**
W'
^SENT^d
flelidnt
The Philipine Meyer^nd Ernst Jacobi
     Library Fund.
y'
ESTABLISHED 1887.
 
-. «<.ji9f«Mi»/ti»ri>».
aCSJk.-.».««**. rfjli
WITHDRAWN
    MAY  13 2009

THE NEW YORK ACADEMY
 OF MEDICINE LIBRARY
t 
 
 
 
THE
PRINCIPLES OF NURSING
              BY


    CHARLOTTE A. BROWN, R.N.
SUPERINTENDENT OF NURSES IN THE NEW ENGLAND HOSPITAL FOB WOMEN
 AND CHILDREN; GRADUATE OF BOSTON CITY HOSPITAL AND BOSTON
  LYING-IN HOSPITAL TRAINING SCHOOL FOR NURSES; LATE
    INSTRUCTOR IN THE BOSTON CITY HOSPITAL TRAINING
     SCHOOL FOR NURSES; LATE SUPERINTENDENT OF
      NURSES IN THE HARTFORD HOSPITAL TRAINING
                  itTFORD,
     SCHOOL FOR NURSES^ gAEl
WITHDRAWN



  OF MEpjCftfeUBBfiS:
i '
              ADEMyl
              m
             19*9

   LEA & FEBlTTBTr^'
PHILADELPHIA AND NEW YORK
         1919 
   Copyright
LEA & FEBIGER
      1919 
PREFACE.
  In the preparation of this volume the author has tried
to adhere strictly to the principles of nursing.
  In  all departments of education the advantage of
carefully graded instruction is now universally accepted,
and her years  of experience in teaching have empha-
sized  in the author's mind  the need of a  concise  and
understandable text-book. Consequently, clearness and
simplicity have been her aim.
  For example, the subject of bacteria is confined to a
short but  practical chapter,  in  which their  growth,
various products and wide distribution, together with
accepted  methods for  their  destruction, have  been
given.  Again,  though a discussion  of the chemistry
of foods and the unsettled subjects of digestion, assimi-
lation and  metabolism  are avoided, a  simple classifi-
cation of diets and their special application to various
disease  conditions and the process of repair are given.
  The  clinical  features  are  emphasized  throughout.
Instruction in  observing and  recording the  patient's
condition, nursing in various disease conditions, surgical
dressings  and  operating-room  technic are fully  and
carefully explained. 
IV
PREFACE
  While the book is essentially elementary,  the  text
covers the general fundamental principles of  nursing.
Hence its title, .1  Text-book  of  the  Principles  of
Nursing.
  A glossary is conveniently placed at the end  of the
book.
                                          C. A. B.
   Boston, 1919. 
CONTENTS.
                        CHAPTER I.

                       Qualifications.

Physical, Mental and Moral Qualifications of the Nurse—
    The Ethical Relation of  the  Nurse to the Patients
    and Their Friends—To Her Superior  Officers—Hos-
    pital Staff—Fellow Workers—Her Duty to Herself  .     17-20


                        CHAPTER II.

                     Personal  Hygiene.

Food and Drink—Clothing—Care of the Feet and Hands—
    Bathing—Exercise—Recreation—Sleep   ....    21-27

                        CHAPTER III.

                         Bed Making.

Economy of Time, Labor, and Hospital Property—Making
    a Bed with the  Patient In—Changing Linen, etc.—
    Fracture  Bed—Cradles—Head-rests—Moving  and
    Lifting Patients   .    .   .  :.......    28-33

                        CHAPTER IV.

                    Admission  of Patients.

Listing  and Care of Clothing and Valuables—Bathing—
    Washing the Hair—Routine Care of Patients—Care of
    Dead..............     34~44 
VI
CONTEXTS
                        CHAPTER V.

                          Bed-sores.
Their Cause and Treatment.........     44-47

                        CHAPTER VI.

           Temperature, Pulse, and Respiration.
Heat Production and Elimination—The Normal Tempera-
    ture—The Pulse: Abnormal and Normal—Respiration,
    Types, and Characteristics—Clinical Thermometers
    and Charts.............     47-60

                       CHAPTER  VII.

               Bacteria and Their  Meaning.
Classification—Growth—Relation  to   Disease—-Protozoa
    —Yeasts—Moulds—Infections—Methods of Steriliza-
    tion—Disinfectants—Antiseptics—Deodorants       .     60-70

                      CHAPTER VIII.

                        Ventilation.
Air and its Composition—Elements Necessary to Animal
    Life—Natural  Ventilation—Methods of  Supplying
    Fresh Air.............    70-78

                       CHAPTER  IX.

           t              Medicines.
Routes  of Administration—Apothecaries'  Weights  and
    Measures—Abbreviations—Relation  of  Drops  to
    Minims—The Metric System—Methods of Computing
    Doses—Methods  of  Converting  Apothecaries'  to
    Metric..............    78-93

                        CHAPTER X.

                          Enemata.
Kinds—Frequency and  Method of Giving—Utensils Used
    and Their Care—Douches.....             94-100 
CONTENTS
vii
                        CHAPTER XI.
                   External Applications.
Applications of Heat and Cold—Counter-irritants—Cup-
    ping ...............   101-109

                        CHAPTER XII.
                     Signs and Symptoms.
Development—Color  of  the Skin—Mouth  Breathing—
    Nausea and  Vomiting—Expectorations—Diarrhea—
    Distention—Pain—Chills:—Convulsions   ....   110-117

                       CHAPTER XIII.
                            Urine.
Normal and Abnormal—Catheterization and its Relation
    to Cystitis—Bladder Irrigation—Preparation of Speci-
    mens—Twenty-four-hour Amount—Simple Tests    .   118-126

                       CHAPTER XIV.
                         Emergencies.
Hemorrhage — Syncope — Epilepsy — Hysteria — Poison-
    ing—Lavage—Artificial  Respiration.....127-140

                        CHAPTER XV.
                   Emergencies (Continued).
Fractures—Sprains—Dislocations—Burns—Shock    .      141-151

                        CHAPTER XVI.
                  Wounds and Inflammations.
Classification and Method of Healing......152-154

                       CHAPTER XVII.
                          Bandaging.
Use of Splints,  Slings, and Supports—Material Used—
    Methods of Application.........155-170 
vin                     CONTENTS
                      CHAPTER XVIII.
               The Care of the  Eyes and  Ears .      171-175

                       CHAPTER XIX.
                         Anesthesia.
Preparation and After-care—Ether Bed......176-179

                       CHAPTER XX.
                      Surgical Technic.
The Operating Room—The Cleaning and Care—Steriliza-
    tion of Dressings, Instruments and Utensils—Disin-
    fecting the  Hands—The Field of Operation—The
    Operating-room Nurse—The Patient—Postoperative
    Care—Complications..........180-200

                       CHAPTER XXI.
                        Aspirations.
Aspiration — Paracentesis — Lumbar Puncture ■— Hypo-
    dermoclysis  and  Intravenous  Blood  Transfusion—
    Preparation and Method of Giving......201-206

                      CHAPTER XXII.
                   Food and Food Values.
Classification  of  Foods—Values—Special  Diets—Infant
    Feeding—Forced Feeding........207-222

                     CHAPTER XXIII.
                          Fevers.
Classification  and Significance — Types  and  Changes
    Brought About in the Body—Nursing in Diseases in
    which Fever is an Important Symptom.....223-235

                     CHAPTER XXIV.
            Baths for Reduction of Temperature.
Sponge Baths and Hydrotherapy Treatment—Cold Packs
    —Hot Packs—Hot Air—Nauheim Baths  ....       236
Glossary
249 
   PRINCIPLES  OF  NURSING.



                 CHAPTER  -I.

               QUALIFICATIONS.

  Physical, Mental and Moral Qualifications of the Nurse—The
Ethical Relation of the Nurse to the Patients and Their Friends—
To Her Superior Officers—HospitaJ  Staff—Fellow Workers—Her
Duty to Herself.

  "The development of sick-nursing has brought into
existence a large, highly skilled, and organized profes-
sion.  It is one of the most notable features of modern
social life."
  Women whose ambition it is to enter this profession
should consider  their  personal  qualifications.   The
desire to be a nurse and the willingness to submit  to
strict discipline and perform hard work, while of utmost
importance, are not all  that is necessary.
  There must always be an element  of self-sacrifice,
eft'acement and an appreciation  of the seriousness  of
the work.  There is no  class of persons  who come  so
close to the tragedies of life as does the nurse, conse-
quently she should be a  woman of sterling qualities.
  The qualifications are good health, both physical
and moral, and a well-trained mind.
     2 
18               QUALIFICATIONS
  Physical efficiency consists  of  being free  from all
organic diseases, all infirmities, peculiarities, and defects
(including enlarged glands, tonsils or adenoids, defective
teeth, and feet weakened or broken  down); the candi-
date should  be in possession  of faultless  sight and
hearing, and sufficient strength  and endurance to make
the best use of her possessions.
  The  mental qualifications are intelligence, common-
sense, perception, adaptability, discernment, executive
ability, cheerfulness, and tact.  The last is a rare asset,
and has been defined as "not the quality by which you
please, but by which you seldom offend."
  A certain amount of  education and mental training
is  indispensable.   This does not  necessarily  mean a
high degree of education  though that is always  to be
desired, as it is true that the educated woman, who has
the power of application, finds in her work much more
that is  of  interest, and is able to perform it better,
more easily, and more understandingly than the woman
whose mind is untrained.
  Mental training is that training received in school,
home life, or business,  which enables one to think for
one's self;  to  be discreet; to possess judgment;  to be
able to  observe  and  study  intelligently;  to  know
instinctively the right thing to do or the right decision
to make; to know how to  receive merited criticism and
profit by it.
  The  moral  qualifications  are those of  any  God-
fearing,  self-respecting  woman.
  Ethics is that  branch of philosophy which  deals
with human  character  and  conduct  so far  as they 
          A  NURSE'S DUTY TO HERSELF        19

depend upon certain general  principles, wrhich include
the conception of duty, honor, loyalty, truth, responsi-
bility, and justice.
  The Ethical Relation of the  Nurse to the Patients and
Their Friends.—To the patients  she should be faithful,
devoted, and a tireless servitor.  She should be willing
to give to them the best she  has to give,  regardless of
color,  creed, or social  standing.   She should forgive
their ignorance and  forget their faults,  remembering
only that  they are human beings,  and that they are
helpless and ill.
  To their friends she should ever be courteous  and
considerate, helping them when possible, and in every
way try to make their burdens lighter.
  Superior Officers.—To her superior officers she owes
deference and loyalty in the fullest sense of the terms,
and an obedience that  is prompt, unquestioned,  and
absolute.
  Her relations with the hospital staff should be purely
professional.  To  them  she owes  allegiance, and she
must remember that her profession supplements that
of medicine: that her part is to help, and not to criticise
nor suggest.
  To  her  fellow-workers she should  be  at  all  times
courteous, helpful, without being officious, and should
respect their privileges  and pleasures.
  A Nurse's Duty to Herself.—The necessity for perfect
health is  obvious, consequently the fundamental rules
of hygiene must be  observed,  including  proper food,
rest, sleep, fresh air,  and outdoor exercise  and recrea-
tion,  which should never mean strenuous effort. 
20               QUALIFICATIONS

  She should cultivate or develop any talent she may
possess, which  is not only  a  diversion, but may also
serve as a recreation, for it has been  truly said that
"rest is not in cessation from work but in  change of
work."
  She should keep  up a general interest in the things
which are happening in the world, and not allow herself
to  become  self-centered,  dull,  or  uninteresting—in
fact, she must  at all times  be true to herself. 
                 CHAPTER  II.

             PERSONAL HYGIENE.

Food and Drink—Clothing—Care of the Feet and Hands—Bathing
              —Exercise—Recreation—Sleep.

  Hygiene is the science of preserving health.  On the
personal or individual side it involves the consideration
of the  character of the  food and  beverages;  of the
clothing; of work, exercise, and sleep; of personal clean-
liness, of  special habits,  such as the  use  of alcohol,
drugs, etc.; and the control of various passions.
  Since an important factor in the efficiency of a nurse
is her health,  it follows  that everything which  may
in any way influence this should be  looked after with
the greatest  care.   It is unreasonable to  expect the
same  amount, quality  of work and power  of endurance
in the girl of eighteen or twenty years as in the  fully
matured woman; also  the young are more susceptible
to infections of all kinds.   As  a  rule, the city-bred
woman is better  able  to  stand the confinement,  close
application, and hard work than  the country-bred girl,
who is, more or less,  accustomed to outdoor life and
freedom, the deprivation  of which is very trying, and
in some cases may entirely disqualify her for hospital
work.
  The ideal nurse  is the one who can resist influences 
oo
PERSONAL  HYCIENE
which may  depress mentally  or physically, and who
has the power to endure fatigue.
  After entering the  training  school, much  of the
individuality and independence of the young  woman
are lost.
  Her  living conditions, food, clothing,  to a  certain
extent; hours for work, sleep,  and recreation are fixed
for her without individual preference.
  Food.—For people who are  in good health there are
two rules which should be observed in regard to their
food:  One  is to choose the  varieties which "agree"
with them  and avoid those which  they cannot digest
and assimilate without harm,  and  the other is  to use
only such foods and in such  quantities as  will afford
sufficient nourishment  and maintain the normal body
energy and weight.
  Drink.—It has been  estimated that about SO ounces
of fluid should be taken during the twenty-four hours
by the average adult person.   A considerable portion
of this should be taken as food.  Water forms the prin-
cipal part of the blood; it holds in solution and distrib-
utes the products of digestion, and is  the medium  by
which waste material is carried from the  body.  It  is
a  well-known fact  that most people  take  too little
fluid, and this is especially true of women.
  Coffee should be used in moderate amounts, and when
properly  taken is probably of benefit to  the  adult.
It contains an alkaloid, cafYein, which acts as a mild
stimulant without producing disagreeable  after-effects;
also, it does not incapacitate one for labor.   It dimin-
ishes  tissue waste  and gives   a feeling  of  rest after 
CLOTHING
23
exhausting mental or physical effort.  For this reason,
and  because  it permits the performance of excessive
labor upon a limited diet, it is often taken in excess.
When tolerance has been established or a habit formed,
coffee is no longer of value, but instead may become
decidedly harmful.
  Tea and cocoa have much the same  effect as coffee
with  the exception that  cocoa contains considerable
nourishment.
  Clothing.—The  objects  of clothing are  to protect
the body from the sun's rays,  from the  cold and from
winds;  from the  rain and other forms of  wet,  and
from mechanical, external injuries and discomforts; to
conserve body heat and prevent interference with the
natural functions of the skin.
   In discussing the value of different materials  for
clothing, the two  important factors  to be considered
are their power of  conducting heat  and of absorbing
moisture.
   The  heat-conducting power of a garment does not
wholly depend upon the  material itself, but upon its
texture.  The looser the texture of a fabric, the greater
the amount of air that is  held  in its meshes.
   Dry air is a poor conductor of heat, consequently  a
 loosely woven garment will feel warmer.
   Wool, for the reason that it is usually woven into  a
 cloth that is loose and porous,  is a most  valuable mate-
 rial for cold weather.
   Cotton material, usually  compact and  non-porous,
 is not so valuable as wool in cold weather.  However,
 when  especially  manufactured so  that  its  texture 
24
PERSONAL  HYGIENE
resembles that of woollen  cloth, it is a fair substitute
for wool.
   Next to the texture of a  material in importance is its
color, and its power to absorb or reflect the sun's rays
which are absorbed to the greatest extent by black, then
in order the dark shades of blue, green, and red.  Heat
is reflected  most  by  white,  then the light shades of
yellow,  green, and blue.
   In  underclothing which  is not exposed  to the rays
of the sun,  the color is unimportant.  Underclothing
should  be changed frequently  (daily, if possible).   It
should,  at least, be thoroughly aired overnight, and  the
same set should never be worn day  and night.
   Damp underclothes favor the  development of certain
parasitic skin diseases, the  organisms of which can live
only in conditions where heat  and moisture are afforded.
   Care of the Feet.—There  is  no part of the body more
generally overworked and  abused than  the feet.  The
shoes should fit perfectly,  yet  they seldom do.  In a
well-made pair of shoes the inner sides should be nearly
parallel and not diverge greatly when the wearer stands
with  the feet  together.  The outer side  of the shoe
should have a curve inward,  and the toe should  in no
case be  pointed.  The greatest amount of comfort may
be  obtained from the  low  shoe, which neither inter-
feres with the free  action  of  the ankle nor constricts
circulation.   The   heels should be  low  and broad.
High  heels are  not worn for comfort in walking but to
dimmish the apparent length of the foot.
  Personal Cleanliness.—Personal cleanliness is essential
to health and  comfort.   Daily bathing is  necessary 
PERSONAL  CLEANLINESS          25
because it removes dirt and infectious material of exter-
nal origin, and is a means of keeping the skin free from
waste products which interfere with its proper function.
  For persons in good health a daily cold bath is advis-
able.  A full tub bath is best and should be taken in the
morning.  A shower bath or sponging with cold water
is a good  substitute,  and may be  borne by many who
Fig. 1.—Proper soles for normal
     feet.  (Whitman.)
Fig. 2.—Shoemaker's
 feet.  (Whitman.)
cannot endure the  shock of  immersion.   The effect is
essentially a stimulant, and increases the activity of all
the organs.  The respirations are at first gasping, then
slowed and increased in depth, the pulse-rate is dimin-
ished,  and  the  temperature  slightly  lowered.   The
nervous system and  mental faculties are stimulated.
Upon emerging from the bath the skin should be dried 
2(>             PERSONAL  HYGIENE

with a coarse towel; the body should be pink and warm,
rather than  cold.
  One of the benefits derived from cold bathing is the
immunity from catching  cold.
  Hot bathing is a grateful means of reducing the lame-
ness of  muscles after hard  work or violent exercise.
It is depressing, and while  of  value  in  conditions of
insomnia,  should  only be taken  by  the  advice  of a
physician.
  Persons who are not in good physical condition should
avoid extremes, the best results being obtained when the
water is at the temperature of  the body.
  For purposes of cleanliness the cold bath should be
supplemented by  the use of warm water, soap, and a
brush, which are effectual means for removing the dirt
and effete material from the surface of the body.
  Care of the Hands.—Especially  should careful atten-
tion be given the hands, not only to keep them immacu-
late, but in  good  condition by the use of  lotions, cold
cream, etc.   This is particularly  necessary for  nurses,
as most of the infections from which they suffer are due
to carelessness in the care of the hands.
  Exercise.—In the majority  of  individuals all  the
exercise needed is  taken  as  an  inseparable element in
their regular work,  and any additional amount should
be performed as a recreation.
  Violent  exertions do harm when a person overworks
the heart (gets "out of breath"); it should be regarded
as a danger signal, and absolute  rest should be enjoined.
  Outdoor exercise when possible is the best.  There are
few people who have not the power to walk, and walking 
SLEEP
27
is  an excellent form of exercise; at the  same time it
furnishes a means of recreation, and is a luxury all can
afford.
  Sleep.—The amount of sleep required depends upon
the physical effort expended; the diet, to a certain extent;
and upon the age and general condition of  the  indi-
vidual.  The average adult requires about eight  hours
of complete repose. 
CHAPTER  III.
                  BED MAKING.

  Economy of Time, Labor, and Hospital Property—Making a Bed
with the Patient in—Changing Linen, Etc.—Fracture Bed—Cradles
—Head-rests—Moving and Lifting Patients.

  In making a bed  there  are three things to be con-
sidered:  (1) The comfort of the patient; (2) the economy
of time, labor, and utensils; (3) its beauty or symmetry.
  The comfort of the patient consists in having an
absolutely  smooth surface on which to lie,  free from
humps  in  the  mattress  and  wrinkles in  the sheets;
the blankets put on to cover the patient, not tucked
under the mattress so tightly that  it is impossible for
the patient to turn over or draw up the feet; the pillows
adjusted to suit the occupant and the existing conditions.
  Pillows which may be  very comfortable  under some
conditions  may be decidedly uncomfortable at  other
times.
  Economy of  time  and  labor consists in  gathering
the necessary clean linen to make the required number
of beds.  Considerable time is lost by the failure  to do
this.
  Place a chair at the foot  of the bed, remove from the
bed each article separately, and fold it over the chair;
thus the nurse is able to get the required sheet or 
BED MAKING
29
blanket from either side of the bed, saving many steps
and considerable time.   Economy of linen means its
proper adjustment.  A sheet carefully and tightly put
on the bed or a spread or pillow case adjusted without
crushing remains fresh much longer.
  That the ward may present an  orderly appearance,
it  is  often  necessary to  change linen which is only
badly crushed.
  To make  an  empty bed, remove separately each
article of clothing and fold over a chair at the foot of
the bed.  Turn  the mattress from head to foot, that
the heavy  part of the body may  not always come in
the same place.  Adjust the under sheet by tucking
it  well  under the mattress at  the  head of  the bed,
allowing about twelve inches for this; then standing at
the foot, pull the sheet tightly and  raising the mattress,
draw it over the  end; when  it is lowered the sheet will
be stretched on  as tightly as it  is  possible to make it.
Fold  back the corners and tuck  under  the mattress,
the ends first, the center last.
  The rubber sheet is put on crosswise over the center
of the bed.  The draw  sheet is to entirely cover  the
rubber  with two thicknesses, or a large  sheet may be
folded and used.  In either  case the upper edge should
come well up under the pillow.
  The upper sheet should be put on so that the smooth
side of the hem comes on the outside when turned down
over  the blanket.  Each blanket is put separately, the
sheet turned down at the top and tucked in all together,
in the order of the under sheet.
   It is possible to adjust the spread in so many different 
30                 BED MAKING
wTays that a description is difficult.  It should be borne
in mind that a spread is not for the purpose of hiding
a poorly made bed, which  it can never do.
  Pillow cases should be carefully put on  so  as not
to crush; the corners should be well filled out with the
seams toward the head of the bed.  With both hands in
the center, press the pillows down so that they will lie
flat.
  To Make a  Bed with a Patient In.—Remove  all the
upper clothing except one blanket, which is to remain
over the patient.   If  not  uncomfortable, the pillows
may also be removed, otherwise they are moved with
the patient to either  side of  the bed.  Standing at
the foot of the bed, pull the upper sheet from  under
the blanket.   Loosen the bottom  sheets and turn the
patient on the side, having  him lie  near the edge of the
mattress.   If  the  patient  needs help in  turning, he
should always be turned toward the nurse, then there
is  no  possibility of his being rolled out of bed.  The
draw sheet, rubber, and bottom sheet are then folded
close up to the patient's back; a fresh bottom sheet
put on  that part of the mattress which  has   been
uncovered and the  ends and outer edge tucked under
the mattress, the free edge rolled, or folded close beside
the soiled linen. The rubber may then be pulled back,
covering the fresh sheet; then the  draw  sheets are put
on, the  outer  edge being tucked in.  Before going to
the opposite side, turn the patient, drawing the pillows
to that  side.  The  soiled linen may then be removed
and the fresh  drawn  through  and tucked  in.   Care
must be taken that there are no wrinkles in sheets or 
     TO MAKE  A BED  WITH A PATIENT  IN   31

rubber, and that they  are  so  securely tucked in that
they will not work loose after a few hours.
n -	n '
i	
	
i	i
	
i	
xn	xr
Fig. 3.—Fracture board made from one-half inch pine, painted white,
                      size of bed.
  Replace pillows and make the patient comfortable;
then proceed as in an empty bed.
  A fracture bed differs from a regular bed only in that
a so-called fracture board is placed  between mattress
and  springs, making a  uniform  unyielding  surface.
Fig. 4.—Bed cradle.
A cradle may be put over the feet to keep off the weight
of the bedclothes.
  Head rests are used for convalescents and patients
who have  difficult breathing from any  cause, or  for 
32
BED MAKING
some reason are more comfortable in a reclining posi-
tion.
  The head rest is not comfortable for  all persons.
When used, it is best adjusted under  the mattress,
the whole being covered with a sheet tucked in.
  Three  pillow's  are  necessary:  the  first  two  placed
one above  the other, and  the  third to stand on end,
should be pulled down under the  back.
                       Fig. 5.


  To  Change the  Position of Patient.—The necessity
for changing the  position of patients increases with
their  degree  of  helplessness, not only  as a  means  of
adding to their comfort but to guard against bed-sores.
  To turn those  who are able to be of slight assistance,
the nurse should stand close to the side of the bed,
with one hand under the shoulder and the other under
the hip of the opposite side,  and the patient' is turned 
     TO CHANGE  THE POSITION OF PATIENT   33

toward the nurse.  By this method it is impossible to
roll a patient out of bed.
  A nurse should never attempt to move an absolutely
helpless patient alone.  It is best done  by two nurses
standing at opposite sides of the bed, and by holding
the sides of the sheet, lift him to any part of the bed or
to a different bed if necessary.
  It also requires two nurses to make the bed: one to
turn  the patient and prevent him  from falling out,
and the  second to adjust the bedclothing.
3 
CHAPTER  IV.
           ADMISSION OF PATIENTS.

Listing and Care of Clothing and Valuables—Bathing—Washing the
        Hair—Routine Care of Patients—Care of Dead.

   In many hospitals patients are admitted to a receiv-
ing ward, w-here, when not too sick, they are  undressed,
bathed and  their  clothing  and valuables  listed  and
cared for.  When no receiving-room is provided they
are admitted directly to the  ward.
   Whatever  the  arrangement  may  be,  the patient
should  receive  immediate attention and  be made as
comfortable as possible, both mentally and physically.
   All patients  should  be given a kindly,  sympathetic
welcome.  This is usually appreciated and helps reas-
sure them  in spite of former fears and prejudice.
   It is particularly true of non-English speaking people
and of children.
   If seriously ill, the patient should  be laid on the  bed
before  undressing.   The clothing, no  matter what its
condition, should be removed carefully.
   When there is injury to either leg or arm, the gar-
ments  should be removed from  the  well side first.  If
badly scalded or burned, the  clothing should  be cut off.
   The  undressing of patients should be done by  two
persons, and duplicate lists made of all articles, includ-
ing contents of  the pockets,  valuables, etc. 
               ADMISSION OF  PATIENTS             35


                WOMEN'S  CLOTHING LIST.
Name_______

Date__________________  ______________Ward_____________.

  N. B.   The Head Nurse  will make out this list  immediately on
the entry of every patient, and send it promptly to the Supervisor's
Office.   After being entered there, it will be returned and kept with
the clothing.   When the patient is discharged the Nurse must verify
the clothing with the list, and return it to the  Supervisor, with the
patient, when she leaves the ward.
Bonnets___________________________________    ____________  _ _
Hats______________________________________  __________________
Boots_____________________________________  __________________
Shoes____________._______________________   _________________
Slippers____________.___________________ ____________________
Stockings_______________________________ .. ...___.....________
Dresses____________    _______________________________________
Skirts_________  . ._  _    . .   _________________________________  .
Waists_____________________________________________________
Flannel Skirts_____   .    ..____________________________________
Drawers: Cotton______ _________________.Flannel__________. _.
C 'orsets______________________-____________.________________
Chemises___________    _______________________________________
Nightgowns____________________________________.______________
Aprons________________________________________________________
Towels___________________________  ___.._________ . _  _________
Handkerchiefs_________________________________________________
Shawls___________._____________________ ____________________
Cloaks___________________________________________________
Gloves__________________._________________  _  _ ._______________
Sacs________________. --t______________________________________
Collars________________________________________________________
Cuffs_________________________________________________________
Neckties______________________________________________,______.
Valises_____________________'__________________________________.
Valuables___________________----------------------------------
___________________Head Nurse.
Entered in "Entry Book" this day.
....._______________________191
                                                   Supervisor.
    Date of Discharge_____________________^____________191
         I have carefully compared the  clothing with this list and
find the articles all accounted for1
                      Head Nurse.
1 Except. 
36          ADMISSION OF PATIENTS
  These lists should be signed by the head nurse and
by the patient, who is allowed to keep one, and the other
is kept with the clothes.
  All clothing should be examined carefully for pediculi,
and  if necessary, fumigated.  Articles returned after
being fumigated which are soiled should be marked with
the patient's name, ward, and bed number,  and dupli-
cate lists made and sent to the laundry, one list to go
with the soiled articles, the other to be kept in the ward.
  Valuables should be sent to the hospital safe, kept
for that purpose.  Money, papers, jewelry, etc.,  should
be put in an envelope and sealed, and a list of the con-
tents with the patient's name and ward written  on the
outside.
  The temperature, pulse, and  respiration  should be
taken. If the temperature is not above 99°  F. and the
pulse is of good quality, the patient may be taken to the
bathroom for a tub bath if there is no  special reason for
not doing so.   A person with  skin disease or  a rash
would be excepted.  Patients should not be  allowed to
take a bath unattended by a nurse; after the bath they
should be given a bath-robe and  slippers, or be  put in
blankets and taken to bed in a wheel  chair.
  When preparing to give a bath in bed, there  should
be at the bedside hot  water, plenty of towels, wash
cloth, soap,  brush, nail  file, scissors, orange stick, and
comb,  both coarse and fine.  If the patient has  no
tooth-brush  one  should be provided, or swab  sticks
with small pieces of gauze  substituted; listerine or
any  suitable mouth wash may  be used to clean the
mouth. 
ADMISSION OF PATIENTS          37
  The bed should be protected with a rubber, covered
with a blanket, the bedclothes neatly folded clown to
the foot of  the bed, and the patient covered with a
warm wool blanket (never a  cotton blanket or sheet).
The face and neck should be bathed first, then the rest
of the body in sections,  keeping all the body covered
warmly except the part  being bathed.
  Special attention must be given to the nails, and the
hairy portions of the  body  should be examined for
pediculi.  If there are  pediculi  the  hair should  be
saturated with tincture of larkspur and securely pinned
up  in a  towel before the bath is  commenced.   Later
the hair  should  be combed with a fine comb and
thoroughly washed.  Several applications of larkspur
followed by the use  of a fine comb may be necessary
before washing.
  Ether or hot vinegar  may be used to remove nits,
but many applications may be required.
  To wash  the head of  a patient in bed, the pillow
should be covered with  a  rubber  and a rubber sheet
placed about  the neck, with the sides folded over to
form a drain, and the end dropped in a pail or slop jar
at the head of the bed.   Two pitchers  are necessary,
one containing warm, soapy water, and the other clear
warm water for rinsing.
  The soapy water should be poured over the hair and
the scalp thoroughly scrubbed until  it  is clean, and
then rinsed with clear, warm water. The head and hair
should be dried as much as  possible with towels, the
tangles combed out, and the hair spread over the pillow
to dry. 
3S          ADMISSION OF PATIENTS

  It is not always possible to wash the hair of a female
patient when the entrance bath is given, as the pro-
cedure is tiresome for the patient who is seriously ill.


       THE ROUTINE  CARE  OF  PATIENTS.

  The first duty of a nurse is to her patients.  She should
make every effort to  make them comfortable both
physically and mentally; she can do  much  for  the
mental  comfort of  one  by showing  an intelligent
interest, not in "the case" alone, but in  the individual.
  Worry and  anxiety may retard  recovery, and  it is
as much a point in good nursing to guard against this
as it is to provide  for their physical comfort.
  Little things which  are  only  annoying when well,
become real  troubles when ill.  Some of  the disturbing
things are unnecessary  exposure  during  treatment,
giving baths, doing dressings or giving a bed-pan.
  A screen should always  be  provided  and an effort
made to give  one as much privacy as possible, also
care should  be taken  that one is not  exposed to a
draught.
  In the care of a  patient do not lean against the bed
nor knock against it in passing.  It is always annoying
and in certain conditions may cause considerable dis-
comfort,  particularly when every  move made by  the
patient himself is painful.
  Never  leave one in doubt when a request  is made.
If not possible to fulfill it immediately tell him so, also
that you will attend to his wants  as soon as possible: 
        THE ROUTINE  CARE OF PATIENTS      39

usually the patient is satisfied to wait  a reasonable
length of time.
  Never allow whispering nor  the discussion of any
patient's condition within hearing of the patient.
  When necessary to do any  treatment explain  its
nature as well as possible before  starting.  It seems
less  formidable and  patients are likely  to consider
such an explanation a compliment to their intelligence
(which of course can do  no harm).
  If possible, give a patient the things he likes to eat.
See that the dishes are perfectly  clean,  not chipped,
and are attractively arranged. Tray cloth and napkin
must be immaculate.  A soiled or crushed  napkin or
badly  served food may  spoil one's enjoyment  of  the
meal or even interfere with its digestion by  creating a
disgust for food.
   Too large portions of food, often something which has
been  anticipated with a great  deal of pleasure, may
take away the  appetite of a patient entirely, or create
such a dislike for the particular article that  it is never
again enjoyed.
  Serve  food  intended  to be  eaten  hot in covered
dishes which have been  heated.  Do not put hot food
on a cold dish,  nor cold food (ices, etc.) on a dish which
has not been chilled.
  When feeding a patient do not hurry.  As much care
should be exercised in this as in doing any treatment,
remembering that it is equally  necessary.   He  should
be put in the most comfortable position  and be made
to feel that this particular duty is a pleasure rather than
an ordeal. 
40
ADMISSION OF PATIENTS
   After  feeding nothing  gives  more comfort  than  a
 thorough cleansing of the mouth.  One who is able to
 do this for himself should be supplied with a cup of
 water, not too cold  (which may or may  not  contain
 a  small amount of listerine or  potassium  chlorate),  a
 tooth brush and kidney basin, also a glass of cold water
 to rinse  the  mouth after using the toothbrush.
   Patients too sick to take this care must have their
 mouths washed by the nurse.   To do  this  will be
 required  the  articles enumerated  above, or  swabs
 made with cotton wound on applicator sticks*.  If the
 patient is very ill or slightly delirious, it is necessary
 to separate the jaws and hold  them apart while the
 tongue is being cleansed.  This is best done by  using a
 wood tongue depressor, which is always of soft wood
 and eliminates the danger of breaking the teeth, which
 is  always present when a harder  material is used.
   If the  mouth shows ulcerations great care  should
 be used in cleansing.  A weak solution of myrrh  and
 very soft  swabs give the greatest degree of comfort.
   A neglected mouth may be the source of a reinfection
 and always reflects discredit upon the nursing, for it is
 the nurse alone who is responsible for the condition.
  The sordes,  which consists  of  mucus, discarded
 epithelial  cells,  blood, from cracks or fissures, partially
 decomposed, and a multitude of bacteria is always a
 menace.  The nurse who cares for such a mouth should
 thoroughly scrub  and disinfect  her hands following
the procedure, remembering that she has come in direct
contact with organisms causing the  disease  in  the
individual treated. 
        THE ROUTINE CARE OF PATIENTS     41

  Change of position is necessary for the comfort, as
well as an efficient measure in the prevention of abra-
sions and pressure sores.
  One suffering from rheumatism or any other condi-
tion in which sweating is  excessive  should be bathed
frequently and powdered, parts  showing the least  sign
of pressure  should be protected by  air rings, pads or
pillows.  Painful joints or  limbs supported by pillows
and elevated when possible.  Sheets changed often and
kept smooth, cool and dry.
  Fever  patients, whose skin is hot and  dry, in their
restlessness  often rub the  skin  from the elbows  and
knees; these parts may be protected by a soft  cotton
dressing  held  in  place by a  bandage; if only slight, a
cocoon dressing.
  I'n all  conditions, turn the patient from side to  side
whenever possible, if necessary  supporting him by a
pillow^ tucked close  up to his back; rub the parts  sub-
jected to pressure, especially the back, very frequently
and bathe with alcohol.
  The giving or removing of a bed-pan, which is such a
frequent and  necessary duty, may  in most cases be
accomplished  with little trouble or  discomfort  to the
patient.  The bed-pan should be warmed, usually under
hot  water,  then dried.  In  taking this to a patient it
should be covered; there should also be  taken  to the
bedside,  toilet paper, warm  water in  a small  pitcher
kept for  the purpose, cotton  pledgets or small pieces
of gauze and a kidney basin.  After using, the patient
should be made as  clean  as possible with  the toilet
paper, then washed  by pouring the  water slowly  over 
42
ADMISSION OF PATIENTS
 the parts  and drying with the pledgets of cotton or
 gauze.  The kidney basin is to collect these after using.
   In removing the bed-pan assist by passing the hand
 under the  hips  and  elevating  the patient slightly.
 When one is particularly helpless  two nurses, one at
 each side of the  bed,  will be necessary  to  do this.

             THE CARE OF  THE DEAD.

   When dissolution has taken place the  friends of  the
 patient, if present, should be allowed to remain with
 their dead for a short  time.
   After the  doctor has pronounced life extinct,  the
 body should be prepared.  If there is an open wound
 it should  be sutured, and in  any case a  fresh dressing
 put on; the body  thoroughly wrashed with soap and
 water, the hair neatly  braided (if a woman).  A trian-
 gular bandage, at least 1 yard square, with a pad of
 non-absorbent cotton, should be pinned on like a child's
 diaper.  This will catch any discharges which may come
 from the  rectum or vagina; the  bladder  should  be
 emptied with a catheter.
   The arms should be  fastened across the body with a
 bandage, the legs should be fastened at the  knees and
 ankles in  the same manner.   The  eyes  may be  kept
 closed by  inserting a small piece of tissue paper under
 the lid,  the chin  supported by a roller  bandage  or a
 support provided for the  purpose.  Packing the body
 cavities is no longer considered necessary; besides it is
thought that it prevents the  escape of gas and causes
distention  of the body. 
THE CARE OF THE DEAD          43
  False teeth which have  been removed should  be
returned to the mouth after death; they do not often
remain in place, however, and it will require the skill of
an undertaker to properly adjust them.
  If death occurs  in a hospital, the name and age of
the patient, the date and hour of death, the ward, must
be plainly written on a card and attached to the patient,
either fastened to  the wrist or securely pinned to the
shroud sheet. 
CHAPTER V.
                   BED-SORES.

               Their Cause and Treatment.

