88 Housemaid's knee, 825 Hunger, air-, 171 Hyaline casts in urine, 235 Hydatid cysts, 360 Hydragogue, definition of, 304 Hydrargyrum chloridum corrosivum as antiseptic, 430 Hydrocarbons, 726, 728 Hydrochloric acid, 740 Hydrocyanic acid, poisoning by, 339 Hydrogen peroxid as antiseptic, 433 Hyoscyamus, poisoning by, treatment. 350 Hyperacidity, gastric, 219 Hyperchlorhydria, 219 Hyperesthesia, 689 Hyperpyrexia, 152 Hypertrophy, 208 Hyphomycetes, 354 Hypnotic, definition of, 304 Hypodermic injection, 316 drugs for, 318 of cocain as local anesthetic, 317 of digitalin, 319 of digitaline, 319 of eucain as local anesthetic, 317 of novocain as local anesthetic, 317 of Schleich's solution, 317 DEX 860 Hypodermic injection, technic, 319 needle, infection from, 395 sterilization of, 456 syringe, 320 tray, 319 Hypodermoclysis, 497, 543 in diabetic coma, 501 in enterorrhagia, 601 in hemorrhage, 597 after abdominal section, 569 in operations in home, 543 in shock, 579 after abdominal section, 567 in vomiting after operations, 561 needles for, 500 sites for, 5(30 tap-water for, 497 technic, 500 Hypophosphites, Fellow's, 311 Hysteria, convulsions in, 670 Ice compress, 81 paddling, 74 poultice, 86 stupe, 83 suppository, 129 Ice-bag, 83 Ice-chest, cleaning of, 831 Ice-coils, 84 Ice-cradies, 74 Ice-cream, 755 Ice-rub, 74 Idiopathic erysipelas, 646 Idiosyncrasy, influence of, on dosage, 305 Illumination of cavities, 199 Illusion, 690 Immersion, constant, in water, 56, 57 Immunity, 396 active, 397 acquired, 397 Ehrlich's theory, 403 exhaustion theory, 402 Metchnikoff's theory, 403 natural, 396 opsonic theory, 405 passive, 402 Pasteur's theory, 402 theories of, 402 theory of the feeding cell, 403 unit of, antitoxin, 401 Wright's theory, 405 Impacted fracture, 614 Imperial drink, 841 pint, 294 Impetigo contagiosa, 721 Improvised tourniquet, 592 Incised wound, 634 drainage of, 639 separation of tendons in, 639 treatment, 638 Inclined plane, 279 double, 280 Incontinence of urine, 182 Incubation period in infectious diseases, 407 of disease, 407 of fever, 711 Index, opsonic, 406 Indican in urine, 255 Indolent granulation, 636 Induration, 207 Infant-feeding, 756 carbohydrate indigestion in, 763 dextrinized barley-gruel, 840 flour with buttermilk, 840 fat indigestion in, 763 indigestion in, 763 protein indigestion in, 763 quantity, 762 strength of food in, 762 Infection, 373 by inoculation, 390 prophylaxis, 393 droplet, 388 in wounds, 641 Carrel method for treatment of, 490 apparatus for, 491 local treatment,- 490 microscopical examination in, 496 procedures, 490 solution for, 495, 496 technic, 496 from bacillus pyocyaneus, 642 from staphylococcus pyogenes aureus, 641 local, 373 of wounds with pus-producing organ- isms, 394 systemic, 373 wound, 415 mixed, 416 Infectious diseases, 373 drugs with specific action in, 409 fever in, decline of, 408 fastigium of, 408 incubation period, 408 nursing in, 409 prophylaxis, 391 treatment by injection of devital- ized bacteria, 406 fevers, 708 sputum, 222 Inflammation, 77 cold in, 79 counterirritation in, 80 heat of, 78, 79 in wounds, 649 interference with function from, 78 of kidneys, diet in, 790 pain of, 78 redness of, 78 swelling of, 78 treatment of, 79 Influenza bacillus, 384 Infusion, continuous rectal, 128 dosage of, 308 intravenous, of salt solution, 502 technic, 503 subcutaneous, of salt solution, 497 of tap water, 497 Inhalation, administering drugs by, 321 for stimulation, 330 of ammonia fumes, 330 of amyl nitrite vapor, 330 of saltpeter for asthma, 330 of steam, 331 Inhalations for throat, 333 Inhaler, chloroform, 323 Clover, 324 Ink-stains on linen, removal, 816 on scrubbed wood, removal, 829 Inoculation, 399 bacterial, 405 INDEX 861 Inoculation, infection by, 390 prophylaxis, 393 Pasteur's method, 399 with attenuated virus, 399 Inorganic murmurs, 185 Insects as transmitters of specific dis- eases, 395 stings of, 658 Insolation, 684 Insomnia, 692 acute, 692 chronic, 693 in children, 694 Inspection, 183 Instep, figure-of-8 bandage of, 253 spica of, 253 Instillation tubes for Carrel treatment of infected wounds, 491, 492 Instruments, closet for, 458 delicate, sterilization of, 455 for intubation, O'Dwyer's, 575 in operating-room, 534 sharp, sterilization of, 455 sterilization of, 454 in operations in private house, 547 surgical, inventory of, 813 Insufflation method of anesthesia, 326 Intermediate pulse, 165 Intermittent fever, 155, 710 malaria, temperature chart in, 156 Intestinal disorders, acute, diet in, 782 chronic, diet in, 782, 787 diet in, 781 irrigation, 125. See also Enteroclysis. juice, 741 obstruction after abdominal section, 565 Intestine, distention of, after abdominal section, 565 perforation of, 610 peristalsis in, 742 Intracellular toxins, 374 Intratracheal etherization, 326 Intra-uterine douche, 132 Intravenous infusion of salt solution, 502 technic, 503 Intubation, 575 instruments, O'Dwyer's, 575 Inunction, administering drugs by, 333 Invasion period of disease, 408 Inventories, ward, 812 Invert sugar, 728 Invertin, 741 Iodin stains on linen, removal, 817 on scrubbed wood, removal, 829 tincture of, as antiseptic, 435 as counterirritant, 104 Iodized catgut, 469 Iodoform as antiseptic, 435 color of urine in, 233 gauze, 474 sterilization of, 474 powder, sterilization of, 472 Ipecacuanha, wine of, as emetic in poisoning, 337 Iris diaphragm of microscope, 363 Iron in epistaxis, 605 in hemorrhage, 594 Ironing surface as remedy for pain, 104 Iron-rust stains on linen, removal, 817 Ironware, enamel, cleaning of, 827 Irregular fever, 711 pulse, 165 Irregular respiration, 171 Irrigation, bladder, 144 in operation, 539 in private houses, 548 intestinal, 125. See also Enteroclysis. preparation for, 486 Irritant poisons, 338, 341 physiologic dose, 341 poisonous doses, 341 table of, 343-346 Irritants, poisoning by, 341 acute, 341. convalescence from, 342 sequels of, 342 chronic, 341, 347 Irritating drugs, time of administering, 308 Itch, rash in, 719 Jacket, cotton, 88 pneumonia, 88 Sayre's, 268 Jaundice, 204, 205 color of skin in, 204, 205 Jaw, bandage of, 256 figure-of-8 bandage of, 256 four-tailed bandage of, 260 lower, dislocation of, treatment, 633 fracture of, treatment, 627 Jelly, barley, 840 milk, 755, 837 oatmeal, 840 Jerky respiration, 171 Junket, 755, 837 Jury-mast, Sayre's, 269 Kangaroo tendon suture, 472 sterilization of, 472 Kefir, 754 Kelly pad, improvised, 42 Kelly's method of sterilization of hands, 448 Keloid, 645 Kempton-Brown tubes for blood trans- fusion, 506 Kerosene oil as vesicant, 109 Kettle, croup, 69, 331 Kidneys, function of, diets for testing, 791 hemorrhage from, 618 inflammation of, diet in, 790 operations on, sterilization in, 450 Kilogram, abbreviation for, 299 Kitchen crockery, cleaning of, 824 diet, 737 Kite-tail tampon, 139 Klebs-Loffler bacillus, 358, 382 Knee, forced flexion of, 587 fracture of, treatment, 649 housemaid's, 825 splint, Thomas', 277 Knee-chest position, 191 Knot, 289 clove-hitch, 291 granny, 289, 290 reef, 290 square, 290 surgeon's, 290 Koch's postulates, 376, 377 tuberculin, 400 Koplik's spots, 715 Koumiss, 754, 837 862 INDEX Labarraque's solution, 244, 312, 438 Label on bottle, reading, 314 Labor, hemorrhage in, 606 Lacerated wound, 635 treatment, 640 Lactalbumin, 756 Lacteals, 744 Lactose, 728 Lady Webster's pills, 312 Laminectomy, 630 Lamp, Schering's, 440, 441 Laparotomy, 561. See also Abdominal