fi  Text-book of
 SimpleNursing Procedure
   for High Schools
jflB*.-~:.-.~-

£b *%-
w <■- * >3f




i~i~*<cjsz
SC5?:



easr
-Mi
"srfSfi
feS?^'
rjsS
—<*B »«■:■» «"*>*'" "'-1 »---d'ir>-Ttfc-KYW««nr:~g^y-
rxjrSS*' -'^: t r i f»-' KpSPHKKSr-v'TT- Via -'\_„ .•&






T""r" :-. ">!•: ■•■:■£-:.-. ■*->*^jjp^:i*;;

-7 »J?'»-v;-v«-l.v-r»i'4 
WY 195 P825t 1921
54810170R
NLM  0526=^0 1
NATIONAL LIBRARY OF MEDICINE
SURGEON GENERAL'S  OFFICE
    LIBRARY.
Section
W.D.S. G.O.
No
.ILMLUtiSf
NLM052894901 
 
 
 
By AMY ELIZABETH POPE
ESSENTIALS OF DIETETICS
A QUIZ BOOK FOR NURSES
ANATOMY AND PHYSIOLOGY FOR NURSES
A MEDICAL DICTIONARY FOR NURSES
PHYSICS AND CHEMISTRY FOR NURSES
PRACTICAL NURSING
     (with Anna Caroline Maxwell)
DIETARY COMPUTER
MANUAL OF NURSING PROCEDURE
ASISTENCIA PRACTICA DE ENFORMOS
  (Spanish Edition of Practical Nursing)
CON LA COOPERACION DE ANNA CAROLINE MAXWELL
A TEXTBOOK OF SIMPLE NURSING PROCEDURE
  FOR USE IN HIGH SCHOOLS 
         A  Textbook  of

Simple  Nursing  Procedure

        For Use in  High Schools

        Together with Instructions  for
          First  Aid in Emergencies
                   By


            Amy  E.  Pope

Formerly Instructor in the  School of Nursing, Presbyterian
  Hospital, New York; Visiting Instructor, San Francisco
    Author of " A Medical Dictionary for Nurses,"
     "A Quiz Book of  Nursing," " Essentials of
       Dietetics,"  " A  Dietary Computer,"
        " Anatomy and  Physiology," " Nurs-
         ing Procedure," and, with Anna
            Maxwell, of " Practical
                 Nursing"
Illustrated
G. P. Putnam's Sons
New York and London
Sbe   fmtckerbocfcer  preas
         1921 
VVY
 165

  197-1
      Copyright, 1921
          by
     G. P. Putnam's Sons V

Printed in the United States of America
s-
AUG ?U 1921V
 1/  ^U<LjL  w J^s>
9CI.A624031-
*  «uJ- 
PREFACE
  Every woman should have some knowledge of
the methods used in caring for the sick and of the
first-aid treatment required in common emergen-
cies and, if these essentials are not taught in the
schools, the great majority of women will never
know them.
  Many people say, " I do not believe in so much
talk about health, it was not considered necessary
when I was young," and  so  forth, but it is to
be  appreciated that one third of the seemingly
healthy men who applied for  military duty dur-
ing the last war {who were reared under the present
regime) were turned down because of physical dis-
ability,  and a most deplorable condition among
school children is indicated  by  the  following
statistics,  recently collected from  official  sources
and made public by Dr. Wood:
  "At least i per cent.—200,000—of the 20,000,000
school children in the United States, are mentally
defective.
  "Over  1  per cent.'—250,000 at  least—of  the
children are handicapped by organic heart disease.
  "At least 5  per cent.—1,000,000—have now or
have had  tuberculosis.
  "Five per cent. — 1,000,000 — have  defective
                      iii 
iv
Preface
hearing which when unrecognized, gives them the
undeserved reputation of being mentally defective.
  "Twenty-five per cent, have defective eyes.
  "About 25 per cent.—5,000,000—are suffering
from malnutrition.
  "From 15 to 25 per  cent.—3,000,000 to 5,000,-
000—have adenoids or  glandular defects.
  "From 10 to 20 per cent, have weak foot arches,  •
weak spines, or other joint defects.
  "From  50  to 75  per  cent,  have  defective
teeth."
  To  summarize,  75  per cent.—15,000,000—of
the 20,000,000 children  in the schools of  the United
States have physical defects which are potentially
or actually detrimental to health.
  Undoubtedly,  a large number of these  defects
are the result of lack of hygienic living and many
of them could be rectified if  parents appreciated
the seriousness of the  conditions sufficiently to
seek medical advice and knew enough about the
simpler treatments and nursing methods to enable
them  to  carry out a physician's  or  nurse's in-
structions correctly.
  It is chiefly treatments and  nursing care that
are described  in this book and, in compiling it,
the author has selected  procedures of which knowl-
edge is particularly essential  for young girls who
may have to help care for their sick.  With a few
exceptions the procedures can  be taught in the
classroom and only methods that can be used by
the inexperienced are included.  But, though the 
Preface
V
descriptions are arranged to facilitate  classroom
teaching, details of procedures that cannot well be
carried out in public but are likely to be necessary
in the care of a sick person, are also included.
Amy Elizabeth Pope. 
 