  Bed-sores are so called because they occur on per-
sons who are compelled to lie in bed.
 • They may be defined as lesions of the surface of the
body, often becoming gangrenous.
  Bed-sores, in many  instances,  may be prevented,
while in some cases they cannot in spite of all care.
  The predisposing causes are poor circulation, mal-
nutrition,  paralysis, and edema.
  Undue pressure and neglect are invariably the imme-
diate causes.
  Restless  patients may rub the  skin  off the elbows
while lying in bed,  which may, through neglect, result
in a deep lesion.  The application of an oily lotion and
protection  from further injury  is  usually all  that  is
necessary.
  Bed-sores  caused by moisture  appear  as a  red,
swollen area, upon which the skin is macerated, and in
places the  epidermis is separated  from the true skin,
forming blebs.
  The skin is easily broken and rubbed off,  leaving a
raw  surface, which is liable to all  kinds of  infection.
Patients who are incontinent, either from paralysis or 
BED-SORES
45
other causes,  are  particularly liable to develop bed-
sores of this class.
  The  treatment  consists in making the part abso-
lutely clean by first washing with soap and water, then
applying a 4 per cent, solution of boracic acid.   The
surface should be  thoroughly dried with sterile cotton
and powdered  with  an antiseptic powder.  The main
object is to keep the part thoroughly clean and dry.  It
is best not to cover  with a dressing, but it is essential
to turn the patient  from side to side that no pressure
may exist in that particular spot.
  Deep sloughing sores are caused by poor circulation,
either  local or general, and pressure.  The  greatest
number are of this class, and are the only ones unavoid-
able.  They occur in persons who are paralyzed and
cannot change their position.  That sensation is lost
and they do not  suffer discomfort, together with the
generally poor circulation, results in their rapid develop-
ment.   A sore may  develop  in a single night or a few
hours.  Death has  sometimes been attributed to the
absorption of toxins from bed-sores of this class.
  They appear first  as a dark  red area,  afterward
becoming a deep purple or black, from which the skin
separates.   This darkened area draws away from the
surrounding healthy tissues and may slough out or be
cut out, leaving a deep, open, infected wound, which
must heal by granulation, if, indeed, healing  ever takes
place.
  The  treatment  is usually ordered in each  individual
case.  It consists of hot, moist dressings until the slough
is removed, followed by one  which will promote granu- 
46
BED-SORES
lation, as fluffed gauze moistened with balsam of Peru,
or equal parts of alcohol, glycerine, and tannin, loosely
packed in.
   "Pressure  sores"  are  usually the  result  of  the
improper application of some apparatus, splint, plaster
cast, or bandage.
  The undue  pressure is  in  a localized area, cutting
off or impeding the circulation.  A deep slough results.
They are less rapid in development than those caused
by general, poor circulation.  The treatment is  the
same as for bed-sores.
  There is nothing which tends to show poor nursing
more than does a bed-sore, for they may in the majority
of cases be avoided.
  First, there  should be absolute cleanliness; the  bed
dry  and free  from  crumbs  and wrinkles;  all undue
pressure should be removed, by changing position,  and
the use of air rings and pads; any friction should be
removed or prevented by protecting the part.
  As a routine the back should be rubbed with alcohol
and  dusted with talcum powder at least once a day.
In many cases this is necessary every  few hours.  This
not only toughens the skin and stimulates the circula-
tion, but affords an opportunity to inspect the prominent
parts thoroughly,  particularly at the shoulder blades
and at the tip of the spine. Any red spots which cannot
be diffused by rubbing, or places where the skin is
broken or worn off, should receive immediate treatment. 
CHAPTER VI.
TEMPERATURE,  PULSE  AND  RESPIRATION.

  Heat Production and Elimination—The Normal Temperature—
The Pulse: Abnormal and Normal—Respiration, Types and Charac-
teristics—Clinical Thermometers and Charts.

              BODY TEMPERATURE.
  All warm-blooded animals have a temperature nearly
constant, regardless of the climate in which they live.
  This  is called the "normal temperature," and is
compatible with health.
  It is the balance between heat production and heat
elimination.
  Heat is produced in  the body by  oxidation of the
food which has, in whole or in  part,  become a part of
the body.
  The oxygen which is  breathed into the lungs event-
ually combining with substances in the body produces
combustion, the result  of which is heat.
  Some of the heat is utilized as energy and some given
off  in the expired air. About 88 per cent, of the  entire
amount lost is from the surface of the body by radiation
and the evaporation of the moisture from  the  sweat
glands: A small amount is lost through the excretions.
The balance  is retained  to furnish  the body  heat,
which with very slight variations is constant. 
4S  TEMPERATURE, PULSE,  AND  RESPIRATION

  Increased  activity results  in  an over-production of
heat which in health is given off through the increased
amount of moisture on the surface of the body and the
expired air by more rapid breathing.  By this  means
the balance is maintained, which is 98.0° F. or 37° C.1
  Deviation  from  this is serious in proportion  to the
degree of abnormality.
  Any rise in  temperature of  the body is  caused by
increased oxidation.  At the same time there may be
an increase in the amount of heat lost, but not in pro-
portion to the over-production, so the balance is lost.
Heat is then stored up in the body, which condition is
spoken of as  fever, or pyrexia.
  This fever may  be generated within the body,  the
result of waste not properly eliminated, or it may be
produced by poison  taken in.   This is usually  in  the
form  of bacteria.
  All infections to  a greater or lesser degree are accom-
panied by fever.
  Subnormal temperature or a  temperature below nor-
mal  is more  often due  to the  low production of heat
than  to its excessive loss, as is  the case of starvation,
shock or collapse, and after wasting diseases.  In hemor-
rhage, excessive  vomiting, diarrhea,  and  exposure  to
  1 To reduce Fahrenheit to Centigrade scale and vice versa:
  Fahrenheit scale:  32°  above 0 is freezing-pomt;  212°,  boiling-
point; between freezing and boiling there are 180°.
  Centigrade 0 is freezing;  100°, boiling-point.  Every Fahrenheit
degree is \%% or f the size of a Centigrade degree.
  To change Fahrenheit to Centigrade scale:
  F.- 32° X f = C.
  Example:  212° F. - 32° =  180° X f = 100° C.
  To change Centigrade to Fahrenheit:
  C. -H | + 32° = F.
  Example:  100° C. -4- f =  100° X f = 180° + 32° = 212° F. 
BODY  TEMPERATURE
49
cold the low temperature is caused by the direct loss of
heat.
  A certain amount of heat is necessary to life; any
diminution shows a low vitality.  If greatly diminished,
death will result.
  The degree of abnormality is second in importance
to its  duration.
  The human body can stand a greater increase than
decrease in temperature.   One may  recover from an
illness in which the temperature has ranged 3° or 4°
above normal for weeks; while  a temperature 3P or 4°
below, results fatally in a few hours.
  The degree  of temperature  compatible  with  life
depends considerably upon the cause of abnormality.
  Patients may recover  from sunstroke after a tem-
perature of 108°  or 110°.  This excessive degree lasts
only a few hours.
  In  pneumonia, which is a disease of short duration,
the temperature frequently reaches 105°, and recovery
follows.
  In malaria 106° is not uncommon, while such a degree
prolonged, as in typhoid,  would undoubtedly be fatal.
  Patients have recovered from shock with a tempera-
ture of 95° and died of a prolonged temperature of 97°,
as in  starvation or cancer of the stomach.

    THE CLASSIFICATION OF BODY TEMPERATURE.

    Hyperpyrexia, 105° F. or over.
    Pyrexia (fever), 101° F. to  105°.
    Subfebrile, 99°" F. to 101°.
      4 
50  TEMPERATURE, PULSE, AND  RESPIRATION

    Normal, 98° F. to 99°.
    Subnormal, 97° F. to 95°.
    Collapse, 9o° F. or below.
  It is customary  to  take the temperature  at  least
twice daily; this should be done at the same hour every
day in order that an exact record may be made.
  In severe cases it is recorded every four hours or
oftener.  In this way any sudden rise or fall  is noted
which otherwise may have been  overlooked.   It is also
necessary in carrying out antipyretic treatment.
  Records are made on clinical charts by drawing lines
up  and down according to the degree of temperature.
  The  records  are valuable as  they afford  a clinical
picture  of the course of the disease.
  As each disease has individual characteristics and
runs a  certain course, an accurate record is  of impor-
tance.
  A clinical thermometer is the instrument used to take
the temperature of the body.  It differs from all others
in that it does not record changes in the temperature of
the atmosphere, but is self-registering.
  For convenience the temperature is usually taken by
the mouth.   The bulb of the thermometer is placed
under the tongue, the lips closed, and the patient told
to breathe through the nose.
  When it is impossible to do so, because of any  mal-
formation or temporary obstruction of the nasal cavi-
ties and the patient breathes through the mouth, an
accurate record  cannot be made.  In such cases  it is
best to  take  the temperature in the axilla or  rectum.
(The vagina or  groin may be used.) 
BODY  TEMPERATURE
51
  When taken by the axilla the record is about TV F.
lower than when taken by the mouth and TV F. higher
by the rectum  than by the mouth, when a change  is
made from the mouth to axillary or rectal temperature.
Nana,----     ___________Ward. _ .________Physician,    .     .  _ .. ,|D»t«.
Del. Dey .1															
															
ioe 104 102 IOO QS <i6															
															106 1Q4 102 IOO 08 96
															
															
															
															
															
															
															
															
															
															
															
															
															
															
160 140 120 IOO BO 60															IOO 140 120 IOO 80 60
															
															
															
															
															
															
															
															
															
															
															
															
															
40 30 20 IO															40 30 20 10
															
															
															
															
															
               Fig. 6.—Temperature chart.

  The first record should  be marked A  (axillary) or
R (rectal), as the case may be. 
.")2  TEMPERATURE,  PULSE,  AND RESPIRATION

  The axilla should be wiped dry, care being taken that
two surfaces of the skin come together,  covering the
bulb completely.  The arm should be held to the body
tightly.
  When taken by the rectum it must be empty, as other-
wise no record will be made.
  A nurse should never leave a patient who is having
the temperature taken by rectum.  The  thermometer
may get lost in the rectum or be  broken off.  Either
accident would  be decidedly serious.
  An ordinary  hospital  thermometer will record in
three minutes by  the mouth or in  six  by  the axilla or
rectum.
  A young child or an unconscious, delirious or insane
patient  should  not  have a thermometer put in the
mouth, because they are liable  to break it between the
teeth, and there is a possibility of swallowing pieces of
glass or the mercury.  When not in use, thermometers
should stand in a jar or mug kept for that purpose,
in which there is  some disinfectant solution or 70 per
cent, alcohol.
  A layer of absorbent cotton may be put in the bottom
of the jar  to prevent breaking the thermometer, but
should be  changed  each time the thermometers are
used.
  The mercury should always  stand as low as 96° F.
before taking the  temperature of any patient. This is
accomplished by grasping the end  firmly  and shaking
it down. 
THE PULSE
53
                    THE PULSE.

  The pulse is the expansion and recoil of the arteries
caused by the contraction of the heart.  By this con-
traction the blood from the left ventricle is forced into
vessels which are  already full; this causes distention,
which may be felt in any of the superficial arteries, and
is called a pulse wave.
  This furnishes an index to the heart's action, whether
it be strong or weak, rapid or slow, regular  or irregular.
  The normal pulse is regular both in strength of beat
and rhythm; it should beat from 70 to 80 times per
minute, and there should be a medium artery, neither
distended greatly  nor very compressible.
  The pulse is slower in man than in woman.  In young
children (three or four years) it may be 100, in newborn
babies 120 to  130.   This gradually decreases until
adult age, when the average pulse-rate is about 72.
  In extreme  old  age it  becomes much  slower than
normal, sometimes reaching 50  or  60.
  The normal pulse is subject to  considerable variation
as  to the number  of beats per  minute.  It is greatly
influenced by exercise; the more violent, the more rapid
the pulse; excitement, emotion, and digestion all affect
the pulse,  increasing the rate somewhat.
  The abnormal pulse differs from the normal in many
ways. The types directly due to  the heart's action are:
(1)  irregular  pulse—may be irregular  in strength  of
beat or in rhythm; (2) intermittent pulse—where a beat
is occasionally  lost; (3) frequency—slow or rapid.
  While these conditions may exist in a diseased heart 
54  TEMPERATURE, PULSE,  AND RESPIRATION

they do not necessarily mean organic trouble; it may
be purely functional, denoting weakness.
  Any of the above abnormalities may exist after  a
long illness, particularly'after typhoid or where there
has been a considerable wasting of tissues.
  Types due to the condition of the bloodvessels are:
  Dicrotic pulse is  caused by  the relaxation  of the
arterial walls:  Two beats are felt.  A strong beat or
pulse wave, followed by a  weaker one, for  each con-
traction of the heart.
  The first wave is caused by the contraction of the
ventricle and  the secondary, or  smaller wave, by the
closure of the aortic valve.  It may  be distinguished
from an irregular pulse by counting the heart-beat for
the same length of time.
  A high-tension pulse, or one in which the arteries
seem distended and are  non-compressible,  is usually
due to the contraction  of the small vessels,  arterioles,
and capillaries.
  A low-tension pulse, the exact opposite, may denote
a weak heart, but more frequently relaxed capillaries.
  Pulse may  be felt at  any superficial artery.  For
convenience the radial artery (at the wrist) is the one
most often used. If the heart's action be weak it may
be felt more plainly at the carotid or temporal arteries.
  It is possible to make an accurate count in one-half
minute, but it is not possible to determine the character
of the pulse in that time;  consequently, it  should be
held long enough to discover any abnormality if there
be one.  The character of the pulse is most important.
  In counting the pulse, the first two or three fingers 
RESPIRATION                55
should be held on the artery, never the thumb.  The
pulsations in one's thumb may often be felt and  con-
fused with that of the patient.

                  RESPIRATION.

  Respiration is the  function  by  which  oxygen  is
absorbed  into the blood and carbonic  acid  exhaled.
The assimilation of  oxygen and the evolution of  car-
bonic acid take place in the tissues as  a  part of the
general process of nutrition.
  The respiratory movements are two, and consist  of
an alternate dilatation (inspiration) and contraction  of
the chest (expiration).  Both are mechanical, muscular
movements, and while involuntary they may be modi-
fied to a certain extent.
  Inspiration, taking in of oxygen, is due  to the con-
traction of the  respiratory muscles, causing dilatation
of the chest.  The air then rushes in to fill the space
thus created.
  Expiration is partially a passive process, and is the
result of the recoil of the walls of the thorax, and of the
elastic tissues of the lungs, whereby the carbonic  acid
is expelled.
  The respiratory movements vary according to  age,
sleep and  exercise, being most frequent in early life.
  The number is increased by exercise and decreased
by sleep.
  The ratio to the pulse is about 1 to 4 in health, and
in the normal adult the average is about twenty respira-
tory movements per minute. 
56  TEMPERATURE,  PULSE,  AND RESPIRATION

  Normal respiration should be quiet, easy, and regular.
  The types vary according to age and sex.
  The abdominal  type is  most  marked  in  children,
irrespective of sex, the movements being effected by
the diaphragm and abdominal muscles.
  The superior costal type in  the adult female:  The
movements are more marked in the upper part of the
chest from the first to the seventh ribs, permitting the
uterus to ascend into the abdomen during pregnancy
without interfering with respiration.
  The inferior costal type  is manifested by the adult
male; the movements are largely produced  by the mus-
cles of the lower part of the chest and by the diaphragm.
In disease the respiration varies according to existing
conditions.
  In  pneumonia the  respirations  are rapid, difficult,
painful, and shallow:   Rapid and difficult because of
diminished air space; painful and shallow because of the
inflammatory process.
  Rapid heart  action also causes difficult or labored
breathing, an increased amount of blood being sent to
the lungs for its  supply of oxygen; Nature labors to
supply that demand.
  Difficult or labored breathing  from any  cause is
called dyspnea. Accompanying this is usually a dusky
or blue  color of the skin called cyanosis; this  is due to
the insufficient amount of oxygen absorbed.
  An upright position with the support of bed-rests and
pillow7s is necessary in conditions of this kind.
  Stertorous  breathing is  that / in w7hich a  snoring
sound is produced. 
RESPIRATION
57
  It usually accompanies unconsciousness from  any
cause;  it may occur during sleep; the unconsciousness
produced  by an anesthetic or some cerebral condition.
In the  latter case it is a serious symptom.  The greater
the degree  of unconsciousness the more marked  and
loud will be the snoring.
  The  Cheyne-Stokes respiration is  a type in which
there is an irregularity which occurs with almost perfect
rhythm.
  It may occasionally  occur  in  elderly persons,  par-
ticularly when asleep.  When associated with disease
it is a  grave symptom.
  It is most likely to occur in diseases or conditions of
the brain, occurs less frequently in those of the heart
and kidneys, and is usually considered  a premonition
of the  end.
  In Cheyne-Stokes breathing there will  be a  very
quiet,  shallow  respiration, the chest movement being
almost imperceptible.  Each successive breath becomes
deeper, more audible, and the respiratory movements
more  pronounced until it  results in a deep snoring
respiration.
  Then it decreases by the same stages until it finally
stops for an interval varying from five to thirty seconds,
when it is repeated.
  As the respiration increases in intensity the interval
between breaths usually  decreases in proportion.
  Edematous breathing is the result  of fluid in  the air
passages.  It is difficult and produces a loud, rattling
noise as the air passes in and out.  It is always accom-
panied by considerable cyanosis, and is a serious  con-
dition. 
58  TEMPERATURE, PULSE, AND RESPIRATION

  Usually little  can be done to relieve the condition.
It is often a premonition of death.
  When counting respirations the action of both sides
of the chest should be  noted: if it be symmetrical or
otherwise; also the frequency, ease, and depth of each
respiration.
  It is best that patients should not know that  the
respirations  are  being counted or they may  involun-
tarily modify their breathing.
  When ascertaining the quality of the pulse the respira-
tions may be counted, and the pulse afterward. Both
may be recorded at the same time.
  In certain  conditions when the frequent record of
temperature,  pulse,  or respiration  is necessary,  an
hourly chart may be kept.  The variations are recorded
every hour, with treatment, nourishment, and general
condition of the patient.
  Such charts are  usually arranged for  twenty-four
hours only. 
Name_________
Diagnosis_______
Date of Admission.
BEDSIDE  NOTES.
                Ward_________  Bed Number.
Physic
When ordered	General Orders	When omitted
	_______i_______________________________	
		
		
		
Time  Temp.j Pulse I Resp. | Urine |  Def.
Total
Treatment
Nourishment
Remarks
&a
to
to

Crt
CO 
CHAPTER  VII.
      BACTERIA AND  THEIR MEANING.

  Classification—Growth—Relation to Disease—Protozoa—Yeasts—
Molds—-Infections—Methods of  Sterilization—Disinfectants—Anti-
septics—Deodorants.

  Bacteria  are the  lowest form of plant life known.
They differ from all  higher forms of life in that  their
whole organism is made up of a single cell.  They are
microscopic,  can only be seen  with a high-power micro-
scope, consequently  they  are defined  as unicellular,
microscopic vegetable organisms.
  Like other plants, each possesses an individuality and
presents characteristics peculiar to  itself.   This  is
shown in  its size, form, and development,  each cell
producing  its kind.  They also  possess the  power of
growing  in different  media and  may be  transplanted
without  injury to themselves, hence the  transmission
of disease.
  These organisms are exceedingly small  and consist
(probably) of  a  nucleus  cytoplasm and a  cell  wall,
which may be a condensation of the superficial proto-
plasm;  they are  colorless  and  transparent.  Unlike
animal  cells  in which  the structure may be studied
(by aid of the microscope), only the nucleus and cell
wall are visible in bacteria. 
SAPROPHYTES
61
  Bacteria multiply by cell division: each  bacterial
cell may grow  to  a certain size, then division  occurs,
each part growing to  the  maximum when it in turn
divides.  Some divide  in one hour, others in a much
shorter period.  It has been estimated that if multipli-
cation  went  on unchecked,  the  descendants from  a
single cell would number two hundred billion in forty-
eight hours.
  Important factors in the prevention of unlimited multi-
plication are that only a  small number grow  to the
reproducing stage;  that in their growth  they produce
substances which  are injurious and the  accumulation
of such material  inhibits growth and reproduction.
  Other  means are insufficient nourishment; lack of
moisture; a temperature too high, or too low; or the
invasion of  other  forms  of bacteria which may be
antagonistic.
  The  study of bacteria has been the work of  botan-
ists, chemists, and physicians. Through this combined
effort it has become known that these minute organisms
are present in, upon,  or have something to do with
the life  of all higher plants and animals.
  There  are  two  very  distinct classes:
  1. Saprophytes.—This class is most essential  to higher
forms of life.  They not only attack and kill other
organisms, but decompose dead  organic bodies, con-
verting  them into simpler  compounds, or setting free
elements which are utilized by higher forms of plant
life, many of which furnish food and clothing for man,
some become the food of herbivora, either utilized as a
food for man or become the prey of the carnivora,
which in their turn again fall to the uses of man. 
62       BACTERIA AND THEIR  MEANING
  The number of this class is unknown.
  2. Parasites.—Parasites are those which exist upon
living  animals or vegetable bodies.
  A parasite is capable of living and multiplying in a
living animal body, often to its  detriment.  If capable
of producing disease it is said to be pathogenic.  There
are  few parasites pathogenic for man.  The animal upon
which  a parasite lives is called  its host.  There are a
few  parasites which can  live a saprophytic existence
for  a short time; these are called facultative.   Others
must have animal juices upon which to exist; these are
called obligate parasites.
  Other classifications are:
  (a) Aerobic—those which cannot  live without air
(oxygen).
  (6) Anaerobic— those which cannot exist in the pres-
ence of oxygen.
  (c) Aerogenic—gELS producing.
  (d) Chromogenic—color producing.
  (e) Fermentative or Zymogenic—producing fermenta-
tion.
  (/) Pathogenic—disease producing.
  (g) Pyogenic—pus producing.
  There are other parasitic forms of  life: the protozoa
(which are believed to be of animal origin); some of these
are  capable of producing disease; among  the protozoa
the  obligate parasite exists very extensively and cannot
live  at all if its normal life within the  animal body
be disturbed.
  They are usually larger than  bacteria,  and differ in *
their method of reproduction. 
PARASITES
63
  In  medicine bacteria are  of  the greater interest,
because protozoa which produce disease are very few.
  Common classification of bacteria is  according to
shape, which is very simple.  They are either spherical
or slightly oval cocci; cylindrical, long or short; rod-
shaped bacilli; or spiral-screw shaped spirilla.   Some
are motile, some not.
                                  Spores.

  The power of movement is due to little appendages,
which are in constant motion; they are called flagelli.
Some species have them only  at the ends, others are
entirely surrounded by them.
  The bacilli and spirilla divide at right angles to their
long axis, while among the  cocci division  may occur
only in one  plane, resulting in  the formation of chains
(streptococci);  after division   the  cells may   remain
united or separate into pairs (diplococci), or into single
cells (cocci).  Others divide  in two planes, giving  rise
to flat sheets or irregular masses (staphylococci), or iri
three planes forming cubical masses (sarcina?).  The growth
of these organisms varies  according  to the  species.
All must have food, a certain amount of moisture  and
heat (90°-100pF.).  They grow best at the temperature
of the human body.
8?  o0  o°
f
3°°^   ^rr^  J»
Fig. 7.—Forms of bacteria. 
64       BACTERIA AND  THEIR MEANING

  Spore Formation.—Spores are characterized by  their
structural and physiologic qualities.  They are spherical
or oval in shape and possess a much higher resistance
to heat and all sorts of poisonous substances than the
cells from which  they  originate.  Spores  are  most
frequently found in bacilli, very  rarely in cocci.  (It
is  believed by some bacteriologists that all bacteria,
under certain conditions, possess the power of sporula-
tion.)
  These spores are  set free, it may be, by the degenera-
tion of the cell itself, and under certain conditions may
develop after remaining dormant  for years.
  The spore stage is a resting stage.  It tides the species
over unfavorable periods,  such as dryness,  famine or
unsuitable temperature, until such times as favorable
conditions occur for development.  Of the disease-pro-
ducing bacteria, only two  of the spore-forming organ-
isms, the anthrax and tetanus, are positively known to
be pathogenic for man.
  Closely related to bacteria and protozoa are yeasts
and moulds which are a higher form  of fungi of which a
limited number are capable  of  producing disease.
  Yeasts multiply  by  budding; a part  of the cell wall
protrudes, into which the protoplasm flows.  When the
bud reaches its proper size it separates from the original
cell, and a new cell is set free.
  Blastomycosis  is  produced by yeast.   It develops
in brewers; just how is not known. It is supposed that
the yeast enters through slight wounds, fissures, or  hair-
follicles and causes abscesses which spread to different
parts of the body.   The development is slow, as is the
process of healing. 
METHODS OF  DESTRUCTION         65
  When the lungs become involved a septic pneumonia
results, which is particularly fatal.  The disease is said
to be due to  the fermentative properties of the yeast
and the destruction of tissue cells.
  It is infectious and all sputum and discharges should
be burned.
  Moulds are not so simple in  structure  as yeasts;
they multiply by sporulation.  Ring-worms, favus and
thrush are caused by moulds.
  Pathogenic organisms are dangerous because of the
poisons (toxins)  they produce.   They are  always a
menace because of their very general  distribution and
the fact that they  are microscopic.
  A person is infected when some organism enters the
body and by its growth  produces disease.   This is a
general  infection.  When a  certain locality is involved
resulting in the formation of pus, either in a wound or by
abscess formation, it is a, local infection.
  The symptoms which follow are due to the activity
of the organism plus the conditions which arise from the
defense made by the body infected.
  Methods of Destruction.—Many organisms are killed
by  exposure to the direct  rays of the sun.  It is an
important factor in inhibiting the growth  and multi-
plication of bacteria.  However, it cannot be depended
upon as a germicide as to kill it must shine directly
upon the organism for a certain length of time.
  Sterilization by  use of  heat either moist  or dry.
Moist heat is said to be most effectual.
  (a) Boiling  (100° C or  212° F.) for  five minutes.
Instruments, hypodermic needles, glass, metal or rubber
      5 
66      BACTERIA  AND THEIR  MEANING

catheters, rectal tubes, rubber nipples, irrigating tips,
douche tips, droppers, etc., may be treated in this way.
  (6) Live steam consists of steam being turned into
an  air-tight container which holds the articles to  be
sterilized (length of time  one hour).
  (c) Autoclave—steam  under pressure  means  that
steam is allowed  to  enter an air-tight chamber of  an
autoclave (which has a double jacket and is of great
strength) and  is forced in after the chamber is full; as
none is allowed to escape,  the incoming steam causes the
pressure. The amount of pressure (expressed in pounds)
means a given number of pounds to the square inch.
The degree of heat  is increased in proportion  to the
amount of pressure (15 pounds' pressure, temperature
120° C).
  Dry  Heat.—Baking or the live flame.  Baking  in
order to be effective  must be brought to the tempera-
ture of 160° C. to  170° C.  The live flame is used  chiefly
in laboratories.
  Interrupted  or fractional  sterilization used  when
steam is not under pressure, the maximum tempera-
ture 100° C. is not thought sufficient to kill all bacteria,
consequently must be subjected to this process several
times, usually three successive days.

              DISINFECTING ROOMS.

  Formaldehyde  gas  destroys bacteria,  checks their
growth and acts as a deodorant.
  To fumigate rooms, they should first be sealed.  By a
special  apparatus gas is generated which is  forced 
DISINFECTING ROOMS
67
through the keyhole.  Formalin ma}' be used to sterilize
utensils in a solution 1  to 200.
  Sulphur dioxide is one  of the oldest  disinfectants.
It is infrequently used not only because of its disagree-
able odor but it destroys carpets, rugs, and all fabrics.
  Alcohol  as  a germicide probably  holds  first  place;
70  per  cent,  alcohol is capable  of  killing non-spore
bearing bacteria in a short time; 50 per cent, is effective
as an antiseptic.
  Coal-tar Products.—Body  discharges, the sputum of
pneumonia or  tuberculosis, vomitus, urine, feces may
be disinfected by carbolic acid, 5 per  cent.
  For linen, carbolic acid, 5  per cent., or creolin, 2 per
cent; formalin, 5 per cent., may also be used.
  For the  skin, carbolic acid, 5 per cent.; creolin, 2 per
cent., or lysol, 1 per cent., are effective.
  Lysol is extensively used in gynecological and obstet-
rical practice in a solution of from |  to 1 per cent.
  Corrosive sublimate (mercuric chloride, bichloride of
mercury) is the best known  and one  of the most effec-
tive of the metallic  salts.  It is valuable in a solution
1 to  1000  for the disinfection of hands, wood-work,
porcelain, glass, etc.
  It must  not be  used  on instruments or come in con-
tact with plumbing fixtures as it corrodes and destroys
metals.
  Biniodide of mercury  may be used  in  the same
strength as bichloride and for the same  purposes.  It
must be  remembered that neither of  the mercury salts
effective   in  disinfecting  body   discharges  as  they
combine  with  albumin to form  insoluble compounds. 
1)8       BACTERIA AND THEIR MEANING

Biniodide has the advantage of being less harmful to
the skin and does not discolor the nails.
  Iodine has been extensively used to disinfect the skin
in preparing for operations.  It is particularly valuable
for this as it penetrates the skin and prevents bacteria
from being carried  from the surface  to deeper tissues.
It is used in tincture (alcoholic solution) in strength of
2 per cent, to 7 per cent.
  Hydrogen  dioxide solution is  decomposed when it
comes  in contact with organic  matter,  pus or blood.
It then yields oxygen which destroys the bacteria with
which  it comes in contact.  At the same time it helps
remove pieces of dead  tissue.  It  is chiefly  used in
wounds.
  Antiseptics are agents which do not kill, but prevent
growth and  multiplication  of  bacteria  and  prevent
decomposition.
  Disinfectants  mentioned in a very dilute form may
be used as antiseptics.
  The most valuable antiseptics have not the power of
disinfection.
  Boracic acid  is very  extensively used.  It is non-
irritating and non-poisonous and may  be used in the
cavities of the body for irrigation with perfect safety.
  Normal salt solution is only mildly antiseptic though
it is extensively used.
  Labarraque's  solution  1 to 6 may be used in  infected
wounds; it also acts as a deodorant.
  Citrate and chloride of sodium.
         Citrate of  sodium            2 parts
         Chloride of sodium          8 parts
         Water to make            100 parts 
DEODORANTS
69
  The combination of these sodium salts, while only
slightly antiseptic, is extensively used  in local septic
conditions.
  Antiseptic powders in  common use  are  aristol,
dermatol, zinc stearate, iodoform, boracic acid.

                  DEODORANTS.

  Deodorants destroy disagreeable odors.   The most
commonly used are  formalin, sulphonaphtol, carbolic,
chlorinated  soda  (Labarraque's  solution),  potassium
permanganate, chloride  of  lime, charcoal and many
proprietary preparations too expensive to be  utilized
for hospital purposes.
  Many of the disinfectants are deodorants.  In their
use, whatever agent is employed must come in direct
contact with that which produces the disagreeable odor. 
CHAPTER VIII.
                 VENTILATION.

  Air and its Composition—Elements Necessary to Animal Life—■
      Natural Ventilation—Methods of Supplying Fresh Air.

  The atmosphere is a mixture of colorless gases which
surrounds the earth a distance of many miles.
  The composition of air is not absolutely  constant
nor exact in atomic proportions, either by weight  or
volume.   Ordinary  air is a  mixture  of  about  four
volumes nitrogen with one of oxygen; it also contains
small quantities of other substances.  It always contains
water, carbonic  acid,  ammonia,  with  small  amounts
of elements from the argon group; also dust and the
products of animal and vegetable decomposition.
  The study of the air and its impurities has received
much attention because of the fact that many diseases
are due to the living particles conveyed  by the air.
  The capacity of the air for holding water increases
as the temperature rises.  The dampness of  the air is
not due to the actual quantity of moisture in it, but to
the amount in proportion to that  which the air can
take up.
  Air saturated with moisture has a relative humidity
of 100 per cent.; if half  saturated 50  per  cent., etc.
When the temperature falls, the moisture separates to
a greater or lesser extent, and rain, dew, or fog is the 
VENTILATION
71
result.  If the temperature falls below freezing-point,
frost or snow may occur.
  The respiration of animals, the process of combustion
and decay are constantly changing the air by removing
oxygen and producing water, ammonia, carbon dioxide
and organic matter.  The constant removal of oxygen
is partially counterbalanced by the  action of plants,
which, under the influence of light, decompose carbon
dioxide, retaining the carbon and setting the oxygen
free.
  The normal condition of breathing is that the oxygen
of the air breathed should be about one-fifth the atmos-
pheric pressure, but it has been found that life may be
carried on by a gradual diminution  of the oxygen to
less than one-tenth.  This is reached at an altitude of
15,000 feet.  Any pressure less than this causes change
in the relation of gases in the blood. Animals subjected
suddenly to a marked decrease  (below 7 per cent.) are
thrown into convulsions.
  On the other hand, oxygen may be increased  to a
considerable extent without marked effect, even to the
extent of 10 atmospheres.  When the oxygen pressure
was increased to twice that  amount (20 atmospheres),
animals experimented upon by Paul Bert died of severe
tetanic convulsions.
  Carbon dioxide  while  an important constituent of
the air exists in relatively very small amounts, about
0.03 of 1 per cent.  This occurs in greatest abundance
near the soil and is the  result of oxidation of organic
matter  from  fermentation and from  the chemical
action in the soil. 
72                 VENTILATION
  It has been determined  that  any marked variation
of the percentage of carbon dioxide would so alter the
atmospheric condition that it might cause the death
of all living things.  The carbon dioxide in the air is
the source from  which all green plants obtain  their
carbon, and this  indirectly is the source of carbon  in
animals.
  The variations  of carbon dioxide in the open are too
small to be of importance.   It is only when stagnant
air of a room is polluted by respiration and combustion
that the  degree of C02 has any sanitary importance.
  Ammonia occurs chiefly from the decomposition  of
organic matter.   It is a  constant constituent of the
atmosphere in slight traces but  varies in amount.
  Argon, which constitutes from 0.75 to  1 per cent,  of
the atmosphere, has not been demonstrated in the body,
and probably has no hygienic significance.
  Ozone, when found, exists as a  mere trace.   It  is
usually absent in large towns.and cities,  never present
in crowded localities.  It is most abundant at sea,  or
near the woods.  It is formed in  nature by electrical
discharges, and by the friction of large masses of sea-
water against the air.  As it only occurs  in about 1  to
1,000,000 part per volume of the air it, too, has  no
hygienic  value.
  Dust always floating in the air contains both living
and dead substances which vary according to localities.
The bacteria in the air are usually attached to particles
of dust.  Dangerous species of bacteria in the air come
directly or indirectly from man or from some of the lower
animals. 
VENTILATION
73
  Oxygen is  the  element essential to all animal life.
That considerable variations of pressure occur without
producing ill-effects is probably due to the fact that the
gases in  the  blood  are  mostly in  a  state of chemical
combination, not in simple solution.
  The amount of oxygen absorbed depends rather upon
the needs of the body than the amount in the air.  The
excess or diminution of oxygen, unless the modification
is extreme, has no effect upon respiration.
  More oxygen is not taken up because more is supplied
to the lungs,  nor  are the processes of oxidation affected
unless influenced by  some other condition.
  Nitrogen forms about four-fifths of the air breathed;
it is inert and acts as a diluent. It may be replaced by
hydrogen, if the oxygen is in usual proportions, without
ill effect.
  The normal adult person breathes about 34 pounds
of air in twenty-four hours, or the amount which corre-
sponds to about 7 pounds of oxygen. As only about a
fourth breathed is absorbed, the daily amount utilized
by the adult human body is less than 2 pounds.
   Moving air is necessary for the maintenance of health;
it is also the chief requisite of good  ventilation.
   In nature  the air is kept in almost constant motion
as  a result of differences in temperature,  the hot  air
rising while the colder flows along at a lower level.
   If the air of a poorly ventilated  room can be kept in
motion, many of  the ill effects of a vitiated  atmosphere
may be avoided. 
74                 VENTILATION
                   VENTILATION.              '

  Ventilation consists in keeping an enclosed place sup-
plied with proper air for breathing or in adapting indoor
conditions to indoor life.
  Ventilation must serve a number of purposes: (1)  it
must bring pure air in from without to dilute and remove
impurities, the result of respiration and other sources of
vitiation; (2) it must aid in maintaining proper temper-
ature and degree of humidity and keep the air of the
room in constant  motion; (3)   it must  remove dust,
odors and any substances which contaminate  the air
of inclosed places, also it must remove the impurities
produced by the burning of coal, gas, or  lamps.
  All systems of artificial ventilation depend upon one
or more of three methods of obtaining fresh air:  The
plenum, a method by which fresh air is forced into the
room: the vacuum, by which  air  is  extracted, or  a
combination of the two.  The efficiency of any  system
depends upon the  results obtained at the breathing
zone.
  There must be an inlet or inlets for fresh air; an outlet
or outlets for foul air  and a motive force to produce a
current.
  In what is known as natural ventilation the forces
are made use of which are supplied by  (1)  the wind;
(2)  the elevation of temperature of the air of the room;
(3)  the  draught of fires used for heating.
  Where a  bright  fire is burning  in  an open grate,
usually  no other outlet for foul air is needed.
  Proper inlets must,  of course, be  provided.  The air 
VENTILATION
75
should not  enter  horizontally nor  through gratings
near the floor, but through vertical  openings high up
to carry the stream of fresh air to the upper part of the
room, where it may become warmed before its presence
is felt.  The first care is to avoid cold draughts.  It is
better to admit air to  a large room through  several
small openings rather than one large one.  This rule
holds in regard  to outlets, which should be of about
the same size as the inlets.
			
0..	^		A\S
			
	/		A
			
             Fig. 8.—The Sheringham air inlet.