section. Laryngoscopy, 202, 203 Laryngotomy, position for, 573 Larynx, foreign bodies in, 675 Laudanum, 311 Laundry books, ward, 814 Lavage of stomach, 146 first step, 147 in poisoning, 336 in vomiting after operations, 560 second step, 148 third step, 149 . Laxatives, time of administering, 30S Lead and laudanum lotion, 83 plaster, 111 Leech, 102 Leeching, 102 Left lateral position, 191 Leg bath, 57, 58 fracture of, treatment, immediate, tils rest, 250 supporting of, by hand, 250 ulcer of, adhesive strapping in, 288 Leiter's coils, 84 Lemonade, 841 Lenhartz diet in gastric ulcer, 782 Lens, crystalline, 200 Lenticular papules, 206 Lentigo, 206 Leprosy bacillus, 385 Ziehl-Neelson stain for, 366 infection by, 390 Leukemia, 212 Leukocytes, 270 ameboid movements, 211 nucleus of, 211 Leukocytosis, 211 Leukopenia, 211, 212 Levis splint, 276 Levulose, 728 Lifting patient, 45 from bed, 46 in bed, 45 Ligatures, 463 absorbable, 463, 467 in hemorrhage, 595 non-absorbable, 463 sterilization of, 463 Lightning, burns by, 656 Limbs, operations on, sterilization in, 451 Lime, chlorinated, as antiseptic, 437 milk of, as antiseptic, 437 Lime-water in milk, 753 Linen, bichlorid of mercury stain on, removal, 817 blood-stains on, removal, 816 care of, ward, 816 coffee stains on, removal, 817 disinfection of, 817 fecal stains on, removal, 816 Linen, fruit stains on, removal, 817 grease stains on, removal, 817 ink stains on, removal, 816 inventory, 815 iodin stains on, removal, 817 iron-rust stains on, removal, 817 oil stains on, removal, 817 supply of operating-room, 533 sutures, 466 tea stains on, removal, 817 torn, repair, of, SI7 Liniments, 110 soap, 110 Linseed poultice, 89 Linseed-tea, 842 Liquid diet, 770 Lister, Joseph, 376 Liter, 298 abbreviation for, 299 Lithia in urine, 231 Lithotomy position, 189 in operation in private house, 546 Lobar pneumonia, temperature chart of, 155 Local applications, 77 Loffler's blood-serum as culture-media, 372 Logwood, color of urine from, 233 coloring stools, 227 Long splint, 273 Loring's ophthalmoscope, 200 Louse, bite of, rash in, 720 Low enema, 117 Low-tension pulse, 161 Lumbar puncture, 512 lateral position for, 512 sitting posture for, 513 Lunar caustic, 312 as antiseptic, 436 Lunga, bacteria in, 388 hemorrhage from, 602. See also Hemoptysis. Luxation, 631. See also Dislocation. Lymphocytes, large, 211 small, 211 Lysis, 154, 397 of fever, 710 Lysol as antiseptic, 433 Machine, hand roller-bandage, 249 Mackintoshes, sterilization of, 463 Macular rash, 206 Macule, 206 Magendie's solution, 311 Magnesia in urine, 231 Making a bed, 21 Malaria, intermittent, temperature chart in, 156 prophylaxis, 395 quinin in, 409 transmission of, by mosquito*, 360 Malarial parasite, 386 Malignant anemia, color of skin in, 205 Maltose, 728, 740, 741 Many-tailed bandage, 260 of abdomen, 261 Marble, cleaning of, 827 Massage in constipation, 703 in fractures, 621 Mattresses, 18 cotton, 18 feather, 18, 19 INDEX 863 Mattresses, fresh, giving of, 27 hair, 19 palm fiber, 18 straw, 18 turning of, 27 Matzoon, 754 Measles, German, nursing in, 413 rash in, 715 nursing in, 413 rash in, 714 Measly pork, 362 Measures, 292 metric, 296 Measuring glasses, 295 solutions, 445 by apothecaries' measure, 445 by metric system, 445 Meat, albumins of, effect of cooking 748 broths, 765 diet of, 772 extracts, 765 Meat-teas, 840 Meatus, urinary, 142 Meconium, 224 Medical bed, changing of, 23 Medicated enema, 122 gauze, 474 purgative enema, 122 stupes, 96 tub-baths, 63 Medicine chest, ward, 314 Medicines, 292 Melangeur, 209 Melanotic stools, 227 Meningitis, spinal, convulsions in, 669 Meningococcus (diplococcus intracel- lularis meningitidis), 381 vaccine, 406 Mental condition as symptom, 181 Mercury and ammonia plaster. 111 bichlorid of, as antiseptic, 430 as vaginal douche, 132 stain from, removal from linen, 817 by inunction, 333 in syphilis, 409 Meringues, 839 Merismopedia, 356 Metabolism, 734 Metal catheters, sterilization of, 462 Metals, cleaning of, 830 Metchnikoff's theory of immunity, 403 Meter, 297 abbreviation for, 299 Methylene-blue, color of urine from, 233 coloring stools, 227 Metric system, 296 approximate values of measures, 299 changing apothecaries' measure to, 300 common measure, 299 measures of capacity, 297 of length, 296 of volume, 298 measuring solutions by, 445 weights, 299 Microbes, 354 Micrococcus, 356, 358 catarrhalis, 382 gonorrheal, 381 Micromillimeter, 361 Micron, 361 Micro-organisms, 353. See also Bac- teria. Microscope, 362 Abb6 condenser, 363 compound, 362 high power, 362 iris diaphragm, 363 low power, 362 oil-immersion lens, 363 parts of, 362 simple, 362 Microscopic examination of urine, 236 Milk, 750 as culture-media, 372 as food for infants, 756 chemical composition, 751 composition of, 756 diet, feces-of, 224 dilution of, 753 fat-free, 752 fermentation of, 754 flavoring of, 755 heating of, 754 human, composition of, 756 indigestibility of, 751 keeping pure, 760 lessening acidity, 753 lime-water in, 753 modification of, 757 Baner's formula for, 758 of lime as antiseptic, 437 pasteurization of, 760, 836 peptonizing, 837 predigestion of, 754 protein of, 756 recipes for, 836 rice-, 842 skimmed, 752 splitting up, 752 sterilization of, 759, 836 Milk-curds, 753, 837 Milk-jelly, 755, 837 Milk-punch, 756, 838 Milky urine, 233, 242 Millimeter, abbreviation for, 299 Mindererus, spirits of, 311 Mineral salts, 729 waters, 757 Minim, 294 abbreviation for, 293 Mitigated silver stick, 436 Mixed infection of wounds, 416 Mixing solutions from crude drug, 446 Mixture, Basham's, 311 Brown, 311 dosage of, 309 Modification of milk, 757 Baner's formula for, 71,4 Moist cold, application of, 81 gangrene, 644 heat, application of, 89 sterilization by, 424 papule in syphilis, 716 rales, 184 Molds, 354 Monococci, 358 Monotrichous spirilla, 359 Monsell's solution, 312 in hemorrhage, 594 Mopping floors, ward, 824 Mops in operating-room, 532 Morbid changes, 208 Morphin in enterorrhagia, 601 864 INDEX Morphin in hemoptysis, 603 in hemorrhage, 597 after abdominal section, 568 Mosenthal's test-diet for renal function, 791 Mosquitos, extermination of, as preven- tive of malaria and yellow fever, 395 transmission of malaria by, 360 of yellow fever by, 360 Motility of bacteria, 359 Motor activity of stomach, determina- tion, 219 Mouth, administering drugs by, 313 bacteria in, 388 care of, 32 condition of, as symptom, 181 operations on, sterilization in, 452 taking temperature in, 159 Mouth-wash, 34 Mucoid sputum, 220 Mucopurulent sputum, 220 Mucous patches in syphilis, 716 Mucus in stools, 225 in urine, 242 in vomitus 217 Mulberry rash, 715 Mulford antitoxin phial, 509 Mumps, nursing in, 413 Muriatic acid, 311 Murmurs, 184, 185 hemic, 185 inorganic, 185 Muscles, sternocleidomastoid, action of, in respiration, 174 Muscular power, 727, 733 Mushroom-poisoning, treatment, 350 Mustard bath, 63 French, 99 leaf, 99 paste, 98 plaster, 98 in shock, 579 poultice, 92 Muttering delirium, low, 689 Mutton-broth, 765, 841 Mydriatic, definition of, 200, 302 Myxedema, induration of skin in, 207 Nail-cleaners, sterilization of, 477 Nape of neck, figure-of-8 bandage of, 257 Narcotic, definition of, 304 time of administering, 307 Nares, 202 plugging, in epistaxis, 605 posterior, 202 Nasal douche, 134 feeding, 150 Natural immunity, 396 resistance of body, 396 Nausea after operations, 559 Neck, glands of, operations on, steriliza- tion