Suggestions for Methods of Teaching
  The teacher of nursing procedures is frequently
confronted with two opposing pedagogic require-
ments, namely: (i)  To encourage  the students'
ingenuity and their ability to follow written and
verbal instruction; (2) Not to allow  the pupils
to become confused  between  right  and wrong
methods by seeing procedures wrongly performed.
Probably this has to be more frequently guarded
against in teaching nursing procedures than almost
any other variety of technical work because errors
in technique  may in some instances be followed
by disastrous results.   For this reason, and also to
save time, it is frequently necessary for the instruc-
tor to demonstrate the procedures before the pupils
attempt  to carry them out.   It is for this reason
that the descriptions of methods have been entitled
demonstrations.   However,  the descriptions are
given in such a  manner  that  the  pupils should
be able  to carry out some of the simpler  pro-
cedures without being shown how to  do so and
to follow the directions when practicing in  their
homes.
  Even when the procedures are to  be demon-
strated, the author would advise  that  the pupils
be required to read the description of the demon-
                      vii 
viii      Methods of Teaching

stration and related matter in preparation  for
class, since  they will then be better prepared to
understand  and remember what they are shown.
Also, it is well to allot a portion of each class time
for a quiz. 
£
CONTENTS
Equipment for Demonstration Room .            i

                     CHAPTER I

Care  of  the Sick-Room and  of  Utensils
     Commonly  Employed   in  the  Treat-
     ment of the Sick       ....     6
      Ideal location and characteristics of a sick-room.
    Suitable furnishings for a  sick-room.  The natural
    phenomena upon which ventilation and the puri-
    fication of the air  depend.  The reasons for  the
    unpleasant effects experienced when in a poorly venti-
    lated room.  Some  methods of ventilation.  Why
    cleanliness is necessary to  prevent the transmission
    of disease and the ways in which some of the more
    common communicable  diseases are transmitted.
    Important rules to observe  when sweeping and dust-
    ing.  Methods of cleaning  and disinfecting utensils
    commonly  used in  the care of  the sick.  Demon-
    stration i:  Methods of ventilating and cleaning  a
    sick-room.   Care of  utensils used for the sick.

                     CHAPTER II

Methods of  Moving,  Lifting,  and Carry-
     ing Patients.....37
      Important points  to remember when moving,  lift-
    ing, and carrying people.  Demonstration 2: How to:
    Raise a patient's head; turn a patient on her side;
    draw her to the side of the  bed; move her up in bed;
    raise her to a sitting position;  lift her from the bed;
    carry her.
                          ix 
X
Contents
                     CHAPTER III
                                                    PACK
Bed-Making......46
      Important points to be considered when stripping
    and making a  bed.  Demonstration 3: Stripping a
    bed and  making a  closed  bed.  Demonstration 4:
    Making a bed with the patient in it, including chang-
    ing the nightgown and turning the pillows.

                     CHAPTER IV

Preparation of a Patient for the Night     59
      Demonstration 5: Preparation of a patient for the
    night, including rubbing the back, cleaning the teeth,
    and doing the hair.  How to give and remove a bed-
    pan.

                     CHAPTER  V

Essentials for a  Patient's Comfort       .    66
      Principles involved in making a patient comfort-
    able under varying conditions, including when she is
    out of doors in cold weather.  Causes and prevention
    of  pressure sores  and chafing.  Demonstration 6:
    Methods of making a patient comfortable when:  (1)
    Lying in  different positions; (2)  sitting up in bed.
    Demonstration  7: Preparing a patient to get out of
    bed and making her comfortable in a chair.