  Whenever possible open windows are the best and
simplest means of ventilating a room.
  A Sheringham air inlet may be placed at the top of a
window and when opened forms  a  wedge-shaped pro-
jection into the room and admits the  air upward through
the open top.  There are many simple devices which
may be used at the top or bottom of windows to admit
fresh  air or  the exit of  vitiated air.  The simplest
method is to open one sash of the window and fill up
the space with a board; the air enters a zigzag course
between  the  sashes.   This  is often used  where no
attempt at mechanical ventilation has been made.
  Fresh air may be admitted through adjoining rooms
or halls.
  The degree  of temperature does not affect the purity
of the air in a room; but it does affect  the comfort and well- 
76
VENTILA TION
}>cing of individuals occupying that room.   It has been
demonstrated  that  no ill  effects result from a highly
vitiated atmosphere while temperature and moisture
remain low7.  Increase temperature and humidity and
depression, dizziness or nausea result.
  The degree of temperature most comfortable for the
sick is between 65° and 70° F. In hospitals this degree
is  usually maintained  during the  cold months.  If a
lower degree is necessary for  any particular individual,
that individual is put near an open window or in an
open-air ward.
  The air should be kept pure and fresh by removing
anything which may contaminate or  cause  an odor.
Particularly should patients be  kept immaculately
clean, with fresh bed and  body linen; all  soiled  linen
should  be immediately removed, as should excretions,
vomitus and soiled  dressings, which  are best disposed
of  by dropping into  a paper bag or some covered recep-
tacle and being immediately taken away.
  Sunlight is essential, and is second only to the  need
of  fresh air. It is a well-known fact that both animal
and plant life are retarded by the exclusion  of sunlight.
It  is not only necessary to purify the air, but there are
certain forms of bacteria which are killed by its direct
rays.
  The cheerfulness of a room not only has  effect upon
the spirits of a sick person, but a sufficient amount of
sunlight is of utmost importance in the treatment of
disease.
  Since it is known that living bacteria exist  in dust,
it  is obvious that the dust must be removed  without 
VENTILATION
77
being disseminated.  This  is  best  accomplished by
using a damp duster, which may  be made  of cheese-
cloth and washed out whenever it becomes the  least
bit soiled.
  For this reason a  basin  of  warm water  and  soap
should be used when dusting. Every article of furniture
and wood wrork of the room or ward should receive
attention.  No disinfectant need be added to the water
used for dusting, as the idea is to gather up the dust, not
to make a pretence at disinfection, which to be effectual
must be carried out under an entirely different regime.
  Floors should  be swept with a soft hair broom and
dusted with  a "dustless mop" (one that  has  been
treated  in such  a  way  that it gathers  rather  than
scatters the dust).
  Brooms should be washed  in soap and water and
dried (in the sun if possible) at least twice such week. 
CHAPTER  IX.
                   MEDICINES.

  Routes of Administration—Apothecaries' Weights and Measures
—Abbreviations—Relation of Drops to Minims—The Metric System
—Methods of Computing Doses.—Methods of  Converting Apothe-
caries' to Metric.

  Medicines are agents  used  in the treatment of dis-
ease.  They are derived  from the animal, vegetable,
and  mineral kingdoms, and may  be  solid, liquid,  or-
gaseous.
  Many insoluble substances which were once used in
the form of powders, because of their disagreeable taste,
are now given in tablets,  pills, and capsules.
  The most commonly  used liquid preparations are the
aqueous and the alcoholic.  Of the aqueous solutions,
waters, mixtures, emulsions, and  syrups, and  of the
alcoholic,  tinctures and  fluidextracts  are  in  general
use.  Wines, spirits, and elixirs are less  frequently used.
  Solutions enter  into the  circulation  more  quickly
than any other preparation, hence their very common
use.
  The different routes  by which drugs may be admin-
istered are the:
     1. Digestive tract, by the mouth, by the  rectum.
     2. Cellular tissues.
     3, The respiratory tract.
     4. By the skin.
     5. Intravenously. 
            THE RESPIRATORY TRACT          79

  1. By the Digestive Tract.—Medicines are commonly
given by mouth.  Solutions taken in this  manner are
rapidly absorbed. Fats, albuminous substances, gelatin,
etc., must  first be digested before they can enter the
circulation.
  In case  of excessive vomiting, gastric disturbances,
hemorrhage of the stomach, or unconsciousness, it may
be  necessary  to give both medicine  and food by the
rectum in  the form of an enema  or suppository.
  2. The  Cellular Tissues.—This method  is  used  in
emergencies  where  it is necessary to get the  quick
action of the drug in unconsciousness and when to give
by mouth is  contra-indicated.
   There are two ways of giving medicinal substances
by the cellular tissue:
   (a)  The hypodermic method,  which is the injection
of  medicines  in the subcutaneous tissue with a  hypo-
dermic  syringe.  They  are   always given  in  small
quantities.
   (b)  Hypodermoclysis, which is the injection of large
quantities of fluid deep into  the cellular tissue.  This
 is usually normal salt solution, and is given to replace
 fluids lost. The amount varies from  1 to 2 quarts.
   3. The  Respiratory Tract.—By this method absorp-
 tion is very swift, because of the extensive blood supply.
 It is more rapid though less practical than the hypo-
 dermic method.
   Substances administered  by  this method  must be
 gaseous, as oxygen; very volatile, as aniyl nitrite, ether,
 or chloroform; or vaporized, as the inhalation of steam
 or atomized  fluids. 
80
MEDICINES
  4.  By  the  Skin.—Inunctions,  or  oily  substances
rubbed into the skin may be used for local or general
effect.
  5.  Intravenously.—Consists of  injecting  substances
into  the veins.
   Used in Extreme  Cases.—Usually the fluid  is  salt
solution.  It may be blood transfused directly from
one person into the vein of another.
  The  nurse must possess a very definite knowledge
of the  action of drugs  in order to be able to detect
unexpected results.  An individual may have an intoler-
ance for a certain drug in  which a  small dose may
produce  symptoms of poisoning.  Or  one may have
an idiosyncrasy in which an ordinary dose produces no
effect, or an unusual or opposite. One should know the
dose ('its maximum and  minimum), be able to detect
the earliest signs of  over-dosing,  also the treatment
for common  poisons.  One  should be exact in com-
putation of doses and accurate in measurement; should
possess a knowledge of the best method of  giving each
individual  drug and the time  its administration is
expected to give the  best result.
  For example, irritants  and mineral tonics should be
given on a full stomach  (after  meals).   Vegetable
tonics (bitters)  before meals.  Drugs expected to  act
upon the stomach (locally) when the organ is empty,  etc.
  In  measuring medicines  extreme  carefulness  is
necessary.  As  many poisons  are used,  a  drop more
than the exact  amount is always  dangerous.
  There  are several  rules which  should  be observed,
not alone for the safety of the patient but for the pro-
tection of the nurse. 
INTRAVENOUSLY
81
  1. Read  the  order, being positive not only  of the
drug but the preparation of the drug.
  2. Read the label on the bottle and the strength of
the preparation, then compare the two.
  3. Hold the bottle in the right hand, the label up,
so that it may not become defaced.  Hold the graduate
on a level with  the eyes.  If held below, one gets more
than the required amount; if held above, less than the
amount.
  Measure  accurately,  again read the label,  wipe the
bottle and return it to the shelf.
  In giving powerful poisons, particularly the alkaloids,
it is best to have a second nurse watch the measuring,
as two persons  seldom make the same mistake  at the
same time.  Where mistakes occur, as they undoubtedly
do,  it is almost  always the result of carelessness  rather
than  ignorance.  Such  mistakes  should  be reported
without delay.

         Apothecaries' or Troy Weight.
    60 grains (gr.)        =   1 dram (5)
     8 drams (5)         =1 ounce (5)
    12 ounces (5)        =1 pound (lb.)

        (Liquid) Apothecaries' Measure.

    60 minims (TKl)        =   1 fluidram (f5)
     8 fluidrams (f 5)      =   1 fluidounce (f5)
    16 fluidounces (f5)    =   1 pint (O)
     8 pints (O)          =   1 gallon (C)
6 
82               MEDICINES
Relation of Drops to Minims.
Acid acetic ....	10 minims	=	18 drops
Acid acetic dilute .	10 minims	=	10 drops •
Acid hydrochloric dilute	10 minims	=	10 drops
Acid hydrocyanic dilute	10 minims	=	10 drops
Acid nitric ....	10 minims	=	17 drops
Acid nitric dilute .	10 minims	=	10 drops
Acid sulphuric .	10 minims	=	24 drops
Acid sulphuric dilute	10 minims	=	10 drops
Alcohol.....	10 minims	=	24 drops
Amyl nitrite	10 minims	=	30 drops
Chloroform	10 minims	=	40 drops
Fluidextract aconite	10 minims	=	25 drops
Fluidextract belladonna	10 minims	=	25 drops
Fluidextract digitalis .	10 minims	=	20 drops
Fluidextract ergot	10 minims	=	20 drops
Fluidextract nux vomica	10 minims	=	25 drops
Oil cinnamon .	10 minims	=	20 drops
Oil gaultheria .	10 minims	=	20 drops
Oil peppermint	10 minims	=	20 drops
Oil croton ....	10 minims	=	15 drops
Paraldehyde	10 minims	=	25 drops
Solution atropine .	not safe to trust to drops		
Solution cocaine, 1 per cent	. not safe to trust to drops		
Solution strychnine	not safe to trust to drops		
Spirits nitrous ether	10 minims	=	25 drops
Spirits ammonia aromat.	10 minims	=	25 drops
Spirits glonoin, 7 per cent	10 minims	=	25 drops
Tincture belladonna	10 minims	=	25 drops
 
ABBREVIATIONS
83
Tincture ferri chloride   .   10 minims  =   25 drops
  (chloride of iron)
Tincture nux vomica .   .10 minims  =   25 drops
Tincture opium   ...   10 minims  =   20 drops
Tine, opium camphorated   10 minims  =   20 drops

  It will be seen that the size of the drop varies accord-
ing to the density of the fluid. A minim is always the
same.
  The weight of fluids varies from
          39 grains of ether to 5 j
         765 grains of mercury to 3 j

                   Abbreviations.

  aa (partis equales), equal parts.
  A. C. (ante-cibos), before meals.
  Ad. lib. (ad libitum), when desired.
  Alt. hor. (altera hora), every alternate hour.
  Aq. (aqua), water.
  Aq. dest. (aquse destillata),  distilled water.
  B. i. d. or B. d. (bis in die), twice daily.
  C. (congius), gallon.
  c. (cum), with.
  c.c, cubic  centimeter.
  Dil. (dilutus), dilute.
  F. (fait), make.
  Fl. or Fid. (fluidus), fluid.
  Gm., gram.
  Gr. (granum), grain or grains.
  Gtt. (gutta), drop or drops. 
84
MEDICINES
Inf. (infusum), infusion.
Lb. (libra), pound.
Lot. (lotio), lotion.
Liq. (liquor), liquid.
M., minim.
Mist, or Mixt. (mistura), mixture.
N. (nocte), at night.
O. (octarius), pint.
01. (oleum), oil.
01. ricin. (oleum ricini), castor oil.
01. tiglii (oleum tiglii), croton oil.
P. C. (post-cibos), after meals.
P. r. n. (pro re nata), when required.
       or as often as  necessary.
Pulv. (pulvis), powder.
Q. i. d. (quatour in die), four times daily.
R- (recipe), take.
S. or sig. (siqua), give following directions.
S. O. S. (si opus sit), when necessary
          (only to be  given .once).
Sp. gr., specific gravity.
ss. (semis), half.  ,
Stat, (statim), immediately.
S. V. G. (spiritus vini gallici), brandy.
S. V. R. (spiritus vini rectificatus), alcohol.
S. F. (spiritus frumenti), whisky.
Sol. (solutio), solution.
Syr. (syrupus), syrup.
T. i. d. (ter in die), three times daily.
Tr. or  Tinct. (tinctura), tincture.
Ung. (unguentum), ointment. 
METRIC SYSTEM OF WEIGHTS       85
THE  FRENCH OR METRIC  SYSTEM  OF  WEIGHTS
                 AND MEASURES.

  The metric  system  is a decimal system, the unit of
which is the meter.  It is the system of measurement
of science, and has been in use in European countries
since 1801.  It is  legalized in  the United States, but is
not compulsory.
  As early as the seventeenth century the idea of adopt-
ing a scientific measurement  had been  suggested.
  In 1790 a committee was chosen to decide the length
of the meter, which was to be the unit of length.
  It was not until 1799 that a report was made, when
it was decided that the meter was to  equal  one ten-
millionth the distance from the equator to the North
Pole (or 39.37  inches).
  A bar of platinum is now preserved in Paris showing
the exact length,  so that the unit may always be the
same.
  The unit  of volume and weight is based upon the
length of the meter.
  Any term less than the unit is expressed by the Latin
prefixes deci, centi, milli.   Greek prefixes  dika, hecto,
kilo express the terms greater than the  unit.
  The unit of  volume or capacity, which is the liter, is
a cube the side of which is yV of a meter, or a decimeter.
  For liquid and dry measure  the unit is the same. 
86
MEDICINES
                      Table.
    10 milliters (ml)       =   1 centiliter (cl)
    10 centiliters (cl)       =   1 deciliter (dl)
    10 deciliters (dl)       =   1 liter (1)
    10 liters (1)            =   1 dekaliter (Dl)
    10 dekaliters (Dl)      =   1 hectoliter (HI)
    10 hectoliters (HI)     =   1 kiloliter (Kl)

  The unit of weight is the gram, and is equal to that
of 1 cubic centimeter  of water at its greatest density,
4°C.
    10 milligrams (mg)     =   1 centigram (eg)
    10 centigrams (eg)     =   1 decigram (dg)
    10 decigrams (dg)      =   1 gram (gm)
    10 grams (gm)         =   1 dekagram (Dg)
    10 dekagrams (Dg)    =   1 hectogram (Hg)
    10 hectograms (Hg)    =   1 kilogram (Kg)

  Instead of the liter  1000 cubic centimeters is gener-
ally used.
  The cubic centimeter,  the gram and  the milligram
are the terms most often  used.

Apothecaries'  Measure  and Metric  Equivalents.
1 gram
1 cubic centimeter
1 liter (1000 c.c.)
1 grain
1 ounce
1 fluidram
1 fluidounce
15.432 grains
16.23  minims
33.81  fluidounces
  . 065 gram
31.103 grams
 3.7   cubic centimeters
29.57  cubic centimeters 
  CALCULATING DOSE FROM STOCK TABLETS 87

            Approximate Equivali nts.
       1 cubic centimeter   =   15 minims
       4 cubic centimeters   =    1 fluidram
      30 cubic centimeters   =    1 fluidounce
       1 liter (1000 c.c.)     =    1 quart
       1 gram              =   15.5 grains

  METHOD OF  CALCULATING THE DOSE  FROM
        STOCK TABLETS AND SOLUTIONS.
  To  give a fractional dose from tablets of different
strength:  Divide the required dose by the strength
of the stock tablet.

  Ex. 1.  To give 1/25 gr. from tablets 1/30 gr.?  1/25 h-
1/30 = 1/25X30/1 =30/25 or \\ or 1/30 stock = 30/25 or
                              1/25 dose
\\ tablets.  Ans.

  The  second tablet should be dissolved in a number
of drops or minims  divisible by the number represent-
ing  the denominator of the fraction.  Thus one may be
dissolved in 15 drops and 3 used, or in 25 minims and
5 used.  This should be added to the first tablet.
  Ex. 2.  1/30 gr.from 1/25 gr. tablets ?  1/30^-1/25 =
1/30 X25/1 = 25/30 = 5/6 tablet.  Ans.
  Dissolve  one  tablet  in 12 minims, use 5/6 of  that
amount = 10 m.

  The fraction of a grain in 1 minim of stock solution is
determined by the ratio or percentage  of the solution. 
88
MEDICINES
  Thus, 1 to 40, 1 m. = 1/40 gr.;  1  per cent., 1 m. =
1/100 gr.; 5 per cent., 1 m. = 5/100; 10 m. to 1/50 gr.
1 m. = 1/500 gr.
  To compute  fractional  grain doses  from a stock
solution:
  Divide the  fraction represented by the required dose
by the fraction representing the amount of drug in one
minim.
  Example:  In a 1  per cent, solution there is 1/100
grain in  1 minim; in 1 to 40; 1/40  gr. in 5 per cent.,
5/100 grain, etc.
  Ex. 1.   To give  1/150  grain from a  1 per cent.
solution: 1/150 -=- 1/100 = 1/150 X  100/1  = f  minim.
  To 1 minim add enough  water to make 3 m. and use
2 of the dilute solution.
  Ex. 2.   Give 1/6  grain  from 4 per  cent, solution,
1/6  -=- 4/100 = 1/6 X 100/4 = 25/6 or 4| minims.  The
fraction is obtained by adding to 1 minim of the solu-
tion water to  make 6 m. and using 1, which should be
added to the 4 m.  of the stronger solution.
  Ex. 3.   Give 1/150 from a solution 10 m. = 1/60 gr.
In this solution 1 m. = 1/600 grain, 1/150 -i- 1/600 =
1/150 X 600/1 = 4 m.
    TO REDUCE APOTHECARIES' QUANTITIES
            TO METRIC EQUIVALENTS.

  1st  Rule—Reduce quantity to ounces and multiply
by 31.1 (the number of grams in an ounce). 
TO REDUCE  APOTHECARIES' QUANTITIES  89
 Ex.  1 pt. 6 oz.  = 22 ounces X 31.1 =  684.2 gm.
         1 pt. = 16 oz. + 6 oz. =  22 oz.
              22  X 31.1  = 684.2 gm.
              31.1
                22
               22
              66
              684.2  Ans.

  Most convenient for large quantities.
  2d Rule—Reduce quantity to grains and divide by
15.43 (number of grains in a gram).

    6 dr. 48 grains = 408 grains -f-  15.43  = 26.44 gm.
    60                  26.44 gm.  Ans.
   360        15.43)408.0
    48              308.6
408 gr.            994.0
                  925.8
682.0
617.2
 648.0
 617.2
  To  reduce  fractional  grains  to metric—multiply
fraction by .065 (number of milligrams in a grain)
and reduce to decimal by dividing the numerator by
the denominator. 
90-                 MEDICINES
  Reduce 1/75 grain to metric.
                  .065
    1/75 X .065 =  —-
                  .0/5
                .065 reduced to decimal.
                .075)065.0(0008  Ans.
                    600
                     50

      TO REDUCE METRIC QUANTITIES TO
          APOTHECARIES' EQUIVALENTS.
  Multiply metric  quantity by 15.43 (the number of
grains in  a gram).  The  answer  is  in grains, which
should be reduced  to proper terms.
  2.5 grams reduced to apothecaries' equals.
  Ex. (1)     2.5 X 15.43 = 38.5 grains.   Ans.
             15.43
               2.5
             7715
            3086
           38.575 Ans.
  For large quantities:
  Divide metric quantity by  31.1  (number of grams
in one ounce), answer will be in ounces and fractional
parts.
  Ex.  684.2 grams to apothecaries.
      31.1)684.2(22 oz. or 1 pt. 6 oz.   Ans.
           622
            622
            622 
HYPODERMIC TREATMENT         91
  To  reduce  small  metric quantities to apothecaries'
equivalent:  Divide metric quantity by .065 (the num-
ber of milligrams in a grain), answer in grains or frac-
tion.

  Ex. (1) 2.75 grams to apothecaries'.
      .065)2.75(4.23.  Ans.
            260
            150
            130
              20.0
              19.5

   Ex. (2)    .013 grams to apothecaries'.

       .013 -h .065 = —or \ gr.   Ans.
                      bo
     or
       .013    1    .
       ---- = \.   Ans.
       .065

   Write  given  quantity  as numerator and  .065  as
 denominator  and reduce to  lowest terms.

  HYPODERMIC  OR SUBCUTANEOUS TREATMENT.
   Drugs for hypodermic use should be non-irritating,
 if  possible; for this reason specially  prepared tablets
 which may be dissolved in a small amount of water are
 in general use.
   Alcoholic   and  ethereal  preparations are  always
 irritating and should be given deeply into the tissues. 
92
MEDICINES
Camphor, which is also irritating and extensively used,
is prepared in oil to render it as bland as possible.
  When giving a hypodermic an area should be chosen
remote from bony prominences, nerve trunks and large
vessels.
  The danger of injecting a powerful drug into a vessel
is that it may go  to a  center in a concentrated form
and alarming symptoms or death may result.
  A hypodermic tray should contain an alcohol lamp;
a jar  (covered) containing alcohol and sponges for pre-
paring the part; a spoon in wyhich  the needle  may be
boiled;  a hypodermic syringe in a medicine glass with
alcohol, unless a  solid  metal  or glass  syringe, which
may be  boiled; a bottle  of distilled water.
  Having boiled the needle in the spoon, and making
both sterile, the needle  should be dropped into alcohol
to cool.
  Wipe off the mouth of the bottle containing the drug
and that  which  contains the distilled  w7ater with a
sponge dipped in alcohol; drop a tablet directly into the
spoon from the bottle, without touching it with the
fingers;  add enough distilled water  to dissolve; fill the
syringe  with the  solution  thus  made;  screw on the
needle securely and expel the air by  holding the syringe
in  a vertical  position and bring a tiny droplet to the
point  of the needle.
  Hold the tissues loosely away from the bone, quickly
insert the needle  straight into  the tissues,  withdraw
slightly  and  expel the  fluid  slowly.
  Hypodermic needles  when not in use should have 
HYPODERMIC  TREATMENT
93
wires through  them; also,  they should be dried by
holding them over the flame before being put away.
  Orders for medicines or treatment of hospital patients
should always be written by the person  ordering, or at
least signed by him.
  Only in case of emergency, when the doctor is present,
should a verbal order be recognized, and never if received
over the telephone.
  When necessary to keep an accurate record of treat-
ment,  the twenty-four-hour chart may  be used.  (See
Bedside Notes,  Chapter IV.) 
CHAPTER  X.
                    ENEMATA.

Kinds—Frequency and Method of Giving—Utensils Used and Their
                    Care—Douches.

  An enema is the injection of fluid into the rectum,
classified according to the nature  of the fluid  or the
work it ia expected to do.
  1. The simple  enema is used  to empty the  lower
intestine and rectum; it is laxative in effect,  and con-
sists of  soap and water at body temperature.
  The  amount  varies according to the  size of  the
patient  and existing conditions.  For a baby, f  to  1
ounce; for an adult, 1 pint to 2 quarts; 1 quart is most
frequently given.
  To the simple enema, glycerin  may be  added in the
proportion of  1 ounce  to  1 pint  of suds.
  2. The stimulating enema, so  called because  it stimu-
lates peristalsis, is given in obstinate cases of constipa-
tion and to relieve flatulence.   It should be given  high
and may consist of:

         Spirits of turpentine,
         Olive oil or glycerin,
         Magnesium sulphate,         aa  5ij
         Warm water,            ad q. s.  Oj 
SHOCK ENEMA
95
  Spirits  of  peppermint may be  substituted for the
turpentine if there be considerable distention.
  3. Oil enema consists of olive oil or  cottonseed oil,
frdm 4 to 6 ounces; it is given at body temperature, and
is to be retained  from three  to four hours, when it  is
followed by  a simple enema, to  be expelled.   It  is
used after operations  on  the  rectum or  the repair of a
lacerated sphincter muscle.
  4. Milk and molasses enema consists  of equal parts
of each, should be at body temperature and given high.
It is  thought the distention caused by gases formed
produces the movement.
  5. Shock enema consists of stimulants given in case
of  shock  or when general  stimulation is  indicated.
Salt solution, or salt solution and black coffee, usually
make up the bulk of the enema.  Brandy, strychnine,
and digitalis may be added if necessary. The amount
should  not exceed one pint,  and should be heated to
110°toll2°F.  Heat is an important factor in treating
the condition of shock.
  Salt solution may be given by the drop method and
continued for an indefinite period,  from thirty-six to
forty-eight hours in extreme cases.
  An irrigating  bag should be about half full of salt
solution, which should be hot.   It  may be kept so by
hanging a hot-water bag on ecah side of it, the whole
to be covered with thick flannel.
  A catheter should be used instead of a rectal tube.
The number of drops may be regulated (usually 30 or
40 per minute) by using a clip on the tubing. 
96
EX EM ATA
  6. Nutritive enema should consist  of easily assimi-
lated liquid food.   In amount  it should not exceed 8
ounces for an adult, and should be given at body tem-
perature every six to eight hours.  It is necessary that
the rectum be thoroughly  cleansed before  introducing
a nutrient.  For this reason a cleansing enema should
be given at least  once  during the twenty-four hours,
preferably in the morning, the nutrient to be given one
or two hours afterward.
  When absorption is very poor 3 or 4 ounces of normal
salt solution  may be given about one-half hour before
each nutrient.
  Nutrient enema mav consist of
No. 1.	
Glucose, Water, Peptonized milk,	5ij aa 3 iij
No. 2.	
Egg, Peptonized milk, Beef juice, Salt,	1 5vj 5j gr. xv
  Brandy may also be added if stimulation is desired.
10 to 20 minims of tincture of opium may be used to
allay irritation.
  A patient may be helped to retain the fluid by plac-
ing a small pad over  the anus and applying tightly a
T-bandage. 
RECTAL IRRIGATIONS
97
  Eggs, or the whites of eggs, are often used.   It is a
question as to whether or not any appreciable amount
is absorbed.
  Possibly glucose,  milk-sugar, liquid  peptones, pep-
tonized milk, and salt solution are of most value.
  7. Emollient.—Is used in diarrhea to  allay irritation
of the mucous membrane.  Boiled starch, of the con-
sistency of heavy cream, may be given at body tem-
perature.  10 minims of tincture of opium to 1 pint of
the starch are sometimes used.
  8. To aUay thirst,  salt  solution or warm water may-
be given.
               RECTAL IRRIGATIONS.

  Rectal irrigations  are given in cases of colonitis and
acute or chronic diarrhea.  They consist of large quan-
tities of salt solution or  water at body temperature.
Boracic  acid,  2 per  cent, solution, is  less frequently
given.
  A solution of alum or silver nitrate may be used for its
astringent effects.
  A glass irrigator or fountain syringe  may  be used.
A  special rectal  irrigating tube  or  two catheters,
fastened together at the eye (one to serve for the inward
flow and the other for drainage) and a douche pan are
necessary. The irrigator should hang only high enough to
allow the fluid to flow through slowly and without force.
  Preparation and Method of Giving an  Enema.—In all
cases the bed should be  protected with a rubber and
draw sheet, and the patient comfortably covered with
a blanket.
      7 
98                   EXE MAT A
  A tray at the bedside should contain a pitcher holding
the fluid to be used; a rectal tube, the funnel, and an
oil cup in  a  dressing basin;  a kidney  basin to receive
the tube after using, and a bed-pan.
  When possible the patient should be  placed on the
left  side with the knees drawn  up.  The tube should
be lubricated, filled  wTith the fluid, so that no air may
be injected,  and inserted slowly, the  tube not  being
allowed to become empty until the enema is given.
  If necessary to keep the patient on the back  while
giving the enema, the hips or the foot of the bed may
be elevated.
  After using the utensils,  they  should  be rinsed in
cold water, then washed in hot water and soap, and the
rectal tube boiled. It may then be dried and put away,
or kept in a  covered jar of dilute alcohol.

                     DOUCHES.

  A  douche is a stream of water or other fluid directed
against some part of the  body.  It is used for purposes
of cleanliness in washing out cavities; for its stimulating
effect; to relieve inflammation; also  in case of  hemor-
rhage.
  The vaginal, the rectal (described under enemata),
and  the aural douche are the most frequently given.
  The vaginal douche, when  used for cleanliness, con-
sists  of 2 to 3 quarts  of mild antiseptic solution at  body
temperature  (boracic acid  2  per cent.,  bichloride of
mercury 1  to 10,000, or potassium permanganate 1 to
15,000 may be used). 
DOUCHES                   99
   To relieve inflammation it must be given hot, 110°
to 118° F., and should consist of 4 to 5 quarts, usually
of sterile water or boracic acid solution.  It must be
remembered  that this  is the  only  way heat can be
applied directly to the parts, hence the treatment must
be prolonged and the utmost care observed in making
the solution the required temperature.
   To guard  against  infection  or  secondary  infection
absolute cleanliness should be observed.  The irrigator
tubing and douche point should be sterilized each time
before using.   Patient to be immaculate.
   She should lie on the back, the hips slightly elevated
and the legs flexed.  The irrigator should be only high
enough to allow the fluid to run gently, and should be
flowing through the tube when inserted.
   Frequently 110° F. is as hot as can be borne at first;
the heat may be  increased gradually.  In all cases the
thermometer should be used to test the temperature
of the solution.
   When the patient  complains that the return flow
over the external parts is uncomfortably warm, vaselin
may be applied before the douche is given,  which will
somewhat lessen the discomfort.
  Intra-uterine  Douche.—This  treatment concerns  a
nurse only in the preparation, as it is seldom one is
required to give it, except in extreme emergency.
  In  addition  to the  instruments  used for vaginal
douche  there must be a bi-valve speculum  and intra-
uterine douche  tube.
  Long   dressing  forceps,  applicators,  small gauze
sponges or soft cotton pledgets may be used. 
CHAPTER XI.
          EXTERNAL APPLICATIONS.

   Applications of Heat and Cold—Counter-irritants—Cupping.

             APPLICATION OF HEAT.
  Applications  of heat are  made so as to give added
warmth to the body, relieve pain and bring more blood
to the part.
  When  additional  heat  is  desired, hot-water bag,
frequently jugs,  or cans may be used.  These  should
be encased in a flannel cover and placed  outside at
least one  blanket.   The bags of rubber are the more
comfortable, though they require  filling much more
often, and should be only about two-thirds full. The
water which should be poured into them from a pitcher
should never exceed a temperature  of 125° F. The
air in the  bag should be expelled by laying the bag flat
so as to allow the water to come up to the mouth, then
the stopper should be screwed in.
  To relieve pain moist heat in the form of fomenta-
tions or poultices is effective.
  The apparatus for fomentation consists of a piece of
coarse flannel (two thicknesses of old blanket)  wrung
out of boiling water.  To do this, a wringer is necessary.
A wringer may be made of  heavy crash  with  a wide 
APPLICATION OF HEAT
101
hem at each end, through which sticks are inserted.
The wringing is done by twisting the sticks in opposite
directions.
  To  make a fomentation, the flannel is placed in the
wringer and dipped  into a basin of boiling water and
wrung out.  The sticks are  then pulled out and the
wringer, with the flannel inside, is put between heated
basins and carried to the bedside.
Fig. 9.—Heated basins in which the fomentation is carried to the
                       bedside.

  The surface of the skin should be oiled and the hot
flannel applied, covered with wax paper, and a second
flannel or a layer of sheet wadding, which must be held
in place by a swathe or many-tail bandage.
  Fomentations should be changed as often as is neces-
sary to keep them  hot.
  Applications to the  eyes should be made  of circular
pieces  of flannel, about two inches  in diameter.
  It is necessary to have near the bed an alcohol lamp,
tripod, and basin of water, which is kept at the required
temperature, 120°  to  125° F.  Into  this  the  pieces
are dipped, wrung  out, and put on the eye.  They
should be  changed as often as they become the least
cool, which may  be every two minutes, or oftener, for
they are exposed to the air and cool rapidly.  They are
used to relieve pain, swelling, and inflammation, conse-
quently they should be kept hot. 
 102         EXTERNAL  APPLICATIONS

   In case  of infected. eyes the pieces of flannel must
 not  be applied a  second  time, but thrown away and
 fresh ones  used.
   Turpentine  stupes  (or  fomentations) are sometimes
 used.  Mix equal parts of turpentine with sweet oil
 and  apply with the fingers a thin coat to the desired
 area, over  which the hot flannel is applied as described
 above.
   The surface should be wiped dry and reoiled before
 making a  second  application.
   A poultice is a  soft,  moist application of semisolid
 consistency and is to be  used  hot.  Poultices may be
 made  from any  kind of meal,  bread, crackers, etc.
 Flaxseed meal  is  generally used, as it is thought to
 retain the  heat better than other materials.  A piece
 of waxed or oiled  paper should be cut the size of the
 poultice required,  also a piece  of muslin large  enough
 to leave a  margin  on  all sides,  and a piece of gauze to
 cover the whole.  The water should be boiling, and the
 meal stirred in slowly.
   Poultices should be made rather soft.  When of the
 right consistency they are to be removed from the fire
 and  beaten until  light.  No boiling is required after
 sufficient meal has been added, as it is apt to make it
 tough, heavy, and uncomfortable.
  The mixture should be  spread evenly on the waxed
paper and  the edges of the muslin folded over to form
a margin.   (This is necessary to keep the poultice from
spilling out.)
  The entire surface of the poultice should be covered
with gauze. 
CO UNTERIRRITANTS
103
  It should be carried to the bedside in heated basins,
the skin oiled, the poultice applied and covered with
sheet wadding.  It should be  kept in place with a
swathe  or bandage.
  A poultice for the chest or abdomen should be made
about a quarter of an inch thick, as any extra weight
causes discomfort.  For the face, neck, or limbs it may
be made three-quarters of an inch thick without being
uncomfortable.
  Charcoal poultice is used infrequently, is an excellent
deodorant, should  be made by first mixing  one part
powdered charcoal  with two parts flaxseed meal which
should be stirred into boiling water (as flaxseed poul-
tice) .
  This  should be applied directly to the part to be
deodorized.
  To make a digitalis poultice:
  An infusion of digitalis leaves (two ounces of prepared
leaves to one pint of water) into which flaxseed meal is
stirred (as flaxseed poultice).

               COUNTERIRRITANTS.

  Irritants are substances which, applied to the skin,
produce vascular excitement, dilating superficial vessels,
producing  inflammation  or vesication.  When used
to excite reflex influence on a  remote part  they are
called counter irritants.
  Counterirritants act indirectly by dilating the vessels
in the part to which they are applied, thus diminishing
congestion and pressure and relieving pain.  They are 
104         EXTERNAL APPLICATIONS
 only applied directly over the painful area when absorp-
 tion of the inflammatory products is desired.
   There are three distinct classes or degrees of irritation:
   Rubefacient, or first degree, irritation produced by
 mustard,  iodine, turpentine,  and various  liniments,
 causes redness of the skin  (a superficial congestion).
   Turpentine used in the form of a stupe.
   (Described under Hot Applications.)
   Tincture of iodine  is applied  with  a camel's-hair
 brush or swab of cotton.   If the first coat does not
 produce sufficient irritation, it  should  be allowed to
 dry before applying a second time.  Care must be taken
 to make  the  application evenly.  It should never be
 used directly  from the bottle, but a sufficient amount
 should be poured out and  used from a glass.
   If the  skin be very sensitive  and the discomfort
 unbearable, the iodine may be removed with ether or
 alcohol.
   Mustard may be used as  a foot bath with hot water,
 and as a poultice or paste; also in the form of mustard
 leaves.
   Mustard poultice  is made of one part of mustard to
 four to six parts of flaxseed meal: the proportion depends
 upon the age of the person, the sensibility of the skin,
 and the degree of irritation desired, whether a redness
 or an  inflammation  of the skin.
  Mix the mustard and the flaxseed thoroughly, crush-
 ing all lumps.  To this add warm  water to  make  the
 right  consistency,   stirring  constantly.   The  water
 should not be  too hot, as the volatile oil, which is  the
irritating property, is  driven off in the  steam.   Beat 
COUNTERIRRITANTS
105
the mixture to make it light and spread on waxed paper,
placing over the back a piece of muslin, with the edges
turned down over the poultice to form  a margin; the
face of the poultice (the surface to be applied to the
skin) should be covered with gauze.
  Mustard paste is made in the same proportions, flour
being used instead of flaxseed meal.  It is more irritating
probably because the flour lacks the oil of the flaxseed.
A layer  of muslin instead  of  gauze  should be placed
over the face of a mustard paste.
  The surface of the body to which the paste is to be
applied should be oiled to prevent  blistering.
  It must be removed when the desired degree of irri-
tation has been  attained.  Fifteen to twenty minutes
is usually a sufficient length of time.
  Liniments are  applied to the skin with friction; they
are mild irritants, and give a feeling of warmth.
  Vesicants, or second degree irritation, cause inflam-
mation and a separation of the epidermis from the true
skin, with the exudation of serum  between, forming
blisters.  They may be produced by a second or third
coat of iodine; by the prolonged application of mustard
poultice or paste or by increasing the  proportion of
mustard in either; by the saturation of a piece of lint
with turpentine, chloroform,  or ammonia and  imme-
diately excluding the air; and by the use of cantharides,
either as a plaster or in  collodion.
   When cantharides plaster is  used the  face of the
plaster must be  oiled, two slits cut to allow the  blister
to  form, and fastened on with narrow strips of adhesive
plaster.  In applying cantharides plaster to any area,  a 
106         EXTERXAL APPLICATIONS
series of small squares, not exceeding lj inches, should
be used, and placed at least one inch apart.
  This  should be done so that the healing process may
be hastened when there is no longer need of irritation.
A blister three inches square may take weeks to  heal,
especially if the condition of the patient is poor, while
the same area broken  up into  a series of  small  ones
heals quickly.
  When the plaster is fresh, a blister forms in from six
to eight hours.  It can be watched  easily, as the slits
cut in the plaster allow it to swell.  If thoroughly  oiled
there is no danger  of breaking the skin when  it is
removed.
  Usually the blister is opened and  dressed with oint-
ment, cold cream, or vaselin. With a pair of pointed
scissors, which have been sterilized, a small cut should
be made at the edge of  the  blister and  the escaping
fluid caught on a piece of sterile cotton or gauze.
  Cantharides  should not be used if the patient has
any  kidney trouble,  as  it is  a  direct irritant to the
kidneys.
  Acute nephritis  has been known to  develop in  per-
sons who were  susceptible to the drug.

                     CUPPING.

  Dry  cupping when applied a  short  time produces
first degree irritation.  Dry cups are of most value in
congestion of the lungs due to poor heart action.   The
difficult breathing which is the result of this congestion
is  greatly relieved.   A  sufficient number should be 
CUPPING                  107
applied to cover nearly the surface of the chest.  When
the last one has been applied the first one should be
removed and reapplied in a different spot.  This may
be continued for any length of  time; a dry cup must
not be allowed to stay in any one spot over five minutes.
  To apply dry cups, prepare the bed by protecting
it with all wool blankets.  One should be put under the
patient's back to come up  over the pillow and cover
the patient's hair, and a second one to cover and  pro-
tect the spread and  top  sheet.  Wool does not burn
readily, and the danger of setting fire to the  bed is
avoided.   A  tray  should  contain  several  cupping
glasses, or small tumblers which have a thick round
edge may be used; spirit lamp; cup of alcohol; swabs;1
extra cotton; matches; extra  cup or basin for  used
swabs, etc.
   Dip the  swab  in  alcohol, light, and apply  to the
inside of the glass, invert  and apply quickly,  taking
the precaution not to use  more than just sufficient
alcohol, so  that it will not burn in the glass.   Injury
may be done by the heated edge of the glass or by
burning alcohol dropping on the skin.
   To remove the glass, pass the finger under one side
and allow the air to enter.
   Wet cupping is nearly obsolete.  It consists of making
 several cuts through the skin and over them applying
 cups as described above.  The skin should be prepared
 as for a surgical operation.
   Leeches are  seldom  used except by the ophthalmic

   » Swabs may be made by winding a small piece of absorbent cotton
 about the end of a probe or applicator. 
108         EXTERXAL APPLICATIONS
 surgeons to relieve  congestion  and  inflammation of
 the eye and to relieve and prevent discoloration after
 an injury.  They are applied on the temple about one
 inch from the corner of the eye.
   The  skin  should be washed with  soap  and water,
 then rinsed with alcohol, and lastly with sterile water.
 Leeches will not bite if the skin is not clean, neither
 do they like soap and water.  It may be necessary to
 prick the skin and draw a drop of blood to induce them
 to bite: each one should be put  into a test-tube sepa-
 rately,  the  pointed  end  (which is  the  biting  end)
 toward  the  mouth of  the  tube, and  the test-tube
 inverted  directly over the spot  desired.
   When full the leeches will drop  off.   They should
 never be detached roughly.  When full they may  then
 be  dropped into a  basin of salt and water, and  when
 they empty themselves of the blood  they should  then
 be returned to the box of earth in which they are kept.