in, 451 nape of, figure-of-8 bandage of, 257 Needles, 456 aneurysm, 456 hollow, sterilization of, 456 hypodermic, sterilization of, 456 sterilization of, 455 Negative chemotaxis, 356 Neisser's organism, 381 Nematodes, 361 Nephritis, diet in, 790 dropsy in, 697 in burns, 655, 656 interstitial, salt-free diet in, 793 parenchymatous, waxy casts in, 235 Nervous diseases, cold bath in, 62 Nettle-rash, 718 Neutrophiles, polymorphonuclear, 211 Newborn, asphyxia of, 680 artificial respiration in, 680 Byrd's method, 681 Schultze's method, 680 white asphyxia of, 682 Nickel, cleaning of, 830 Night nurse, 804 report, ward, 810 Nipples, rubber, care of, 761 Nitrate of silver as antiseptic, 436 Nitric acid, poisoning by, 339 test for albuminuria, 239 Nitrites, action of, 306 Nitrogenous foods, 727 Nitrous oxid anesthesia, 322 oxid-oxygen anesthesia, 322 Nits in hair, examination for, 44 treatment, 44 Nodules, 206 Non-hemolytic streptococci, 380 Non-pathogenic bacteria, 355 Nose, bacteria in, 388 condition of, as symptom, 181 examination of, 202 foreign bodies in, removal of, 673 hemorrhage from, 603. See also Epistaxis. operations on, sterilization in, 452 Novocain, hypodermic injection, 317 for spinal anesthesia, 330 Nucleus of leukocytes, 211 Nummular sputum, 222 Nurse, clean, 479. See also Nurse, sterile. duties of, in emergency operations, 539 in operating-room, 533 hands of, cleansing, 484, 485 head, 801 Bpecial duties, 820 visiting rounds, 834 night, 804 sterile, 479 in operating-room, 535 (No. 1), duties of, 480 unsterile, 479 in operating-room, 537 (No. 2), duties of, 481 Nursing bottles, care of, 761 in chicken-pox, 413 Nutrient bouillon as culture-media, 371 Nutritive enema, 140 Oatmeal, 764 gruel, 839 jelly, 840 poultice, 93 water, 842 Objective symptoms, 179, 180 Obligate bacteria, 355 Observation, 179 Odor of breath as symptom, 181 of stools, 226 of urine, 233 O'Dwyer's intubation instruments, 575 INDEX 865 Oese, 364 Oil, carron, 312 croton, as vesicant, 109 enema, 122 kerosene, as vesicant, 109 poultice, 94 Russian, for sterilization of instru- ments, 455 stains on linen, removal, 817 sterilization of, 473 Oil-immersion lens of microscope, 363 Oily casts in urine, 236 Ointment, cantharidal, as vesicant, 108 savin, 108 sterilization of, 473 Olein, 728 Oliguria, 234 Operating-room, 523 anesthetist's table, 527 basins in, 530 cupboards in, 529 duties of nurses in, 533 emergency table, 528 equipment of, 523 furniture of, 523 gowns in, 532 instruments in, 534 linen supply of, 533 mops in, 532 operating-table, 524 patient's dress in, 532 pitchers in, 530 preparation table, 529 reserve table, 528 sponge receptacle in, 530 stands in, 529 sterile nurse in, 535 unsterile nurse in, 537 wash-stands in, 530 water-supply of, 530 Operating-table, 524 Boldt's, 525 crutches on, 526 in private house, 546 pads on, 526 pillows on, 526 position of patient on, 537 of patient's arms on, 537 Operations, bladder conditions after, 559 care after, immediate, 556, 559 before, 551 catharsis before, 551 catheterization after, 559 cleansing patient before, 553 condition of bladder after, 559 counting sponges in, 539 diet before, 552 duties of nurse after closure of in- cision, 540 between, 541 emergency, catharsis before, 552 duties of nurse in, 539 ether bed, 555 etherization for, 554 field of, preparation, 449 hot-water bags after, 557 immediate care after, 556 preparation for, 553 in patient's home, 541 after the operation, 550 carrying patient, 549 gowns, 548 irrigation in, 548 55 Operations in patient's home, outfit of nurse, 543 position of patient, 546 sterilization of instruments, 547 protecting floor, 546 requirements, 542 room of, 544 arrangement, 547 salt solution in, 543 sterilizer in, 544 table for, 546 irrigations in, 539 nausea after, 559 on eye, 570 care after, 571 pain after, 571 Paquelin cautery in, 539 preparatory period, 551 immediate, 553 pulse after, 558 respiration after, 558 restlessness after, 558 sheet, 535 thirst after, 561 urinary examination before, 551 vomiting after, 559 bismuth subnitrate in. 561 bromids in, 561 cerium oxalate in, 561 cocain hydrochlorid in, 561 hypodermoclysis in, 561 lavage of stomach for, 560 salt solution in, 561 Ophthalmia, infection by, 390, 394 of newborn, douching eye in, 138 ice compresses in, 82 Ophthalmoscope, 201 Loring's, 200 Opisthotonos, 663 Opium plaster, 111 poisoning, physiologic antidote for, 336 treatment, 350 Opsonic index, 406 potency, 406 theory of immunity, 405 Opsonins, 405 Optochin, 409 Orange-red urine, 232 Orbit, fracture of, treatment, 627 Orderly, 805 Organic matter in urine, 231 Orthopnea, 171 Ounce, abbreviation for, 293 Oxalic acid, poisoning by, treatment, 339 Oxaluria, diet in, 793 Oxidation, 725, 733 Oxygen, value of, 725 Oxygen-nitrous-oxid anesthesia, 322 Oxytocic, definition of, 304 Pack, 50 cold, 75 hot, 66 dry, 67 wet, 75 Packing cavity, 488 sinus, 488 vagina, 139 Pad, Keliy, improvised, 42 Padding splints, 270 Paddling, ice, 74 866 INDEX Pads on operating-table, 526 Pain, 687 after operations on eye, 571 boring, 687 character of, as symptom, 180 causes of, 687 dull, 687 influence of, on dosage, 306 lancinating, 687 of inflammation, 78 onset of, 688 sharp, 687 symptoms of, objective, 688 subjective, 687 throbbing, 687 varieties of, 687 Palate, operations on, sterilization in, 452 Pallor, 204 Palm fiber mattress, 18 Palmitin, 728 Palpation, 183 Pancreatic juice, 741 Pap, 840 Papular eczema, 719 rash, 718 Papule, 206 lenticular, 206 moist, in syphilis, 719 pustular, 206 vesicular, 206 Paquelin cautery, 105 in operations, 539 sterilization of, 457 Paracentesis, 514 Paralysis, 182, 695 facial, 697 Paraplegia, 695, 696 Parasites, 355, 360 in feces, 228 Paratyphoid bacilli A and B, 383 Paregoric, 311 Parenchymatous nephritis, waxy casts in, 235 Paronychia, 661 Paste, mustard, 98 Pasteur, Louis, 375 Pasteurization of milk, 760, 836 Pasteur's method of inoculation, 399 theory of immunity, 402 Patella, fracture of, treatment, 623 Pathogenic bacteria, 355 action of, 407 description of, 379 protozoa, 386 Pediculi in hair, examination for, 44 treatment, 44 Pediculosis, 720 Pelvic spica, 250 Pelvis, fracture of, treatment, 627 immediate, 620 rest for, 250 support of, by hand, 250 Peptonizing milk, 837 Percussion, 185 Perfection bed-pan, 41 Perforation, 630 in typhoid fever, 62 symptoms of, 630 treatment of, 630 Pericarditis, sait-free diet in, 793 Pericardium, aspiration of, 521 exploratory puncture of, 511 Perineum, handkerchief bandage for, 264 Peristalsis, 117 in stomach and intestine, 712 Peritoneal cavity, aspiration of, 519-521 fluid in, paracentesis in, 515 Peritonitis, tuberculous, salt-free diet in, 793 Peritrichous spirilla, 359 Permanganate of potash as antiseptic, 434 Pernicious anemia, color of skin in, 205 Petechia, 207, 599 Petri dish, 369 Pewter, cleaning of, 830 Pfeiffer's bacillus, 384 Phagocytes, 78, 403 function of, 396 Phenol, 312 as antiseptic, 431 Phlebotomy, 504 Phosphates in urine, 238 triple, in urine, 236 Phosphoric acid in urine, 231 Photogenic bacteria, 356 Phthisis, diet in, 799 hectic fever in, 157 Physical signs, 180, 183 Physiologic antidote, 336 limit of drug, 335 Picking at bed-clothes, 182 Picric acid in burns, 653 Pigmented patches on skin, 205 Pigments in urine, 231 Pillows, 19 down, 19 feather, 19 hair, 19 on operating-table, 526 Pills, A. B. and S., 312 Blaud's, 312 blue, 312 Lady Webster's, 