                     CHAPTER VI

Baths.  Care of the Hair.      ...    90
      Purposes of baths.  Effects of cold, hot, and tepid
    baths and how  they produce these effects.  What is
    meant by muscle tone, Reasons for the necessity of
    cleansing baths. Demonstration 8:  Giving a cleans-
    ing bath to a person in bed.  Care of the hair.   De-
    monstration 9:  Cleaning  the  hair.  Demonstration
    10: Washing the hair.  Demonstration  11: Methods
    of giving foot baths. 
Contents
xi
                     CHAPTER VII

Temperature.   Pulse.   Respiration.   Re-
     cords   .......
      Heat  production,  elimination,  and  regulation.
    Fever.  Nature and care of thermometers.  Demon-
    stration 12:  Procedure in taking the temperature.
    The  nature  of the pulse.  Conditions  that cause
    changes in the rate and character of the pulse.  The
    nature  of respiration and  of  breathing.  Factors
    controlling   these  functions.  Demonstration   13:
    Counting the pulse and breathing.  Some important
    reasons for keeping records of a patient's condition.
    Nature of records.

                      CHAPTER VIII

Medication.   External   Applications.  Ir-
     rigations    .      .     .      .     .       .139
      Method of administering drugs.   Bad  effects
    that  may arise from  the unadvisable use of drugs.
    Important points to  be remembered regarding  the
    care and  administration of drugs.  Measuring medi-
    cines.  Application of medication to the nose, throat,
    ears, eyes, and skin.  Demonstrations 14 to  21, in-
    cluding: Measuring medicines; application  of medi-
    cation to  the throat and steam inhalations; irrigation
    of the ear; application of medicine to the eyes; mak-
    ing poultices and sinapisms; applying ointment, lini-
    ments, iodine,  fomentations, hot-water bags,  and
    substitutes,  ice-caps  and substitutes.  The  nature
    and uses of counter-irritants.

                     CHAPTER  IX

Care of  Children.....196
      Normal development of children and measures to
    promote it.  Some especially important facts regard-
    ing mental development.  Requirements for  health.
PAGE

116 
xii
Contents
    Method of taking  a baby's temperature.  Suitable
    clothing for an infant.  Care of diapers.  Demon-
    stration 22: Lifting, weighing and dressing a baby.
    Reasons for the modification of milk.  Care necessary
    in the preparation of an infant's food and in its feed-
    ing.  Care of feeding bottles and nipples.  Demon-
    stration 23: Preparation of an infant's food and the
    care of utensils required for the purpose.

                     CHAPTER X

Bandaging  .     .      .      .      .     .     .241
      Uses, kinds and sizes of  bandages. How to make
    bandages.   Points  to  remember when  bandaging.
    Demonstration 24:  Circular, spiral, spiral reverse,
    and figure-eight bandages.  Bandages  for the leg,
    foot, heel, knee, arm, fingers, shoulder.  Tailed and
    handkerchief bandages and slings.


                      PART II

                    CHAPTER  XI

First  Aid   Treatment  in  Accident  and
     Other  Emergencies    ....   257
      The principles  of first  aid treatment.  Nature,
    causes and first aid treatment of: Unconsciousness;
    fainting or syncope; hysteria; sunstroke; heat pros-
    tration;  convulsions;  chills.  Demonstration  25:
    First aid treatment in the above  emergencies, includ-
    ing lifting and carrying an unconscious patient who
    has fallen to the ground.

                    CHAPTER XII

Asphyxia    or     Suffocation.  Artificial
     Respiration ......   279
      Mechanism of breathing.  Nature, common causes
     and treatment  of asphyxia.  Demonstration 26. 
Contents                 xiii
    Artificial respiration and treatment of an individual
    rescued from drowning.


                    CHAPTER XIII

Wounds.......287
      The nature, classification, means of repair,  and
    common complications of wounds.  Causes of,  and
    means of preventing, the infection of wounds. First
    aid   treatment  of  wounds.  Demonstration  27:
    Dressing a wound.


                    CHAPTER  XIV

Fractures.   Dislocations.  Sprains.  Hem-
     orrhage     ......   304
      Nature of  fractures.  How  bone is  repaired.
    Symptoms  and  first  aid  treatment  of  fractures.
    Nature, symptoms,  and treatment of dislocations
    and sprains.  Nature and symptoms of hemorrhage.
    Natural  resources of the body for arresting hemor-
    rhage. First aid treatment of hemorrhage. Demon-
    stration  28: First  aid treatment of fractures  and
    hemorrhage.