               COLD APPLICATIONS.

  Cold  is applied  locally to lessen  congestion  and
 relieve  pain.  It also retards suppuration and lowers
 temperature.
  Iced  compressors and rubber  ice-bags of various
 shapes  are in most common use.   Ice-coils and ice-
 poultices are used  occasionally.
  To fill an  ice-cap, collar, or bag,  the ice should be
crushed very finely, and the bag filled one-half or two-
thirds full.  The air  is expelled  by twisting the  bag
above the ice before screwing on the  cover.  For the 
COLD APPLICATIONS
109
chest or abdomen it should be put into a flannel cover.
A cotton cover is used for other parts of the body.
  Ice-coils are sometimes used because they are lighter.
They consist of coiled rubber tubing.   Two  long ends
serve to  siphon the water from one receptacle, which
is placed on  a stand by the  patient, through  the coil
into a  second receptacle, which stands on  the  floor.
The upper end of the tube may be supplemented by
attaching a  bulb syringe,  which may  be left on,  to
start the flow of water at any time.  This is convenient
when the tube becomes clogged, as it often does.
  Iced compressors are made of old cotton  cloth, cut
the required size, wet, and laid on ice  until  cold, then
applied.  The mistake  should not  be made of  using
several thicknesses, thinking  thereby to save time and
labor.  They will keep moist, but they will also become
very warm.  Instead of an iced application it is warm,
and partakes somewhat of the nature  of a poultice.
  In some cases the continued use of ice is accompanied
by  considerable danger.  The pain may be relieved,
while  a  suppurative  process is  going on  unnoticed,
because the patient is comfortable. This is particularly
true in the use of ice for earache.
  The application of extreme cold should  not be made
without  the  sanction of the  physician, and  unless the
patient can be carefully watched. 
CHAPTER XII.
            SIGNS AND SYMPTOMS.

  Development—Color  of  the Skin—Mouth  Breathing—Nausea
and Vomiting — Expectorations — Diarrhea — Distention — Pain —
Chills—Convulsions.

  Symptoms are those conditions or features of condi-
tions of which the patient himself is aware or of which
he complains.
  Signs.—(Physical signs)  are evidences of those con-
ditions which the physician may see, hear, or feel.  For
example, a patient who  complains of pain with every
breath  consequently  takes  quick, shallow  breaths.
This pain is a symptom, the character of the respira-
tions a  sign that he probably has pain; just what the
cause may be must be determined by  examination.
  Thus the study of  physical signs lies  chiefly with
the physican.   Symptoms in a way,  to  that of the
nurse, who by the skilful application of nursing methods
makes   patients comfortable, remembering that  no
symptom is too trivial to be regarded if it troubles the
patient.
  Nearly every disease presents a group of signs and
symptoms, characteristic of that disease,  and by this
group it is  recognized.  One disease complicated  by
another somewhat modifies the signs, but the charac-
teristics of both present themselves. 
THE COLOR OF THE SKIN         111
    That a nurse may be of value to patient and doctor
  alike, it is essential that she observe  and report  any
  abnormalities or conditions  that  exist,  and learn to
  report  them clearly  and  concisely,  making  a plain
  statement of facts.
    There are conditions or symptoms which may exist
  in any case important  for  a  nurse  to  observe,  and
  which may have a distinct bearing on the treatment,
  and  possibly the ultimate recovery of the patient.
    Development.—First  it  should  be  observed if the
  patient is properly nourished, also if there be obesity
  or great emaciation.  In children  the large, flat head,
  inability to sit up or walk (a condition known as rickets)
  are all evidences of poor nutrition.  This is not always
  due  to an insufficient amount of food—in  bulk—but
  sometimes improper food.
    A deformity in an adult may be due  to  some past
.  condition.  In a child it may be due to some present
  trouble.  The  nature  and  extent of the  deformity
  should  be carefully noted.
    The position the patient assumes, be it either child
  or adult, is that which gives the greatest degree of
  comfort.  For example, one with colic doubles up, and
  draws the knees close up to the body; one with difficult
  breathing assumes an upright position; the  baby puts
  its fingers in the mouth when teething, or the hand to
  the ear, holding the head on one side if the ear aches.
    The Color of the Skin.—If it be white,  with a  trans-
  parent, waxy look, it is usually due to anemia, a condi-
  tion of the blood.  A sudden pallor may mean faintness
  or pain.  A gradually increasing pallor, with blue lips 
112
SIGNS AND  SYMPTOMS
and circles around the eyes, accompanied with restless-
ness;  a low  or subnormal  temperature;  rapid pulse,
increasing  in rate; "air hunger"  and thirst are signs
of hemorrhage.   It may be concealed.   But it  is none
the less important, and is one of the gravest of emer-
gencies.
  Blue color denotes an insufficient amount of oxygen,
which may be due to either the heart or the respiratory
organs.   A yellow skin (jaundice)  is usually indicative
of gall-bladder trouble or some obstruction  of its ducts.
  Any eruption, its character and extent, are of impor-
tance; scars,  either the result  of surgery or old ulcers,
their location and color, should not be overlooked.
  The Eyes.—The eyes afford an important index to
the mental condition.  Their movement,  expression,
and the size and reaction of the pupils should be noted.
  The Mouth,  Tongue, Nose,  and  Lips.—The  mouth,
tongue,  and lips; whether they be  moist, dry, cracked,
or bleeding; if there are ulcers on the tongue or inside
of the cheeks; if the tongue is coated, and its character
also if it be tremulous.
  Any discharge from the  nose may mean a  local or
cerebral condition.  It is particularly apt to be cerebral
if the discharge  be purulent.   A  bloody,  mucous, or
serous discharge is more likely  to be local.
  Mouth breathing, particularly in children, is rather
common.   It may mean only  a temporary condition,
or it may  be due to  adenoids, the removal of which
may become necessary, as permanent obstruction may
be the cause of deafness.
  It is possible for a person to modify the respiration 
NAUSEA AND VOMITING           113
to a certain extent, but the type, frequency, and ease
should be noted, also if the symmetry in the action of
the chest is lost.  It frequently occurs in persons who
have had pleurisy that one side of the chest is nearly
or quite normal, while on the other side there is little or
no action.
  Retraction of the soft parts, below the sternum and
clavicle,  sometimes  even  between  the  ribs, denotes
obstruction of  the larynx.   In diphtheria or croup it
is an important symptom, and one which should never
escape the notice of a nurse. It may develop suddenly,
and therefore one should be constantly on the watch,
for when it occurs no time should be lost in  reporting
the symptoms.
  Nausea and  Vomiting.—When  nausea or  vomiting
occurs, the time, quantity, and quality are of impor-
tance.  If it be directly after taking something into the
stomach, food or medicine, it shows that that particular
article has caused irritation, or there may be persistent
vomiting.   Occasionally a person  may vomit large
quantities  of fluid even when  nothing has been taken
by the mouth for a number of hours, possibly all night.
This is probably the normal secretion  of the stomach
which  cannot leave by the  natural exit, showing there
is an obstruction.  This is often caused by cancer.
  Blood  vomited,  if  fresh,  clotted,  or mixed with
particles of food, is easily recognized, but when acted
upon by the gastric juice it has the appearance of coffee-
grounds, or it may be decomposed and black (the so-
called "black vomit").
  Blood  from the stomach differs  greatly from that
     8 
114
SIGNS AND SYMPTOMS
from the lungs.  From the latter it is bright red and
filled with air, making it frothy.
   The green or bilous vomitus is due to the presence
of bile and may occur whenever vomiting persists after
the stomach has been emptied.
   Fecal  vomiting may be due to the same condition
as in peritonitis.  It more frequently is  the result of
paralysis or obstruction of  the intestines.
   Pus in vomited material would indicate an abscess
of the stomach.
   Projectile vomiting (the expulsion of  vomitus with
great force, often coming  through the  nose) in an
infant ma}' be  due  to pyloric  spasm;   in  an adult
usually some condition  of the brain; also often occurs
in the last stages of peritonitis.
   Expectorations.—Sputum  with  a foul   odor  (fetid)
usually denotes abscess or gangrene of the lungs.
   Purulent sputum containing pus may be from abscess
or extended empyema.  Purulent may be fetid.
   Prune-juice  sputum occurs in  pneumonia.  Is thin
and  streaked with blood.
   Rusty  sputum is due to blood in smaller amounts.
  The characteristic  sputum  of  tuberculosis is  thin
and  watery in which there are solid coin-like masses
which sink to the bottom of the fluid.   Often called
"nummular."
  Cough.—A cough is caused by some irritation of the
respiratory tract and is usually  described as  "dry,"
if  the sputum be scanty or absent, and "loose" if
abundant.  A dry cough may have a slight, rather
constant   "hacking"  sound,  or  may be  loud,  hard,
ringing or barking. 
PAIN
115
  Whenever a cough is accompanied by expectora-
tions, their  character should be carefully noted.
  Stools.—If there is diarrhea present it  is necessary
to know the character and  frequency of  the  evacua-
tions.  There may be blood and mucus, or large watery
stools.
  Clay-colored stools denote the absence of bile in the
intestines and consequent decomposition of the intes-
tinal  contents.   Usually occurs  in  inflammation  or
obstruction  of the bile ducts.
  Slow bleeding into the intestines is evidenced by the
"coffee ground"  if digested, or black stools if  decom-
posed blood.
  Distention of the  abdomen may be caused by either
gas or fluid. If gas, it is indicative of obstruction due
to tumor or adhesions, or may be caused by  a tem-
porary loss of the peristaltic movement of the intestines.
If a quantity of fluid collects in the  abdominal cavity,
a diseased condition  of the heart, kidneys, or liver may
be  the  primary cause.   With  this condition there  is
likely to be  edema (a swelling in which the cell spaces
are distended with fluid).  This pits  upon pressure.
  The  temperature, pulse,  and  respiration   afford
important symptoms and have been discussed elsewhere.
  Pain.—Pain of all symptoms is the one  which most
interests patients. It is too little understood that pain
is a sensation,  hence a phenomenon  of consciousness.
To one too unconscious to feel there is no pain, no matter
how badly the body may be injured.
  Pain never is "imagined." Imagination  may be the
cause,  but the  discomfort is  very real, and one suffers 
116           SIGNS AND SYMPTOMS

just as truly as if it were caused from disease.  We may
consider  pain as purely a mental  condition.  It is a
very well-known fact that pain may not be in the place
where one thinks it is felt (referred  pain).  Severe pain
may be distant from the seat of disease, as headache or
backache in  pelvic trouble,  or down  the left arm in
heart disease.
  Symptoms may be misleading, but if one searches for
signs in practically all cases the real trouble is located.
  Chills.—Chills are  nervous phenomena varying in
intensity from slight shivering  to  involuntary  move-
ments of sufficient strength  to  shake the bed; they
may be  caused  by coming in contact with something
colder than the body, or by poison (infection) taken in,
which acts on the nervous system.  This is the most
frequent cause.  Chills  are an accompaniment of local
infections, and diseases which are rapid in their onset
are ushered in with a chill.   After a chill the tempera-
ture may be  elevated to 104° or 105° F., dependent
upon the cause of the chill,  and the pulse and respira-
tion affected  in proportion to the degree of temperature.
  Convulsions.—Convulsions  indicate  an irritation of
the nerve cells of the brain resulting from various causes,
among  which are kidney   diseases,  lead poisoning,
paralytic dementia, some local  destructive disease of
the brain, tumor of the brain, or scar tissue, the result
of some  previous injury.
  Convulsions resulting from any of the above causes
are symptomatic, while those of epilepsy are idiopathic.
  A patient in convulsions should be kept from injuring
himself,  and if  they  are so  severe that there is  danger 
CONVULSIONS
117
of the patient's  succumbing  to  physical exhaustion,
ether or chloroform should be administered.
  The  nurse should observe  the  pupils of the eyes,
their relative size, and whether they react to the light;
the cry which precedes the convulsion and its character;
the time the attack comes  on, as an epileptic attack
may come in the night, or when a person is sleeping;
an hysterical attack does  not thus occur; whether the
patient loses consciousness at  once or gradually.  It is
important to note the order in which the movements
appear, also their character. 
CHAPTER  XIII.
                      URINE.

  Normal and Abnormal—Catheterization and  its Relation to Cys-
titis—Bladder Irrigation—Preparation of Specimens—Twenty-four-
hour Amount—Simple Tests.

  The  urine affords  the most important index of the
amount of waste excreted by the body.   It is dependent
upon the perfect action of the kidneys, modified  to  a
greater or lesser degree by the food and the amount of
fluids ingested.  Hence  any abnormality  in the  urine
is of utmost importance.
  Color varies from a pale amber to a brownish shade;
this variation is due to the relative  amount of coloring
matter held in solution.
  The reaction of  normal urine is acid.  The degree of
acidity  varies at different periods of the day.  Urine
voided in the early morning is strongly acid, while  that
passed during, and  after digestion, especially if the
food  is largely  vegetable in character, is  neutral or
may be slightly alkaline.
  The specific gravity is 1.015 to 1.025.
  Of the total quantity of urine  voided in twenty-four
hours (3 pints or 1500 c.c.) the normal constituents are: 
URINE
119
    Total quantity
    Water .   .    .
    Solids  .
Of the total solids:
    Urea
    Uric acid .
    Sodium chloride
    Phosphoric acid
    Sulphuric acid
    Ammonia .
    Chlorine
    Potassium
    Sodium
    Calcium
    Magnesium
    Creatinin .
 Grams.
1500.00
1440.00
  60.00
30 to 35.90
        .75
     16.50
      3.50
      2.00
        .65
     11.00
      2.50
      5.50
        .26
        .21
        .90
  The most  abundant constituents are water, urea,
and sodium chloride.
                      amount  of  urine is voided in
twTenty-four hours it is usually of a high color.  It is
still normal if the requisite amount of solid matter is
present; this  is particularly noticeable in patients with
high temperature, being  due to depletion of fluids in
the body.  Such urine,  upon standing, throws down
a sediment resembling brick-dust in color.  This  will
disappear upon heating or adding wrater, again showing
concentration.
  A sediment which will not disappear upon the addi-
tion of water is usually pus.  Decomposed pus renders
urine thick and ropy. 
120                   URINE
  Abnormal color is due to bile, blood, or the adminis-
tration of drugs.
  Blood from the bladder, if fresh, gives to the urine a
bright red shade; if from the kidneys, usually a smoky,
brown, or black color.  The difference in shade is due
to the quantity of blood and amount of decomposition
which have taken place.
  Urine  which  contains  blood  (unlike high-colored
urine) will retain its red shade when water  is added so
long as any color remains.
  Bile gives to the urine a dark-brown, greenish, and
in extreme cases an almost black color.  This may be
recognized by the yellow stain which it gives to white
fabric (paper or cloth).
  Urinalysis. — Abnormal  constituents are  albumin,
sugar, casts, indican,  acetone, diacetic  acid, mucus,
blood, calculi.
  It often becomes necessary for nurses to make simple
tests  for albumin, glucose, pus, or bile.   One should
also know how  to test for  the reaction and specific
gravity.
  Important points to be recorded are:
  Name         date        hour         sex
    Amount for twenty-four hours.
    Color.
    Specific gravity.
    Reaction.
    Albumin.
    Sugar.
    Bile.
    Sediment. 
   METHOD OF TESTING SPECIFIC GRAVITY  121

  These abnormal substances are determined by boil-
ing and by chemical tests.
  Specific gravity is the weight of any fluid compared
with that of some standard fluid;  wrater at its greatest
density (4° C.) is understood (if  no other standard is
mentioned).
  One c.c. of water at 4° C. weighs 1 gram.
  One c.c. of urine may weigh from 15 to 30 milligrams
more than the water.   Hence  the specific gravity  of
urine is  1.015 to 1.030.  This shows  the  amount  of
solids contained.
  Method of  Testing  Specific Gravity.—The  urinometer
glass should be about three-fourths full and stand abso-.
lutely level.  The urinometer should be put in to touch
the bottom of the glass, then allowed to find its proper
level.  The last mark below the surface of the fluid
(the meniscus) is  the proper  specific  gravity. This
should be read through the fluid from below.
  Reaction is tested with litmus paper.  Red litmus is
turned blue by an alkali.  Blue litmus is turned red by
an acid.
  Sometimes red litmus is turned  blue, and blue litmus
turned red by the same specimen.  This is due to the
presence of acid  and  alkaline salts.
  Albumin Test with Nitric Acid.—Put a small  amount
of filtered urine in a test-tube; with a pipette carry an
equal amount of nitric acid to the bottom of the tube,
allowing the urine to remain on top.
  If albumin is present a white  precipitate forms  a
zone or ring at the junction of the two fluids. 
122
URINE
  Heat  Test.—Filter and  render acid by addition of a
few drops of acetic acid a test-tube half full of  urine;
boil the upper half.  Any opacity will be due to albu-
min or  phosphates;  to determine which the addition
of three or four drops  of acetic or nitric acid will clear
the specimen  if  the opacity is due to phosphates, and
further  precipitation will  occur if it is due to albumin.
  Sugar.—The sugar wThich usually occurs is glucose.
  The Fehling Test.—If albumin is present, boil,  add a
few drops of  acetic acid, then filter before testing for
sugar. This should be  done as a routine.
  Having filtered out  albumin (if  there be  any), mix
in a test-tube about 1 c.c. of Fehling's A  and B, add
3 c.c. of water and boil.   This is  to determine  if the
solution will form a precipitate.  If none is formed add
ten drops of  urine.  A red precipitate indicates that
sugar is present.  If the solution remains  clear, heat a
second time when, if  a precipitate appears, the test
should be repeated, omitting the last heating and allow-
ing the  solution to stand for twenty-four hours,  when
precipitate forms if sugar is present.
  Quantitative tests are not usually required of nurses.
  Pus is best determined by aid  of  the  microscope,
though  it  may frequently be  seen  in  considerable
quantities.
  The sediment may be due to any of the salts which
occur in  normal  urine  (when  the  twenty-four-hour
amount is  small,  these salts  recrystallize  when  urine
becomes  cold), or  to abnormal organic and inorganic
constituents, which are demonstrated by various tests
and the  aid of the microscope. 
CATHETERIZATION
123
  Retention.-—The condition in which urine is secreted
and retained in the bladder may be caused by stricture,
paralysis, unconsciousness, nervousness, or some sur-
gical procedure or  injury.  This is not considered an
especially serious condition,  and may be  relieved by
the use of a catheter.
  Suppression.—Suppression of urine means that urine
is not being secreted normally;  that the poisonous urea
is not being thrown out of the body.   Suppression is,
therefore,  an  important symptom,  and indicative of
some impairment  of the kidneys, and sooner or  later
the patient must, in some degree, succumb to uremic
poisoning,  with possibly convulsions, coma, or  death.
Complete suppression results in death in a short time.
  Incontinence.—Incontinence of urine  is the inability
to retain it in the bladder; paralysis or unconsciousness
may  be the  cause.   An  overdistended  bladder will
cause incontinence.  Catheterization at regular intervals
will relieve this condition.
   Catheterization. — Catheterization  is  withdrawing
urine from the bladder by use of the catheter  under
the influence  of bacteria.  Urine  decomposes quickly,
furnishing for them a suitable medium in which to
grow and  multiply, causing cystitis  (inflammation of
the bladder).
  Catheterization must be performed under the strictest
aseptic regime.
  Due consideration should  be given  to the choice of
catheters.   The  glass  catheter, which may be kept
beautifully clean,  is in some  cases contra-indicated.
It would not be  safe  to use  a glass catheter  during 
124
URINE
labor, nor in case of a violently  delirious  or insane
patient.  A soft-rubber catheter is safer.  Even in the
hands of an unskilled person, provided those hands are
clean, a sterile, soft-rubber catheter can do little harm.
  Preparation.—Choose  two  catheters  (always  two,
in case one may become contaminated in some way),
fold them  in  a towel and boil ten minutes at least.
These should  be taken to the patient in the basin in
which they were boiled and  must not  be uncovered
until used.
  At the bedside there should be a basin of water and
green soap; a second one of boracic acid, 4  per cent.;
pieces of gauze; sponges or puffs, and a kidney basin
for used sponges.
  If the hands of the nurse are to be prepared at the
bedside, there should be ready for her use  one basin
with green soap and water with a brush and  one basin
containing 70 per cent, alcohol or bichloride of mercury,
1 to 1000.
  Arrange  the  patient  comfortably on  a  bed-pan,
with knees slightly flexed.  Fold the bedclothes back
to the knees, covering the upper  part  of  the body
with a blanket or a sheet; the thighs  should  be  cov-
ered with a second sheet, tucking it well down under
the buttocks.
  Separate the labia and cleanse thoroughly, first with
green soap and water, then sponge with boracic acid.
(If  the patient has any venereal disease, bichloride  of
mercury, 1  to  2000, may be used, then  rinsed off with
sterile water.)
 . If a glass catheter is used, test the end to see that 
CYSTITIS                  125
there are no  sharp places, which may be the result of
boiling, hold the catheter so  that  it will not become
contaminated and insert quickly about 1| or 2 inches;
never use force.  In case of  obstruction, withdraw  the
catheter slightly and wait for a minute, then  repeat
the attempt.  A spasmodic  contraction of the urethra
sometimes takes place which will pass away almost
immediately.
   If there has been considerable distention, the bladder
should never be entirely emptied; 20 to 25 ounces may
safely be withdrawn, and the balance allowed to remain
for three or four hours, then the catheterization  should
be repeated.   A greatly distended bladder may collapse
if completely  emptied, causing temporary paralysis
after the tissues have been stretched to their utmost.
   Cystitis.—The most important treatment in cystitis
is local, and consists  of catheterization and bladder
irrigation. In severe cases the patient may not be able
to void urine naturally, and the accumulation of a  few
ounces in  the bladder  causes great discomfort, which
may be relieved by catheterization, followed by irriga-
tion.  Usually  2  per  cent, boracic acid, sterile  water
solution or salt solution may  be used, at the tempera-
ture of the body  (about 100° F.).
   A glass or rubber  irrigator  may  be used.   Both
irrigator and tubing should be boiled, and should be
just high  enough to enable the fluid to flow without
force, a return flow catheter being used.
   Or the patient being on the douche-pan, the bladder
may be emptied with  a soft-rubber  catheter,  which
without being removed, should be connected with the 
126
URINE
tube of the irrigator and a small amount of the fluid
allowed to enter the bladder.   The bladder should be
emptied  each  time through   the  catheter  and  the
irrigation repeated until fluid returns clear.
  To prepare specimens  for the laboratory,  a clean
specimen glass or bottle should contain  not less than
5 or 6 ounces, enough for all the tests it may be necessary
to make.  The name  of  the  patient, ward,  and  bed
number,  and the time when the specimen was obtained
should also be attached.   If it be a catheter specimen,
or a twenty-four-hour  specimen, that fact should be
plainly written on a label and attached  to the bottle
or glass, which should be covered to prevent contamina-
tion.
  Should the specimen be wanted for bacterial exami-
nation, it should be  a catheter specimen drawn directly
into a bottle which  has been sterilized and the mouth
stopped with sterile non-absorbent cotton.
  To obtain a specimen of twenty-four-hour urine,
the bladder should be emptied at a certain hour.  From
that time all urine should be saved until the same hour
the following day, when the bladder should again be
emptied.   A twenty-four-hour  specimen is taken from
this  amount.  It should  be marked twenty-four-hour
specimen, so  as not to confuse  it  with a morning or
fresh specimen. 
CHAPTER XIV.
                 EMERGENCIES.

Hemorrhage—Syncope—Epilepsy—Hy st eria—Poisoning—Lavage —
                 Artificial Respiration.

                  HEMORRHAGE.
  Hemorrhage is the escape of blood from some part
of the vascular system.  It may be internal or external,
and is usually caused by a wound (traumatic) or by a
disease condition (spontaneous).
  An injury may be accompanied  by more or  less
bleeding; therefore, most hemorrhages are traumatic,
and are serious in proportion  to the amount of blood
lost.
  When  the bleeding occurs from a  superficial  vessel
it is easy  to distinguish an  arterial  from a venous
hemorrhage.  The blood from an injured artery flows
in jets, is bright red in color, and comes from the  side
of the wound nearest the heart.  The blood from a
vein is dark red in color, and flows in a steady stream,
and comes  from the distal end. If a deep-seated vessel
is injured  it is impossible to  distinguish  whether the
blood is  from a vein or an artery, because the blood
wells out and fills the wound.
  Capillary hemorrhage usually  comes from  a  large,
denuded area. 
128               EMERGENCIES
  Hemorrhage may be checked or controlled (1) by
always, if possible, elevating the bleeding part, and (2)
by  applying pressure, either direct  (at the  bleeding
point) or along the course of the vessel.
  Direct pressure may be made by packing the wound,
by a pad tightly bandaged over it,  or in extreme cases
by making pressure with the fingers.
  Indirect  pressure may be made  by placing a small
pad over the bleeding vessel above the wound if it be
an artery,  below the wound if it be a vein, and by a
tourniquet or Esmarch bandage.
  Hemorrhage is sometimes checked by the  applica-
tion of heat, hot water douching, or towels wrung out
of hot water  and  applied  with slight pressure.  The
latter is  generally used in capillary hemorrhage.  Also
by the application of cold, in the form of ice, iced water,
or ice-bags.
  The surgeon generally uses torsion,  which  is  done
by twisting and crushing the end of a vessel, and liga-
tion, which, of course,  is the safe and sure way.
  Astringents   are  used  internally  and  externally.
Ergot  and  adrenalin  chloride are the most useful;
ergot  is  given internally, and adrenalin may  be used
both internally and externally.
  Styptics  are  seldom  used, because of the  danger of i
infection.
  A hemorrhage from a large  artery may cause  death
in a  few minutes.   Hemorrhage  from a small artery
will surely  cause death if not controlled.
  Primary  hemorrhage occurs at the time of the injury
or operation.   Secondary hemorrhage  may occur at 
SYNCOPE
129
any time after the primary bleeding has been stopped;
it may he by the slipping of a ligature or by sloughing.
  In hemorrhage from internal parts the blood may not
be expelled for some time, as in intestinal bleeding, or
the bleeding from gastric ulcers,  or  it may be  entirely
concealed  and the  person bleed into his own  body
cavities.   It is only by general symptoms that such a
condition  can  be recognized. •  The symptoms are:
A bluish-white pallor with blue circles under the eyes,
blue lips,  and finger-tips. A weak,  irregular, or rapid
pulse, usually increasing in rate.  Restlessness, increas-
ing up to a  certain p'oint.   Thirst.  Air hunger.  A
falling temperature.  The skin is usually cold.  Shallow,
sighing respirations.
  In  spontaneous hemorrhage from any part of the
body, as in the nose, throat, lungs, stomach, intestines,
uterus, etc., it is necessary to keep the patient as quiet
as possible,  and in the recumbent  position,  so as  to
give the heart the least amount of work.   If the  hemor-
rhage has been severe,  it often becomes necessary  to
supply the body with  fluid, which  may be  done by
means of  a hypodermoclysis or intravenous injections
of salt solution.  This  is  not  done until the bleeding
has been  controlled, as  any  increase  in the  blood-
pressure prolongs the hemorrhage.


                     SYNCOPE.

  Syncope or fainting is caused by anemia of the brain,
induced by  poor heart action.  The symptoms are
     9 
130
EMERGENCIES
 pallor,  unconsciousness, rapid or poor  quality pulse,
 feeble respirations, and usually a moist skin.
   The patient first feels weak, moisture appears on the
 face, vision becomes dim, and there is  a sound as of
 running water or the wind blowing the leaves; then he
 gradually becomes unconscious and falls,  not a hard
 fall, but he generally "wilts down;" if in a chair he may
 slip to the floor.
   It may occur as a result of fright, the sight of blood,
 or an accident, upon hearing bad news, or because of the
 "close" atmosphere in a crowded  room.
   The patient must be placed in the recumbent position,
 and the head must be lower than the body, so that  the
 blood, through gravity, may be assisted in circulating
 through the brain.   All  constricting bands must be
 loosened,  especially  about the neck and waist.
   Plenty  of fresh air must be allowed.  Occasionally
 stimulants are needed.
   A prolonged fainting fit is dangerous, because  the
 centers  located in the  brain, and which control  the
 functions  of the body, cease to act when for a certain
 length of  time they are deprived of blood.

              EPILEPSY—HYSTERIA.

  Epilepsy  is  a  nervous  disease characterized  by
 convulsions.  It is generally a chronic  condition and
 progressive.  There  is  usually a  premonition  of the
 seizure, but the convulsion follows so rapidly that the
 patient  is  seldom able to get into a position  where he
cannot injure himself. 
E PILE PS Y—H YS TERIA
131
  First  is  the  tonic  spasm.  The patient falls,  the
muscles become rigid, and because of this rigidity of
the respiratory muscles, he becomes cyanotic, and at
times almost black.  This spasm may last from thirty
to forty seconds, sometimes longer. Then the muscles
relax and  there is involuntary twitching of all  the
muscles of the body.  After a short time, varying from
one or two minutes to ten or more, the patient either
sleeps or becomes  comatose.
   Serious injury is sometimes caused  by the fall; deep
burns, cuts,  bruises,  and  even fracture of the skull
may occur.
   A patient suffering from epilepsy should  be put in a
position where the violent  movement can do him no
harm.  A gag or towel may be used to prevent biting
the tongue, and he should be  watched carefully,  but
never restrained.  It  may become necessary to admin-
ister ether or chloroform to prevent physical exhaustion.
   Hysteria somewhat  resembles  epilepsy.   It  is  a
nervous condition, and convulsions  closely resemble
those caused by diseases of the brain.  Unlike epilepsy
the  attacks never occur in the night; the movements
are  not involuntary, but  rather studied;  such  as an
effort to perform some act, like pulling the  hair, feeling
the collar, or beating the hands against anything with
which  they  may  come  in contact.  An hysterical
patient  never  injures himself,  either by falling or by
any act during the attack. The skin does not change
color. 
132
EMERGENCIES
                    POISONING.

   Poisons are substances which taken into the body
are destructive  to health or life.   They  are classified
according to their action.
   Irritant  poisons  are  those which  irritate, corrode,
or excoriate.
   Narcotic  poisons are  those which produce profound
sleep or coma.
   Irritants may be either acid or alkaline in reaction,
and they may also be narcotic in their action.
   Antidotes are  agents wrhich  counteract  poisons.
Antidotal measures  may be mechanical,  chemical, or
physiological. The object to be attained is to remove,
to neutralize, and to counteract the effects on the body.
As much of the poison  as possible should  be removed
by emesis or with a stomach-tube, and the balance neu-
tralized by giving the chemical antidote, which either
produces a  non-poisonous or an insoluble compound
in the stomach.  The physiological antidote counteracts
or antagonizes the effects of the poison in  the system.
  While the chemical antidote has no effect on poisons
which have been absorbed, the entire antidotal treatment
should be carried out, as it  is impossible to determine
just how much absorption has taken place.
  Powerful poisons,  as the alkaloids,  require powerful
antidotes, which should be carefully  used, as there is
danger of substituting one poison for another.
  Emetics should not be given after corrosive poisons;
lavage should be used instead.
  Emetics in common  use  are warm water in large 
POISONING                133
quantities alone, also salt and water, one teaspoonful
of salt to a  tumbler of water.   Mustard  and water
may be used in the same proportions.
  Warm  soap-suds  are  usually  effective.   Ipecac,
sulphate of  zinc, tartar emetic, may be  used,  and
apomorphine hypodermically.
  There  are a number of drugs in common use which
are "cumulative" in action: that is,  when given in
continued doses  they  accumulate in the body  and
symptoms of poisoning may result.  Others may accu-
mulate because they are given more rapidly than they
can be eliminated, or because of an individual pecu-
liarity which makes one more susceptible to the effect
of drugs.  It is important that these conditions be
recognized (which may be classed as chronic poisoning)
and the use of the drug discontinued.
  Arsenic is  "cumulative" in action.  It is  also an
irritant and a  narcotic. It is most frequently given
in the form of Fowler's solution, and  in combination
with iron and strychnine or iron and quinine.
  Signs of the  accumulation of arsenic in the system
are:  edema and itching of  the eyelids, particularly in
the  morning;  slight  diarrhea;  nausea and  possibly
vomiting; feeble heart;  dyspnea; skin eruptions;  and
albumin  in the  urine.
  In  full toxic doses (which may be  in the form of
arsenous acid, Paris green, or Rough on Rats), gastro-
intestinal or cerebral  symptoms may develop.   The
first  are the most common: there are burning  pain in
the stomach and abdomen; vomiting of bloody mucus;
thirst; bloody  stools;  suppressed or  bloody  urine; 
134
EMERGEXCIES
rapid, feeble heart;  cold breath; collapse; death from
paralysis of the heart.  In the cerebral form the pro-
found coma, like that  of opium, comes  on suddenly
without gastro-intestinal symptoms.   The  treatment,
if vomiting has not  occurred, is  an emetic  or the use
of the stomach-tube.   The antidote  is hydrated iron
with  magnesia  and demulcent  drinks,  like flaxseed
tea or gum-arabic water.  Stimulants should be used
if necessary.  The bladder must be emptied frequently
to prevent reabsorption.
   Digitalis is cumulutive, a cardiac tonic and vascular
stimulant and is also a diuretic and emetic.  In overdoses
it irritates the mucous membranes, causing sneezing
and severe gastric disturbances, nausea, vomiting, and
purging, the discharge being  a grass-green color.  The
heart's action becomes affected; the pulse is slow, and
may possibly be irregular  or intermittent.   There  is
dizziness,  also the appearance  of vibrating fringes of
color around objects. In toxic doses the respiration is
first slow, then  becomes rapid and feeble; there are also
cyanosis, coma, and convulsions.  Death  occurs by
sudden paralysis of the heart.
  The chemical antidote is tannic acid.  The stomach ,
should then be washed out, as the tannate is not inert.
Aconite is the  best physiological  antidote  for  large
doses, and opium to those of long-continued use.
  Strychnine is "cumulative" in  action.  The first
constitutional symptoms are restlessness, with  slight
twitching  of  the limbs  and stiffness  of the jaw; the
corners of the mouth are drawn  up in an unmeaning
smile. 
POISONING
135
  After poisonous doses the symptoms come on rapidly
with convulsions, the limbs  are rigid, and the head is
drawn backward until head and heels  nearly  meet.
The arms are bent and the hands clinched; the jaw
is the last to  become  rigid.  The eyes are wide open
and staring; the face  is first pale and then becomes
livid from asphyxia.
  The spasms resemble tetanus and  follow each other
rapidly; the mind remains clear until the end.  Death
takes place in  two to three hours  from paralysis of the
respiratory muscles.
  Tannic acid is the chemical antidote; it should be
followed by an emetic  or stomach-tube.
  Chloral and chloroform are the  physiological antago-
nists.  The treatment for strychnine poisoning must
be  carried out as soon as the drug has been taken, as
it  is rapidly absorbed and  a delay  of a few minutes
may prove fatal.
  Opium and morphine are not cumulative in their
action,  though  symptoms  of overdosing result when
the interval  between  doses is not  sufficient for its
elimination to take place.
  Signs of overdosing are nausea and vomiting, profuse
sweating, depression of the  heart action, pupils  some-
what  contracted,  slow  respirations,  and  sleep  or
stupor.
  In poisonous  doses  there  are cold, clammy skin;
slow  heart action;  lost  reflexes;. minutely contracted
pupils;  very  slow respiration, possibly  three or four
per minute; coma; death by paralysis of  respiration.
  If narcotism comes  on gradually after giving medi- 
136
EMERGENCIES
cinal doses, the patient should be kept awake until
the effects gradually disappear.
  The treatment  for  opium or morphine  poisoning
consists in the evacuation of the stomach, maintaining
respiration, and keeping up the circulation.
  The chemical  antidote  is potassium permanganate,
the dose of which  should be one-half greater than the
amount of morphine taken.  When taken hypodermi-
cally, both the emetic  and the chemical antidote may
be omitted.
  Atropine antagonizes its cerebral action, also action
on the heart and respiration.  Strong, black coffee by
mouth or  by rectum  may be prescribed.   Caffeine,
strychnine,  and cocaine  also  counteract  morphine.
The faradic current of electricity applied to the chest
muscles and artificial  respiration are of great value.
The bladder should  be emptied cautiously  with  a
catheter to prevent reabsorption.
  Mineral acids: Hydrochloric,  nitric, phosphoric, and
sulphuric.  The  antidotes are alkalies, as sodium  bi-
carbonate, lime water  or soap suds, to neutralize the
acid.   The stomach should be emptied cautiously with
a stomach-tube.  Stimulants may be given if necessary;
also opium for the discomfort, and demulcent drinks.
  Carbolic  acid:  Wash out the stomach with 50 per
cent, alcohol (whisky or brandy may be used).  Having
completely emptied the stomach,  three or four ounces
of a solution of  50 per  cent, alcohol and  water (or
brandy or whisky may  be used) should be given by the
stomach-tube and allowed to remain in the stomach.
  Sulphate  of magnesium and  sodium are chemical 
ALKALIES
137
antidotes.   After their  use the  stomach should  be
emptied  by  lavage,  as  it  is  impossible to  produce
emesis after the ingestion of carbolic acid.  Either of
the above methods may be used, but alcohol is usually
given precedence.
  Atropine  is a  physiological  antagonist, and  main-
tains the heart and respiration until elimination occurs,
which  should be promoted  by giving drinks freely.
Demulcents  may be  given to protect  the  mucous
membrane,  but  no  oils  or glycerine.  The  bladder
should be emptied frequently.