312 Plummer's, 312 Pilocarpin in conjunction with sweat- bath, 67 Pink urine, 233 Pint, abbreviation for, 293 Imperial, 294 Pjn-worm, 362 Pitchers in operating-room, 530 Plague, bubonic, infection by, 390 Plane, inclined, 279 double, 280 Plasmodium malariae, 386 Plaster, 110 adhesive, 111 anodyne, 110, 111 asafetida, 111 belladonna, 110, 111 cantharides, 108 capsicum, 111 diachylon, 111 lead, 111 mercury and ammonia, 111 mustard, 98 opium, 111 removal of, 111 soap, 111 Plaster-of-Paris bandage, 266 interrupted, 267, 268 opening in, 267 technique of applying, 266 Plating, 369 INDEX 867 Pleura, aspiration of, 520, 521 Pleurisy, salt-free diet in, 793 Plugging nares in epistaxis, 605 Plummer's pills, 312 Pneumococcus (diplococcus pneumoniae), 380 types of, 380 Pneumonia jacket, 88 lobar, temperature chart of, 155 poultice in, 92 Poached egg, 838 Poisoning, 335 apomorphin as emetic in, 330 blood-, 416 by acetanilid, treatment, 349 by aconite, treatment, 348 by alcohol, treatment, 348 by antifebrin, treatment, 349 by antipyrin, treatment, 349 by belladonna, treatment, 349 by carbolic acid, treatment, 339 by chloral, treatment, 349 by cocain hydrochlorid, treatment, 350 by corrosives, 338 convalescence from, 339 symptoms, 338 treatment, 338 by daturin, treatment, 351 by digitalis, treatment, 350 by functional poisons, 347 by hydrocyanic acid, 341 by hyoscyamus, treatment, 350 by irritants, 341 acute, 341 convalescence from, 342 sequels of, 342 chronic, 341, 347 by nitric acid, 339 by opium, physiologic antidote for, 336 treatment, 350 by oxalic acid, treatment, 339 by snake-bite, treatment, 352 by stramonium, treatment, 351 by strychnin, convulsions, tj69 treatment, 351 by sulphuric acid, 339 by veratrum viride, treatment, 352 carbonate of ammonia as emetic in, 337 emetics in, 336 lavage in, 336 mushroom-, treatment of, 350 treatment of, 335 wine of ipecacuanha as emetic in, 337 zinc sulphate as emetic in, 337 Poisons, 335 antidotes for, 335 corrosive, 337, 338 table of, 340 functional, 338, 347 in feces, 228 irritant, 338, 341 physiologic dose, 341 poisonous doses, 341 table of, 343-346 Poliomyelitis, acute anterior, 697 Polished furniture, care of, 828 Polishing floors, ward, 825 Politzer's bag, 204 Polyuria, 234 Poraphi, 206 Pons, 696 Poppy-head stupe, 97 Porcelain, care of, in ward, 828 Pork, measly, 362 Poroplastic felt. 280 Position after abdominal section, 562 dorsal, 189 recumbent, 189 for laryngotomy, 573 for tracheotomy, 573 genupectoral, 191 horizontal, 189 knee-chest, 191 left lateral, 191 lithotomy, 189 in operation in private house, 546 Sims', 191 standing, 194 Trendelenburg, 193 in operations in private house, 516 Positive chemotaxis, 356 Posterior nares, 202 Postpartum hemorrhage, 608 , ergot in, 608 primary, 608 salt solution in, 608 secondary, 608 treatment, 608 Potash in urine, 231 Potassium iodid in syphilis, 409 permanganate as antiseptic, 434 Potato bacillus, 359 raw, as culture-media, 372 Potential energy of food, 735 Pott's fracture, treatment, 622 Poultice, 89 bread, 93 charcoal, 93 flaxseed, 89 digitalis, 94 flaxseed, addition of glycerin and belladonna to, 92 of opium, 92 foxglove, 94 ice, 86 linseed, 89 mustard, 92 oatmeal, 93 of ground corn, 93 oil, 94 soap, 93 spice, 99 starch, 94 wheatmeal, 93 Pound, abbreviation for, 293 Powder, B. B. C, 436 Dover's, 311 dusting, sterilization of, 472 gray, 311 Gregory, 311 iodoform, sterilization of, 472 Seidlitz, 312 Tully's, 312 Practical methods, 17 Predigestion of milk, 754, 837 Pregnancy, hemorrhage in, 606 uremia in, 66S vomiting in, 700 Preparation table in operating-room, 529 Preparations, familiar, 311 relative values of, 308 Prescription, diet by, 737 868 INDEX Pressure, digital, in hemorrhage, 589 of brachial artery, 584 of femoral artery, 588 direct, in hemorrhage, 586 in hemorrhage, 584 indirect, in hemorrhage, 586, 589 of facial artery, 589 of radial artery at wrist, 586 of subclavian artery, 587 of temporal artery, 588 of ulnar artery at wrist, 586 relieving of, 39 Pressure-sore from splint, 271 Private house, operations in, 541. See also Operations in patient's home. Probang, 674 horsehair, 674, 675 Prodromes, 407, 408, 709 Profuse sputum, 220 vomiting, 216 Projectile vomiting, 211 Proof spirit, 434 Protargol as antiseptic, 436 Protective in dressing of burns, 489 Protein, 725, 726 digestion of, 740 effect of cooking on, 748 foreign, skin test for, 400 in Allen's starvation diet, 796 of milk, 756 Protozoa, 354, 360 pathogenic, 386 Provisional callus, 616 Prune-juice sputum, 221 Prussic acid, 312 Ptomain, 374 Ptyalagogue, definition of, 304 Ptyalin, 740, 741 Pulmonary embolism, 645 Pulse, 160 after operations, 563 capillary, 166 compressible, 163 Corrigan's, 166 dicrotic, 166 frequent, 165 full, 163 and bounding, 163 hard, 163 high-tension, 161 intermediate, 165 irregular, 165 low-tension, 161 quick, 165 rapid, 165 regular, 165 resistant, 163 size of, 163 slow, 165 small. 163 soft, 163 taking of, 160 at common carotid arteries, 160 at facial artery, 160 at femoral artery, 160 at radial artery, 160 at temporal arterv 160 tension of, 161 thready, 163 varieties of, 164 volume of, 163 water-hammer, 166 wiry, 164 Pump, air-, sterilization of, 458 Punctiform rashes, 205 Puncture, exploratory, of pericardium, 511 lumbar, 512. See also Lumbar puncture. Punctured wound, 635 tetanus from, 640 treatment, 640 Purgative, definition of, 304 enema, compound, 123 medicated, 122 Purpura, epistaxis in, 604 hemorrhagic, 609 Purulent sputum, 221 Pus, 79, 416 blue, 642 casts in urine, 236 in feces, 226 in sputum, 221 in urine, 236, 241 in vomitus, 218 Pustulants, 98, 109 Pustular papules, 206 Pustules, 206, 416 Pustulous eczema, 719 Putrefactive alkaloids, 374 Pyogenic bacteria, 415 incubation period, 416 Pyrexia, 152 Pyuria, 241 Quassia enema, 124 Quick heart, 165 pulse, 165 Quinin, full doses, symptoms of, 352 in malaria, 409 Rabies, 657 infection by, 390, 393 Race, influence of, on dosage, 305 Radial artery, compression of, at wrist, 586 pulse, 160 Raising patient into sitting posture, 46 Rales, 184 bronchial, 185 bubbling, 185 coarse, 185 crackling, 185 crepitant, 185 dry, 185 fine, 185 gurgling, 185 moist, 184 sibilant, 185 sonorous, 185 tracheal, 185 vesical, 185 Rapid pulse, 165 Rash, 205 accidental, 717 acne, 717, 719 circumscribed, 205 diffuse, 205 erythematous, 205, 717 in chicken-pox, 713 in eczema, 719 in erysipelas, 716 in German measles, 715 in itch, 719 INDEX 869 Rash in measles, 714 in pediculosis, 720 in roseola, 715 in rubella, 715 in rubeola, 714 in scabies, 719 in scarlet fever, 713 in smallpox, 714 confluent, 714 in syphilis, 716 in typhoid fever, 715 in typhus fever, 715 in varicella, 713 macular, 206 mulberry, 715 nettle-, 718 papular, 717 punctiform, 205 scarlatinous, 714, 717 stomach, 718 typhoid, 285 Raw potato as culture-media, 372 Reaction, diazo-, Ehrlich's, in typhoid fever, 245 of urine, 232, 237 Widal, positive, 367 Reaumur thermometer, 158 Receptors, 403 Recipes, 836 beverages, 835 eggs, 832 gruels, 833 milk, 830 Rectal infusion, continuous, 128 suppository, 129 tubes, 114 sterilization of, 461 Rectum, 113 administration of drugs by, 315 examination of, 198 operations on, sterilization in, 451 taking temperature in, 159 Recurrent bandage of head, 258 of stump, 255 Red corpuscles, 210 stools, 227 wash, 312 Red-currant jelly sputum, 221 Redness of inflammation, 78 Reduction of dislocation, 