                    CHAPTER XV

Fire.   Burns.   Scalds.   Frost-Bite.  Chil-
     blain   .......   321
      How to put out fires.  How to escape and help
    others  escape  from  burning  buildings.  Demon-
    stration 29: Extinguishing flames from the clothing
    and use of  fire  extinguishers.  Various causes  and
    treatments of burns.  Treatment of scalds.  Nature,
    causes,  and treatment of  frost-bite and chilblain.
    Other consequences of exposure to cold. 
fciv                Contents
                  CHAPTER  XVI
                                              PAGE
Removal of  Foreign Bodies  and  Treat-
    ment of Poisoning     .    .      .     .   331
     Methods of removing foreign bodies from the eye,
   ear, nose, throat, bronchial tubes, and alimentary
   canal.  Nature of poisoning and the first aid treat-
   ment for  poisoning  by some of the more common
   poisons.

Glossary     ......   349

Index.......355
Index  of  Demonstrations    .      .      .  359 
     A Textbook of
Simple Nursing Procedure
  For Use in High Schools 
 
A  Text-Book  of  Methods
            of  Nursing
EQUIPMENT FOR DEMONSTRATION ROOM

  If possible the room in which nursing procedures
are demonstrated should be furnished as a bedroom
and there should be a sufficiently large cupboard
in it to hold the  articles other than the furniture
required for the demonstrations.  If it is not prac-
ticable to have all the furnishings of a bedroom
there should be at least:  A  bed, see page 8;
a screen; 2 tables, one of which should be a small
one to stand at the bedside and the other a fairly
large  one on which to place the equipments re-
quired for a  day's demonstration; it is also well if
possible to  have  an adjustable  invalid's table;
2 chairs, one of which should be suitable for Dem-
onstration 6 and the other for Demonstration 7,
see Figs.  15 and 22.
  Bedding:  1 mattress,  5 pillows, 6 sheets, 6
pillow cases, 2 bed blankets, 1 colored blanket and
1 cotton bath blanket, 2 spreads, a bed pad large
enough to cover the mattress, a piece of  rubber
sheeting  about 1 yard  wide and ij^ yards long. 
2            Nursing Methods

As far as possible the bedding should correspond
with the description given on page 9.
  Two nightgowns, a kimono or wrapper, and a
shoulder wrap.
  Two or 3 bath towels and about 6  hand towels
and washcloths.
  Toilet articles including:   A  toilet basin and
pitcher, toothbrush and holder, glass, a small bowl,
soap and nailbrush  in appropriate dishes, orange
stick, scissors, and nail file.
  A fountain syringe bag, or else an irrigator with
tubing attached.
  A rubber air-ring, if possible.
  An ear bulb syringe, a return flow aural tip and
an atomizer.
  A hot-water bag and quart bottles with corks to
be used as substitutes.
  An ice-cap and a pick and mallet for breaking ice.
  A bedpan and cover. If  the pan is not provided
with a cover  one can be made of heavy washable
material or double-faced rubber sheeting.
  Sputum  cups, both porcelain  or  enamel and
paper varieties.
  A bath thermometer, an  atmospheric thermome-
ter and clinical thermometers, if possible one for
each pupil, a tall glass to hold a disinfectant for the
thermometers.
  A foot-tub or baby's bath.
  Scales for weighing baby.
  Two enamel  trays, one  about 14 by 20 inches
and the other about 6 by 9  inches. 
   Demonstration Room Equipment 3

   A croup kettle or a substitute as described, page
 I5i-
   An electric or gas stove.
   A flatiron.
   An  asbestos mat.
   A saucepan with a capacity of about I quart.
   An  agate basin  with a capacity of at  least I
 quart.
   A measuring cup, teaspoon, tablespoon, knife,
 and spatula.
   Two wooden boxes arranged as described on page
 78, and, if possible, a  bed-cradle, back-rest,  and
 Meirinecke non-slipping knee and thigh support.
   A first aid box1 containing:  Small packages of
 sterile gauze and absorbent cotton, adhesive plaster,
 bandages, a pair of scissors and a pair of forceps
 and a small deep dish to sterilize these in (a deep
 agate soap dish will answer), a small bowl; a medi-
 cine glass, a small  nailbrush, orange  sticks, some
 small pieces of soft, clean muslin, boric acid powder,
 small bottles containing a 3 per cent, dilution of
 tincture  of  iodine,2 denatured  alcohol,3  liquid
 green soap, lysol or other disinfectant.  A bundle
 of wooden tongue depressors.
  1 Either a metal box or a wooden one lined with wax paper
 will be the best.  The box should be locked.
  2 The official tincture of iodine is 7 per cent., but this is irritant,
especially for children, and a 3 per cent, solution is an adequate
disinfectant for  the skin. The dilution should be done by the
druggist as pure alcohol must be used.
  3 Alcohol to which a poison is added that renders it unfit for
drinking but does not interfere with its value for external use. 
 4           Nursing Methods