                      Alkalies.
  For poisoning by ammonia, caustic potash, etc.,
vegetable  acids  form the  antidotes.  Lemon juice,
lime juice, and dilute vinegar may also be used.  Milk
or  oil and white of egg are of value.  The  stomach
should be emptied cautiously.  Plenty of fresh air is
essential.  Digitalis  is an antagonist.   Sedatives may
be  given if necessary.
  Gases,  illuminating,  carbon dioxide:   Fresh  air,
external heat, and  stimulants if necessary, are the
antidotes.
  Mercury,  bichloride,  or  corrosive sublimate:   The
external use of bichloride of mercury  has been known
to  produce symptoms of poisoning.  An eruption  of
small pimples appears.  The gums  and teeth become
sore and salivation  may follow.
  For accidental poisoning by mercury  one egg  to
every four grains of the bichloride; more than  this may
redissolve the mercury. 
138
EMERGENCIES
   Vomiting should be promptly induced and actively
 kept up for some time after giving the antidote.
   The  symptoms which accompany  large  doses of
 mercury are nausea, burning in the stomach, abdominal
 pain and diarrhea.  The urine is diminished, and may
 contain blood and albumin, or may be suppressed.  In
 the  course of a number of hours, or it may be days,
 there is collapse,  syncope or convulsions, coma  and
 death.
                       Lavage.

   Lavage is the washing out of the cavities of the body,
 usually the stomach.   It is most often used in cases
 of poisoning to empty the stomach; it is also used as
 a  therapeutic measure  in  acute  or chronic  gastritis,
 in excessive vomiting, and for the chemical analysis
 of the contents of the stomach.
   Necessary  Articles .— Rubber  dressing-sheets  and
 towels to protect the patient and bed; a slop-jar or some
 receptacle  for the fluid  and  material  washed out; a
 pitcher of sterile water; salt solution of whatever fluid
 is to be used, from two to four quarts, at body tempera-
 ture.
  The stomach-tube,  funnel,  and mouth-gag may be
 sterilized together and brought to  the bedside covered.
 Patients who are conscious may sit up during the pro-
 cedure.  The head should not be thrown back,  but held
 slightly forward. Those who are unconscious, delirious,
or hysterical are placed on the back and the mouth-
gag used.
  The  tube should  be moistened and passed gently 
ARTIFICIAL RESPIRATION          139
into the pharynx.  If mentally responsible the patient
should be instructed to swallow while the tube is being
rapidly pushed into the stomach, the distance of which
should have first been estimated.
  Before pouring the fluid into the tube it is necessary
to see that the patient breathes normally, that his
color  is  good (not cyanotic), and that he does  not
cough.  Any of these conditions may indicate that the
tube is in  the trachea,  when it should,  of course, be
withdrawn.  This  is a precaution which should  never
be overlooked even in the gravest emergency.
  About one pint of water or solution to be used should
be poured  into the funnel, then,  while about half full
the funnel must be quickly inverted into some receptacle
which  is lower than the  level of the stomach, when the
fluid poured in and the contents of the stomach  will
be  siphoned out.  This  should be repeated until the
fluid is returned clear.

             ARTIFICIAL RESPIRATION.

  Respiration is  carried  on by  the  contraction  and
relaxation of the respiratory muscles, by which inspira-
tion and expiration  are performed.  By producing
certain movements the same result is procured, that of
creating greater space in the chest, which fills with air,
and of forcing the air out.,
  There are several methods of performing artificial
respiration.   Sylvester's method  is most commonly
used, which consists in first raising the shoulders slightly,
the head being allowed  to  drop  backward; the arms 
140               EMERGENCIES
between  the wrists  and  elbows should  be  grasped
firmly  and the arms swung  horizontally  away  from
the body until they meet over the head.  This creates
greater air space (inspiration), and should be performed
slowly, to give the lungs a sufficient length of time to
fill with air.  The arms should then be brought down
across the chest and  pressure made against the chest
wall, which expels the air (expiration).
  Both  movements should occupy at  least three  or
four seconds, as  not more  than sixteen  to twenty
movements should be performed per minute. 
CHAPTER XV.
          EMERGENCIES (Continued).

       Fractures—Sprains—Dislocations—Burns—Shock.

                   FRACTURES.
  A  fracture is  a break in a bone which  may  be
complete or only a fissure.  When classified according
to the nature  of  the injury there are two  distinct
classes:
  1.  The  open or compound fracture,  when  there is
an external wound leading down to the seat of injury,
usually caused by  the  sharp end of the bone being
driven through the skin.
  2.  The  closed fracture, of which  there are  several
varieties:
  (a) The simple fracture is a break in a bone without
external wounds or complications.
  (6) The comminuted fracture, in which the bone is
shattered  or broken in several places.
  (c) The impacted fracture, in which the ends of the
broken bone are driven together.
  (d) The green-stick fracture—which is like a green
stick splintered and broken  while the fragments still
hang together.
  {e) The subperiosteal fracture — a fracture of the
wrist in which the periosteum is  not broken, often
spoken of as the "chauffeur's wrist." 
142
EMERGENCIES
  A depressed fracture is of the skull; it is only dan-
gerous when both plates of the bone are broken.
  In young persons the types most frequent are:
  1. The green-stick, because of the excess of animal
matter in young bones.
  2. Separation of  the  epiphysis along the epiphyseal
line.  This is likely to occur up to the age of about
sixteen years, or until  the  epiphysis has united with
the shaft of the bone.
Fig. 10.—Impacted fracture of the hip.
  In the old, a not infrequent occurrence is impacted
fracture of the hip, the head of the bone being driven
into the cancellated portion.
  The other types occur in both old and young, and the
breaks may be transverse, oblique, or fissured.
  Signs of fracture:  Abnormal mobility  at  the seat
of fracture.  Pain always.  Deformity usually; some
breaks do not show deformity.  Crepitus  not always;
when present, fracture is positive.   In impacted  hip
and  subperiosteal fractures it does not exist.  Loss 
FRACTURES
143
of function not always; impacted  hip  and lower end
of fibula  are  exceptions.  Discoloration  usually, but
may be hours or days after the injury.   Blebs are apt
to occur with  the swelling.
  Treatment.-—First immobilize the part by using some
temporary support until the swelling subsides.  For a
fracture of either bone of the leg a pillow splint may
be used, which consists of a soft pillow pinned about
the leg reinforced on  each  side by straight pieces of
splint wood and held in place by two or  three straps.
  This permits  the swelling without causing pressure
or obstruction of circulation.  Later the blebs should
be opened with a sterile needle, to allow the fluid to
come out, then dusted with an antiseptic powder, as
boracic acid.   Carelessness in caring for  these  blebs
may result in infection.
  A plaster cast is usually the permanent dressing for
any fracture below the knee.
  For  fracture  of the femur,  the patient should be
placed on a Bradford frame with sand-bags  until it is
safe  to use a  Buck's extension.  For a small child a
crane may be used instead of the Buck's extension.
  A fractured forearm may be  put up in an anterior
and posterior splint; as the sides are open there is room
for the swelling.
  In open or compound  fractures the danger lies in
infection,  because there is always an infected wound.
The outcome depends upon the amount  of the infection
and the virulence of the organism.
  The  patient is invariably anesthetized, the w7ound
thoroughly cleansed with soap and water and  antiseptic 
144
EMERGENCIES
solutions.  The bones are then put  in apposition, and
after the wound has been dressed a plaster cast applied.
The plaster is applied at the first  dressing of a com-
pound fracture, because the draining of exudation fluid
from the wound allows very slight if any swelling.
  Later an opening, called a window, is cut in the cast
so that the wound may be dressed.




               Fig. 11.—Extension straps.

  In the first treatment of  a  fracture there is danger
from  too  tight application  of a bandage, plaster,  or
adhesive straps.  The improper  application of either
of the above may so obstruct  the circulation  that
gangrene  may  result  with  amputation of  the  part
following.
  To  prepare for a Buck's extension the leg should  be
thoroughly  cleaned  with soap  and  water and then
shaved.  An extension strap is applied  to  each  side
of the leg, which may be reinforced by strips of adhesive
plaster applied spirally.
  An  extension strap consists of a  piece of mole-skin
plaster (which should come above the knee), to which
a buckle is fitted; the end is then turned back and
stitched, the non-adhesive  side of the plaster serving
as a facing for the strap.
  A sheet-wadding bandage is placed over the strap,
padding  it well,  and  last  a  cotton  muslin bandage, 
FRACTURES
145
which  has been starched,  should be soaked in warm
water  and put  on damp.  This when  dry makes a
firm bandage, and one  which will  not slip.   It also
keeps clean much longer than the unstarched bandage.
At the point of fracture, coaptation  splints are applied
and  kept in  place with  straps, fastened with buckles.
   A T-splint should extend from the foot to the axilla,
and  be kept  in place  by being strapped to the leg and
by the use of a pocket swathe.  The  extension straps
are then fastened to a spreader and the required amount
of weight put on.  The  foot of  the  bed should be ele-
Fig. 12.—T-splint used with a Buck's extension.
vated with bed blocks,  the bed making an inclined
plane; the  weight of the  body  serves  for counter-
traction.  An unyielding  surface is obtained by the use
of the fracture board, and for convenience in moving
the patient should lie on a Bradford frame.
    Articles needed for a Buck's extension are:
    Sheet-wadding, 6 sheets.
    Straps, with buckles, 6 to 10 (12 and 18  inches for
      adults).
    Safety pins.
    Adhesive strips.
    Sheet-wadding bandages.
    Cotton muslin bandages (starched).
    Coaptation splint.
    T-splint.
      10 
146                EMERGENCIES
  Pocket Swathe—A swathe with a pocket or straight
piece  sewed on the outside, through which the end of
the T-splint is put.
    Extension straps.
    Spreader.
    Extension pulley.
    Weights.
    Bed blocks.
    Bradford frame.
    Fracture  board.
    Cradle.
Fig. 13.—Extension crane for a child. 
PLASTER CAST               147
  Extension for a  Child.—When the child is from six
months to twelve years a crane may be substituted
for a Buck's extension.
  The leg is treated as for an adult, then extension is
made by  passing  the rope attached to the spreader
through a pulley fastened  to the crane.   Weights are
attached to the free end of  the rope.
  The leg should be in an upright position; and at right
angles to the body, the weight  of  the body makes
counter-traction.   This is a simple apparatus and per-
mits of considerable movement on the part of the child
without disturbing the position of the bones.


                  PLASTER CAST.

  A car or table should be  at the side of the bed, upon
which are placed rubber sheets to protect the  bed and
the floor.  A doctor's rubber apron, sand-bags, three
for short  plaster and  five  if the plaster  is to extend
above the knee.   Sheet-wadding bandages, to be put
on under the plaster; plaster bandages; plaster of Paris,
dry, in a basin; a flannel bandage or stockinette tubing
to serve for a cuff.  This is put on under the first layer
of plaster;  when  the plaster  has  reached sufficient
thickness, the cuff is turned back and fastened down
by the last layer of the plaster bandage.
  A receptacle of wrarm water sufficiently deep  to allow
the bandages  to stand on end and still  be  covered
with water.
  If salt is added  the  plaster sets more quickly.  The 
148
EMERGENCIES
proportion is one teaspoonful to a pint of water, which
should be put in a cup, to be used if desired.
  The bandage should be  soaked  just  before using
and not allowed to stand in the water after it has ceased
to bubble.
  That the best  results may be  obtained, the  patient
is usually anesthetized when a fracture is put up per-
manently. Where this is the case, an ether cone, ether
towels, tongue forceps, and a kidney basin are necessary.
  Fractures  may be complicated  by sprains  or dis-
locations when in the vicinity of a  joint;  by laceration
of large bloodvessels;  also  in case  of fracture of the
ribs or  of the pelvis, puncture or injury  of the lungs,
liver,  spleen, kidneys, bladder, or the intestines.

                     SPRAINS.

  A  sprain is an excessive strain,  laceration,  or com-
plete  separation of a ligament from the bone at a joint
without dislocation of that joint.
  The ankle is most often involved.  There are pain,
tenderness, swelling and discoloration; the seriousness
depends upon the extent of injury.
  The first treatment required is to immerse the part
in water  as hot  as can be  borne until the first sharp
pain  subsides,  then  if the injury is not extensive the
part should be strapped with adhesive plaster.
  If the injury be to the ankle, the patient is instructed
to walk as usual. It is found more difficult when the
knee  is involved, but even in such a case there should
be exercise. 
BURNS
149
  When  there is separation of the ligament from the
bone, the same treatment as for a fracture is indicated
—complete rest and usually a plaster cast.


                 DISLOCATIONS.
  A dislocation is the displacement of a bone at a joint.
It may be partial, complete, or compound.
  A compound dislocation is  always a serious injury.
The open wound, which is the  result  of  the tearing
apart of the soft tissues, results in an infected wound.
  Signs of Dislocations.—Pain, deformity, loss of func-
tion,  and later  swelling and  discoloration.
  There is but  little that a nurse can do other than
to keep the part at rest and use hot applications. Lead
water and  laudanum may be applied hot  in the form
of  a  fomentation, to  lessen the pain.
  To reduce a dislocation, an anesthetic is necessary.
The part should be immobilized and kept at rest for a
few days, the length of time depending upon the extent
of the injury.
                      BURNS.
   Burns are  among the most  frequent emergencies.
They are classified according to the extent of the injury
into three degrees:
  First degree—consists of injury to  the epidermis,
resulting in its destruction with superficial inflammation.
  Second degree—separation of the epidermis from the
true skin with  injury to  the corium.   The  result  is
sloughing of the superficial tissue. 
150
EMERGENCIES
   Third degree—injury and destruction of  the  deeper
tissues, which may  involve muscles, tendons, nerves,
ligaments, and even  the periosteum.
  The mortality from burns depends upon the physical
condition of the person and the character and locality
of the burns;  the chest and the abdomen are the most
dangerous localities.
  Old persons and  children  have  low  resistance and
stand burns poorly.
  There are two stages to be considered in the treat-
ment of all extensive  burns:   First the shock,  which
is  immediate  and always present.  Later  sepsis, as
there is always  sloughing of tissue according to the
degree of the injury.
  The Immediate Treatment.—Shock should  be treated
first, then the burns  should be  dressed.   Blebs may be
opened with clean, sharp scissors.
  It is generally admitted that picric acid gives  better
results than  carron  oil dressing,  which  has been so
much used  in the past.
  Picric acid is not  popular because it  stains a  bright
yellow, leaving stains on the nails  which will not dis-
appear for months.   It should be used in a  2 per cent.
solution (saturated).  It is an antiseptic, a  deodorant,
a stimulant, and an anodyne.
  Gauze should  be saturated and fluffed, not allowed
to lie flat against the  surface.  It should be used because
it permits of  free  drainage.  After the daily dressing
the gauze may be saturated two or three times during
the  twenty-four hours without removing  from the
wound. 
BURNS
151
  After granulations  appear,  an ointment should be
used.   Boracic acid is highly  efficient, and should be
spread on material which does not have wide meshes.
  Scarlet-red ointment  stimulates the growth of epi-
thelial cells.  It should  only be  used sparingly, a thin
layer  around the edge of a granulating surface for one
day,  then  skip  at least for two days, otherwise the
granulations become too exuberant.
  In  extensive  burns  a skin-graft  is  nearly always
necessary,  as  epithelial tissue will not grow across  a
wide  space.
  It may be necessary to apply  a splint when the skin
begins to grow  to prevent contracture and deformity
from  scar tissue.
  Burns may be complicated  in many ways; the most
frequent is acute nephritis, induced by the extra work
thrown on the kidneys as a direct result of the injury
to the sweat glands.
  Pneumonia is a serious complication, and may occur
if there has been any inhalation of smoke. 
CHAPTER XVI.
       WOUNDS AND INFLAMMATIONS.

           Classification and Method of Healing.

  A wound is an injury or separation  of any tissue
of the body induced by violence either direct or indirect.
  They are classified according to the nature of the
injury.
  Incised wounds are those with smooth parallel edges,
which  may be made with a sharp instrument, glass,
etc., but usually with a surgeon's knife.
  Punctured wounds also have smooth edges, but the
depth greatly  exceeds the extent of injury on the sur-
face.  A stab wound is a good example of a punctured
wound.  If a punctured wound  extends to any cavity
of the  body,  it is usually referred to as a penetrated
wound.
  Contusions are injuries to the  tissues under the skin,
resulting in the rupture of small  vessels and the escape
of blood into  the cell spaces.   A contused wound is
irregular, with crushed and bruised edges.
  Lacerated wounds are those in which  the edges are
irregular and torn; there may also be a loss of tissue.
  The  immediate  complications of  wound are hemor-
rhage and loss of  function.  Loss of function may  be
the result of a division of muscles, tendons, or nerves. 
INFLAMMATION.
153
  Secondary complications are  due to  infection,  in
which  there must be a period of incubation followed
by  inflammation and probably suppuration  and loss
of tissue, or general blood infection.
  Wounds heal by:
  1. Primary Union or First Intention.—A clean, incised
wound the edges of which are held together is repaired
very rapidly.  The edges are  joined  by  connective
tissue  and a thin  white scar  is formed.  The process
usually takes about eight days.
  2. By  Granulation or Second Intention.—The process
of repair is slower, as new cells must fill up the space
made by destruction  of tissue.  These new cells grow
from the bottom and sides of the wound, the epithe-
lium eventually covering their surface.
  3. Repair.—Repair  of a  superficial wound is by the
formation of a crust or scab over the surface, forming
a  protection while the  healing process  is  going  on
underneath.

                  INFLAMMATION.

  Inflammation is Nature's response to injury, and is
the first step in the process of repair.  It is associated
with heat,  redness, pain, and swelling.
  First the bloodvessels dilate,  bringing  more blood
to the  part, or causing congestion,  which gives rise to
an extra amount of heat and redness.  Next there is
the transudation of the blood plasma and the migration
of the white cells into  the  cell spaces,  forming the
exudation fluid, which is always present when tissues
are injured. 
154      WOUNDS AND INFLAMMATIONS
   This results in swelling.  The pressure on the nerves,
brought  about by this condition, causes the pain.
   Whenever there is injury  to any tissue, this phe-
nomenon takes place.   If  there be no  infection the
inflammation subsides and the healing process continues
rapidly.
   Any wound,  however simple, may be  complicated
by infection and  the healing process greatly  delayed
by the destruction of tissue, the  formation of an abscess
or phlegmon, by blood intoxication  or blood infection,
with the ultimate result  of loss  of function, loss of the
part, and possibly loss of life.
   No wound, whether clean  or otherwise, should  be
dressed without the utmost surgical cleanliness.
   Any person  who  dresses an  abscess,  carbuncle,  or
infected  wound without taking every precaution  to
guard  against further infection is criminally negligent.
Pus is  no excuse for dirty fingers.
  Hot, moist dressings are usually indicated for infected
wounds.  These should  be of sterile gauze even when
used with an  antiseptic  solution. It is  a well-known
though inexplainable fact that wounds of this class do
better with moist heat than with dry, sterile dressings.
  The  ends to be met in  the treatment of sepsis are:
  1. To keep up the resistance of the tissues.   (This is
done by direct application of heat bringing more blood
to the  part.)
  2. To  prevent  the  further growth  of  organisms.
(The use,of antiseptics.)
  3. To remove organisms.   (Drainage.)
  4. To counteract the effect of  the toxins in the body. 
CHAPTER  XVII.
                   BANDAGING.

Use of Splints, Slings and Supports—Material Used—Methods of
                      Application.

  The word bandage may be used as a noun, meaning
a strip of material used to cover a wound, or as a verb.
  To bandage is to apply a bandage to any part of the
body by successive turns.
  Various materials are used, which are chosen  accord-
ing to their usage.   They may  be  used for support,
protection, pressure, or to keep a dressing or apparatus
in place.
  Plaster of Paris,  or a  cotton  roller, which  may be
starched or used with a splint,  is  generally used  for
support.
  When used for protection or to  keep dressings  in
place,  cotton rollers and  muslin  and gauze bandages
are used.  Gauze is to be preferred,  as it is cool, com-
fortable, and easily adjusted.
  Flannel  bandages, both straight and  cut  bias, are
used for pressure.  Occasionally elastic rubber bandages
are used for the same purpose, or to control the  circula-
tion, but they can only be left on for a short time.
  Cotton rollers, starched or otherwise, are used  for
keeping splints, extensions or other apparatus in place. 
150
HAXDAGIXG
  A good  bandage  is one which  fulfils its  function,
whatever that may be, without discomfort.
  Bandages vary  in size from £ of an  inch wide and
3 yards long to 6 inches wide and 10 yards long, accord-
ing to  the part to which they are to be  applied.
  The  principles of bandaging are  few,  and consist of
several different turns:  the circular,  oblique  spiral,
reverse spiral, figure-of-eight,  and  recurrent.
  By the combination of two or more of  these any part
of the body may be covered.
Fig. 14.—Spiral reversed bandage of the upper extremity.
                  (Wharton.)
  A circular bandage consists of circular turns, each
one entirely covering its predecessor.
  An oblique spiral consists of oblique turns, each suc-
cessive turn applied above the preceding one, and over-
lapping it  by two-thirds, can be applied to parts of
equal diameter.
  The reverse spiral is applied to parts which gradually
increase in  diameter.  The turns are oblique and should 
     (
                    BANDAGING                 157

lie flat to the surface of the part they cover. The upper
edge of  the bandage is reversed, or turned down at the
median  line; the upper edge becomes the lower, and
should form a line which corresponds to that made  by
the lower edge.
Fig. 15.—-Spiral reversed bandage of the lower extremity.
                  (Wharton.)
  The figure-of-eight bandage may be used instead of the
reverse.   It is oblique and consists of alternate turns,
ascending and descending, which cross  at the center,
forming  the  figure-of-eight.   The  bandage is easily
applied and looks neat.   It also  stays  in  place.  It
should only be used, when cut straight, over a splint
or heavy  dressing as it does not fulfil one of the  first
principles.  It does  not  lie  flat   to  the  surface it
covers.
  The reverse figure-of-eight  combines the good points
of both the reverse  and  figure-of-eight.  It  does lie
flat to the surface, also it  remains in place as does the
figure-of-eight.
  After fixing the initial end, carry the bandage up the 
158                  BANDAGING

limb as in the figure-of-eight, reverse on the posterior
surface, then bring the bandage down as in the figure-
of-eight.
Fig. 16.—Recurrent bandage of a stump.  (Wharton.)
Fig. 17.—Recurrent bandage of the head.   (Wharton.)
  The  recurrent bandage consists of successive  folds
carried back and forth over the part and held  in place 
BANDAGING
159
by  circular turns  and  securing  the end;  it  is  used
principally  to cover the  head, stumps  and  ends of
fingers.
Fig. 18.—Crossed bandage of       Fig. 19.—Barton's bandage.
  both eyes.  (Wharton.)               (Wharton.)
  To adjust a bandage begin at the smallest part, and
fix it by two or three circular turns.   If it is a limb
      Fig. 20.—Bandage of forearm and elbow (arm flexed).

being bandaged the bandaging should be done toward
the trunk, making spiral and reverse or  figure-of-eight
turns according to the shape of the part. 
160
HAN I) AGING
  A bandage for the hand is fixed at the wrist, then with
oblique turns it should be carried down  to the lowest
	all ■
Fig. 21.—Dcrnigauntlct bandage.   Fig. 22.—Spica bandage of the
         (Wharton.)                 thumb.   (Wharton.)
Fig. 23.—Bandage of foot covering the heel.  (Wharton.) 
BANDAGING
161
point it is to cover, winding upward toward the wrist.
The foot  and  ankle may be  bandaged  in the same
manner.
Fig. 24.—Figure-of-eight band-    Fig. 25.—Figure-of-eight band-
      age of the heel.                  age of the ankle.
    Fig. 26.—Velpeau's bandage.  (Wharton.)
11 
162
BANDAGING
  The essentials of a good  bandage are:
    1. That it must lie flat against the surface it covers.
    2. That it must stay in place.
    3. That it must not be too tight.
    4. That it fulfils the purpose for which it is applied.
  A many-tail bandage  is made of cotton cloth cut to
form  an equal  number of tails on each side.  These
are brought around the part to be covered and tied in
a single knot, each successive pair of tails covering the
ends of the preceding pair, the last ones being secured
by a bow-knot.  Many-tail bandages are used when fre-
quent changing of a dressing is necessary.
              Fig. 27.—Many-tail bandage.

  The sling  is a form of triangular  or handkerchief
bandage.  It is used for support, and consists of a piece
of cotton, one yard square, folded to  form a triangle.
The point of the triangle should be at the elbow, the
folded edge reaching  to the tips of the fingers.   The
outside of  the sling should  be  carried across to the
opposite shoulder, the ends tied about the neck, and
the corner at the elbow turned in and  pinned.  Where
immobilization is required a double sling may be used.
The first is applied as described  above. In the second
 
BANDAGING
163
the folded edge at the waist is carried around the body
and secured  by pins under the  arms.   The point at
the shoulder is turned in and fastened in the same
^
Fig. 28.—Sling.
Fig. 29.—Second sling. 
164
BANDAGING
manner.  It should be firmly applied, in the back com-
pletely covering the scapula on  the  injured  side.
Fig. 30.—Lund swathe (front).
Fig. 31.—Lund swathe (back).
  The Lund swathe  affords efficient means of support
and immobilization, and is particularly useful for chil-, 
BANDAGING
165
dren.  It is made according to the size of the patient.
For an adult a piece of cotton cloth 3 yards long and
16 inches wide  is necessary.   Both edges  should be
folded into the center, then again folded through the
center, making when finished  a swathe 4 inches wide
and of four thicknesses.
Fig. 32.—Straight chest swathe.
  To apply this kind of swathe, the hand of the injured
side  should be placed  on  the opposite shoulder.  The
first  end is fastened about  the injured arm half-way
between the shoulder and  the elbow; the swathe is then
carried across the back, under the arm on the opposite
side, across the chest, over the arm and forearm, under
the elbow from  the outer side, up over the  shoulder
and  fastened to  the circular turn in the back with
safety-pins.
  A  swathe is a straight  bandage made of two thick- 
166
BANDAGING
nesses of material,  usually canton flannel.  It may be
used  to  cover or  hold  in  place chest or abdominal
dressings, or applied to the chest to restrict the move-
ment in respiration.
Fig. 33.—Fitted swathe with shoulder straps.
Pattern
                       Fig. 34.

  An abdominal swathe  varies in length and width.
It should be long enough to pass around the body over 
SPLINTS
167
the hips,  and wide enough  to extend from  the sym-
physis pubis to the lower border of the ribs.
  A chest swathe should extend from the axilla to the
lower  border  of the ribs and  be held in place with
shoulder straps.
  To adjust, it  is best to begin at the bottom and pin
upward, making  darts  on  each  side, so that it may
fit smoothly.
                      SPLINTS.

  Splints are made of rigid material and are used for
support, to immobilize  and to hold broken bones  in
place.
FIG. 35.__lt  T-splint; 2, coaptation splints; 3, anterior and (4)
           posterior splints for wrist; 5, splint wood.

  A splint may be formed from a bandage, as plaster
of Paris, or many thicknesses of starched crinolin.
  Wood, tin, iron,  wire,  aluminum,  felt  and water-
board1 may be used.
  Tin is possibly used more than any other material,
as it has the advantage of being less cumbersome.

  i Waterboard is a form of  paper which may be soaked in warm
water and moulded to fit the part to which it is to be applied. 
168
BANDAGING
  Whatever  material  used a splint should  be padded
with  non-absorbent  cotton  (sheet wadding is best)
and  smoothly covered.  It  should  be long enough to
immobilize the joint above and below the injury.
  When a splint is to be  applied, the skin  should be
wrashed with soap and wrater, bathed  with alcohol and
powdered.
Fig. 36.—1, 2, ham splints; 3, shoulder cap (for fractured clavicle);
      4, 5, 6, anterior angular splints (for fractured elbow).
  Strips of adhesive  plaster or webbing  straps  with
buckles may be used  to hold them in place.  The cir-
culation must not be  restricted, but at the same  time
they must be so firmly adjusted that they will not slip
nor cause chafing.

                    STRAPPING.

  Strapping with  adhesive plaster is to immobilize
while allowing partial use  of the  part.  The chest is
strapped for fracture of the ribs and to restrict respira-
tory movement in pleurisy.  Strapping is used to  give
support to the ankle, knee,  or wrist in sprains or other 
STRAPPING
169
injuries.  The part to which straps are to be applied
should be washed and shaved.
  For the chest, the straps should be about three inches
wide and long enough to pass half around the body and
across  the sternum in front and the spinal column in
the back.
  The strapping should be begun  at the bottom, one
end  fixed across  the spinal  column on the opposite
side; the patient directed to take a  long breath, then to
expel the air; while the chest is comparatively empty
drawT the straps tightly around and fix the  other end
over the sternum.  The second strap  should overlap
the first by one-third, and should first be fixed in front,
then carried around to the back, and continued in this
manner to the axilla.  The ends should be covered with
a narrow strip to prevent rolling up.
  For the knee strips 1 \ inches wide, and long enough to
pass half around will be required.  The first four should
be applied nearest to the patella  by  fixing the outer
end  first and drawing each  strap  toward the center,
crossing  the  ends  above and below the patella;  each
strap should overlap  the  preceding one by  one-third.
A bandage is preferable for keeping the ends from rolling
in this locality.
  To Strap  the Ankle.—Place the  heel on a foot-rest,
pass a strap or  bandage back of the "ball  of the foot"
and allow the patient to hold the ends so that the foot
will  not become  extended.   The  straps  of  adhesive
are made one  inch wide  and long enough  to  extend
three or four inches above the ankle.  The end on the
inner side  should be adjusted  first,  well up on the 
170
BANDAGING
ankle; it  should  be drawn tightly under the heel and
up on the outer side, passing just back of the malleoli.
The  second  should be fixed just back of the big toe
and brought  around back of the  heel to the  little toe.
Alternate  straps are applied in  this manner until the
ankle is well covered and  finished with a narrow  strap
across the ends to prevent rolling up.
  In cases where  the ankle rolls  inward  due to relaxed
muscles or "flat-foot"  the order of applying straps
should be reversed and the first end should be  fixed
on the outer side and straps drawn tightly inward. 
CHAPTER XVIII.
     THE  CARE OF THE EYES AND EARS.

              THE CARE OF THE EYES.
   As a rule no  organ is so universally abused and so
 poorly cared for as the eye.  The knowledge necessary
 for the intelligent care of the eyes in diseased conditions
 can only be gained by a special training.
   In the general care of the sick it  often  becomes
 necessary to wash out the eyes;  to put in drops or
 powTder; to apply ointment or compresses, either hot
 or cold.
   The  sickest  patients,  particularly those  suffering
 from various forms of  nervous diseases, meningitis or
 unconsciousness, may lie with  eyes open.   Particles
 of dust containing bacteria may fall on  them, causing
 irritation and inflammation.  The tears are not diffused
 over the surface as in normal conditions, the conjunc-
 tivae become dry with possible ulcerations, which are
 likely to  occur  over the cornea, this being the most
 prominent part  of the eye.
   Such eyes  should be washed out frequently with
• sterile water or boracic acid 2 per cent.  Pieces of gauze
 should  be  wet and  laid over them; this prevents the
 dust from  getting in, and at the same time keeps them
 moist. 
172    THE CARE OF  THE EYES AND  EARS

  To wash  out  the  eyes, separate the lids with  the
finger and  thumb of one hand, making the pressure
necessary  to keep them  open  on the  bony  promi-
nences above and below the eye.   Direct the  stream
from the inner angle outward; this is necessary in order
to prevent  the discharge, if there be one, from getting
into the other eye; the eye should be wiped in the same
direction.   A  soft-rubber  bulb syringe  or  pieces  of
absorbent cotton may be used.
Fi<;. 37.—Method of putting drops into the eye.
  To put drops into the eye, separate the lids, drawing
the under one  well downward;  this forms a  shallow
pouch, into which from the outer angle the drops should
be put, taking care that the dropper does not come in
contact with any part of the eye.  When using atropine
it sometimes becomes necessary to close the tear-ducts
by gentle  pressure at  the inner angle,  to prevent the
drug from passing through  the ducts and thence into
the throat.
  Ointment may  be applied with a swab made of an 
THE CARE OF THE EARS          173
applicator and absorbent cotton.  The lids should be
separated and the ointment applied on the inside of the
under lid; the eye should then be closed and the oint-
ment diffused over the surface by a gentle rotary motion
of the finger on the outside of the lid.
  Powder may be shaken from a camel's-hair brush
directly into the  eye, which  is  held open as  described
above.
             THE CARE OF THE EARS.

  Neglect of earache often results  in serious  complica-
tions.  A discharge accompanied by occasional attacks
of dull pain, and a discharge without pain or the sudden
onset of acute pain, are important symptoms.
  Earache, sudden in its onset and accompanied with
a sharp, "crackling" pain upon  swallowing, is the result
of acute inflammation of the middle ear (otitis media),
and may follow  or complicate any of the  infectious
diseases,  the  infection  extending  from  the throat
through the Eustachian  tube, or it may be carried by
the blood stream.
  Neglect  of any of these  conditions may result in
deafness (partial or complete),  mastoiditis, meningitis,
brain abscess, inflammation  of  the large bloodvessels,
and the formation of clots  creating  an embolism, or
general infection of the blood stream and death.
  In acute  otitis media or mastoiditis, ice  is usually
applied to relieve the pain and inflammation.  It should
be  remembered that this must  be constant.   The ice-
cap should be large enough to  cover the entire side of
the  head, and should be filled only  about  half  full; 
174    THE CARE  OF THE  EYES AND  EARS

it  should never be allowed  to become even  slightly
warm.
  The extreme cold may  be borne better if the  ice-
cap is covered with a flannel cover.
Fig. 38.—Ear irrigation.
  Aural Douches or Irrigations are used for cleanliness
and to reduce inflammation. When used for cleanliness,
a mild antiseptic  is used, the  temperature of which
should be about 100° F.  When used to reduce inflam-
mation, sterile water or 2 per cent, boracic acid solution,
which should  be of a temperature of 110° to 118°  F.
If the solution is too cold it often causes faintness. 
THE CARE OF THE EARS         175
  The irrigator should not be high enough to give any
amount of force to the  stream.  Too much force has
produced  unconsciousness.  The  stream  should not
be directed straight into the ear, but against the pos-
terior wall; it will then flow in without causing pain
or dizziness.
  The auditory  canal,  which is  curved,  should be
straightened in an adult by lifting the auricle upward
and backward; it may be done in a child by pulling it
downward and outward.
  After an irrigation the canal should  be  thoroughly
wiped out, small twists of absorbent cotton being used
to absorb the fluid.  Probes, applicators and forceps
should never  be  used in the  ear, as by any sudden
movement of the patient he may do himself  consider-
able injury. 
CHAPTER XIX.
                  ANESTHESIA.

           Preparation and After-care—Ether Bed.

        PREPARATION  AND AFTER-CARE.
  Anesthesia is loss of sensation, in whole or in part,
due to a condition of the nerves,  or brought about by
the administration of drugs.
  Drugs which produce loss  of, sensation  are  anes-
thetics, and are of two classes:
  Local, those which are applied to an area and act
by causing loss of sensation in that particular part, by
paralyzing the nerve endings.  Those most often used
are cocain, novocain and ethyl chlorid.
  General anesthetics act directly  on the nerve centers
and produce unconsciousness.  Ether, chloroform, and
nitrous oxide are most  commonly used.  The prepara-
tion for general anesthesia is the  same, regardless of
the agent used.
  The stomach  should contain no solid  food.  All
food must be omitted for twelve hours, when possible;
clear  broth or black coffee may be given  six hours
before, then nothing but small amounts of water.
  The night before taking  an anesthetic  a laxative
should be given and in  the morning an  enema of suds,
making sure that the rectum is empty. 
        PREPARATION AND AFTER-CARE      111

  The bladder should be emptied naturally if possible,
otherwise by the catheter.
  Particular attention should be given to the patient's
mouth.  The teeth must be thoroughly cleaned with a
brush and peroxide or  other  antiseptic, the  mouth
washed  out, and the throat gargled (when the patient
is able to do so), as a routine, every four hours from the
time the preparation begins until the patient goes to
the etherizing room.   False teeth on plates must be
removed.
  During the period of unconsciousness, material from
the mouth may be drawn into the air passages.  If this
has been rendered as free from bacteria as possible, the
danger  from pneumonia following anesthesia is greatly
diminished.   With  proper preparation,  pneumonia
seldom  occurs.
  The patient should receive a full bath, special atten-
tion being given to the hair. If the patient be a woman,
the  hair should be parted and braided in two braids,
and the braids pinned around the head.  A  cap should
then be put on the head,  covering all the hair, effect-
ually keeping it out of  the way of both  the operator
and the anesthetist.
   The After-care of Ether Patients.—During anesthesia
the  patient loses considerable body heat,  consequently
the  bed should be well warmed.  This is best done by
using three stone heaters, which should be filled with
water  at  a temperature  of 125°  F.,  covered with
flannel  covers, and put in the center of the bed.  When
the  patient is returned, the heaters may be removed,
or put outside of at least one blanket and away from the
      12 
178
ANESTHESIA
 body, so that there will be no possibility of burning.
 This is  necessary,  as burns result much  more easily
 than under normal conditions.
   The patient must be placed  in bed in a comfortable
 position, preferably on the side, with the head straight,
 resting well on the cheek, as a greatly flexed or extended
 head obstructs the breathing and, being on the side,
 allows mucus and vomited material to  drain from the
 mouth.
   A  kidney basin, small pieces of gauze, and ether
 towTels should be close by the bed.
   In using pieces of gauze to wipe out the mouth they
 should be first moistened in cold water.
   Careful watching is necessary to avoid choking or
 injury,  wrhich may  result from extreme  restlessness
 during a semiconscious state.


               THE  ETHER BED.

   Considerable care should be exercised  in the prepara-
 tion of a bed for an ether patient.  Fresh linen must
 always be used.  Over the draw sheet a  blanket should
 be placed, which  should be tucked in at the sides;  a
 rubber sheet, covered  with a draw sheet at the head of
 the bed,  should be so  arranged  that it will come down
 under the shoulders when the patient is in bed.
   A pillow should not be placed under the head but
pinned to the bed frame, so that it stands up, making
it  impossible for the  head  to be pushed through the
bars at the head of the bed. 
THE ETHER BED
179
  A second blanket should be used to come next the
patient, then the remainder of  the bedclothing.  This
is to be tucked in at  one side and folded back to the
edge of the bed.   The extra blanket covers the heaters,
which are in the center of the bed.
  When a pillow is used, it should be a thin one, pro-
tected  by a rubber pillow-case. 
CHAPTER  XX.
              SURGICAL TECHNIC.

  The Operating Room—The Cleaning and Care—Sterilization of
Dressings, Instruments and Utensils—Disinfecting  the Hands—
The Field of Operation—The Operating-room Nurse—The  Patient
—Postoperative Care—Complications.