631 Redundant granulation, 636 Reef knot, 290 Reflex vomiting, 699 Regular pulse, 165 Regurgitation, 699 Relapse, 398 Relapsing fever, infection by, 391 Remittent fever, 155, 710 Renal function, Mosenthal's test-diet for, 791 Rennin, 752 Repair of fractures, 615 of wounds, 638 Report book, ward, 809 Reporting of nurse, 808 Reproduction of bacteria, 359 vegetative, 359 Reserve table in operating-room, 528 Resistance, natural, of body, 396 Resistant pulse, 163 Resolution, 79, 207, 403 Respiration, 167 abdominal, 172 Respiration, abdominal, restricted, 172 action of sternocleidomastoid muscles in, 173 after operations, 558 artificial, 676 Byrd's method, 681 Hall's method, 677 character of, 170 Cheyne-Stokes', 171 crowing, 171 deep, 170 estimation of, in nervous patients, 174 grunting, 171 in drowning, 678 Schultze's method, 680 Sylvester's method, 676 irregular, 171 jerky, 171 mechanism of, 172 position of patient in, 172 rate of, 170 shallow, 170 stertorous, 171 stridulent, 171 thoracic, 172 tidal, 171 Rest, bed-, 47 for pelvis, 250 in bandaging, 249 , leg, 250 Restlessness after operations, 558 Restricted abdominal breathing, 172 Retina, 200 Returning patient to bed, 47 Revealed hemorrhage, 581, 599 Rheumatic fever, salicylic acid in, 409 sweating in, treatment, 707 Rhubarb, color of urine from, 233 Rib, fracture of, adhesive strapping in, 286 complications from, 624 treatment, 624 immediate, 619 Rice, 765 Rice-flour gruel, 839 Rice-gruel, 839 Rice-milk, 842 Rice-water, 842 Rickets, 732 diet in, 800 Riegel's test-meal, 218 Rigor, 705 treatment of, 706 Ringer's solution, 439 Ringworm, 721 treatment of, 722 Robinson's apparatus for intratracheal anesthesia, 327 Rochelle salts, 312 Roller bandage, 248 machine to roll, 249 rules for, 250 Room, disinfection of, 440. See also Disinfection of room. for operations in private houses, 544 arrangement, 547 operating-, 523. See also Operating- room. Roseola, rash in, 705 Round-worms, 361 Rub, ice-, 74 Rubber bougies, sterilization of, 462 catheters, 140 870 \ INDEX Rubber catheters, sterilization of, 461 Esmarch bandage, 249 gloves, sterilization of, 460 nipples, care of, 761 sheeting, 20, 21 sheets, sterilization of, 463 sterilization of, 459 tissue, sterilization of, 461 Rubefacients, 98 Rubella, rash in, 715 Rubeola, rash in, 714 Rubner's estimation of caloric value of food, 735 Rupture of Fallopian tube, hemorrhage from, 608 Russian oil for sterilization of cutting instruments, 455 Rusty sputum, 221, 222 Sacchabomycetes, 354 Salicism, 352 Salicylic acid, full doses, symptoms of, 352 in rheumatic fever, 409 Saliva, 740 Salt bag, 88 common, as antidote, 436 solution enema, 119, 121 enterocylsis, 126 in enterorrhagia, 601 in hemorrhage, 597 after abdominal section, 569 in lavage of stomach, 149 in postpartum hemorrhage, 607 in shock, 579 after abdominal section, 567 in vomiting after operations, 561 intravenous infusion, 502 technic, 503 normal, 436 subcutaneous infusion of, 497 Salt-free diet, 792 Saltpeter, inhalation of, for asthma, 312 Salts, 724 definition of, 303 enema, 122 Epsom, 312 Glauber's, 312 in urine, 231 mineral, 729 Rochelle, 372 Seidlitz, 312 Salt-water bath, 62 Sand-bags, 285 Santonin, color of urine from, 233 Saprophytes, 355 Sarcinae, 356, 358 Saucepans, cleaning of, 830 Saulter's cradle, 285 Savin ointment, 108 Sayre's dressing in fracture of clavicle, 287, 288 jury-mast, 269 spinal jacket, 268 Scabies, rash in, 719 Scalds, 648 treatment of, 648. See also Burns. Scales, 207, 713 Scar tissue, 635 from burns, 653 Scarlatina anginosa, bleeding from throat in, 606 Scarlatinous rash, 714, 717 Scarlet fever, condition of tongue in, lsl in burns, 655 infection from wounds, t>46 nursing in, 411 rash in, 713 Schatz's method of sterilization of hands, 448 Schering's lamp, 440, 441 Schizomycetes, 354, 357 Schleich's solution, hypodermic injec- tion of, 316 Schott system, 64 Schultze's method of artificial respira- tion, 680 Scrambled egg, 838 Scrubbed wood, stains on, removal, S29 Scrubbing floors, ward, 824 Scruple, abbreviation for, 293 Scultetus bandage, 260 Scurvy, 730 diet in, 799 epistaxis in, 604 hemorrhage in, 609 Sea-sponges, 476 sterilization of, 476 Seat-worms in feces, 228 Secretions, bacteria in, 388 Section, abdominal, 762. See also Abdominal section. Sedative, definition of, 304 stupe, 96 Seepage, 128 Seidlitz powder, 312 Senna, color of urine from, 233 Sepsis after abdominal section, 569 Septicemia from wounds, 645 Sequestrum, 643 Serum, antimeningococcus, 381 antistreptococcus, 401 antitoxin, 401. See also Antitoxin. reaction in typhoid fever, 367 Sex, influence of, on dosage, 305 Shallow respiration, 170 Shaving, unnecessary, 451 Sheets, 21 operation, 535 rubber, 20, 21 sterilization of, 463 top, turning of, without exposing patient, 26 Shingles, 718 Shirred egg, 838 Shirt of patient, changing, 31 Shivering, 693 after Brandt bath, 61 as symptom of sepsis after abdominal section, 569 Shock, 578 after abdominal section, 567 atropin sulphate in, 567 digitalis in, 567 early, 567 late, 567 oil of camphor in, 567 salt solution in, 567 strychnin sulphate in, 567 after an accident, 578 atropin in, 579 camphor in, 579 cerebral, 683 dosage in, 306 electricity in, 579 INDEX 871 Shock, ether in, 579 hypodermoclysis in, 579 in accidental wounds, 637 in burns, 654 mustard plaster in, 579 salt solution in, 579 strychnin in, 579 symptoms of, 578 treatment of, 579 whisky in, 579 Shoulder, handkerchief bandage of, 265 spica, 252, 253 support of, by hand, 250 Sialagogue, definition of, 304 Sibilant raies, 185 Sickness, green, color of skin in, 205 sleeping, trypanosome of, 386 Side splints, 274 Side-chains, 403 Sighing, 171 Sigmoid flexure, 113 Silicon bandage, 270 Silk bougies, sterilization of, 462 sutures, 465 sterilization of, 465 Silkworm-gut, 464 sterilization of, 464 Silver catheters, sterilization of, 457 cleaning of, 830 nitrate as antiseptic, 436 enteroclysis, 127 in hemorrhage, 594 in lavage of stomach, 149 protein, 436 stick, 436 mitigated, 436 vitellin, 436 wire sutures, 466 sterilization, 466 Sims' position, 191 speculum, 196 Sinapism, 98 Singultus, 182, 701 Sinks, cleaning of, 831 Sinus, 643 packing of, 488 Sippy diet in gastric ulcer, 782, 785 Sitz-bath, hot, 55 Skimmed milk, 752 Skin, blueness of, 204 bronzing of, 205 color of, 204 in jaundice, 204, 205 condition of, as symptom, 180 induration of, 207 observation of, 204 pigmented patches on, 205 preparation of, for operation, 449, 450, 485 tests for foreign proteins, 400 Skin-grafting, sterilization in, 453 Skull, fracture of base of, treatment, 626 of vault, complications from, 626 treatment, 625 treatment, 624 immediate, 619, 620 Sleeping sickness, trypanosome of, 386 tsetse fly as carrier, 360 Sleeplessness, 692 Sling, foot-, 48 for support of arm, 266 Slough, 38, 643 Slow heart, 165 Slow pulse, 165 Small pulse, 163 Smallpox, nursing in, 412 rash in, 714 confluent, 714 vaccination in, 398 Smear, blood-, 212 Smear-culture, 364 Smoky urine, 232, 240 Snake-bite, 658 poisoning from, treatment, 352 Soap liniment, 110 plaster, 111 poultice, 93 suppository, 129 Soapsuds enema, 119 Soda, chlorinated, as antiseptic, 438 in urine, 231 Soda-water, 767 Soft pulse, 163 Soft-boiled eggs, 838 Solutions, measuring, 445 mixing of, from crude drug, 446 sterilization of, 473 Somnifacient, definition of, 304 Sonorous rales, 185 Soporific, definition of, 304 Sordes, 32 Sore, cold, 717 