   Red Cross emergency charts.
   A small bandage roller if possible.
   Bandages, 2^ and 3 inches wide,  about 3 for
 each pupil, or the material to make the bandages.
   A ball of heavy white twine.
   Paper bags of different  sizes  and a number of
 newspapers.
   Pieces  of old muslin, cheesecloth, flannel and
 flannelet.
   Mustard, flour, linseed, and antiphlogistine.
   Cleaning utensils, including: Dusters of cheese-
 cloth and suitable  pieces of old muslin; dustless
 dusters; an o'cedar mop; a broom, whisk, dustpan,
 if possible a carpet sweeper and vacuum cleaner; a
 small scrubbing brush, a twig sink brush and a jar
 in which it can be kept, a small agate pail, a can of
 bon ami, soap and a dish to keep it in.
   A board about 9 inches wide and as long as the
 width of the window in the classroom  as shown  in
 Fig. 2, on page 21.
   A large and a small demonstration doll.
   Baby's clothes.
   Feeding bottles, a basket to keep them in, and a
 pot large enough to hold the basket of bottles.
   Nipples in a glass jar.
  A brush for cleaning the bottles.  For descrip-
 tion of these articles see page 227.
  A number of the articles in the foregoing list are
required for only one or two demonstrations and,
in some cases, demonstrations that are likely to be
omitted if there is not time to have all  those de- 
  Demonstration Room Equipment 5

scribed in this volume.  However, on the first page
of each chapter there will be found either a list of
the equipment required for  the  demonstrations
described in the Chapter or else the number of the
pages on which the lists are  given. Thus it will
be an easy  matter for  those choosing classroom
equipments to eliminate unnecessary articles. 
CHAPTER  I
Care of the Sick-Room  and of Utensils Com-
     monly Employed in the Treatment of the
     Sick

  Articles required  for Demonstration i.   Ideal location and
characteristics of a sick-room.  Suitable furnishings for a sick-
room.  The natural phenomena upon which ventilation and the
purification of the air depend.  The reasons for the unpleasant
effects experienced when in a poorly ventilated room.  Some
methods of ventilation.  Why cleanliness is necessary to prevent
the transmission of disease and the ways in which some of the
more common communicable diseases are transmitted. Impor-
tant rules to observe when sweeping and dusting. Methods of
cleaning and disinfecting utensils commonly used in the care of
the sick.  Demonstration i.

  Equipment for Demonstration ix:
  The entire equipment should be on  view.   The
articles especially  required are:
  The window board.
  Cleaning utensils.
  Articles that need special attention  when they
are cleaned, as the bedpan, hot-water bag, ice-cap,
and rubber tubing.
  The procedure of this demonstration is to consist

  1 The furniture mentioned on page  I, is not listed with the
equipment for the demonstrations because  it is supposed to be
always present,
                         p 
   Care of Sick-Room and Utensils  7

of an exposition of methods of ventilation, sweep-
ing and dusting, and cleaning utensils.

Desirable Characteristics of a Sick-Room and its
                  Furnishings

   A room in which a sick person is confined should
be quiet, bright, and as attractive as possible.  A
room with a southern exposure, that has at least
two  windows and a hard wood paraffined  floor,
that is near  a bathroom and removed from the
noises of the street and house is the ideal.
   If the patient is likely to be ill for any length of
time, heavy  curtains that interfere  with ventila-
tion  and superfluous  ornaments that  make  it
difficult to keep the room clean should, if present,
be removed,  but the room must not be allowed to
have a bare appearance and medicine bottles and
utensils suggestive of illness are to be kept out of
sight, out of the room if possible.  Growing plants
are valuable ornaments in  a sick-room because
they not only help to  make it look pretty and
bright,  but,  as explained later, during the day-
time, they give off oxygen and absorb carbon dioxid
and thus they help to keep the air in the room pure.
In steam-heated  rooms water flowers growing in
open bowls are particularly good, because, as the
water evaporates, it helps to prevent the air be-
coming too dry.
   It is not advisable to use expensive  bedspreads,
blankets, and the like on the bed of  a very sick 
8
Nursing Methods
patient, nor to have a valuable rug or table near
the bed, especially if the patient is receiving much
treatment,  because,  under  such circumstances
there are many chances of accidents,  even if those
caring for the patient are particularly careful.
  A  suitable bed and bedding are of great impor-
tance to a patient's comfort.  The ideal bed is one
                           with an iron  frame
                           (which is easily kept
                           clean) and a good wire
                           spring, that  is about
                           twenty-four inches
                           high, thirty-six inches
                           wide and, for an adult,
                           a little over six feet in
  Fig. i.  Ideal bed for an invalid's  length.   If  the  bed
                           is much lower than
                           twenty-four  inches it
makes it difficult to move the patient easily.  Of
course when the patient is able to move without
much assistance and the illness is of a transitory
nature, this may not be of much importance, but,
when the patient is suffering from a chronic disease
and  requires considerable assistance, the  height of
the bed is of so much importance for the comfort
both of the patient  and those caring for her that, if
a bed about the required height cannot be obtained,
it is well to get four wooden blocks of  sufficient size
to raise the bed to the required height; in the center
of each block, there should be a hole about two
inches deep into which the legs of the bed will fit.
use.  The back-rest can be lowered and
raised as desired. 
   Care of Sick-Room and Utensils  9