  Technic  means the most correct  methods of pro-
cedure employed  in  the carrying  out of any piece of
work which requires  special knowledge and skill.
  Error  in technic is a departure  from the recognized
procedure  with  resulting decrease  in  efficiency and
failure to attain  the desired result.
  Surgical  technic covers  every  surgical  procedure
from  the most simple (as giving a hypodermic) to the
most  difficult and extensive surgical operations.
  Surgical errors  may  result in prolonged  illness,  or
even  loss of life, when otherwise the patient may have
had every chance  for a  good recovery.   "Sterilization"
means the absolute destruction of  all  single-cell organ-
isms.   No material is  sterile while it  contains  living
organisms, either  upon its surface or within its sub-
stance.
  The most efficient method of sterilization is by heat,
and  should be employed whenever possible.  Steam
under 15 pounds' pressure (120° C.) is effective in one- 
          PREPARATION OF THE HANDS       181

half hour;  live steam in one hour: boiling ten minutes.
Any material that has been sterilized which afterward
comes into  momentary contact with an  unsterile object
ceases to be sterile.
   "Disinfection" is the term used to  indicate either
the  destruction of or rendering inert  any infectious
organisms.
   "Antiseptic" is used  in much the  same way,  but
usually refers  to  the effect upon bacteria in septic
wounds.
   While wounds may become infected in several ways
(by  the air, or through  the  blood stream), experience
shows that  almost the only cause for wound infection
is the conveying of bacteria by contact, or by the implan-
tation into  a wound of some germ-bearing material.
   Prevention of wound infection requires that every-
thing which comes in contact with a wounded  surface
must be  rendered  entirely  free  from living  single-
celled organisms.
   Since we cannot sterilize the hands, nor the skin of a
patient in the field of operation, we must use the best
means we possess in making the skin free from bacteria.

         PREPARATION OF THE HANDS.

   All  methods include  mechanical  scrubbing with
soap  and water, and  immersion in some antiseptic.
   Brushes  used for  the preparation  should first be
boiled.  The hands and arms should be scrubbed under
hot running water  for  ten  minutes,  the nails and
palmar surface  of hands and fingers receiving particular 
 182            SURGICAL TECHNIC

 attention; then soak in some antiseptic solution for at
 least five minutes.
   When  any  disinfectant  solution injures  the skin,
 making the hands rough, its use should be discontinued.
 An irritated  skin is a greater danger than  failure  to
 use strong antiseptics.  Hence a  nurse in her effort  to
 disinfect her  own hands may commit her first surgical
 error.
   The simpler methods  of preparation  are  generally
 considered best.   After  scrubbing—alcohol 70  per
 cent, immersion is always safe (three to five  minutes).
   Bichloride  of mercury 1 to 1000  is also considered
 effective (five minutes).
   Potassium  permanganate 1 to 1000 followed by a
 solution  of oxalic acid 1  to 16 is  another method con-
 stantly in use.   Its disadvantage is that oxalic acid  is
 very irritating  and  immersion in this  solution should
 be followed by thoroughly rinsing in sterile water.
   Gloves should  alwrays be worn and are usually  put
 on dry.  When this is done the hands should first be
 dried wTith a sterile towel  and powdered with sterile
 talcum powder.

           PREPARATION OF  GLOVES.

  Thoroughly rinse the gloves with cold water: then
wash inside and out with hot water and soap,  dry
thoroughly and  examine for puncture.  Dust both
sides to  prevent sticking  and turn  down  the wrist
about two inches to form a cuff.   (This makes it easier
to pull on.)   Wrap  each glove in separate side of  the 
      TO PREPARE INSTRUMENTS FOR USE   183

cover and fold toward the center.1  Sterilize twenty
minutes at 15 pounds' pressure.
  To repair gloves:  First test for punctures  by inflat-
ing, then watch for the escape of  air.  Gloves may be
perfectly  air-tight  by using small  pieces of  rubber,
held in place with  a rubber cement. They  should be
mended on the inside  and should not be sterilized for
twelve hours after the patch has been put on.
  These gloves may be used for  dressings and minor
work, but it is best to use unmended  ones  for major
operations.

       TO  PREPARE INSTRUMENTS FOR USE.
   Blunt instruments may be rolled and tied  in a towel
 and boiled in a solution of soda bicarbonate from 0.5
 to 1  per cent, for a period of twenty minutes.  Sharp
 instruments, scissors,  knives, needles, etc.,  should  be
 protected by being wound in absorbent cotton and put
 in a package by themselves and boiled for five minutes.
 The  water should be boiling when instruments are
 put in.
   After  using, instruments  should be  rinsed  very
 thoroughly in cold water, otherwise the blood or any
 discharge is very  hard to  remove.  Then scrub  on a
 board with turpentine and bon-ami.  The  turpentine
 removes any particle  of rust; afterward rinse in hot
 water and dry with a soft towel.

   1 Glove cases are a convenience and may be made like a bill-fold,
 with two pockets which fold in the center.  The gloves may be put
 in flat, the right and  the  left in corresponding pockets.  The size
 should be marked on the outside. 
184
SURGICAL TECHNIC
   Sharp  instruments  should again  be wound  with
absorbent cotton before they are returned to the case.
   Basins may be boiled or subjected  to live steam for
twenty minutes.
   Rubber tubing or rubber dam should first be rinsed
with cold  water and scrubbed with soap and hot water,
then boiled ready for  use.  If it is to be kept sterile
for any time it may be stored in a solution of formalin
in a glass jar.   In this case,  it should be thoroughly
rinsed  in saline solution before using.
   Gauze and material used for dressings, to be  kept in
the wards,  should be prepared  according  to  their
intended uses.   It  is best to have each dressing in a
separate cover; the package should contain everything
necessary, from the small sponges to clean the  wound
to  the  outside  dressing.   The  articles  should be so
arranged that when the package is opened  the first
needed should be on top.

          THE OPERATING-ROOM  NURSE.

   The  operating-room  nurse  must  be a  competent
general nurse, as she will  be  called  upon to perform
one of  the most responsible and important functions of
her profession; hence,  she  should possess intelligence
and good  judgment in no ordinary  degree.  A  good
memory is  indispensable.   She  should be  punctual,
reliable and sure of herself; hesitation or uncertainty
may prove disastrous.   Prompt  action is always de-
manded.
   She  should possess  a practical working knowledge
of bacteriology.   Her preparation of  dressings, suture 
          THE OPERATING-ROOM NURSE      185

material,  instruments,  utensils  and  appliances,  also
the general care of the operating-room should be based
upon this knowledge.
  Unless the room  in which operations are performed
is  absolutely clean infection must result.   As dust is
one  of the great dangers, means  should  be taken to
prevent  its  entrance  as much  as  possible.  AVindows
should be dust-tight, and  those  in  adjoining rooms
kept closed.  Ventilators and warm-air flues should be
screened  with canton flannel, the rough side  toward
the  inlet; this will  collect the finest  particles  of dust
and they should be changed frequently. Radiators where
they must be used should  also be covered.  A sheet
may be pinned over and around this when the  room is
prepared for an operation.
  Frequent and thorough washing of the walls and daily
scrubbing of the  floor is essential.   One should depend
upon mechanical scrubbing as the first and most impor-
tant part of surgical cleanliness.
  It is well to keep  this  in mind in caring for all
operating-room equipment.
  The  Preparation  of  Suture Material.—Some of the
more simple  and  satisfactory ways of preparing catgut
are:
  Cut in  desired  length  (about 18  inches).   Coil
around the finger and fasten the end so that it will not
loosen during sterilization.   This  should  be put  in a
jar and covered with Park's solution:
         Mercuric chloride           gr. xv
         Tartaric acid               gr. lxxv
         Ether
         Columbian spirits       aa  Oj 
186
SURGICAL TECHNIC
  Soak in this solution (the length of time depends
upon the size of the material).

           No. 0 should remain in  4 hours
           No. 1   "        "6   "
           No. 2   "        "     8   "
           No. 3   "        "    12   "
           No. 4   "        "    18   "
           No. 5   "        "    20   "

  Pour off the Park's solution and store in Columbian
spirits in a tightly covered jar until needed.
  Chromicized Catgut  ("forty day").—Cut  in desired
length and coil over the fingers  as in plain catgut.
  Place in an air-tight jar and cover the material with
95 per cent, alcohol; allow it to stand twenty-four hours.
  Dry in the open air for twelve hours.
  Place in chromic solution1  (the length of time varies
according to  size).
  Numbers. 1  and 2 to remain in forty-eight hours.
  Numbers 3 and 4 to remain in six days.
  Dry for forty-eight hours in open air.
  Place in 1 to 500 solution  of mercuric chloride made
of 95 per cent, alcohol for eight days.
  Store in 95 per cent, alcohol and  soak in a water-
bath ten minutes before using.
  Iodized Catgut.—Roll over fingers or on glass reels.
  Drop these into a 15 per  cent, solution of iodine in
ether.  Allow to remain seven days.
  1 Chromic solution:
     Bichromate of potassium.....grs. lxxx
     Carbolic ac. sol. (5 per cent.)   .       .  O v 
THE OPERATING-ROOM NURSE       187
  Remove and rinse in ether to remove excess of iodine.
  Place in  sterile  air-tight  jars  to  be  removed  as
needed.
  Silk Woven Gut.—Boil five minutes.
  Remove  and store  in Columbian spirits or 1 to  40
solution of carbolic acid.
  Preparation of Silk and Thread Sutures and Ligatures.
—Silk and thread sutures or ligatures may be placed
in a towel and sterilized at 15 pounds' pressure.
  Kangaroo  tendon  may  be sterilized  in the same
manner as catgut but does not stand high temperatures
as well.
  Formulae for  Saline Solutions.—1. Physiological salt
solution:

     Sodium chloride                      9 gm.
     Distilled water to                 1000 c.c.

  This should be brought to a boiling-point and kept
at that degree  thirty minutes, after cooling should be
filtered, put in the flask and sterilized.
  2. Ringer's solution:

     Sod. chloride                     9.00 gm.
     Potassium chloride                0.20 gm.
     Sodium bicarb.                    0.20 gm.
     Distilled water to               1000.00 c.c.

  Treated  as above described.   The  first is the usual
"saline,"  the  second is  an attempt  to more  closely
approximate the true blood serum. 
]SS
SURGICAL TECHNIC
                  THE PATIENT.

  It must be remembered that one loses considerable
heat during an operation, not only through exposure
of the field  of operation but by shock, be it ever so
slight; consequently he  should be  sufficiently covered
with light, warm blankets. Small blankets may be made
to cover the chest and arms f yard wide, 1 \ yards long;
they may be sterilized and used as a routine in abdom-
inal  operations.   They  have the advantage of being
light and can do no harm when they get very near the
field of operation.  If necessary,  use hot-water bottles
protected with blanket covers to  keep the body warm.
  Do not depend upon  the temperature of the room
to keep the patient warm.
  The position of the patient upon the table depends
upon the operation to be performed.
  The arms of a patient must never be  allowed to slip
down and hang over the edge of the table; acute neuritis
may be the result of this carelessness.
  A  very comfortable and safe  way of securing the
arms is to fold  a blanket and lay it across the upper
part of the table.  The patient is put on this, the ends
brought up between the  body and the arms, then over
the arms and the ends smoothly  tucked under the
back.
  Final preparation depends upon  the nature of the
operation.  The disinfectants used vary  from  1 to 1060
bichloride of mercury to 2 per  cent, iodine followed
by 70 per cent, alcohol.
  For rectal or vaginal operations green soap and water 
   REACTION OF FEAR TO SURGICAL SHOCK   189

followed by 1 to 1000 bichloride of mercury may safely
be used.   This should be thoroughly rinsed out with
sterile water.
  In emergency the preparation consists of shaving,
washing with alcohol 70 per cent, for five minutes, then
with ether, two  minutes; when the skin is dry, paint
with 7 per cent,  iodine.


 THE REACTION  OF FEAR TO SURGICAL SHOCK.

  Dr. George Crile has demonstrated the relation of
fear  and extreme exhaustion to shock  due to severe
physical injury.
  The phenomena are the same.
  The conditions attendant upon extreme fright, i. e.,
fear, are: rapid heart, increased  respirations, pallor of
skin, sweating, dilatation of the pupils,  a sensation of
weakness  (commonly described  as a  sinking feeling),
and disturbance of the digestive function.
  Muscular  exertion carried to  the point of extreme
exhaustion gives rise to  the same conditions  as  fear
at its highest intensity.
  The symptoms  of  "shock"  resulting from  severe
physical injury are the same in all essentials, differing
only in slight or minor detail.
  One cannot always  tell  at first glance whether a
man is badly hurt,  badly  scared or  exhausted from
overexertion.
  "The attitude of  the  persons  in whose hands  the
patient has committed himself in the face of a trying
ordeal will make the strongest  impression upon  his 
190
SURGICAL TECHNIC
mind in the way of encouragement and reassurance."
It is not sympathy alone, nor a friendly, personal interest
and attention to matters pertaining to his comfort and
well-being which make a  very strong appeal to one,
but the thing one wishes most to see is the keen atten-
tion to every detail of the situation and a serene con-
fidence in the  ability to meet any emergency that can
possibly arise.
  "The impressions the patient should receive  are—
that the  group of workers are highly  trained, familiar
with every detail of the situation, keenly interested, and
alert to their several duties.  That the whole purpose
of this alertly attentive body of workers is to bring the
patient's own case  to a successful conclusion."
  The other impression the patient should  not fail to
receive is of the absolute certainty  in the minds of
every member  of the hospital  team that in  this par-
ticular case they are going to win.
  The nurse can do much to allay the fear of a patient.
She  should not talk too much and volunteer nothing
about operative risks.
  Overanxiety  in insisting upon the absence of danger
may  have the opposite   effect  from  that  intended.
Optimistic assurances of the nurse carry little weight;
still  she need not hesitate, when questioned, to express
her confidence  that the result  will be good.  Possibly
the most  difficult part will  be to maintain  a proper
reticence without veering  from the strict path of sin-
cerity and truth.  To deceive a patient is neither right
nor fair nor in any way justifiable.  If a patient sus-
pects he  is being deceived or that important matters 
   REACTION OF FEAR TO SURGICAL SHOCK  191

are being withheld  confidence is lost  which is most
difficult to regain.
  Sympathy,  rightly  understood,  is  of  value  and
importance.   "To  be  effective  and  helpful  is not
emotional but intellectual;" its office is to  understand,
not to commiserate; its purpose is to bring the  person
who is its object, by a clearer knowledge, to a view-
point corresponding to our own.  If the object  aimed
at is attained  the effect upon the patient's mind  will be
to share our own feeling of confidence.
  The Condition of the Patient.—Following an operation
the patient is  more or less depressed, or in a condition
of shock of varying degree.  Anesthesia plays  an  impor-
tant part in this condition as it is increased  or  dimin-
ished according to the  length of time the patient has
been  anesthetized.
  Considerable heat has been lost and an abnormally
small amount is being produced as  a  result  of  dimin-
ished oxidation.
  There  is also  complete muscular  relaxation, the
muscles of the heart, bloodvessels, stomach and intes-
tines  as well as  the  voluntary muscles. As the  result,
there will be  poor  heart  action, cold skin, inability
of the stomach to retain anything  taken  into  it, loss
of peristalsis,  which is increased and prolonged if there
has been much manipulation or exposure of  the intes-
tines  during the operation.  This results in  the accu-
mulation of gas often becoming a distressing  condition.
  There is likely to be considerable irritation  of the
membranes of the  respiratory tract; the kidneys  in
their  effort to  excrete  unusual  substances,  plus the 
192
SURGICAL TECHNIC
effect of the drug and the depletion of fluids become
irritated; this condition may become a serious compli-
cation.
  The depletion of fluids is due to the small amount
taken and the purging necessary in the general prepara-
tion.
  This  group of symptoms added to the presence of
the wound and the condition which made this wound
necessary, determines the seriousness of the  patient's
condition.
  The treatment following an operation is to counter-
act the effect of conditions arising as  a result of the
operation and  to  prevent complications if  possible.
  The first  of importance is that  the patient should
never be left alone until consciousness is restored.

      THE CARE  OF POSTOPERATIVE  CASES.

  First  the  bed must be thoroughly warmed and the
patient  put between blankets.  If an abdominal opera-
tion, placed  on  the back with the head turned to the
side.  The head greatly  flexed  or  extended interferes
with respiration.  A  roll, knee-rest  or pillow should be
put under the knees, which affords  considerable degree
of comfort after consciousness is established and should
be done during the unconscious period, when the patient
will not be disturbed.
  When the  nature  of the operation permits, patient
may be  placed upon the side; in operations of  the  nose
and throat,  always on the side with the head turned
well on  the  cheek.  The  knees  should  in such a  case 
      THE CARE OF POSTOPERATIVE CASES   193

be flexed, as it prevents the patient from rolling on  to
his face.
  There should be absolute quiet in the room.  Prepara-
tions  for  any expected  emergency  should be  made
before the patient is returned  to the room that any
treatment may be carried out as quickly and efficiently
as possible.
  Hypodermoclysis or proctoclysis may be given before
the patient leaves the operating table if the condition
is poor. Otherwise it may be necessary to carry out this
treatment after  patient is  in bed.  Hypodermic tray
with the  usual stimulants should alwavs be at hand.
  The patient should be kept quiet, that there may be
no strain upon the wound or stitches.
  Thirst  is  present  always and causes considerable
discomfort.  If there is nausea and vomiting it is hard
to allay,  because fluids will not be  retained.  Then a
saline  enema  is  the method  most  frequently  used.
Otherwise ice in very small amounts or hot water by
teaspoon may be given.
  Washing the mouth frequently and keeping the lips
moist  is   important  in relieving the  condition.   If
vomiting persists lavage may be necessary.
  Retention of urine may  be due to nervousness, or
the nature of the operation may have been such that
the parts are injured or swollen. It is most important
that urine should be voided because of the unusual
substances which must be  thrown  out of the  bod}'.
Catheterization may be necessary and the urine whether
catheterized or voided should be measured (for at least
forty-eight hours) and a specimen sent  for urinalysis.
      13 
194
SURGICAL TECHNIC
  When conditions  permit and the patient can retain
it, nourishing food should be given as soon as possible.
If nausea  is  present  only  liquids and  predigested
foods should be allowed.  If there is some  particular
thing the patient likes it is often retained better than
a much more easily  digested food he does not like.

   COMPLICATIONS FOLLOWING OPERATIONS.

  Complications which may  follow operations are:
  First, shock, which may occur during the operation
or several hours after, is usually prepared for before
the patient returns  to his  room,  by  having the bed
warm;  hypodermic tray  with  any stimulant which
may  be  needed;  apparatus for hypodermoclysis or
proctoclysis, with normal saline at body temperature
ready in an adjoining room  or dressing-room; oxygen
tank.
  External heat is  always indicated.  Heaters should
be placed in heavy covers and used to  warm  the bed,
not to come in contact with the patient who will burn
very easily in this condition.   With everything at hand
treatment can be carried out without loss of time.
  Delayed  shock may occur usually after patient has
regained consciousness after the stimulating effect of
the ether has passed off.  It is not so  profound as the
primary shock and  is most  likely to manifest itself
when the patient has shown very slight  symptoms
directly following  the  operation.  One  should not
feel that a patient is safe from shock for at least eight
hours  following the  operation,  consequently  should 
   COMPLICATIONS FOLLOWING OPERATIONS   195

be carefully  watched during this time, even though
seemingly recovered from the anesthetic.
  The tongue, because of the relaxed condition of the
muscles of the body, may slip back and obstruct respira-
tion.   (This is more likely to occur during the admin-
istration of the anesthetic but often happens afterward.)
The condition should be watched for, and is evidenced
by the blue color of the skin and the absence of respira-
tion,  the  patient making a "choking sound"  in the
effort to get  air.
  The tongue should be seized  and brought forward,
and the jaw  lifted upward and forward to prevent its
recurrence.
  Hemorrhage.—Hemorrhage is one of the most serious,
and   fortunately  a rather  infrequent complication.
It may occur during the operation, immediately fol-
lowing  (primary  hemorrhage) or after a  number of
hours  or  days  (secondary hemorrhage).  The  causes
are either failure to ligate some vessel, the slipping of a
ligature which has been tied, or bleeding from the capil-
laries of a denuded surface.
  Symptoms.—The symptoms come on suddenly  or
gradually, according to the size of the vessel involved,
and the interference of the  flow  of blood by the sur-
rounding tissues.
  In the more gradual, there is a steady increase in the
pulse-rate with a  corresponding  decrease  in volume,
often  becoming irregular  or intermittent. The respira-
tion is rapid, shallow and sighing.  Temperature falls,
there  is  pallor,  restlessness, thirst, air hunger,  and
sometimes fear of approaching death. 
196
SURGICAL TECHNK
  When the vessel is large the succeeding stages have
passed  so  rapidly that death  may occur before  help
can be summoned.
  The  symptoms described which may occur in  an
internal, concealed hemorrhage,  might  follow an  ab-
dominal operation.
  The nurse can do nothing.  Her duty is none the  less
important, for  she must be alert and  watchful of any
change which  might  indicate  bleeding.   The  early
detection of these signs  is most important, for upon this
depends the life of the patient.
  Treatment.—The treatment  is to limit the supply
to the bleeding vessels  as much as possible by elevating
the part.   If abdominal or  intestinal,  elevate the foot
of the bed; this also serves to keep the blood circulating
in the brain where it is most needed.   Patient should
be kept quiet.  For  this morphine is often  ordered.
The subsequent treatment depends upon the extent of
the bleeding.   Heart  stimulants  or anything which
might increase  the blood-pressure are contra-indicated
until the hemorrhage has been controlled.
  Then  stimulants,  hypodermoclysis  or  intravenous
to supply  body fluids  (direction  for the  preparation
described in another chapter), and possibly direct blood
transfusion as a last resort.
  If  hemorrhage is from  the surface of  the body,
limbs or scalp, the part should be elevated and pressure
applied, either  direct or along the course of the vessel;
a ligature is the safest method.  Ice,  hot  sponges,  or
towels,  and styptics  have  been  used.  (The use  of
styptics is not safe from an aseptic standpoint, though
for minor injuries some are still in use.) 
   COMPLICATIONS FOLLOWING OPERATIONS  197

  Acute  Dilatation of the  Stomach.—This may occur
suddenly, is always alarming and a dangerous compli-
cation.   Large quantities of fluid are vomited  greatly
in excess of the amount taken.   There are frequent
eructations of gas and collapse is an early symptom.
  The temperature may not be elevated or only slightly
so.   The pulse  is weak, respirations increased, often
dyspnea.  Distention  is present and persistent:  the
lower border of the stomach may reach the level of the
umbilicus.  No  peristalsis  can be detected.  Death
usually results.
  Pneumonia.—The  predisposing  causes  are lowered
resistance from  any  cause,  undue  exposure  before,
during or after the operation.  The exciting causes are
bacteria,  and more rarely the inspiration of  foreign
materials.
  Symptoms.—Pain  in the chest, the chill and initial
rise of temperature, increase of  pulse-rate with a dis-
proportionate increase of respiration; the cough and
characteristic sputum do not  differ from the ordinary
types of  lobar  pneumonia, the recovery  by crisis is
the same.  The onset may be confused by  the other
conditions following the operation.
  In  bronchopneumonia the  course of the disease is
much less characteristic, the symptoms  being  very
indefinite.
  Retention   of  Urine.—This  is  very  frequent and
usually   of  slight  importance  following  anesthesia.
In retention with an overflow, there is a most complete
retention while  the dribbling  of urine gives the false
impression of incontinence.  At the same time a dress- 
198
SURGICAL TECHNIC
ing may completely cover the  suprapubic  area if  it
has been an abdominal operation and  it  is difficult
to determine the overdistended bladder.
  Where there is a possibility of such a condition, all
doubt should be removed by the passing of  a catheter.
  Suppression of Urine.—This is not a frequent complica-
tion of operations, but when it occurs is a most serious
one.  Failure of the  patient to  void  within twelve
hours following an operation should be catheterized
to determine whether there is retention or suppression.
  If  suppression  immediate treatment  is essential,
often  to the life of the patient.
  Careful charting of all symptoms is most necessary.
The temperature,  pulse, and respiration so that any
marked deviation from their  normal ratio  may  be
noted: the absence or presence of nausea  and vomiting
or hiccough; the absence or presence of a bowel move-
ment, the character and the fact that gas has or has
not been passed; the voiding or retention of urine;  if
voided, whether voluntary or involuntary: the presence
of cough and pain.  Pain is a matter of great impor-
tance: character and location should be noted.
  Infections (as the name implies)  are due to the pres-
ence of bacteria.  They may be local or general.
  The simplest of the local infections is a stitch abscess,
and next a mild wound infection which varies in degree
but in general they are not serious.
  Symptoms appear from  the  third to  the  seventh
day.  There are elevation of temperature,  local  pain
and tenderness, headache and general discomfort. 
   COMPLICATIONS FOLLOWING OPERATIONS  199

  Peritonitis.—The symptoms appear in from twenty-
four to forty-eight hours following the operation.  The
onset is gradual.  At first there is localized pain which
afterward becomes  general throughout the abdomen.
This  is intense in character; the  patient usually lies
with  the thighs flexed  on the body in the effort  to
relieve the tension  of the abdominal muscles.  There
may  be rigidity of these muscles.  Later there are
extreme  tenderness and distention.  There are  very
rapid pulse, high temperature and shallow frequent
respirations.  Early and persistent  vomiting which
may  in  the later stages  become fecal in  character;
there may be diarrhea or constipation; the latter is the
more frequent.  Hiccough is  a common and persistent
symptom.
   In the rapidly fatal  cases there may be little rise
in temperature, but profound depression from  the first
followed by collapse.
   Septicemia.—The result of bacteria and their toxins
in the blood.  Symptoms may develop in a few hours
or in several days.  There is usually the initial chill
with high temperature (the  fever  is of the remittent
type), the pulse is rapid and small, respirations increased
and  shallow.  The other symptoms are  common to
all  infections,  headache,  nausea,  vomiting,   scanty,
high-colored urine, possibly diarrhea.
   Intestinal Obstruction. — This  is  usually  caused  by
adhesions, and may develop  at almost any time follow-
ing an operation, particularly if there has been exten-
sive  inflammation.  The  time varies from a few days
 to months. 
200            SURGICAL  TECIINW

  The signs of the more acute forms are:  Distention,
pain, nausea,  vomiting which  is distressing and per-
sistent, often containing fecal matter.  There is increase
in pulse-rate  and respiration  often  accompanied  by
subnormal  temperature.  There is  the  inability  to
move the bowels by enemata and early collapse, unless
the condition  is relieved by surgical  measures. 
CHAPTER XXI.
                  ASPIRATIONS.

  Aspiration—Paracentesis—Lumbar Puncture — Hypodermoclysis
and Intravenous  Blood Transfusion—Preparation and Method of
Giving.

  Aspiration  is  withdrawing  fluid from the  body
cavities by means of an aspirator.
  Hydrothorax. — A collection of  fluid  in the pleural
                   «
cavity is usually the result  of pleurisy;  it sometimes
accompanies  or  follows pneumonia, and may  occur
during the early stage of tuberculosis.
  To remove this fluid an  aspirator  is used, which
consists of a  large  bottle to which is attached two
tubes; on the end of one is  the aspirating needle, on
the other an  exhaust pump, by which  a  vacuum is
formed in the bottle.  The needle is then inserted into
the pleural cavity and  the fluid withdrawn.  The use
of this apparatus prevents the entrace of air into the
cavity.
  The puncture  is made through the  posterior chest
wall.   When  possible the patient should be  allowed
to sit up in  bed, with the  body and shoulders well
forward; otherwise he may lie on the side.
  The preparation consists of shaving and thoroughly
scrubbing the part with green  soap and water,  then 
202
ASPIRATIONS
with  alcohol or  any disinfectant  desired.  The area
should be protected with sterile gauze or a towel.
  Articles needed:
  1 blanket to cover the patient's shoulders.
  1 dressing sheet.
  1 tube of ethyl chloride.
  1 culture tube.
  1 finger bowl with green soap and water.
  1  finger  bowl with  alcohol or  some  disinfectant
solution.
  1 kidney  basin.
  1 bottle collodion with camel's-hair brush.
  Sterile sponges.
  Sterile cotton for collodion dressing.
  Aspirating needles sterilized, covered  and  brought
to  the  bedside  on a  tray  in  the vessel  in which
they were boiled; they  are  not to  be  uncovered until
used.
  It is best in all cases to prepare an  emergency tray
upon which should be  a  hypodermic syringe  with
needles  sterilized and ready for use, and stimulants
of various  kinds, which are chosen according to  indi-
vidual needs.
  Ascites.—A collection  of  fluid  in  the abdominal
cavity may be caused by disease of the heart,  liver, or
kidneys; it  may  occur in  tuberculous  conditions.
Cirrhosis of the liver is one of the most frequent causes.
Whatever the cause, it results in obstruction to the
circulation  and the transudation of the  fluid portion
of the blood, which collects in the body  cavities.  To
remove  this fluid a cannula and trocar are generally 
       ASPIRATION  OF THE PERICARDIUM   203

used; occasionally a small incision is made before the
cannula is inserted.
  The patient is  most comfortable sitting up  and the
drainage is much better.  The legs should be warmly
covered and the  back well supported.
  The preparation is the same as for aspiration of the
thorax, and in addition is needed:
  1 scalpel (if incision is made).
  1 pair of scissors (if incision is made).
  Suture (if incision is made).
  Sterile gauze.
  Sponges.
  Swathe.
  Occasionally  the wound is not sutured but left  to
drain.  In such cases a tight swathe is of value.
  In all cases there should be:
  1 cannula and trocar.
  Rubber tubing.
  1 slop-jar to contain the fluid.
  The  tubing may be attached  to  the cannula and
arranged to drain into the slop jar, which should be  on
the floor beside the bed.
  Aspiration of the Pericardium. — This operation be-
comes necessary  when  there is  a collection  of  fluid
in this cavity,  usually  due to inflammation of the
membrane  itself.  The  preparation  and  procedure
are  the same as for aspiration of the thorax.  The
operation is accompanied by great danger and is seldom
practised. 
204
ASPIRATIONS
               LUMBAR PUNCTURE.

   A puncture into the lumbar region of the spinal canal
to withdraw fluid which is the result of an inflammatory
process of the membranes of the brain or spinal cord.
The patient should lie on the side with the  body bent
well forward.
   The  preparation and procedure are  the same as
described above.   The puncture is  usually made with
an aspirating needle or a specially designed trocar  and
cannula.
   Any  of these operations  may be followed more or
less  by shock.   In all cases it is well to prepare for
emergency by having at hand a tray, which  contains a
hypodermic syringe and various stimulants.

               HYPODERMOCLYSIS.
                       i
  Hypodermoclysis is  the forcing  of  large  amounts
of fluid into  the  Cellular  tissue  to  replace fluids  lost
(usually loss of blood).
  It consists of normal salt solution, and  varies in
amount from one pint to two quarts. This is generally
given under the breast (subpectorally), but it may be'
given in the soft tissues of the abdomen  or below  the
shoulder-blade.
  In postpartum hemorrhage the manipulation of  the
breast,  necessary  in giving  "subpectoral saline,"  fre-
quently results in mastitis  later, which  causes much
discomfort.  Not infrequently abscesses have occurred. 
H YPODERMOCL YSIS
205
  Preparation.—Saline at body temperature  may be
heated and  kept at this degree by standing the flask
in a pail of water,  which is tested by a thermometer.
  2 aspirating needles.
  Rubber tubing (2 short  pieces  and 1 long piece).
  Y-iglass  connecting tube, all  of which  should be
sterilized and brought to the bedside  covered.
  When advisable to give more slowly, only one needle
need be used.
  The surface  should be prepared as  for any minor
surgical procedure  and the  puncture may be covered
with a collodion dressing.
  The flasks used for saline in hospitals are provided
with rubber stoppers, through which are inserted two
glass tubes; when in use one serves as a vent; to the
other is  fastened the rubber tubing with the needle
attached; the flask  is then inverted.
  The solution  should flow freely through the needle
when it is inserted  into the  tissues.  This excludes the
possibility  of introducing air.
  Intravenous.—In  an  intravenous  the  fluid  enters
directly into the circulation.  This method of intro-
ducing fluid into the body is accompanied by a certain
amount of danger, and is used only in case of grave
emergency.
  One of the veins of  the  forearm is  usually chosen
because of  its  nearness  to  the  surface.  The  area  is
prepared as for minor surgical operations.
  Articles needed are:
  Saline—body temperature.
  Tubing.
   Curved dropper. 
206
ASPIRATIONS
   1 scalpel.
   2 rat-tooth forceps.
   1 pair of scissors, curved, flat.
   1 aneurysm needle or spear.
   Ligatures.
   Sutures.
   Sponges.
   Gauze dressing.
   Bandage.
   A curved dropper is used in the end of the tubing
instead of a needle.
   A local  anesthetic may or may not be used.  When
the  condition warrants  such  a procedure, but little
pain is felt.
              BLOOD TRANSFUSION.

   The operation is performed only in extreme cases.
The blood is  taken from one  person and transfused
directly into the vein of another.  This is a compara-
tively safe procedure when performed with the Kimpton
tubes.
   Articles needed:
   A scalpel.
   Hemostats.
   Rat-tooth forceps.
   Carrier.
   Suture material,  silk and silkworm-gut.
   Sponges, gauze.
   Bandage.
   A local anesthetic is used for the donor.
   Both patients should be watched carefully and made
as comfortable as possible. 
CHAPTER XXII.
           FOOD AND  FOOD VALUES.

 Classification of Foods—Values—Special Diets—Infant Feeding—
                    Forced Feeding.

   Food  is any  substance which when taken into the
 body is capable  of supplying heat or energy, of building
 up the body, or repairing waste.
   Every movement of our bodies requires energy, which
 means that a certain amount of heat must be supplied.
   In a locomotive,  energy comes from  oxidation  of
 the fuel  with which it is  supplied.  In the  body, food
 serves  as fuel;  first becoming,  through a  process  of
 chemical changes, a  part of the body.
   Not all the food  taken into the body is converted
 into tissues or heat, or used  up as energy.  Some  is
 stored up usually in the form of fat, in the subcutaneous
 tissues, or as glycogen in the liver.
   The nutritive value of any foodstuff is measured by
 the heat, set free during its transformation into those
 products in which it is to leave the  body.   The unit
 of this measure  is the calorie.
   A calorie represents that amount of heat necessary
 to raise one kilogram of water 1 ° C.  This in mechanical
force is equal to 1.54 foot tons  or sufficient energy to
raise 1 ton 1.54 feet.
   In the  Centigrade scale 0°  is freezing-point,  100°
boiling-point.  Therefore,  to raise  1 kilogram of water 
208
FOOD AND FOOD VALUES
 at  0° C.  (freezing-point)  to  100° C.  (boiling-point)
 would require heat equal to 100 calories.
  The necessary amount  of food  varies according to
 age, weight, sex, and activity  of the individual.  The
 proper choice of food depends upon the knowledge of
 food principles and the amount of energy they yield.
  The value of different principles when  oxidized in the
 body is approximately:
  Organic  Foods.—1  gram of protein yields 4  calories.
  1 gram of carbohydrate yields 4 calories.
  1 gram of fat yields 9 calories.
  Inorganic Foods.—Water  is an inorganic food and has
 no  caloric  value,  but is absolutely  indispensable,
 because it  holds the  products of digestion in solution,
 forms the  principal  part  of the  blood stream, is the
 channel through which waste is thrown  off and makes
 up about 70 per cent, of the body weight.
  Salts  also have no caloric  value and are  equally
 indispensable.  They  are an essential part of all tissues
 and enter largely into the composition of bone, teeth, and
 cartilage.   They help in regulating the flow of fluids to
 and from tissues: they maintain the normal reaction of
 body fluids and furnish material for the acidity  or alka-
linity of digestive fluids and other secretions: they are
also necessary for proper  clotting of the blood.
  Fat can replace carbohydrates.  Protein  can replace
fat or carbohydrates, and  be partly replaced  by them;
but that which represents  the amount necessary  to
replace that lost by the breaking down of tissues cannot
be replaced.
  If fat is  combined  with  protein and carbohydrates, 
INORGANIC FOODS              209
less than one-half the quantity of protein is necessary
to repair body waste.
  It has been estimated that a man weighing 70 kilo-
grams (154 pounds), to perform moderate work would
require 40 calories per kilo, of weight for twenty-four
hours, or 70  X  40  =  2800 calories, sufficient heat to
bring 28 kilograms of ice to the boiling-point; for  labo-
rious work he would require  60 calories per kilo, or
70  X  60  =  4200 calories.  At rest he would  require
30 calories, or 70 X 30 = 2100 calories.
  A mixed diet is  always more completely absorbed
and more palatable.  Of protein about 80 per cent,  is
absorbed, fats almost  completely, and  carbohydrate
completely.   Foods which  have a  small  amount of
residue are desirable, as it stimulates peristalsis, thereby
regulating the bowel.
  Among the important things to be remembered are
the regularity of meals;  rest before and after; variety and
temperature  of the food.
VALUE OF	SOME	OF THE STANDARD		FOODS.
	Protein,	Fat,	Carbo-	Calories
In 10 grams of	gm.	gm.	hydrate.	approximate.
Beef, mutton, fish,				
fowl ....	20.0	5 to 10		125 to 170
Ham ....	20.0	25		305
Bacon ....	12.0	50		500
1 egg (50 gms. with-				
out shell)	6.5	5		75
Milk ....	3.0	4	5	70
Cream (very thick)	3.0	40	3	385
Cream, good	3.0	20	3	200
Butter ....	1.0	85		780
Cheese ....	25.0	33	2	400
Bread ....	9.0	1	60	275
Wheat flour	12.0		75	350
Oatmeal	16.0	7	66	390
Rice ....	8.0		80	350
Potato ....	2.0		20	90
14 
210           FOOD AND FOOD  VALUES
   From the above list  a diet may  be chosen for any
condition where proteins  or carbohydrates  are  not
restricted.
              A STRICT DIABETIC DIET.

   Meat,  poultry, game, fish, clear soups, gelatin, eggs,
butter, olive oil, tea, coffee,, and for a variety, tongue,
sweetbreads, tripe,  kidneys,  pigs'  feet,  brains, bone-
marrow,  anchovies,  caviar,  lobster,  crabs,  sardines,
shrimp, smoked or pickled meat or fish.
TABLE  I.—FOODS UNCONDITIONALLY ALLOWED.