Sounds, adventitious, 184 friction-, 184, 185 uterine, 197 Southey's tubes, 516 Spanish windlass, 592 Special chart, 176 Specific gravity of urine, 231, 237 Speculum, Sims', 196 Sphincter ani, 113 Sphygmograms, 167 Sphygmograph, 167 Sphygmomanometer, 162 Spica, 252 of groin, 253 of instep, 253 of shoulder, 250, 253 of thumb, 254 pelvic, 253 Spice poultice, 99 Spinal anesthesia, 330 jacket, Sayre's, 268 meningitis, convulsions in, 669 puncture, 512. See also Lumbar punc- ture. Spindle-shape bacillus, 358 Spine, fracture of, treatment, 629 immediate, 620 Spiral bandage, reversed, 251 of lower extremity, 251 of upper extremity, 251 simple, 251 Spirilla, 356, 357, 358, 359, 386 comma, 359 monotrichous, 359 peritrichous, 359 Spirit, proof, 434 Spirits, dosage of, 308 of mindererus, 311 proof, 434 Spirochsetae, 356, 359 Spirocheta pallida, 386 Spirochete of syphilis, 386 Splint, 270 angular, 274 872 INDEX Splint, angular, anterior, 275 internal, 274 back, 273 Bond's, 276 box-, 274 Dupuytren's, 278 hip, Thomas', 277 Hodgen's, 278 immobilization in, use of, 273 in fractures, 621 knee, Thomas', 277 Levis, 276 long, 273 padding of, 270 preparation for application, 271 pressure-sore from, 271 rules in applying, 272 side, 274 straight, 272 Thomas' hip, 277 knee, 277 Splinting, Gooch's coaptation, 280 Sponge, cold, 71 receptacle in operating-room, 530 Sponges, counting of, in operations, 539 sea-, 476 sterilization of, 476 Spontaneous hemorrhage, 581, 598 Spore of bacilli, 358, 359 Spots, Koplik's, 715 typhoid, 715 Sprain, 631, 633 adhesive strapping in, 288 ice compresses in, 82 treatment, 634 Spread, 21 Sputum, 220 as source of infection, 222 bloody, 221 examination of, 223 microscopic, 223 false coloring of, 222 fetid, 222 gangrenous, 222 in tuberculosis, 222 infectious, 222 microscopic examination, 223 mucoid, 220 mucopurulent, 220 . nummular, 222 profuse, 220 prune-juice, 221 purulent, 221 pus in, 221 red-currant jelly, 221 rusty, 221, 222 scanty, 220 watery, 221 Sputum-cups, 222 Squamous eczema, 719 Square knot, 290 Stadium, 709 of fever, 157 Staining bactria, 364 precautions, 365 Stains, acid, for bacteria, 365 basic, for bacteria, 365 bichlorid of mercury, on linen, re- moval, 817 blood, on linen, removal, 816 on scrubbed wood, removal, 819 coffee, on linen, removal, 817 fecal, on linen, removal, 816 Stains, fruit, on linen, removal, 817 grease, on linen, removal, 816 on scrubbed wood, removal, 819 ink, on linen, removal, 816 on scrubbed wood, removal, 819 iodin, on linen, removal, 817 on scrubbed wood, removal, 829 iron-rust, on linen, removal, 817 oil, on linen, removal, 817 on scrubbed wood, removal, 829 tea, on linen, removal, 817 Standing position, 194 Stands in operating-room, 529 Staphylococcus, 356, 357, 358, 379 pyogenes albus, 379 aureus, 379 wound infection by, 641 citreus, 379 Starch, animal, 727 as infant food, 762 bandage, 269 bath, 63 effect of cooking on, 748 enema, 124 poultice, 94 Starchy beverages, 769 Starvation, 686 diet, Allen's, in diabetes mellitus, 794 Status epilepticus, 668 Steam, inhalation of, 331 sterilization by, 424 sterilizer, 424 improvised, 425 Steapsin, 741 Stearin, 728 Stercoraceous vomitus, 218 Sterile nurse, 479 (No. 1), duties of, 480 in operating-room, 535 Sterilization, 422 Arnold sterilizer for, 424 autoclave for, 425, 426 by actual flame, 423 by baking, 423 by boiling, 423 by dry heat, 423 by heat, 422 by moist heat, 424 by steam, 424 chemical, 429 control in, 428 fractional, 428, 474 in cauterization, 453 in dirty and infected wounds, 453 in operations on abdomen, 450 on brain, 451 on breast, 451 on cervix, 451 on ear, 452 on eyes, 452 on glands of axilla, 451 of neck, 451 on kidney, 450 on limbs, 451 on mouth, 452 on nose, 452 on palate, 452 on rectum, 451 on stomach, 450 on tongue, 452 on vagina, 451 in skin-grafting, 453 in surgical work, 447 INDEX 873 Sterilization in wet-cupping, 453 of air-pump, 458 of cannulas, 457 of catgut, 467 of china, 463 of delicate instruments, 455 of dressings, 473, 485 of dusting-powders, 472 of enamelware, 463 of field operation, 449 of filiform catheters, 462 of gauze, 475 of glass, 463 catheters, 462 of glycerin, 473 of hand-brushes, 477 of hands, 447, 484 Fiirbringer's method, 448 Kelly's method, 448 Schatz method, 448 Stimson's method, 449 Weir's method, 449 of hollow needles, 456 of horsehair sutures, 466 of hypodermic needle, 456 of instruments, 454 in operations in private houses, 547 of iodoform gauze, 474 powder, 472 of kangaroo tendon sutures, 472 of ligatures, 463 of mackintoshes, 463 of metal catheters, 462 of milk, 759, 836 of nail-cleaners, 477 of needles, 455 of oils, 473 of ointments, 473 of Paquelin cautery, 457 of plain catgut, 468 of rectal tubes, 461 of rubber, 459 bougies, 462 catheters, 461 gloves, 460 sheets, 463 tissue, 461 of sea-sponges, 476 of sharp instruments, 455 of silk bougies, 462 sutures, 465 of silkworm-gut, 464 of silver catheters, 457 wire sutures, 466 of skin, 485 of solutions, 473 of sutures, 463 of syringes, 458 of transfusion tubes, 506 of trocars, 457 patent control in, 428 steps, 427 Sterilizer, Arnold, 424 in operations in patient's home, 544 steam, 424 improvised, 425 Sterilizing hopper, 443 Sternocleidomastoid muscles, action of, in respiration, 173 Stertorous respiration, 171 Stiff bandage, 266 Stimson's method of sterilization of hands, 449 Stimulating bath, 63 enema, 121 Stings, 658 Stitches, removal of, 490 Stock-books, ward, 812 Stomach, absorptive activity, determin- ing, 219 baby's, capacity of, 762 contents, anacidity of, 219 hyperacidity of, 219 subacidity of, 219 dilatation of, dry diet in, 792 diseases of, diet in, 781 examination of, 218 test-meals, 218 hemorrhage from, 602 lavage of, 146 first step, 147 in poisoning, 336 in vomiting after operations, 560 second step, 148 third step, 149 motor activity, determination, 219 operations on, sterilization in, 450 perforation of, 610 peristalsis in, 742 rash, 718 Stomachics, time of administering, 307 Stomach-tube, feeding by, 150 Stomatitis, condition of tongue in, 181 Stools, 224. See also Feces. Stramonium, poisoning by, treatment, 351 Strapping, 285 adhesive, 285. See also Adhesive strapping. Straw mattress, 18 Strawberry tongue, 714 Streptococcus, 356, 357, 358, 379 hemolytic, 380 non-hemolytic, 380 pyogenes, infection by, symptoms, 416 Stretcher, carrying patient on, 47 Strict bacteria, 355 Stridulent respiration, 171 Strychnin in hemorrhage, 597 in shock, 579 overdose of, treatment, 351 poisoning, convulsions in, 669 treatment, 350 sulphate in shock after abdominal section, 567 Stump, bandage of, 255 recurrent, 255 handkerchief bandage of, 265 Stupe, 94 alkaline, 97 as a counterirritant, 96 belladonna and glycerin, 96 digitalis, 97 ice, 83 medicated, 96 method of making, 94 poppy-head, 97 sedative, 96 turpentine, 96 in intestinal distention after ab- dominal section, 565 in tympanites after abdominal sec- tion, 566 Stye, 660 Styptic collodion in hemorrhage, 594 cotton in hemorrhage, 594 874 INDEX Styptics in hemorrhage, 594 Subacidity, gastric, 219 Subclavian artery, compression of, 587 Subcutaneous infusion of salt solution, 197 Subjective symptoms, 179, 180 Subluxation, 631 Subsultus, 182 Succus entericus, 711 Sucroses, 728 Sudamen, 708 Sudorific, definition of, 304 Sugar, 728 as culture-media, 372 cane-, effect of cooking on, 749 fruit-, 728 grape-, 728 in urine, 242. See also Glycosuria. invert, 