  The mattress should be about two inches shorter
than the bed.  Hair, Ostermoor felt, and silk floss
are generally considered to be the best fillings for
mattresses.  Even mattresses with cheaper fillings
than  these  are expensive  and,  therefore,  the
mattress should be covered with a protector.  The
most comfortable kind of a protector is a quilted
pad, such as is used to protect the mattress in a
baby's crib,  but, if the patient has to use the bed-
pan and is at all helpless, it is advisable to have a
rubber protector also.  In emergency pieces of old
blanket  or newspaper^ sewn to a muslin foundation
can be substituted.  The sheets should be about a
yard longer  and a yard wider than the mattress.
The spread should be of light weight material for
the weight of those of heavy material is quite out
of proportion to the degree of warmth which  they
provide.
  The location of the bed is often of importance.
The points to be considered being: (i) That it is far
enough away from the walls to make it unnecessary
to move it when making the bed or when doing
anything for the patient;  (2) that it is in the right
position with  regard to the window.  What the
right position will be depends somewhat upon the
patient's condition, a person who is not very ill is
likely to want to look out of the window, but, if the
patient  is very ill, the points to be considered are:
(1) To have the bed where it will not be in a draft
—for example, between the window that will be
opened for ventilation and the door; (2) where the 
10           Nursing Methods

light will not shine in the patient's eyes.  This is
very important, because except in  diseases that
affect the eyes or  the brain, or when the  patient
wants  to rest,  it is usually desirable to have as
much sunlight as possible enter the sick-room, both
because it helps to make it cheerful and because
sunlight is an excellent disinfectant, that is, it will
destroy bacteria.  If the  bed  cannot be  placed
where the light will not annoy the patient a screen
should be put between it and the window.

             Care of the Sick-Room

  Care of the sick-room involves attention to its
ventilation, temperature, and cleanliness.

                  Ventilation

  Ventilation  has been defined as the continuous
introduction  of pure air into a  room or building,
thoroughly mixing it with the contained air  and the
simultaneous extraction of a like quantity of impure
air.l
  Before considering the  methods of ventilation
it will be well to recall: (r) The nature and com-
position of the air; (2) the sources of its impurities;
(3) nature's methods of purifying the air;  (4) the
cause of winds and drafts; (5) the nature and cause
of humidity;  (6)  the  reason for the  discomfort
experienced  in badly  ventilated  rooms;  (7) the
causes of odors in badly ventilated rooms.
  1 Principles of Hygiene.  Bergy,   W. B. Saunders Co. 
   Care of Sick-Room and  Utensils n

  Air is a colorless, odorless, transparent mixture
of gaseous  elements.  When  pure, it consists of
approximately, nitrogen  79 parts; oxygen 20.96
parts; carbon dioxid, 0.04 parts; small amounts of
other gases such as argon and ozone and a varying
amount of aqueous vapor.
  The impurities in the air are both gaseous and
solid.  The most common gaseous  impurities are:
(1) Those  arising from  the  combustion  taking
place in stoves, furnaces, and the  like;  (2) those
due to the oxidation going on in the bodies of all
animals and given off through the respiratory
organs; (3) those produced during the decomposi-
tion of animal and vegetable matter.  Ordinarily,
this gaseous matter is chiefly carbon dioxid, with
possibly some sulphur and  ammonia compounds,
and unless  present in excess it is not injurious to
health, but, in localities where there are defective
sewer pipes or where  there are factories or much
decaying vegetable or animal  matter, there may
be other gases present some of which, if continu-
ously inhaled, may cause destruction of the  red
corpuscles  in  the  blood  or otherwise affect  the
body in a manner that lessens its resistant  powers
to bacteria and other causes of disease.
  The more common solid impurities in the air are:
Sand, dust, soot, products of street refuse,  micro-
organisms,  the pollen of plants,  and where there
are factories and the like there may be substances
derived from material worked upon in the build-
ings. 
12          Nursing Methods