        DIABETIC  DIET.  APPROXIMATE  VALUES.
STRICT
Foods and portions.
Bacon, 1 slice, 30 gms.
Beef:
  Roast (lean), 1 slice, 100 gms
  Roast (fat), 1 slice, 100 gms.
  Scraped (4 in. portion), 100 gms
  Corned (canned), 1 slice, 50 gms
  Juice, 5 iv (£ cup)
Brandy, gj......
Butter, 1 portion, 10 gms.
Cheese, 1 cube (American red)
Chicken (roast),  1 slice, 100 gms.
Coffee without sugar or cream
Egg (one)......
  Yolk (one).....
Fish (fat) (salmon), 1 hp. tb. sp.
  Lean (cod), 1 hp. tb. sp.
French dressing (olive oil, vinegar
  etc., 5ij)......
Gelatin, 1 hp. tb. sp.
Lamb chop (with bone),  100 gms
Olive oil (1 teaspoonful)
Pork Chop (one)   .   .
Soup, clear, 5v.....
Steak (without fat), 1 slice, 100gms
Turkey (roast), 1 slice, 100 gms.
Tea (without sugar or cream)
Whisky, 5j......
Carbo-
hydrate.
Protein.
3.0	19.4
23.0	1.6
20.0	20.0
21.0	10.5
13.0	9.3
6.0	0.7
0	0
0	8.5
4.0	5.5
32.0	4.4
0	0
6.6	6.0
5.0	2.5
11.0	6.5
8.5	
0	8.0
4.5	0.05
14.7	9.5
0	4.0
17.2	4.2
1.4	0
27.6	7.7
27.8	18.4
0	0
0	0
Fat.   Caloric:

       190
110
250
180
140
 30
 85
 80
 70
180

 80
 55
105
 35

 74
188
150
 38
110
 10.2
185
285
85 
A  STRICT  DIABETIC DIET          211
  Bread and puddings of gluten flour or gelatin flavored
with lemon and sweetened with saccharin.  All kinds
of natural or  artificial carbonated water, with  or with-
out lemon and saccharin.   Whisky, brandy, and light
wines.
TABLE II.—DIABETIC DIET.  ANY FOUR EQUAL IN CARBO-

       HYDRATE VALUE TO ONE SLICE  OF BREAD.
Foods and portions.
Carbo-
hydrate
Protein.	Fat.
1.5	
2.0	2.8
4.8	0.8
0.5	0.2
4.0	24.0
4.5	0.4
24.0	18.0
1.5	0.5
4.5	19.5
1.2	1.8
8.0	1.6
3.0	6.0
2.0	3.0
Calories.
Beets, 2 hp. tb. sp......
Beans (string), 8 hp. tb. sp.
Cabbage, 8 hp. tb. sp.....
Carrots, 3 hp. tb. sp.....
Cream (20 per cent.), 8 hp. tb. sp.
  4 oz.........
Clams (6), six......
Eggs:
  Scrambled \ . ,   ,,-
  Omelet    / 4 hp" tb" Sp
Lettuce, 2 hp. tb. sp.  .
Nuts (filberts), 30 nuts
Onions,  cooked (one)
Oysters, (eight) .
Soups, clear  ....
Spinach, 3 hp. tb. sp.
Turnip,  8 hp. tb. sp.
 25
 50
 40
 18

240
 47


280

 50
215
 42
 76

 85
 24
  It  is usual  to start  with a  diet practically carbo-
hydrate free.  If the sugar disappears from the urine,
as it may in light cases, measured quantities of bread or
other starchy  food may be added, taking care not  to
give enough to cause sugar to appear.
  Protein and  fat must  be given in sufficient quantities
to make up the necessary food value.  As these foods
create acids in  the body, acid poisoning must be watched
for. 
212
FOOD  AND FOOD VALUES
  To lessen this danger "starvation days,"  or days
when only  green vegetables  are allowed, are  usually
prescribed.


TABLE III.—DIABETIC DIET.   ANY TWO EQl'AL IN CARBO-
       HYDRATE VALUE TO ONE SLICE OF BREAD.
Foods and portions.
Carbo-
hydrate
Protein.
Fat.
Calories.
Beans (butter beans), 2 hp. tb
Buttermilk, 5v -
Fish chowder, 100 gms.
Hash (meat hash), 2 hp. tb. sp
Macaroni, 2 hp. tb. sp.
Milk, gv, 2 hp. tb. sp. .
Scallops (fried), 2 hp. tb. sp.
Squash, 2 hp. tb. sp.
Strawberries, 4 hp. tb. sp. .
Tomatoes (one medium size)
Walnuts (14 nuts)  .
 3.2
 4.5
 3.0
 1.9
 2.0
 4.5
28.0
 1.5
 1.0
 2.4
10.5
 0.2
  .07
 8.0
 1.4
 1.0
 5.9
 1.7
  0
 0.6
 4.0
37.5
 60
 50
 90
 80
 50
100
160
 60
 40
 46
420
  A liberal allowance of butter should be served with
each meal.  Vegetables should be seasoned with butter,
though it should be as little obvious as possible. Olive
oil may be used, either on salad or taken clear.
  The  above tables  show  the approximate  carbohy-
drate value of various foods compared with that of one
slice of bakers' bread cut | inch thick.
  From this and the following table showing the per-
centage  of carbohydrate found in many of the green
vegetables a suitable diet of  almost any carbohydrate
value mav be chosen. 
A STRICT DIABETIC DIET         213
TABLE  IV.—DIABETIC DIET.  ANY ONE EQUALS IN CAR-
      BOHYDRATE VALUE ONE SLICE OF BREAD.
Foods and portions.	Carbo-hydrate.	Protein.	Fat.	Calories.
Apple (one medium) ....	15	0.5	0.5	75
Apple sauce, 1 hp. tb. sp. .	15	—	0.5	70
Apricots (stewed), 1 hp. tb. sp.	15	0.7	0.5	80
Banana (one medium size)	15	1.0	—	70
Beans:				
Baked, 2 hp. tb. sp.....	15	7.5	8.0	150
Butter, 4 hp. tb. sp.....	15	4.0	0.2	65
Lima, 2 hp. tb. sp.....	15	64.0	0.5	130
Breakfast roll, \ of (1) one	15	1.0	,—	70
	15	9.3	i-4	100
Cereal (dry):				
Cornflakes, etc., 4 tb. sp.	15	1.2	—	8.0
Coffee, 1 cup, ? cream, 2 cubes				
sugar ........	15	3.0	7.5	155
Chocolate (Baker's), 5 gms., 28 grs.	15	6.5	24.0	300
Crackers, 3 round or graham .	15	1 .5	1.5	90
Cream soup, 5v.....	15	4.0	3.0	100
Custard, 2 hp. tb. sp.....	15	5.0	1.0	100
Gruel with milk, 6 tb. sp., 200 gms.	15	4.0	4.0	100
Macaroni, 4 hp. tb. sp.	15	4.0	4.0	100
Milk, gx....... . .	15	9.3	11.8	200
Muffin (one)......	15	1.0	-	70
Orange (one medium size)	15	1.0	—	70
Pears (one medium size)	15	1.5	5.0	75
Peaches, stewed, 1 hp. tb. sp.	15	0.7	0.5	80
Potato:				
Baked (one medium size)	15	2.0	—	80
Mashed, 2 hp. tb. sp.	15	2.0	2.0	85
Peas, green, 3 hp. tb. sp. .	15	7.5	3.0	120
Rice, 1 hp. tb. sp......	15	1.0	—	60
Tea, 1 cup; \ cream, 2 cubes sugar	15	3.0	7.5	155
	15	1.0	-	77
Zweibach, 1 slice .....	15	3.0	3.0	120
  From the above tables a diet of any given carbo-
hydrate value may be chosen.
  An actual record of the amount of fluid and carbo-
hydrate intake and output should be kept.
  A simple  comprehensive  chart should  be  used  for
this purpose. 
214          FOOD AND  FOOD  VALUES
           PERCENTAGE OF  CARBOHYDRATES.

  5 per cent, or less.             6 per cent, or less.
    Lettuce                     Cabbage
    Spinach                     Oysters
    Celery                      Radishes
    String beans
    Dandelion greens            10 Per cent- or less-
    Tomatoes                   Onions
    Rhubarb                    Turnips
    Swiss Chard                 Beets
    Egg plant                   Oranges
    Cauliflower                   Blackberries
    Asparagus                   Watermelons
    Cucumbers                   Brazil nuts
    Water cress                  Squash
    Pickles (unsweetened and       Carrots
      unspiced)                  Mushrooms
    Clams                      Strawberries
    Ripe olives                   Peaches
    Butternuts                   Muskmelons
    Fish roe                     Pecans
    Sauerkraut                   Hickory nuts.

  In  nephritis the  condition of  the kidneys is the

problem to be considered.  The normal kidney excretes

urea, water, and salts.  In diseased conditions they are

unable to do this; therefore in order not to throw work

upon these organs, certain foods,  the waste  of which

is eliminated  by them, are restricted, namely, protein,

salt, and water.

  A milk diet is no  longer considered the proper diet,

because  it contains such a large  percentage of protein.

In a quart there are about 35 grams.   The three quarts

necessary for one day would contain  105 grams of pro-

tein, which is in excess of the ordinary amount taken

under normal  conditions.

  A small amount of milk, possibly  a quart,  is allow-

able.  Cream and milk-sugar should be substituted to

make up the balance, where a liquid diet is essential. 
A STRICT DIABETIC DIET
21.:
s	"ifj:	I II	1 I"	llll	1 1 1 1 1 1 1 1 IJ 1		llll	.11.
		t--I fli	i 1	1	1J Hvf			
«		X- fitf&S	H X	I	i'iy			
		l. 1 ill	p 1		w\f\ w			
«	is	t4-ES	H1	III	Hi			
		1 illi	11 1		11 If			
3	IT	\\vkm	H 1	1	y		1 '<x%	
	-I-h-		H 1		He'			
« N	t	1. A <	u.-T-	1	Lf/T			
		l,,rl^|		1	| I			
^]	__L _	f|W I	m I-l	1	N			
		JL;i-	11 I	1	Hlfr			
c		Ik1	H t	1				
			H 1	\\\\				'
CS		A.&q&i'd	n	1	Jfi,		7 '• *	
		T kIPI	H T		| if;			
X	—i-L+-	i	n 1	m	1 TwA		,	
			^HTil Hill		11 (Hl/i			
-		,.!.. "i^B			\\\\wMfc,			
					Itliv*			
	wi	! i' 1 1	l|		Irifnl) 1			
		T___iii			"[[Mill J!			11
-	u \	^IjTMl	! ■ ' 1 11 1 1 IT		•JJ	' 'T		
	T	^ij^			O-n	t Jj		1
-*	'.Mil	yj ,				[mm	*?f|$	
-	'JET	4 JiMli						
								
-	1 1 1 \l	^.raJki						
								
=	"ti ,				\\	II w		
								
2	1 j 1	i TT			III"*			
	T	1122.1			TIT	i| |]\J Jrl 1		
-	j	^ Ji						
		-^-Pl						
X		/ Tills ^				Jw^P	|||	
								
-	L7		% 'III			W^'w^		
	Tfjf	/ ffl^	:§j fswo loeel 1		1 11 j	ia/ilJ H		
-		/	1	IIJ	tttt		'yWh	
	::±r	i?iiliii	lt#t	hvfp	HOGy	'0|^i-3ia( 1	WfW	
is? < £ 0 0	c 0 0 0 0 If; CO Cl	000' 0 if; 0 Cl —1 i-l	solo z> 10 0 O <M (M		0 in	0 c 0 u-	> 0 )	+++ +♦
- s. z a T 0 z 1 It; < 7-	m 0 0 0	mom rt< **i- co	=> w 0		in	O IT 1-1 <3	0 0	11
Q<< Mm-1*	10 0 0 0	us O 10 < ■* •* co c	z> 10 0 "5 MM		m	0 in	0	< O Hi. p 3 <
BODY WT IN KQM.	0 0 m •*	DO t^ 0 I »J1 ■* tJ<	0 Etll ? § \ wool		0 w 0	0 c T»H CO O O	0 0	
 
216          FOOD  AND FOOD  VALUES
  In less  acute conditions the white  meat of chicken,
fat ham or bacon,  raw oysters, clams,  and fresh  fish,
boiled   or broiled,  onions,  cauliflower,  mushrooms,
lettuce, spinach, celery,  cabbage,  rice, tapioca,  and
ripe fruits should be given sparingly.
  Alcoholic beverages and  quantities  of meat,  eggs,
peas, and beans should be especially avoided.
  As  salt is also excreted in the urine,  it  becomes
necessary to regulate the amount of salt by giving a salt-
free diet or one in which the amount has been carefully
regulated. This is  only a temporary measure, but  is
particularly necessary if  the  patient  has  ascites or
edema. Salt, having an affinity for water, holds water
in the body.  By the omission of salt  a patient may
lose ten pounds (of fluid) per week.
  Water,  always necessary, must  be  taken in  very
limited amounts.
  Gout is caused by an excess of uric acid in the body
and the difficulty of its excretion.  It is the waste of
the nuclei in broken-down animal  cells  not only those
of our own bodies,  but  of the meat  which we  eat,
consequently the  omission of meat diminishes the  uric
acid by one-half.
  The  protein may be supplied by  eggs, milk, vege-
tables, and  cheese.   An  excessive  amount  of fat  and
all forms of alcohol  should be avoided.  A fair amount
of exercise should be taken daily.
  In stomach trouble three  things must be considered
in choosing the diet:  First, if there  be too much or
too little  acid;  secondly,  if the stomach be irritable,
and if the food leaves the stomach properly. 
A STRICT DIABETIC DIET         217
  If there is too much acid, all foods which tend  to
stimulate the  flow  of gastric  juice  (acid secretion)
should be omitted,  such as beef tea, bouillon, clear
soups, and  highly seasoned food.   Albuminous food,
preferably eggs, should be substituted, as the albumen
in the egg unites with the acid and renders it harmless.
Fatty articles, as cream, butter, and olive oil, diminish
the secretion.
  The absence or diminution of acid may be remedied
by giving those foods which stimulate the secretion  of
acid,  as beef tea,  clear  soups,  bouillon,  and  highly
spiced and seasoned foods.
  When the stomach  becomes  irritated  upon  taking
an ordinary meal, a non-irritating diet should be chosen,
which consists of (no alcohol) foods not highly seasoned
and which disintegrate easily in the stomach; only a
limited amount of salt should be partaken.
  Cereals, bread (better toasted), eggs, macaroni, and
simple puddings may be  used in nearly all cases.  In
those less severe, white meat of chicken, beef, lamb
(provided it is properly cooked and finely divided), rice,
mashed potatoes,  celery  cooked soft,  butter,  cream,
and a moderate amount of milk.
  A cancer or ulcer may cause a partial obstruction,
and the food will not leave the stomach promptly.
Finely divided, concentrated  food should be  used.
Fat should  be given freely  and starchy  foods  which
leave  little  residue.   Fluids should be restricted, as
they are likely to distend the stomach. To make up
for the loss of fluid in the body, an enema of normal
salt solution may be given, which will  allay the  thirst. 
21S          FOOD AND  FOOD VALUES
  Constipation, to a certain  extent, may be  relieved
by  regulating the diet and  omitting all constipating
foods,  such as milk, eggs, cheese,  white bread, also
any food which leaves a large amount of residue.  In
the morning before  breakfast  a  glass of water  or  an
orange may be taken; honey  also helps.  At noon a
simple salad,  celery, cucumbers, lettuce, or chopped
cabbage; cooked fruit, as a baked  apple or  a pear;
stewed prunes, apricots, or ripe, raw fruit.
  A mixed diet,  with a  variety of vegetable's and
always a large amount of water, is essential.
  Diarrhea is caused  by irritation  of the intestines,
brought about by some food (usually protein or fat), or
by the presence of bacteria, possibly causing fermenta-
tion or decomposition of the intestinal contents.
  The irritating food should be  omitted.  The surest
method is to omit all food for forty-eight hours  or more
when possible.  It is often necessary to keep up the
nourishment.   Such foods as  milk  and lime water,
or  milk  with rice cooked  very  soft,  tapioca,  corn-
starch, and a small amount of tea or coffee.  After the
acute stage, chicken  or beef may be  prescribed.  A
complete change of food often effects a cure.
  In the various febrile diseases the diet must be regu-
lated according to existing conditions, always  keeping
in mind the necessity for a certain amount of  protein.
  To  prevent excessive  waste, easily  digested,  non-
irritating, concentrated food should be given, the main
object being to afford as great  a  variety as possible.
  The custom  of  giving milk  only  to  fever patients,
under general conditions,  is almost  obsolete.   While 
A STRICT DIABETIC  DIET         219
milk  contains all the elements necessary to sustain
life,  and has  been termed  a "perfect food,"  it also
contains 87.6 per cent, of water and leaves considerable
residue.
  Patients are likely  to become tired of it, though  an
occasional glass of milk is beneficial.  It should not be
given so often that the  patient gets tired of it, as one
may if  it  be given every few hours.
  Cream may be substituted, in a measure, and is of
high value as a food.  It may be taken in oyster broth
or clam broth.   Two or three ounces  flavored with
weak tea  or coffee, and one  or two lumps of  sugar,
make a pleasant change;  besides, the sugar affords
considerable nourishment, as one lump  is equal to the
white of one egg in value.
  Cocoa,  beef,  mutton,  and  chicken  broth   afford
variety.
  Eggs  in the form of albumen  water, egg-nog, or egg
lemon or orangeade, and a soft dropped egg, custard,
and ice-cream also may  be used.
  In certain conditions a half-ounce of olive oil may be
given morning and night.  It should be ice cold, and
should be given with  the medicines, so that it will not  *
be overlooked.
  Less severe conditions, soft solids, such as milk toast,
cereals,  tapioca,  rice,  junket,  and  gelatin  flavored
with fruit juice or wines may be allowed.
  It has been found  that typhoid patients who have
been fed small amounts of concentrated food frequently
and been  given  plenty  of fresh, cold water to drink,
have made a much shorter convalescence and are con- 
 220         FOOD AND FOOD  VALUES

 siderably less emaciated than with the old method of
 feeding.
   There are conditions when this  method of feeding
 must be modified somewhat, but tin1  rule to prevent
 excessive waste holds good.
   In cases of nausea  or vomiting it is  best to omit all
 feeding by  mouth and feed by  the rectum,  if neces-
 sary, . thus allowing  the stomach  to rest and  adjust
 itself.
   A teaspoonful of iced champagne may then be given
 every two hours for a number of hours.  If it is retained,
 toast water, albumen water,  or buttermilk may  be
 given  by teaspoonfuls every four  hours,  gradually
 shortening the time and increasing the amount until a
 greater variety of food may be  allowed.

                FORCED FEEDING.

   In feeding patients  who are unable to swallow, as is
 sometimes the case in diphtheria, or hysterical patients
 who refuse food,  it may be necessary to resort to forced
 feeding.  The food usually consists of milk, eggs, beef
 juice, and  sometimes  brandy  or whisky.  It should
 be prepared  in a pitcher and heated to 100° F.
  A stomach or nasal  tube should be boiled, connected
 with a glass funnel, and carried to the bedside on a tray
 with the pitcher,  the whole neatly covered with a
 napkin.
  A mouth gag is necessary if the stomach tube is used.
The tube should  be moistened and passed quickly into
the stomach.  Before  pouring in  the  food sufficient
time should elapse to be certain that the tube  is in the 
FORCED FEEDING
221
stomach, not in the air passages.  The tube should be
removed quickly to guard against regurgitation.
  Infant Feeding and Artificial Food.—Many infants
die yearly from improper feeding—not lack  of food,
but poor and particularly unclean food.
  Some of the indications for artificial  feeding are a
diseased mother, poor quality or an insufficient amount
of maternal milk, or by the separation of mother and
child.  This is possibly  the most frequent  reason for
resorting to artificial food.
  As a substitute for mother's milk it has been proved
that cow's milk is the best, not as it is drawn  from the
cow, but so modified that in composition it is practi-
cally the same as maternal milk.  In  this age of pure
food, dairy inspection,  etc., it is  possible to  obtain
fairly clean milk from a healthy herd, which is always
better than that from a single cow.
  The difference in composition is:  Maternal  milk,
3.8 to 4 per cent, fat, 6 per cent, sugar, 2 to 2.5 per cent.
protein; cow's milk, 3.7 to 4 per cent, fat, 4.5  per cent.
sugar, 4 per cent, protein.  Maternal  milk is  alkaline;
cow's milk is neutral or acid.
  The manner  of modifying milk  is to separate it,
then recombine it according to a specified formula.
  The milk should be cooled at a temperature of about
40°  F.  and allowed to stand undisturbed for eight or
ten hours for  the cream to rise.  The upper one-third
will then be approximately 10 per cent, fat, or the upper
one-half 7 per cent. fat.  Either may be used.
  The 10 per  cent,  fat is 3 per cent, fat to 1  per cent.
protein.
  The 7 per cent, fat is 2 per cent, fat to 1 per cent, protein. 
999
FOOD AND  FOOD VALUES
  The sugar—1  part of milk-sugar to  20 parts of the
mixture, or 1 ounce to 20 ounces.  Lime water, 1 part
to 20 of mixture or 1 ounce to 20 ounces.

         • FORMULA FOR TWENTY OUNCE*.
Milk-sugar, 1 oz.	With 10%		Formulas	
Lime water, 1 oz.	cream.	Fat.	Sugar.	Protein
Boiled water, q. s. ad 20 oz.	4 oz. =	2.0%	6.0%	0.60%
" q. s. ad 20 oz.	5 oz. =	2.5%	6.0%	0.83%
" " q. s. ad 20 oz.	6 oz. =	3.0%	6.0%	1.00%
" q. s. ad 20 oz.	7 oz. =	3.5%	6.5%	1.16%
" q. s. ad 20 oz.	8 oz. =	4.0%	7.0%	1 ■ 33%
   Dissolve the milk-sugar in hot water, add sufficient
 10 per  cent, cream, lime water, and  boiled water to
 make the desired amount.
   Divide into portions necessary for each feeding and
 put in separate bottles.   Close the mouth of the bottle
 with non-absorbent cotton and do not  open until used.
   To sterilize milk it must be brought to the boiling-
 point, which changes the nature of the  food to such an
 extent that it is not considered good for babies—hence
 the custom of pasteurization.
   Heat to 170° F. and keep at that temperature for
 twenty  minutes,  then cool rapidly on ice.  About 99
 per cent, of all bacteria are killed  by this process, but
 the milk will not remain good for a great length of time,
 and ought to  be  used within forty-eight hours.
  Rubber nipples should be boiled for each  feeding,
 and not allowed to stand  in a cup of water or any solu-
 tion.
  When the child appears to be hungry after the regular
feeding, the value, not the amount should be increased,
and the same  quantity given. 
              CHAPTER  XXIII.

                     FEVERS.

  Classification  and  Significance — Types and Changes  Brought
About in the Body—Nursing in Diseases in which Fever is an Impor-
tant Symptom.

  Pyrexia or fever is understood to mean an abnor-
mally high temperature.  It is always a symptom, not
a disease, and must be considered  as one of a group of
symptoms caused by some derangement of the chem-
istry of the body.
  Causes may be generated from  within, from failure
to cast off waste products (urea); from certain changes
in the blood  (as in anemia); from  exposure to extreme
heat, as sunstroke;  from  mental  abnormalities,  as
hysteria.
  Most frequently fever is due to  substances taken in:
namely, bacteria or protozoa.  In  either  case they act
by  affecting the  nervous  system,  and the normal
balance between heat production and heat elimination
is lost.   This is more often due to  overproduction than
to lack of radiation.
  Classification.—Continued  Fever.—The  temperature
may remain high, with only slight variation for a longer
or shorter period.  It may  be  for only a few hours, or
it may last days or weeks.  Typhoid is a typical con-
tinued fever. 
224
FEVERS
  Intermittent type is marked by periods when the tem-
perature may fall  to  normal, and then  rise again.
Malaria is an example of this condition.
  Remittent  type  is  characterized  by  a temperature
continually above the  normal, which  rises and  falls,
but without  intermissions.   The  remissions between
afternoon and morning temperature equal or exceed 2 °.
For example, tuberculosis.
  Another  classification  which  includes a group of
accompanying conditions  is:
  The Sthenic Type.—Temperature high; skin hot and
dry; pulse full, strong,  rapid and of high tension; ner-
vous  system overstimulated with delirium which may
become active or  violent.
  The Asthenic  Type.—Temperature high; skin cold
and clammy; pulse feeble; nervous system  depressed.
  In rare cases there is an inverse type, when the tem-
perature is highest in the morning, the opposite of the
general  rule.
  The return  from a high degree  of  temperature to
normal  is known  as the defervescence.  If  this return
is gradual it is spoken of as lysis; if sudden,  it is called
crisis.
  Recrudescence is the rise in temperature, lasting only
a short  time, after it has regained the normal.
  When fever returns  with all  its  accompanying
symptoms a reinfection has taken place. It  is generally
known as relapse. The elevation of temperature, as a
rule,  is accompanied by  certain symptoms referable
to other organs and tissues. 
MUCOUS MEMBRANES
225
  Changes  which  Take  Place  in the Skin.—First,
according to type, moist or dry.  Second, the various
eruptions associated with eruptive fevers.
  Tiny vesicles (blisters) often appear in great numbers
upon various parts of the body.
  Delicate skins often show a general rosy flush.  This
is probably due to the increased quantity of blood in
the cutaneous capillaries.
  In the later  stage desquamation may  take place—
always in the eruptive fevers.
  Mucous Membranes.—Herpes, sometimes known  as
fever  sores,  may occur, particularly in pneumonia
and malaria.
  There are thirst and dryness of the mouth and tongue;
the latter may be swollen, cracked, or have indentations
made by the teeth.  The teeth, tongue, and  lips may
have a deposit  of sordes. (Sordes is an accumulation
of mucus, the natural secretion of the mouth; discarded
epithelial cells;  blood, and a multitude of bacteria.)
  The lips become fissured and the gums spongy and
bleeding.  The  tongue becomes tremulous, and has a
coating which varies from a white, furry coat to a dark
brown crust.
  The pharynx is at  first dry, and may be the seat of a
catarrhal inflammation;  the tonsils may be swollen
or ulcerated; the salivary glands  tender or swollen.
  The membranes of the eyes and nose are congested,
and there is an increase of their watery secretion at first;
later they become dry.  Nose-bleed may occur, espe-
cially in  typhoid.
15 
226
FEVERS
   Organs of Digestion.—The appetite is diminished  or
 entirely absent.
   At the onset nausea  is common, and vomiting often
 follows:
   Gas in the intestines causes little  discomfort, except
 in typhoid, in which it frequently occurs, and is the
 result of  partial paralysis of the muscular coat of the
 intestines, due to  the general infection rather than by
 the presence and growth of bacteria.
   Usually there is constipation, caused by depletion  of
 fluids.  Diarrhea  may  occur in rare cases;  however,
 constipation is the general rule.
   The Circulatory System.—The pulse in fever is gener-
 ally one of increased force and frequency and of high
 tension.   As a rule the  increase is proportionate to the
 degree of temperature, though  there  are, of course,
 exceptions to this  rule, according to individuals and
 the type of the disease.
   In children the pulse  is particularly prone to increase
 out of proportion to the rise in temperature, sometimes
 reaching 150 to 170 per minute.
   A dicrotic or intermittent pulse or one irregular  in
 force or rhythm denotes heart weakness.   Any sudden
 increase  in rapidity or  weakness  is  likely  to indicate
 the onset of some complication.
   Position, emotional  excitement,  or any  muscular
 effort influence the strength  and rapidity of  the pulse
 to a considerable degree.
   Consequently the position should always be a recum-
 bent one, for any saving of the heart's strength may be
 a considerable factor in the  preservation of life if the
disease be of long duration. 
NERVOUS SYSTEM
227
  Respiratory  System.—The  number  of  respirations
may be increased and the depth of breathing diminished
even when there is no lung complication.
  When  pulmonary  disease  exists,  the  respirations
may be rapid, irregular, and painful.   In marked pul-
monary disease the breathing may become difficult,
or become almost impossible when the patient is lying
flat in bed and it becomes necessary to have him sit up.
A cough may exist, often with expectoration.
  Urinary  System.—The urine is lessened in quantity
of high specific gravity;  dark in color and possibly
turbid.  L'pon standing it often throws down a reddish-
brown sediment, consisting  usually  of  uric  acid  or
urates.  It may cause  a  burning sensation  on  being
voided,  due to its increased acidity.   In  severe cases
albumin,  casts,  and  even blood may  appear; these,
however, do not mean a permanent impairment of the
kidneys.
  As the disease progresses toward recovery the amount
increases  and the  urine becomes more normal  in  all
respects.  Retention of urine is rare in febrile diseases.
  Nervous System.—Febrile diseases, particularly when
the onset  is rapid, usually are ushered in with a distinct
chill;  there may be marked shivering, pallor, blueness
of lips,  and chattering  teeth, or there may be  chilly
feelings of greater or lesser  severity.
  In  a child  it is often a convulsion which may vary
from slight muscular movements of the face and extrem-
ities to violent movements of the whole body.
  Following this .chill or convulsion the rise in tempera-
ture, accompanied by other symptoms, appears. 
228
FEVERS
  Secondary chills usually indicate some complication.
Secondary convulsions are rare.  When they do occur,
they are  usually due  to hysteria or the  presence of
waste products which have not been eliminated by the
kidneys.  Urinalysis determines this.
  Headache is one of the most frequent symptoms at
the onset.  It may vary from a dull ache to an intense,
persistent, and almost unendurable pain.  At  times it
is of the  neuralgic type.  The  pain  is usually in the
forehead and temples, more rarely in  the top and back
of the head.
  Pains in the back, limbs, and bones often accompany
the headache.   Dizziness  exists,  which  is increased
upon assuming an upright position.
  Mental  symptoms  are  common  manifestations.
They vary from  a mere dulness and indisposition to
mental  exertion,  to extremes of delirium,  or absolute
coma.  These symptoms vary according to the tempera-
ment  of the individual and type and severity of  the
disease.
  Extremes  of mental disorder usually manifest them-
selves when the disease is at its worst.
  Delirium may  be a  mild  type and appear  only at
night, or  it may become so noisy and violent that
restraint is necessary.
  Habitual users of alcohol are especially liable, during
pneumonia, to develop delirium tremens.
  The sense of taste is perverted  or wholly  lost.  Hear-
ing  may be  impaired in typhoid, but more often  it is
abnormally acute; there may be ringing or  other noises
in the ears. 
NERVOUS  SYSTEM
229
  Infectious fevers may be complicated by middle-ear
infections.
  The secretions of the eyes at first increase, and later
diminish, causing  dryness.  At times the lids  may be
gummed together.  There is  often dread  of bright
lights.
  Fever is  always accompanied  by increased  tissue
waste  and  consequent  emaciation, which  is increased
by the disinclination of the patient to take food and the
inability on the part  of the digestive and  assimilative
powers to supply  the increased bodily  nourishment.
  Disease has  been  defined as  " an  active  process
depending essentially upon altered activities of some
of the cells  of the body, due to the presence of some
abnormal stimuli."   The cells  are made to  do,  not
new things, but too much or too little of the things they
do normally, thus the harmonious action, as a whole,
is interfered with.
  There may be death  of some and an active repro-
duction of others, interfering with nutrition, oxidation,
secretion, excretion, etc.
  Nutritional changes give rise to structural changes,
or organic  changes.  Such diseases are called organic
diseases.
  When there is no tissue change but simply altered
cell action it is spoken of as a functional disease.
  A chronic disease is  slow in development and long
continued.
  An  acute  disease  is  relatively  short  and  severe.
Many of the  acute  diseases  are self-limited, run a
definite course, after which recovery may be expected. 
230                   FEVERS
   Constitutional diseases affect the whole system to a
certain extent (rickets, gout, scurvy).
   Communicable diseases may be transmitted by con-
tact, by  inoculation or by carriers, and are caused  by
the growth and multiplication of pathogenic organisms
in the  body.
   Diseases are said to be epidemic wyhen a large number
of persons in any locality are  stricken with the same
disease.
   An acute communicable disease (so-called contagious
or infectious disease)  is  due to a specific organism,
each particular organism  producing special  manifes-
tations peculiar to itself.
   These  manifestations (signs and symptoms) are due
to. the action  of the bacteria plus the active defense
made by the body cells.
   Some bacteria multiply in the body and their effect is
due to their mechanical presence.  Others produce a
toxin  or  poison which  is added to the  effect of the
bacteria  themselves.
   Diphtheria  organisms  (Klebs-Loeffler  bacilli) may
colonize upon  a mucous surface and produce a soluble
toxin which may be absorbed by the blood and carried
all over the body, the organism not entering the blood
stream.
   In typhoid the bacterial cell circulates in the blood
stream, the toxin remains within itself until  the cell
disintegrates, when the poison is  set free.
   The  necessary  precaution  to prevent  the  spread
of infection is isolation.   This does not mean that each
individual disease must  be  in  a separate building  or 
NERVOUS SYSTEM             231
 room.  A patient whose diagnosis is doubtful, as one
 suffering  from an  infectious  disease other than that
 treated in the ward, may be treated as a  separate
 unit, a unit being an area which represents a separate,
 distinct infection.  This area may be only a single bed,
 or  a whole  room.  A nurse caring for such a patient
 should wear a short-sleeved  uniform,  and over this a
 long gown when coming in contact with him.  After
 caring for him, making  the  bed, feeding or touching
 him in any way, or coming in contact with anything
 touched by him, she should remove her gown, scrub
 her hands and forearms to the  elbow with soap and
 water.  Before going to  another patient a different
 gown should be put on.
  In this way a typhoid patient may be barred or kept
 apart from  any others.  Other  patients must not  be
 allowed to go near or touch anything which is used by,
 or comes in contact with, such a patient.
  He should  have a separate thermometer, separate
 dishes and  utensils, which should be sterilized  after
 using.
  Fever is a  symptom which occurs  to a greater  or
 lesser degree in the majority of diseases, probably due
 to the altered activity of the cells and derangement of
 the chemistry of the body.   It is  one of the prominent
 symptoms in infections, caused not only by the presence
 of the toxins but the resistance of the body cells in their
effort to combat them.
  In caring for fever patients  the first  consideration is
the cause of the fever.  If it is due to a transmissible
disease, how the infection leaves  the body, the length 
 232                  FEVERS

 of time the organisms may live outside the body, and
 the means by which  they  may be  transmitted to
 another.  With this knowledge one may be able to, in a
 measure, prevent the spread of the disease while caring
 for a patient.
   First secure good ventilation, and do not allow the
 room to become too hot.  When the  weather is hot
 provide some means of keeping the air in motion; an
 electric fan if possible.
   Absolute  cleanliness  is   most  essential.   (Baths
 given for  the reduction of temperature must never be
 allowed to take the place of daily cleansing bath  with
 soap  and water.)   Patient  should be isolated (which
 means he  should, with his nurse, be kept absolutely
 by himself) or barred from  others.   There should be
 thorough  disinfection  of  all  clothing  and body   dis-
 charges and complete and thorough sterilization of all
 dishes and utensils.
  Then follow the  simple nursing procedures  for the
 comfort and well-being of the patient.
  Antipyretic treatment may or may not be indicated.
 If the disease is self-limited and of short duration,
 usually nothing is done to reduce  the temperature, as
it is its duration rather than its degree which is  serious.
  If hydrotherapeutic measures are used, the applica-
 tion which is least tiring to the patient should be chosen,
 and whenever possible the method liked best, or  dis-
liked  the  least.  The  result is much  better  than  to
persist in  using  some particular  method,  while   the
patient protests.  (See page 236.) 
QUANTITIES OF FLUID           233
  Measures for Saving the Patient's Strength.—With the
elevation  of temperature  there  is  always  increased
heart action.  Conserving the heart's strength may be
a considerable factor  in saving life if the fever is pro-
longed.  Consequently the patient should be kept quiet
and  should  lie perfectly  flat  in  bed.  The  position
makes the work of the heart easier, while every act or
effort adds to its work.
  If the condition is such that the patient's head must
be elevated, because  of difficult breathing,  the back
and  shoulders  should  be  comfortably supported  in
each individual case.  It must be remembered that one
arrangement cannot suit all persons.
  "Quiet" means no effort or noise; patient should not
be allowed to help himself in any way; he should not
be allowed to talk, nor  be obliged to listen to the talk
of others; above all  things  never let a patient  hear
whispering in or outside the sick room.
  It is always well to  remember that a patient may not
be able to speak or make any sign, but may be able to
hear perfectly any discussion  of his condition which
may be carried on in  a  whisper.
  Quantities of Fluid.—The  body is dependent upon
a certain amount of fluid to functionate properly.  The
kidneys secrete a large portion of its waste. In disease
the debris is largely thrown off by them.  The kidneys
do their hardest work when compelled to excrete con-
centrated  urine.  A high temperature causes a deple-
tion of fluids in the body, and as the amount ingested
materially affects the  output, one should see that such
patients have quantities of fresh cold water (not from a 
234
FEVERS
 pitcher with a piece of ice in it, which has been allowefl
 to stand in  a sick room for hours, or until the ice is
 melted).   This  should  be  given the patient, usually
 with a feeder; if breathing is difficult, as in pneumonia,
 with a  spoon.  It requires too much effort  under such
 conditions to drink from a feeder or draw fluid through
 a drinking tube.
   Food.—Easily assimilated foods should be given fre-
 quently and in  small amounts, served as attractively
 as possible.  It often becomes difficult to give sufficient
 food when exhaustion is great and breathing labored;
 the added effort of taking the food many times balances
 the benefit received.  Milk, icy cold; beef juice, either
 hot or  cold, given  with  a  spoon; ice-cream, coffee, or
 cocoa, with one-third cream and sugar, either hot or
 icy cold,  may be used under such conditions.  While
 the  temperature  is  high generally almost  any liquid
 food may be used, but proteins should always be used
 sparingly.
   In infections when the kidneys may become involved
 (scarlet fever, diphtheria,  measles,  typhoid or pneu-
 monia), it is best to limit the protein and depend  upon
 carbohydrates until convalescence is well established.
   Constipation is usual with a high temperature; this
 is in a measure due to the depletion of fluids.  Plenty
 of water with fruit  juices  will help;  if not sufficient,
 drugs or  enemata  will  be necessary to produce the
 daily evacuation.
   Distention may  accompany constipation,  or  exist
 independent  of it.   If it be due to  constipation,  an
enema  affords the surest relief; if to other causes, a 
FOOD
235
rectal tube may be used.  Hot applications may afford
relief.  In  any case one must have  the  sanction  of
the attending physician.
  Nervous phenomena may be entirely absent or may
vary from inertia to violent  delirium.  The control
of this rests entirely with the attending physician.
  Drugs  or hydrotherapeutic measures may  be used.
Restraint should only be resorted to when the safety
of the patient is involved.
  The  nurse should  be on guard against  any sudden
change.  One who has been in a state of semiconscious-
ness or suffering  from a mild  type of delirium may
suddenly become violent and do  himself or  others
considerable injury. 
CHAPTER XXIV.
BATHS  FOR REDUCTION OF TEMPERATURE.