728 Sulphate of copper as antiseptic, 436 of zinc as emetic in poisoning, 337 Sulphur bath, 63 disinfection of room, 441 Sulphuric acid in urine, 231 poisoning by, 339 Sunstroke, 684 Suppository, 129 glycerin jelly, 129 ice, 129 rectal, 129 soap, 129 urethral, 129 vaginal, 129 Suppuration, 79, 207, 416 Surgeon's knot, 290 Surgical bacteriology, 415 bed, changing of, 24, 25 procedures, minor, 510 technic, 478 principles of, 478 work, preparation in, 447 sterilization in, 447 Sutures, 463 absorbable, 463, 467 iodized catgut, 469 linen, 466 non-absorbable, 463 removal of, 490 sterilization of, 464 Sweat-bath, 66 pilocarpin in conjunction with, 67 Sweating, 706 induction of, by hot bath, 253 treatment of, 707 unilateral, 708 Sweeping ward floors, 824 Swelling as symptom, 180 brawny, 207 of inflammation, 78 Sylvester's method of artificial respira- tion, 677 Symptoms, 179 objective, 179, 180 subjective, 179, 180 Syncope, 682 treatment of, 683 Syphilis, blebs in, 716 gummatous nodules in, 716 infection by, 390, 394 mercury in, 409 moist papules in, 716 mucous patches in, 716 potassium iodid in, 409 Syphilis, rash in, 716 spirochete of, 386 tubercles in, 716 Syringe, ball, 115 hypodermic, 320 sterilization of, 458 Syringing ear, 136 Syrup, dosage of, 308 Fellow's, 311 Systole, 160 Table, anesthetist's, 527 emergency, 528 for operations in private house, 546 operating-, 524. See also Operating- table. preparation, in operating-room, 529 reserve, in operating-room, 530 Tablespoon, apothecaries' equivalent, 396 Tachycardia, 165 Tallqvist's method for estimating hemoglobin, 214 Tampon, 138 kite-tail, 139 vaginal, 138 Tank bath, 56 Tannic acid enteroclysis, 126 in epistaxis, 605 in hemorrhage, 594 Tap-water for hypodermoclysis, 497 Tapeworms, 361 in feces, 228 Tapping, 514 Tarry stools, 226, 227 after enterorrhagia, 601 Tartar emetic, 312 T-bandage, 259 Tea, 768 beef-, 841 chicken-, 841 flaxseed-, 842 ginger-, 842 linseed-, 842 meat-, 840 stains on linen, removal, 817 Teaspoon, apothecaries' equivalent, 296 Technic, surgical, 478. See also Surgical technic. Teeth, condition of, as symptom, 181 injury to, from drugs, 314 Temperature, 152 as symptom, 181 chart, 174 in intermittent malaria, 156 in typhoid fever, 156 of lobar pneumonia, 155 decline of, 157 favorable to growth of bacteria, 356 lowering of, 153 normal, 152 deviations from, 152 of bath-room, 51 of enema, 118 raising of, 153 remissions of, in fever, 710 rise of, as symptom of sepsis after abdominal section, 569 slightly raised, 152 subnormal, 152 taking of, 159 INDEX 875 Temperature, taking of, by voiding urine over bulb of thermometer, 159 in axilla, 159 in mouth, 159 in rectum, 159 ward, 833 Temporal artery, pressure of, 588 taking of pulse at, 160 Tendons, separation of, in incised wounds, 639 Teniacide, definition of, 313 Tension of pulse, 161 Tent, croup, 332 Test, Bottger's, for glycosuria, 243 copper, for glycosuria, 242 Fehling's, for glycosuria, 242 for acetone in urine, 244 for diacetic acid in urine, 244 Fowler's, for urea in urine, 245 Heller's, for albuminuria, 239 nitric acid, for albuminuria, 239 skin, for foreign proteins, 400 Trommer's, for glycosuria, 242 Widal, 367 in typhoid fever, 214, 367 Test-diets for determining kidney func- tion, 791 Test-meals, 218 Boas', 218 Ewald's, 218 Riegel's, 218 Tetanic convulsions, 663, 664 Tetanus antitoxin, 401, 418 in gunshot wounds, 647 bacillus, 385 in surgery, 417 spore formation in, 358 convulsions in, 664, 669 from gunshot wound, 641 from punctured wound, 640 from wounds, 647 infection by, 390, 394 Tetany, convulsions in, 664, 670 Teter nitrous oxid-oxygen apparatus 323 Tetracocci (tetrads), 356, 357, 358 Tetrads (tetracocci), 356, 357, 358 Tetragenococci, 356 Thermic fever, 684 Thermometer, care of, 159 Centigrade, 158 converting to Fahrenheit scale, 158 clinical, 158 Fahrenheit, 158 converting to Centigrade scale, 158 Reaumur, 158 Thermostat, 89 Thiersch's solution, 439 Thirst after hemorrhage, treatment, 597 after operations, 561 Thomas' hip splint, 277 knee splint, 277 Thoma-Zeiss hemocytometer, 209 Thoracic breathing, 172 Thready pulse, 163 Three-cornered bandage for arm, 264 Thrill, 183, 184 Throat, bacteria in, 388 burns of, treatment, 651 condition of, as symptom, 181 examination of, 202 foreign bodies in, removal of, 673 Throat, hemorrhage from, 606 inhalations for, 333 Thrombosis, 644 Thrombus, 644 Thrush, condition of tongue in, 181 Thumb, spica of, 244 Tidal respiration, 172 Tinctures, dosage of, 308 Tinea circinata, 720 favosa, 721 sycosis, 720 tonsurans, 720 tricophytina, 720 Tissue, rubber, sterilization of, 461 Toast-water, 842 Tolerance to drugs, 306 Tongue, condition of, as symptom, 181 in scarlet fever, 181 in stomatitis, 181 in thrush, 181 operations on, sterilization in, 452 strawberry, 714 Tonic convulsion, 663 Tonics, time of administering, 308 Top sheet, turning of, without exposing patient, 26 Torsion in hemorrhage, 595, 596 Tortuous -bandage, 254 Tourniquet, field, 591 application of, 591 improvised, 592 in hemorrhage, 590 Toxemia, 408 Toxins, 374, 401, 403 bacterial, kinds of, 374 extracellular, 374 intracellular, 374 Toxophore, 404 Trachea, foreign bodies in, 675 Tracheal rales, 185 Tracheotomy, 572 position for, 573 tube, 573 in place, 574 Trance, 692 Transfusion of blood, 506 direct, 508 donor in, 507 indirect, 508 patient in, 507 preparations for, 507 technic of, 507 tubes for, 506 sterilization of, 506 Trauma, 634. See also Wounds. Traumatic embolism, 645 erysipelas, 647 gangrene, 644 hemorrhage, 581, 598 scarlet fever, 646 Tremor, 182, 183 Trendelenburg position, 193 in operation in private house, 546 Trephining in fracture of skull, 626 Treponema pallidum, 386 Triangular bandage, 263 Trichiniasis, 362 Triple phosphates in urine, 236 Trocars, sterilization of, 457_ Trommer's test for glycosuria, 242 Trypanosoma gambiense, 386 Trypanosome of sleeping sickness, 386 Trypsin, 741 876 INDEX Tsetse fly as carrier of sleeping sickness, 360 Tub-bath, cold, 58. See also Cold bath. hot, 50. See also Hot bath. in bed, 64 medicated, 63 Tubercle bacillus, 359, 385 Ziehl-Neelson stain for, 366 Tubercles, 206 in syphilis, 716 Tuberculin, 400 Tuberculosis, diet in, 799 infection by, 391 nursing in, 413 sputum in, 222 sweating in, treatment, 707 tuberculin in, 400 Tubes for blood transfusion, 506 Southey's, 516 Tully's powder, 312 Tumblerful, apothecaries' equivalent, 296 Turning mattress under patient, 27 patient, 45 top sheet without exposing patient, 26 Turpentine bath, 64 enema, 123 • in intestinal distention after abdomi- nal section, 566 stupe, 96 in intestinal distention after ab- dominal section, 565 in tympanites after abdominal sec- tion, 566 Tympanites after abdominal section, 566 as symptom of perforation, 610 Tympanum, 201 Typhoid bacillus, 359, 383 agglutination, 384 Widal reaction of, 367, 384 fever, bacteria in feces in, 229 Brandt bath in, 58 cyanosis and shivering after, 61 hemorrhage and perforation during, 62 symptoms of injurious effect, 60 diet in, 777 Ehrlich's diazo-reaction in, 245 hemorrhage in, 62 nursing in, 409 perforation in, 62 rash in, 741 temperature chart in, 156 Widal reaction in, 214, 367 rash, 216 spots, 741 Typhus fever, infection transmitted by body louse, 391 rash in, 715 Ulcer, duodenal, diet in, 782 gastric, diet in, 782 of leg, adhesive strapping in, 288 Ulnar artery, compression of, at wrist, 586 Undigested stools, 