  In many industries the impurities, either gaseous
or solids, are  particularly  injurious and, unless
adequate  protective measures are  taken,  may
undermine the health of the workers.  Impurities
of this kind are known as industrial or occupational
poisons.
  The air is kept pure by rain, plant life, and the air
currents known as winds and breezes.
  The rain helps to purify the air by beating down
the solid impurities and by absorbing the gaseous
and carrying them down into the ground.
  Plants help to purify  the air by:  (i) Taking the
carbon dioxid (C02)  and using it,  with salts and
water (H 2 O), which they abstract from the ground,
to form  their  substance;  (2)  liberating  oxygen.
Plants set oxygen free  because the compounds of
which they consist contain  less oxygen than they
absorb as CO2 and H20 and, as the chemical re-
actions upon which their growth depends proceed,
the oxygen is set free and passes into the air. This
is practically the only source of the world's supply
of oxygen.  The chemical reactions are activated
by chlorophyl (the green coloring matter of plants)
and light and they take  place only in light and thus
oxygen is not set free from plants in the dark.
  Cut plants do not  liberate oxygen; on the con-
trary, once they begin to fade, they absorb oxygen
and give off C02.
  The origin of winds: Heat  causes  all matter,
including the air, to expand and cold makes matter
contract.  Therefore, in proportion to its bulk, hot 
   Care of Sick-Room and Utensils 13

air is lighter than cold air and will rise, but, being
expanded and lighter, it will  not exert as much
pressure as cold air.   When the atmospheric (air)
pressure in any locality is reduced in this way, air
from colder regions is, as it were, pressed forward,
this  creates the  air currents known  as winds  and
breezes.   The greater the differences between the
temperatures of the air  in  different regions, the
stronger will be the air currents, thus they may be
so slight that they will be hardly perceived or so
violent that they constitute a hurricane.  Even the
difference in the temperature of the air in the
shade and in  the direct sunlight is sufficient to
maintain movement of the air.
   In the natural ventilation of  rooms  the same
forces are depended upon to change  the air as out
of doors.  The air around the radiators, stove, or
open fire becomes heated, expands, spreads through
the room, especially upward,  some  of the colder
air then comes nearer the source of heat, becomes
heated,  and so on.  As the heated air expands it
forces its way through the crevices around windows
and  doors and therefore the amount of air within
the room is soon reduced and there  is not enough
to oppose the weight of the air on the outside of the
windows and doors which is therefore pressed into
the room.  The greater the difference between the
temperature out of doors and in doors,  the more
rapid will be the interchange of air; therefore,  on a
cold  day, a very  small opening will afford as much
ventilation as a wide-open window on  a hot day.  If 
14          Nursing Methods

there is much difference between the incoming air
and that out of doors the movement of air may be
perceived and it is then called a draft.  A draft is
particularly likely to occur when two openings are
directly opposite to each other.
  A fire, or even a lighted lamp, in an  open fire-
place affords an excellent means of ventilating a
room in cold weather, because, as  the  air in the
chimney, becomes heated, it passes upward and out,
and thus there is soon a partial vacuum  in the
chimney and air from the room and also, to an
even greater extent, from outside is pressed into it.
The  air  from the room being  warmer  than  that
coming down the chimney,  and coming first in
contact with the fire, rises while most  of that from
outside passes into the room.   If, when the fire is
lighted, the air in the chimney is much colder than
that in the room it, and with it the smoke, will be
forced into the room.  This can be prevented by,
before lighting the fire, holding a piece of burning
paper a little way up the chimney flue.
  To summarize: Ventilation  is maintained by
inducing currents of air and, in natural ventilation,
the currents are produced by  differences in  tem-
perature, because hot air diffuses rapidly and rises
while cold air falls.
  In what is known as artificial ventilation the air
is kept in  motion by various mechanical devices,
such as fans and pumps, which, as a rule, are situ-
ated in chimney-like passages  that communicate
with the rooms by means of ventilators. 
   Care of Sick-Room  and Utensils  15