  Sponge Baths and Hydrotherapy Treatment—CcJd Packs—Hot
             Packs—Hot Air—Nauheim Baths.

  Cold or cool  baths may be given in the tub, by
sponging in bed, by spraying or showering and by cold
packs.
  The degree of coldness should depend upon the con-
dition of the patient: his circulation,  degree of tem-
perature, and susceptibility to  antithermic treatment.
  The method used should be that which causes  the
least possible fatigue to the patient.
  Baths  for the reduction  of temperature should be
given in  such a way that they not only abstract heat
from  the body,  but also lessen the  heat production.
This result is best obtained by means of friction; by
this method the superficial  vessels are dilated and  the
active movement  of the blood is maintained.
  Cool rather than cold  bathing is, as a rule, the more
effective, as the reaction which often  results in heat
production rather than  heat elimination  is lessened;
also  the  possibility  of  shock  from  extreme  cold is
eliminated.  The  essential point is to have the water
of the bath several degrees lowrer than the temperature
of the patient and to maintain that degree all through
the bath; or it may  be  gradually decreased according 
  BATHS FOR REDUCTION OF TEMPERATURE 237

to existing conditions.  95° F. is a safe degree to main-
tain, or it may be gradually reduced to 85° F. without
ill effects. In either case the bath should be continued
long enough to produce a decided effect upon the tem-
perature of the patient, twenty minutes or one-half hour
at least.
  The length of  the bath, rather than an  excessively
cold one, is of vast importance in the reduction of tem-
perature. It is also essential that it should not  cause
any degree of exhaustion, consequently it is best  given
in the form of a sponge bath in bed.
  To prepare for a sponge  bath, first  protect the bed
with a rubber sheet covered with a wool blanket, upon
which the patient is to lie.  Have at the bedside water
at the required temperature  (92° to 95° F.); a bath
thermometer should stand  in the water, so  that the
degree of temperature may at all times  be watched; a
basin with a piece of ice, upon  which the sponges are
to be cooled; an ice-cap for the  head; a heater well
covered, to  use  in case  of necessity (if  the patient
shivers,  if the extremities  become cold, and if  there
is pallor or  cyanosis); two towels and several sponges1
are also necessary.
  A towel should  be folded diagonally, wetted, and
laid across  the  abdomen,  and  the  corners tucked
between the  thighs.
   Pieces of gauze (or a sponge prepared for the purpose)
should be wretted and placed around the neck, also one
in each hand and in the axillae.

  1 Sponges should be made of several  thicknesses of gauze, sewed
together, and kept for bathing only. 
 238  BATHS FOR REDUCTION  OF TEMPERATURE

   The  face should be bathed first, the sponges to be
 cooled  on the ice before they are returned to the bath-
 water;  then with a sponge in each hand the attendant
 should  begin  at the feet  and with  one  long sweep,
 sponge up the legs and arms and down across the chest,
 making the sponges  follow the course  of  the venous
 return.
   Sufficient friction should be made to keep the body
 a pink color.   If  the skin suddenly  becomes pale or
 blue  the  bathing  should  cease.
   Towels and sponges should be changed  frequently,
 first cooling them  on the ice before they are returned
 to the water.
   The  patient  should be  bathed first while lying on
 the back, then turned on the side so that the back can
 be bathed.
  The bath should continue at least  twenty minutes.
 He should then be  covered with a dry blanket and
 allowed to rest one-half hour.   The water should be
 allowed to evaporate from  the  surface of the body,
 but not dried with a towel.
  Alcohol baths may be given in the same manner.
 The alcohol should  be diluted  50 per cent,  by the
 addition of water sufficiently warm to bring the tem-
 perature up to 95° F.
  Whatever method is used, cold baths for reduction
 of the temperature should always be accompanied  by
friction.
  The Cold Pack.—The bed should be protected with a
rubber sheet.  Two sheets wrung out of water of the re-
quired temperature should be placed one under and one 
THE COLD PACK
239
over the patient, care being used to allow no two surfaces
of the skin to come  together.  An  ice-cap should be
applied to  the head.  It is seldom necessary to have a
heater for  the feet.   When one is used it should be
only moderately warm (about  110° F.).
  The patient should remain in the  wet sheets, which
should be exposed to the air for twenty minutes,  and
if evaporation takes place so rapidly that they become
dry, they should be sprinkled or wetted a second time.
Fig. 40.—Method of applying sheet in a cold pack.
  After a rest of one-half hour between dry blankets,
a bed-gown may be put on and the temperature taken.
  The good results expected from cool or cold baths,
in the order of importance are:
  1. Improve or  equalize circulation  (this may  be
partially accomplished by  the prolonged  bathing—
twenty minutes to a half hour).
  2. Reduction  of  temperature,  due  to  improved
circulation. 
240  BATHS FOR REDUCTION  OF TEMPERATURE

   3. Allay nervous conditions.
   4. Finally to promote sleep, a patient who rests after
a  bath even  though the  temperature has not  been
reduced, is benefited by the bath.
   Bad results are shock and  elevation of temperature.
   Danger signals are change in  color (either pallor or
cyanosis).   Change  in rate  or  quality of the pulse,
sighing or gasping respirations, shivering.
   When any of the above symptoms develop during
the process of bathing,  the  bath should be  stopped
at once,  heaters and blankets  applied  and  doctor
notified.
   The Hot Pack.—The bed should be protected as  for a
sponge bath.  The patient should lie on a dry blanket.
One large wool blanket (or two if the blankets are small)
should be wrung  out of water at a temperature of not
less than 140° F. This should be done with a wringer
so that the blankets will not drip, and carried to the
bedside in a covered pail.
   The  patient should be turned  on the side and the
wet blanket slipped  under him and brought around the
whole  body, being  careful that it is  well tucked in
around  the neck.  The dry  blanket  is then brought
up over the wet one and securely  pinned.   Several
dry blankets are  put over all. Heaters should be put
to the  feet, also  one on  each side.   They should be
filled with water not over 110° F., well protected and
placed  outside at least one dry  blanket,  making  sure
that  they are  far enough away from the patient  that
burning cannot occur.
  An ice-cap  should be  kept on the  head  and  cold 
THE HOT PACK               241
water given frequently  (about four ounces every  ten
minutes) during the pack, which should continue from
twenty minutes to a half hour.
  When  removing the  wet  blankets,  it  should  be
done with the least possible exposure, and the patient
left in warm, dry blankets for one-half hour; then he
should be rubbed dry with a bath towel.
  The  effect is to communicate  heat  to  the body,
promote heat production, and decrease heat elimination.
The temperature "and pulse are increased,  and when
prolonged for twenty minutes or a half-hour, profuse
sweating occurs.
  Hot packs are valuable in Bright's disease, and in acute
nephritis, which so frequently complicates the infec-
tious diseases, edema, uremic  coma, albuminuria, and
eclampsia of pregnant women.
  Hot-air baths are given for  any  of the above condi-
tions, though much less frequently than hot packs.
  The bed should be  prepared as for a pack, and the
patient securely pinned in a blanket; two cradles  are
placed  over the patient, one  over the chest and the
other over the legs; these should be covered with rubber
and blankets, making  a rubber-lined tent in which the
patient  lies;  blankets which come closely  about the
neck of the patient are then securely tucked in on the
sides. An open space should be left at the foot, through
which is passed  the funnel of the hot-air apparatus.
  An ice-cap should be kept on the head and frequent
drinks of cold water given.  If  pallor or cyanosis occurs
the treatment should be discontinued.
  A thermometer  may  be placed under the  canopy
     16 
242  BATHS FOR  REDUCTION OF TEMPERATURE

to register the temperature of the bath, which should
not exceed 120°  F.
  Patients should never be left alone while having a
hot pack or hot-air bath.  A hypodermic syringe and
stimulants of various kinds should be at hand ready
for use in case of emergency.
  Hot packs may be supplemented by  hot air when
prolonged moist  heat is  desired.
  There are many forms  of medicated  baths given
under  varying conditions,  as the  bran bath, used in
skin disease, the saline,  bicarbonate of soda, etc.
  The  Nauheim Bath.—The Nauheim bath  is of  most
importance.  It  is an effervescent bath given at the
famous resort,  Nauheim,  Germany,  from  which it
receives its  name.  It consists of a full  bath of the
natural mineral water, which is charged with carbonic
acid gas, and contains a large amount of calcium chloride
in solution.
  Its effect is to stimulate the  superficial circulation
to a high  degree.  In  this way deep-seated congestion
is relieved and  the  work  of the heart considerably
lessened.  The action  of the skin is  also  increased,
lessening the work of the kidneys.
  In this respect the Nauheim bath, at the temperature
of the body, has  the same effect as a hot bath, and the
extreme temperature  is  avoided.  This  is  important
in cases of weak heart and  in chronic nephritis.
  This bath given by a skilled person  produces excel-
lent results.  It may be used in cardiac conditions when
there is dilatation and dropsy,  and  also in nephritis. 
THE NAUHEIM BATH
243
The  dropsy  gradually  disappears  and the  heart's
action is improved.
  The baths are usually given on alternate days until
three or four have been given, then not for two or three
days;  they may be  gradually increased  in  number
until  four are given on successive days.  The patient
should not be allowed to  get exhausted.   In heart
disease the breathing  should be  normal  when the
patient is  put in the bath.  Friction must be used.
The patient should never be left alone.
  Artificial Nauheim salts, in packages with directions
for  using, can be procured from most druggists.
  Inexperienced or  unskilled  persons  should  never
undertake to give a Nauheim  bath  unless supervised
by  a physician. 
CHAPTER XXV.
          TRANSMISSIBLE  DISEASES.

            Modes of Transmission—Immunity.

    INFECTIOUS AND CONTAGIOUS DISEASES.
  Disease is any mental, moral, or physical disorder.
  Infectious diseases are those caused by entrance into
the body of small,  living organisms of either plant
(bacteria) or animal  (protozoa) life.   As a rule,  the
organisms which produce  disease  are dependent upon
other living bodies for existence.   The large majority
of those that infect man are able to live only a limited
period outside  the  human  body.
  The transmission of disease in most cases is dependent
upon  contact either directly with  the infected  person
or with material recently  cast off  from such an indi-
vidual.
  Contagious diseases are always  infectious and differ
only in the mode of  transmission, which  may be by
direct or indirect  contact.   They may  be  transmitted
by a third person or anything which has come in con-
tact with the infected individual.
  In several of the contagious diseases the infectious
element  has not been  discovered—smallpox,  scarlet
fever, measles, etc.   It is  possible  the  infecting agent
is  contained in  the  discarded epithelial  cells,  the
excreta, or discharges from the nose and throat.
** 
         MEANS OF SPREADING DISEASE      245

         MEANS OF SPREADING DISEASE.

    1. By carriers.
    2. By contact (direct and indirect).
    3. By infected objects.
    4. By insects.
    5. By air.
    6. By food and drink.
  1. Carriers.—Carriers  are  persons  carrying  in their
bodies the bacteria which produce  disease, but who
show  no sign of having the disease.  The person  fre-
quently has had the disease and produced an immunity
to it, so the bacteria do him no harm, but he may infect
others.  These means of spreading disease are important
in diphtheria, typhoid,  and gonorrhea.
  2. Contact Infection.—Contact  infection  is infection
caused  by coming in direct contact with a  diseased
person (actually touching him) or by touching objects
or persons who have recently come in contact with
him.  This is the most common  method of spreading
disease.   The   diseases  usually  contracted  in  this
manner are scarlet fever, diphtheria, measles,  typhoid,
gonorrhea and syphilis.
  3. Infected Objects.—Infected objects, such as cloth-
ing, bedding, or furniture, which  have been in contact
with  diseased  persons  days  or  weeks, may spread
disease.   Spreading disease  by  infected  objects is
important in   the  spore-forming bacteria,  such  as
tetanus  and  anthrax.   Tuberculosis,  scarlet  fever,
diphtheria, and typhoid may be spread in this manner. 
246         TRANSMISSIBLE DISEASES

  4. Insects.—Flies are the most common insects that
carry disease in this part of the world, typhoid  being
one  of the principal ones.  Malaria and yellow  fever
are carried by mosquitoes; bubonic plague by fleas.
  5. Air.—Bacteria may become dried and  be blown
about in the dust, or may be scattered from an infected
person by coughing or sneezing.  This manner of trans-
mission is not common and is unimportant  except in
tuberculosis and measles, which are sometimes spread
in this way.
  6. Food and Drink.—Uncooked  foods,  milk,  fresh
vegetables, and shell-fish sometimes contain disease-
producing bacteria  from infected persons or  materials
with which  the foods have come  in  contact.   Milk
may spread typhoid, diphtheria, or tonsillitis.  Infected
water supplies  from reservoirs or wells may produce
epidemics of  disease, especially  typhoid,  cholera, and
dysentery.  The most common manner of spreading
disease is by carriers and by contact.


                    IMMUNITY.

  All the higher forms of  life  are susceptible under
certain  conditions  to  the  invasion  of  parasites of
various forms;  also some degree of resistance to  this
invasion is manifested  by all animals and plants. In
some instances this resistance or defence is so  complete
that bacteria  and other organisms  rarely infect the
body under normal  conditions.  This power of defence
is called immunity. 
IMMUNITY
247
  Resistance to certain forms of bacteria is often the
natural possession of a race or of an individual.  The
resistance is a natural immunity which depends  upon
the fact that certain disease-producing organisms find
unfavorable conditions  for reproduction and  growth
in one  animal  or person  and  suitable  conditions  in
another.
  There is also a condition the  exact opposite  to this,
a natural susceptibility.  Most children are  susceptible
to scarlet fever, measles, etc., but later in life  acquire
a certain degree of immunity by having had the dis-
ease (acquired immunity).
  Acquired immunity may be active or passive.
  Active immunity depends upon the activity of the
body cells  and their power to produce a certain sub-
stance which counteracts  the  toxin produced  by the
bacteria and in some instances renders them inert  or
kills them.
  This antitoxic substance is only produced in response
to the presence of the organism in the body, and is the
direct result of its stimulation.
  Active immunity may be acquired in  several ways:
  By the injection of attenuated organisms, or those
which have  been rendered  less virulent  by  passing
through other animals.   A familiar example of this is
smallpox vaccine.
  By the injection of dead organisms.
  By the toxin produced by certain of the  organisms.
  The injection of living bacteria is said to produce a
higher degree of immunity than the attenuated  or dead
microorganisms. 
24S         TRANSMISSIBLE DISEASES

  Passive immunity is acquired by the injection of the
antitoxin produced in the body of other animals which
have  been  rendered  immune  by  any  of  the above
methods.
  Vaccines produce active immunity.
  Antitoxins produce passive immunity. 
GLOSSARY.
  Abrasion.   A break in the skin or mucous membrane.
  Abscess.  A collection of pus.
  Acetone.  An  easily evaporating liquid with a characteristic
odor found in the urine of many cases of diabetes.
  Acute Disease.  A disease of short duration.
  Adhesion.  The adhering of two surfaces.
  Adrenalin.  That substance  to  which  the  secretion of the
adrenals owes its ability to contract the bloodvessels powerfully.
  Aerobic.  Preferring or demanding atmospheric oxygen for life.
  Affinity.  Attraction.
  Affusion.   A pouring upon, or sprinkling.
  Ameba.  One  of  the simplest protozoa, without  membrane
and which moves by means of  pseudopods; it is very common in
fresh water.
  Amputation.   The cutting off of a portion of the body.
  Anaerobic.  Preferring or demanding the absence of atmos-
pheric oxygen for life.
  Anemia.  A deficiency  in the amount of hemoglobin or of red
blood corpuscles in the b.lood, or in the  amount of blood.
  Anesthesia.  Condition in which sensation is lost.
  Ankylosis.  Stiffness of a joint, due to adhesions.
  Anodyne.   A medicine that relieves pain.
  Anterior.   Toward the front of the body.
  Antibodies. Substances developed in the blood  serum which
neutralize extracellular toxins of bacteria.
  Antiseptic.  Preventing the growth of bacteria.
  Antitoxins.  Antibodies developed in the blood serum  which
neutralize extracellular toxins of bacteria.
  Aphasia.  Partial or complete loss of the power of speech.
  Aphonia.   Loss of voice.
  Apoplexy.  Sudden paralysis generally caused  by ruptured
bloodvessel in the brain. 
250
GLOSSARY
  Arthritis.   Inflammation of a joint.
  Ascites.  An abnormal collection of fluid in the abdominal
cavity.
  Asepsis.   Free from septic matter.
  Asphyxia.  Suffocation.
  Aspiration.  Withdrawing of fluids from the body by means
of an aspirator.
  Atony.  Lack  of power; weakness.
  Atrophy.   A wasting away.
  Attenuate.   To reduce in virulence.
  Auditory.   Of hearing; pertaining to hearing.
  Auscultation.  Listening to sounds  produced  in  the body,
usually of the heart and lungs.
  Autoclave.   Instrument for sterilizing by steam under pressure.
  Bacillus (pi., Bacilli).  Rod-shaped bacteria.
  Bacteria  (sing. Bacterium).   Unicellular microscopic,  vege-
table organisms.
  Bacteriology.  The study of bacteria.
  Benign.  Not  malignant; mild.
  Bistoury.   A narrow-bladed knife.
  Blood  Casts.  Abnormal microscopic bodies  found in  the
urine; mould of the tubules of the kidneys formed of blood cells.
  Bougie.  An instrument used to dilate the urethra and other
canals.
  Bronchitis.  Inflammation of the living mucous membrane of
the bronchial tubes.
  Calculus.   A stone-like concretion found in the body.
  Callous.  Hard.
  Callus.  A new deposit about a fractured bone, formed in the
process of repair.
  Calorie.  A heat  unit; the amount of heat necessary  to raise
the temperature  of 1 gram of water 1c  C.  .
  Cannula.  A small tube, usually of metal.
  Carbohydrate.  The chemical term  applied  to one;  of  that
group of substances which includes all  sugars and starches.
  Carbon Dioxide.  A gas consisting of carbon and oxygen, and
an important constituent of exhaled air.
  Cardiac.   Pertaining to (1) the heart or (2) the cardia of  the
stomach.
  Caries.  Local death of a bone. 
GLOSSARY                    251
  Carrier.   A  term applied to  a person  who  carries germs
capable of being transmitted to and infecting others, but himself
not necessarily suffering at the time from the disease caused by
the germ.
  Cathartic.  A drug to move the bowels; a purgative.
  Catheter.   A  tube to be introduced through a canal into a
cavity in order to empty it, the bladder, renal pelves, middle ear,
etc.
  Caustic.   A substance which destroys tissue  (burning).
  Cautery.  Any hot metal instrument used to burn or to irritate
tissue.
  Centimetre, Centimeter.   The hundredth part of a metre.   It
is equal to 0.39 inch.
  Cheyne-Stokes Respiration.  An undulating type of breathing.
  Chronic.  (1) Of long standing; (2) a term describing conditions
which are the results of acute processes.
  Cilia.  Short hairs which some cells possess.  In the case  of
certain protozoa these  hairs are their means of locomotion.
  Coaptation.   The  adjustment of the  edges  of  a wound or
fractured bone.
  Collapse.  Complete prostration of the vital powers.
  Coma.  Unconsciousness from  which  the patient cannot be
aroused by external stimuli—shaking, shouting, etc.
  Comatose.  In a state of coma.
  Comminution.  Breaking into small pieces.
  Communicable.   Contagious.
  Congenital.   Existing at or dating from birth.
  Congestion.  An  abnormal accumulation of blood in  any
part or organ.
  Conjunctiva.   The covering of the eye-ball and lining of the
eye-lids.
  Contagious  Disease. Any  disease  which  can be  directly
communicated from the patient to those  about him.
  Convulsion.   An  unnatural,  violent  and  involuntary con-
traction of the muscles.
  Counter-extension.  Opposing   traction  upon  a  limb  in
extension.
  Crepitus.  Grating of the ends of broken bones.
  Crisis.  A sudden change;  the turning-point in disease.
  Culture.   The mass of bacteria grown artificially upon labora-
tory foodstuffs.  The general term applied to the way  bacteria
grow. 
252
GLOSSARY
  Debris.  Fragments; rubbish.
  Dejecta.  The feces and urine; also used to mean sputum,
sweat and morbid discharge.
  Delirium.  A  disordered mental condition with excitement and
illusions.
  Dementia.  Loss of reasoning power.
  Desquamation.  A peeling off of the skin.
  Diagnosis.  The  recognition of a disease by its  signs  and
symptoms.
  Dicrotic.  A kind of pulse characterized by a double beat.
  Disease.  A disturbance of the function or structure  of  any
part of  the body.
  Disinfect.  To free from organisms  (bacteria, etc.); to make
innocuous.
  Dyspnea.  Difficult breathing.
  Edema.  Accumulation of fluid in the cellular tissues.
  Emaciation.  The state of being emaciated.
  Embolism.  A clot or other obstruction in a bloodvessel.
  Emesis.   Vomiting.
  Emollient.  An agent that softens or soothes.
  Enema.  A rectal injection.
  Enzyme.  The products of  life of organisms by which they
digest their foodstuffs.  A  substance capable of splitting others
into simpler ones without itself undergoing any change of enter-
ing into the new product.  Also called ferment.
  Epidemic Disease.  A  disease  affecting  large  numbers  of
persons  at the same time.
  Excision.  A cutting out.
  Excoriation.  Abrasion of the skin.
  Excreta.  Waste  products discharged from the body.
  Extension.  Traction upon a fractured or dislocated limb.
  External.   (1) On the surface of the body; (2) removed from
the midline of the body.
  Exudation.  The  oozing  of  fluids.
  Febrile.  Characterized by fever.
  Feces, Fecal Matter.  The discharge from the bowels.
  Ferment.  Any substance (e. g.,  pepsin)  or organism (e.  g.,
yeast) which can break  up a  complex substance into simpler
substances.
  Filter.   To pass a liquid through a cloth or porous paper in order
to strain out solid particles. 
GLOSSARY
253
   Fixation.   Making rigid.
   Fomites.   Substances  capable  of absorbing contagion.
   Function.  The normal or special action of a part.
   Gangrene.  Mortification or death of a portion of tissue.
   Gastric.  Pertaining to the stomach.
   Gastro-intestinal.  Pertaining to the alimentary canal.
   Germicidal.  Capable  of killing germs.
   Gram,  Gramme.  The unit  of weight in the metric system.
It is equal to 15.43 grains, and is the weight of 1  c.c. of distilled
water at 4°  C.
   Granulations.  New cell growth.
   Grape-sugar.   Glucose.
   Hallucination.   A false sense perception.  The patient sees,
hears or smells, etc., that which does not exist.
   Hemorrhage.   An escape of  blood from the bloodvessels.
   Hemorrhoids.   Piles.  Enlarged  and  varicosed veins,  espe-
cially of the rectum..
   Hemostatic.  An  agent that arrests  hemorrhage.
   Hernia.  An abnormal opening  in  the walls  of any of the
cavities of the body into or through  which portions of organs
protrude.
   Host.   The body  which carries a parasite.
   Hydrolysis.  The splitting-up of a complex substance by intro-
ducing water into molecules.
   Hydrotherapy.'  The treatment of disease by the use of water
(bathing  is  usually meant).
   Hyperacidity.   Excessive acidity.
   Hyperpyrexia.   Excessively high body temperature {%.  e., over
106° F.).
   Hypersensitive.  Over-acute sensitiveness.
   Hypertrophy.   An abnormal increase in the size of a  part or
organ.
   Hypodermic.   Introduced under the skin.
   Hypodermoclysis.  The giving of salt solution under the skin.
   Hysterical.  Resembling, but not necessarily due to, hysteria.
   Idiopathic.  Without known  cause.
   Idiosyncrasy.   Individual peculiarity.
   Immune.   Protected:  immune bodies are substances within
our organs or blood which protect us against a given disease.
   Impacted. Wedged  in.
   Incontinence.   Involuntary evacuation of urine or feces. 
254
GLOSSARY
  Incubation.   The  period  which  intervenes   between   the
implantation of the virus and the development of the disease.
  Infective.  Any material carrying disease viruses.
  Infiltrate.  To  ooze into the  spaces of a tissue.
  Inflammation.  Response of  living tissue to  injury.
  Infusion.  The product obtained by  extracting the  active
principles of a substance by water without boiling.
  Inhibit.  Restrain, limit.
  Inoculate.  To introduce a virus into the body.
  Inorganic.  In  chemistry an  inorganic substance is one which
contains no carbon.
  Intermittent.  Occurring at intervals.
  Internal.  Situated within; on the inside.
  Interstitial.  Situated in the  interspaces of a tissue.
  Intestine.  The alimentary  canal from  the  pylorus  of  the
stomach to the anus.
  Intubation.  The introduction of a tube.
  Inunction.  The act of  rubbing in an ointment.
  Isolate.  Used to indicate the procuring of germs from morbid
fluids or to the obtaining of a single kind, a pure culture, usually
by finding a type of colony.  Related word: isolation.
  Laceration.  Tearing.
  Lavage.  The  washing out  of an  organ (as  the  stomach,
bowel, etc.).
  Lesion.  Used  to indicate  any physical  change from normal.
  Ligature.  A cord or thread for tying arteries,  etc.
  Litmus.  A  coloring  matter used to distinguish  acids  and
alkalies.
  Livid.   Congested; pale lead  color.
  Lumen.  The space inside a  tube.
  Lysis.   The gradual decline  of a disease.
  Malaise.  A  general feeling of illness.
  Malignant.  Virulent; threatening life.
  Mania.  A form of insanity marked by great excitement.
  Medium (pi.  Media).   General name given to foodstuffs upon
which bacteria are grown  artificially.
  Medulla.  The marrow.
  Meningitis.   Inflammation of the membranes of the  brain.
  Microbe.  A microorganism.
  Micrococcus.  A spherical-shaped bacterium.
  Microscopic.   Not visible to  the naked eye. 
GLOSSARY
255
  Motile.   Able to move.
  Mucous.  Containing, resembling or producing mucus.
  Mucus.   The sticky  liquid which the  mucous  membranes
secrete.
  Narcotic.  Producing stupor.
  Nares.  The nostrils; the openings into the nose in front and
behind into the throat.
  Nausea.   The sensation which makes one wish to vomit.
  Necrosis. The death of tissue.
  Nephritis.  Inflammation of the kidneys.
  Neurasthenia.  Exhaustion of nerve force.
  Normal.   Typical; conforming to the natural order or law.
  Occlusion.  Sealing or blocking up.
  (Edema.  A swollen condition of a part, due to a great increase
in the fluid it contains within its tissues.
  (Esophagus.   The tube through which the food passes from
the mouth to the stomach; the gullet.
  Ophthalmia.   Inflammation of the conjunctiva.
  Organic.  A substance having the form, the chemistry or some
characteristics of living matter; example, egg white.
  Organic  Compound.   The chemical term for a substance con-
taining carbon.
  Osmosis. Diffusion of fluids through membranes.
  Otitis Media.  Middle-ear disease.
  Paralysis.  A loss of motion or of sensation in a part.
  Parasite. An animal or vegetable which  lives in or on, and at
the expense of a larger animal or  vegetable, called the host.
  Pasteurization.  Checking  decomposition by heating.
  Pathogenic.  Disease-producing.
  Percussion.  Light tapping on  any part  of the body for diag-
nostic purposes.
  Peristalsis.   Undulating movements of  the intestines.
  Poisons.  Used generally to indicate any substance dangerous
to the body.
  Premonitory. Forewarning.
  Prognosis.  The prediction of  the course and termination of
a disease.
  Prophylaxis.  Prevention of disease.
  Protozoan.   One of the simplest animals,  consisting of but
one cell.
  Pseudo.  False, resembling. 
25(5
GLOSSARY
   Ptomaine  Poisoning.   Infection of  the  intestinal  tract by
 the products of decomposition; usually of food.
   Putrefaction.  The decaying  of protcid,  with production  of
 foul odors and poisonous substances.
   Pyogenes.  Pus-producing.
   Pyuria.  A condition marked by pus in the urine.
   Rash.  A skin eruption.
   Reaction.  Recuperation or return  of power after depression.
   Recurrent.   Returning at intervals.
   Relapse.  Recurrence of disease before complete convalescence.
   Remittent.   Alternately abating and returning.
   Renal.   Pertaining to the kidney.
   Resolution.  The return of a diseased part to its natural state.
   Retching.  Attempts at vomiting.
   Saline.   Salty.
   Salt.   (1) Any compound of a base and  an  acid; (2)  sodium
chloride or table salt; (3) a saline laxative,  as Epsom salts.
   Scar  Tissue.   Fibrous  tissue  which develops  to  repair an
injury.
   Scurvy.  A disease resulting from a long-continued diet which
lacks fruits and fresh vegetables.
   Secondary.   Due to a known  cause.
   Self-limiting Disease.   A disease which runs a definite course,
independent of treatment.
   Septic.   Relating to putrefaction.
   Serum.   The clear yellow fluid part of the blood which exudes
after clotting has occurred, and  in which  antibodies  reside.
   Spirocheta   (pi.  Spirochetae).   The  spiral or  corkscrew-like
organisms; name given both family and genus.
   Staphylococcus. The spherical coccus which grows in grape-
like masses.
   Streptococcus.  The spherical coccus which grows in chains.
   Styptic.  An astringent that will check hemorrhage.
   Subnormal.   Lower than normal.
   Suppression.  The sudden cessation of a secretion.
   Suppuration.  Inflammation with pus formation.
   Symptoms.  Those evidences of disease which are conspicuous.
   Tachycardia.  Excessive rapidity of heart  action.1"'
   Tap.  To empty of fluid.
   Thermic.  Pertaining to heat.
   Thrombus.  A blood clot in a  vessel forming an obstruction. 
GLOSSARY                   . 257
   Torsion.  Twisting.
   Toxemia.  A condition in which the blood is poisoned by the
poisons of germs, not by the germs themselves.   (The latter is
called septicemia.)
   Toxins.  The poisonous products of bacterial life.
   Traction. Drawing or pulling.
   Traumatic.   Produced by injury.
   Tumor.  (1)  A  swelling; (2) an abnormal mass formed in the
body by a growth of tissue which does not belong there.
   Tympanites.  The accumulation  of gas in the abdomen.
   Typhoidal.   Resembling, but not identical with, typhoid fever.
  Ulcer.  A cavity on the skin or on a mucous membrane which
is left when there is death and sloughing off of a tissue.
  Urticaria.  Hives,  or a skin eruption of like nature.
  Vaccine.  Originally used for the inoculation of cow-pox as
a  protective against smallpox;  now used for  that and for the
injection of dead or attenuated bacteria for active immunization
or treatment during  disease.
   Vascular. Well supplied with bloodvessels.
   Vesicle.  A blister.
   Viable.  Capable of living and reproducing.
   Virulence.  The power possessed by  organisms to  develop
poisons and produce disease; it varies in different strains, but
depends also upon the resistance of the host.
  Virus.  Any  factor which  produces disease, either individu-
ally recognized or  obscure; usually applied to poisons not specific-
ally isolated, like rabies virus.
  Viscid.   Glutinous.
17 
 
INDEX.
              A

Abbreviations, 83
Abdominal swathe, 166
Acute dilatation of stomach,
Air, composition of, 71
Albumin, heat test for, 122
  nitric acid test for, 121
Alkalies, poisoning by, 137
Anesthesia, after-care, 177
  preparation of, 176
Antidotes,  132
Antiseptics, 68
Artificial respiration, 137
Ascites, 202
Aspiration, 201-203
Aural douche, 174
              B

Backache, 228
Bacteria, 60
  classification of, 63
Bandaging, 155
Bathing patient (cleansing), 36
Baths, cold, 236
  for reduction of temperature,
    236
  hot-air, 141
  Nauheim, 242
  sponge, 236
Bed, ether, 178
  fracture, 31
  making, 28
    with patient, 30
Bed-sores, 44
Bladder irrigation, 125
Blood transfusion, 206
Buck's extension, 144
Burns, 149

              C

Calorie, the, 207
Carbolic-acid poisoning, 125
Care of mouth, 40
Catheterization, 123
Centigrade scale, 48
Chest swathe, 166
Chills, 116, 227
Clinical thermometer, 50
Cold applications, 108
  baths, 236
  packs, 238
Constipation, diet in, 218
Convulsions, 116, 227
Cough,114
Counterirritants, 103
Cupping,  106
Cystitis, 125
              D

Dead, care of, 42
Deodorants, 69
Diabetes, diet in, 210
Diarrhea, diet in, 218
Diet in constipation, 218
  in diabetes, 210
  in diarrhea, 218
  in fever, 219-234
  in gout, 216
  in nephritis, 214
Digitalis, poisoning by, 134 
2G0
INDEX
Dilatation  of stomach,  acute,
  1<)7
Discharging nose, 112
Disease, 229
Disinfectants, 67
Disinfecting rooms, 66
Doses, computing of, 87
Douche, aural, 174
Douches, 98
Dressings, 1S4
E
Ear irrigations, 174
Earache, 173
Enemata, 94
Epilepsy, 130
Ether bed, 17S
Ethics, 18
Expectorations, 114
Extension crane for child, 147
Eyes,  general care of, 171
Fahrenheit scale, 48
Feeding of patient, 39
Fehling's test for sugar,  122
Fever, 223
  diet in,  219-234
Flagelli, 63
Fomentations, 101
Food and  food values, 207
Forced feeding, 220
Fracture bed, 31
  board, 31
Fractures, 141
French  or  Metric  system  of
  weight and measures,  85
              G

Glossary, 249
Gloves, preparation of, 182
Gout, diet in, 216
              H

Hair, washing of, 37
Hands, preparation of, 181
Head rests, 31
Headache, 228
Heat test for albumin, 122
Hemorrhage, 127-195
Hot applications, 100
  pack, 140
Hot-air bath, 141
Hydrothorax, 201
Hygiene, personal, 21
Hypodermic treatment, 81
Hypodermoclysis, 204
Hysteria, 131
Ice-caps, coils and compresses,
  109
Immunity, 246
Infant feeding, 221
Infectious diseases, 244
Inflammations, 153
Instruments, preparation of, 183
Intestinal obstruction, 199
Intravenous, 205
Irrigation of bladder, 125
  of ear, 174
Irrigations, rectal,  97  ~
Jaundice, 111
Laboratory specimen of urine,
  preparation of, 126
Lavage, 138
Leeches, 107
Lumbar puncture, 204
Lund swathe, 164

             M
Mastoiditis, 173
Medicines, routes of adminis-
  tration of, 78 
INDEX
261
Mercury, 137
Metric system, 85
Mineral acids, 136
Minims, their relation to drops,
  81
Morphine poisoning, 135
Mouth breathing, 112


              N

Nauheim baths, 242
Nausea, 113
Nephritic diet, 214
Nitric acid test for albumin, 121
Nose, discharge from, 112
0
Operating room, care of, 185
    nurse, 184
Opium poisoning, 135
Organic foods, 208
Otitis media, 173
Oxygen, 73
Ozone, 72
Pack, cold, 238
  hot,  140
Pain, 115, 198
Parasites, 62
Patient, 41, 188, 191
  admission of, 34
  feeding of, 39
  routine care of, 38
Peritonitis, 199
Physical signs,  110
Plaster cast, 147
Pneumonia, 197
Poisoning, 132
  by alkalies, 137
  by carbolic acid, 125
  byghgitalis, 134
  by morphine, 135
  by opium,  135
  by strychnine, 134
Postoperative care of patient,
  192
Poultices, 102
Preparation of gloves, 182
  of hands,  181
  of instruments, 183
  of  laboratory  specimen of
    urine, 126
  of suture material, 185
  of tubing, 184
Pressure sores, 46
Protozoa, 62
Pulse, normal and abnormal, 53
Pyrexia, 223
              R

Rectal irrigations, 97
Respiration, artificial, 137
  normal and abnormal, 55
Retention of urine, 123
Retraction, 113
S
Saline solution, 187
Saprophites, 61
Signs and symptoms, 110
Shock, 189-194
Skin, care of, 46
  color of, 111
Sordes, 40
Sores, pressure, 46
Splints,  169
Sponge bath, 236
Sprains, 148
Stomach,  dilatation of,  acute,
  197
Stools, 115
Strapping, 168
Strychnine poisoning, 134
Stupes,  102
  turpentine, 102
Styptics, 196
Sugar, Fehling's test for, 122
Suppression of urine, 123
Surgical technic, 180
Suture material, preparation of,
  185 
202
INDEX
Swathe,
    Kiti
  Lund,
abdominal  and chest,

164
Temperature of the body, 47
  reduction of, baths for, 236
Thermometer, clinical,* its use,
  50
Transfusion of blood, 206
Tubing, preparation of,  184
Turpentine stupes, 102
Typhoid fever, 230
U
Urinalysis, 120
Urine, its constituents, 118
  laboratory  specimen of, pre-
    paration of, 126
  retention of, 123
  suppression of, 123
Vomiting, 113 
 
 
 
 The New York Academy of Medicine


   This book must not be retained for
longer than one  week after the last
date on the slip unless permission for its
renewal be obtained from the library.
...&
*">.''
	JU01	i.		
				
				
	\A#			
		m+Bi	=1AW(S -------- onnn	i
	W			1
		&JAV 1 *\		
		MAY 1 j	2009	
	TH	E NEW YOR	C ACADEMY	
	~C	F MEDICINI	: LIBRARY	
				
		_	---------	
				
				
				
				
				
				
	i			
 
 
'!<;t,
> . .TviiT :i; »
 :-.-'^^mn
■'• ''■::li;:i:-i:ii:''!ii!ii!i;:!"'|l
 ■■^iiii'iil  '!»!\\m
T-.:;ii!:!!!! li ! i  i! I
   ■:.•■■■• vM Wy $li
   ■ ,;  !i'ii in!  y
I
m
 :M T!|tl|
. j«j;; •
ilHfI li
 III
111
m\
w-\
Mtf'Mv  •■■  '■■idlliJiM