224 Union of fractures, 615 bony,616 delayed, 617 fibrous, 617 Unit, immunity, of antitoxin, 401 Unsterile nurse, 479 (No. 2), duties of, 481 Urates in urine, 230, 238 Urea, 734 in urine, 230 chemical tests, 245 Fowler's test, 245 quantity, estimation of, 245 Uremia, 734 \ convulsions in, 665 treatment, 667 in pregnancy, 668 Ureters, catheterization of, 198 Urethral suppository, 129 Uric acid in urine, 230 Urinary meatus, 142 tract, hemorrhage from, 608 Urine, 229, 734 abnormal substances in, 232 acetone in, 244 test for, 244 albumin in, 239 Esbach's albuminometer for esti- mating amount, 239 Heller's test for, 239 alkaline, 232 ammoniacal, 233 aromatic substances in, 231 bacterial casts in, 236 bile in, 244 blood casts in, 236 in, 236, 240 blood-red, 232 boiling, 238 calcium oxalate in, diet for, 793 calculus in, 231 casts in, 235 chemical examination, 236 chlorin in, 231 chyle in, 242 clearness of, 232 cloudy, 237 color of, 232 composition of, 230 creatinin in, 231 crystals in, 236 density in, 231 dextrose in, 242. See also Glycosuria. diacetic acid in, 244 test for, 244 epithelial^ casts in, 236 examination of, 234 before operation, 551 chemical, 236 microscopic, 235, 236 fatty casts in, 236 granular casts in, 236 grape-sugar in, 242. See also Glyco- suria. gravel in, 244 hippuric acid in, 231 hyaline casts in, 235 incontinence of, 182 indican in, 244 lithia in, 231 magnesia in, 231 microscopic examination, 235, 236 milky, 233, 242 mucus in, 241 odor of, 233 oily casts in, 236 orange-red, 232 INDEX 877 Urine, organic matter in, 231 phosphates in, 238 phosphoric acid in, 231 pigments in, 231 pink, 233 potash in, 231 pus casts in, 236 in, 236, 241 quantity voided, 233 reaction of, 232, 237 salts in, 231 smoky, 232, 240 soda in, 231 solids in, 230 specific gravity of, 231, 237 sugar in, 242. See also Glycosuria. sulphuric acid in, 231 test solutions for, 236 triple phosphates in, 236 urates in, 230, 238 urea in, 230 chemical tests, 245 Fowler's test, 245 quantity, estimation of, 245 uric acid in, 230 waxy casts in, 235 Urticaria, 718 Uterine sound, 197 Uterus, douching of, 132 Vaccination, 398, 399 technic, 399 Vaccines, 398 autogenous, 406 meningococcus, 406 Vagina, operations on, sterilization in, 451 packing of, 139 Vaginal applicators, 197 douche, 130 bichlorid of mercury, 132 boric acid, 132 position of patient in, 131 examination, 195 suppository, 129 tampon, 138 Varicella, rash in, 713 Vaselin in burns, 652 Vegetable acids, 730 Vegetables, cooking of, 749 diet of, 773 ground, preparation of, 749 Vegetative reproduction of bacteria, 359 Velpeau's bandage, 258 Venesection, 504 Venous hemorrhage, 580 Ventilation, ward, 833 Veratrum viride, poisoning by, treat- ment, 352 Verbal reports, 810 Vertical extension, 283 Vesical rales, 185 Vesicant, definition of, 304 Vesicants, 98, 107 Vesicle, 206 Vesicular eruption, 206 papules, 206 Vibrios, 359 Vincent's angina, 383 bacillus, 383 Vinegar in hemorrhage, 594 Virus, attenuated, inoculation with, 399 Visiting rounds of head nurse, 834 Visitors after abdominal section, 565 Visitors, ward, 822 Vital knot, 169 Vitamins, 731 Volatile drugs, action of, 306 Volume of pulse, 163 Vomiting, 182, 698 after operations, 558 bismuth subnitrate in, 559 bromids in, 561 cerium oxalate after, 561 cocain hydrochlorid in, 561 hypodermoclysis in, 561 lavage of stomach for, 560 salt solution in, 560 bilious, 217 causes of, 698 central, 699 character of, 216 forcible, 217 in pregnancy, 699 profuse, 216 projectile, 217 reflex, 699 treatment of, 699 Vomitus, 216 blood in, 217 altered, 217 fresh, 217 coffee-ground, 217 consistence of, 217 fecal, 218 mucus in, 217 pus in, 218 stercoraceous, 218 Von Fleischl's hemoglobinometer, 213 Walls of ward, cleaning, 831 Ward management, 801 blankets, 818 care of linen, 816 of porcelain, 828 charts, 811 cleaning bedding, 83i2 beds, 832 brass, 830 copper, 830 enamel ironware, 827 glass, 827 hopper, 831 ice-chest, 831 kitchen crockery, 830 marble, 827 metals, 830 nickel, 830 pewter, 830 saucepans, 830 silver, 830 Binks, 831 walls, 831 diet-sheets, 811 division of labor, 802 doctor's orders, report of, 810 domestic work, 823 dusting, 826 and cleaning, 803 hours off duty, 807 inventories, 812 laundry books, 814 mopping floors, 824 night nurse, 804 report, 810 orderly, 805 patient's effects, 819 visitors, 819 878 INDEX Ward management, polished furniture, 828 polishing floors, 825 pulse, report of, 814 report book, 814 reporting, 802 respirations, report of, 810 scrubbing floors, 824 stock-books, 806 sweeping floors, 824 temperature, 833 report of, 810 ventilation, 833 verbal reports, 810 visitors, 822 ward-maid, 805 medicine chest, 314 Ward-maid, 805 Wash, black, 312 mouth-, 34 red, 312 yellow, 312 Wash-stands in operating-room, 530 Washing bed-pan, 41 hair, 42 patient without exposure, 29 Water, 725, 726 amount of, to be added to solution, method of finding, 446 as food, 766 carbonated, 767 cold, in hemorrhage, 594 glass bandage, 270 hot, in hemorrhage, 593 mineral, 767 proper care of, in prevention of infec- tion, 392, 393 Water-bed, 40 method of placing patient on, 40 Water-borne diseases, 388, 389 prophylaxis, 392 Water-hammer pulse, 166 Water-supply of operating-room, 530 Watery sputum, 221 stools, 225 Wax bandage, 270 Waxy casts in urine, 235 Weights and measures, 292 metric, 296 Weir's method of sterilization of hands, 449 Wet pack, 75 Wet-cupping, 100 sterilization in, 453 Wheals, 206 Wheat-meal, 764 poultice, 93 Wheezing, 171 Whey, 752, 837 white wine, 756, 837 Whisky enema, 122 in shock, 579 White asphyxia of newborn, 682 corpuscles, 210 wine whey, 756, 837 Whitewash as antiseptic, 437 Whitlow, 661 Whooping-cough, nursing in, 413 Widal reaction, 214, 367 in typhoid fever, technic, 384 Wild delirium, 689 Windlass. Spanish, 592 Wine and egg-albumen, 839 measure, 293 Wine of antimony, 312 of ipecacuanha as emetic in poisoning, 337 whey, white, 837 Wineglass, apothecaries' equivalent, 296 Wire sutures of silver, 466 sterilization, 466 Wiry pulse, 164 Wood, scrubbed, stains on, removul, 829 Wooden bedsteads, 18 Worms in feces, 228 Wounds, 634 accidental, cleansing of, 637 shock in, 638 treatment of, 638 adhesive strapping of, 289 complications of, 641 contused, treatment of, 640 dirty and infected, sterilization in, 453 embolism complicating, 644 erysipelas from 646 gunshot, 641 tetanus from 641 healing of, 635 by first intention, 635 by granulation, 635, 636 by secondary intention, 635 primary, 635 incised, 634 . drainage of, 639 separation of tendons in, 639 treatment of, 638 infection in, 415, 642 Carrel method of treatment, 490 apparatus for, 491 local treatment, 490 microscopical examination in, 496 procedures, 490 solution for, 495, 496 technic, 496 from bacillus pyocyaneus, 642 from staphylococcus pyogenes au- reus, 642 mixed, 416 with pus-producing organisms, 394 inflammation in, 641 keloid complicating, 645 lacerated, 635 treatment of, 639 punctured, 635 tetanus from, 640 treatment of, 640 repair of, 638 scarlet fever infection from, 646 septicemia from, 645 sloughing of, 643 tetanus from, 647 Wright's theory of immunity, 405 Yawning, 171 Y-bandage, 263, 264 Yeasts, 354 Yellow fever, prophylaxis, 395 transmission of, by mosquitos, 360, 391 wash, 312 Young's rule of dosage, 304 Y-shaped binder, 263, 264 Ziehl's carbol-fuchsin solution, 366 Zinc sulphate as emetic in poisoning, 337 Zymogenic bacteria, 356 ******