  By humidity is meant the aqueous (water) vapor
in the air.  It is derived, as the result of evapora-
tion, from oceans, rivers, and other bodies of water,
and from the moisture on the ground after  rain.
The evaporation is induced  by  heat.   In other
words, heat changes the liquid water to vapor and
the vapor, being of a  gaseous nature and lighter
than air, rises and spreads through the atmosphere.
   Localities in which there are no large bodies of
water will have a relatively low degree of humidity,
but, even in such places, there will be some water
vapor for it will be driven thither by the winds.
In cities, that are near large bodies  of water and
where  the  buildings  are high,  the humidity is
likely to become excessive on hot days,  because
the high buildings interfere with the passage of air
currents and,  consequently, with the escape of the
extra vapor that the heat induces. This will occur
also in badly ventilated rooms in which there are
several  people because the perspiration, which is
being constantly secreted by the sweat glands in
the skin,1 is evaporated and the vapor passes into
the air.  When there is  a lack of air movement
in a room the vapor resulting from the evaporation
of sweat is not driven away from  around the body
  'Usually, at ordinary room  temperatures about a quart of
water is excreted through the sweat glands  in twenty-four hours,
but, in a hot environment, a very much larger amount will be
excreted.  We are not, as a rule, conscious of this excretion, be-
cause it is evaporated as soon as it flows to the surface of the skin,
but we feel and see it when it becomes excessive or if its evapora-
tion is interfered with. 
16            Nursing  Methods


and this interferes with further evaporation,  be-
cause the  air will  only take up a  certain  amount
of moisture.l
   It is now believed  that the  sense of discomfort
that one experiences in a  badly ventilated room
is due chiefly to the results of this interference with
evaporation and not, as was formerly supposed, to

  1 The air will only hold definite amounts of moisture,  how much
depending upon the temperature; for example, a cubic  foot of air
will hold:
               1.32 grams of moisture at 200 F.
               2.11   "   "    "    " 320 F.
               2.84   "   "    "    " 400 F.
               5-74.....'    " 60° F.
              10.93   "   "    "    " 8o° F.
              14.79   "   "    "    " 900 F.
  Out of doors, even  before  saturation  occurs if the weather
becomes cooler, the vapor begins to condense.  If it appears on
the ground, it is called  dew; if it condenses on dust particles, in
small amounts and near the ground, it is called mist; if in larger
amounts, fog; if high in the air, cloud.  Unless a large amount of
water vapor becomes condensed, the minute  droplets are lighter
than the air  and are wafted about with the air currents, but if
large amounts of moisture condense in the clouds, the particles of
water become heavier than the air and fall to the earth  as rain or,
if the rain comes in contact with cold currents while falling,  hail,
or, if the atmosphere around the clouds is below freezing point,
snow. When the actual amount of vapor in a given amount of air
is stated in weight, as in the above table, it is termed the absolute
humidity, but when the degree of humidity is expressed in  per-
centage it is spoken of as the relative humidity, and the  amount of
moisture that the air will hold, i.e., when the air is saturated, is
called 100  per cent.  The  most desirable degree of humidity is
between 60 and 70 per cents.  If there is too little moisture in the
air, evaporation of moisture from the surface of the body goes on
too freely and the skin and the membranes covering the eyes and
lining the nose, mouth,  throat become abnormally dry. 
    Care  of Sick-Room  and Utensils  17

the carbon dioxid that collects nor to the lessened
mount  of oxygen1   because  experiments have
shown that in rooms as they are ordinarily built,
there is too much interchange of air through the
cracks around windows and doors to allow of the
carbon  dioxid reaching a poisonous concentration
or of the oxygen becoming  sufficiently reduced to
account for the effects.   Also, it has been found
that if the air is kept in motion by means of a fan
a greater degree of air vitiation can be borne with-
out discomfort than when  the air is still and, of
course,  the movement of the air  drives away the
humid air around the body.   If the air in the room
is hot, the effects of bad ventilation will be more
keenly felt, because the loss of heat from the body
by radiation2 will be interfered with.
  The results of the interference with evaporation
are as follows:  The skin becomes moist and warm,
the  superficial blood-vessels dilate and,  conse-
quently, a larger amount of blood  flows to the skin
(this is  shown by its red color) and the quantity of
blood in the internal organs, especially the brain, is
therefore diminished.  As the result of the reduc-
  1 As we breathe we take oxygen away from the air and if gas is
burning or there is fire in a stove, etc., oxygen is taken to maintain
the burning, because burning, or, as it is sometimes called com-
bustion or, when it goes on slowly, as in the human body, oxida-
tion consists in the union of oxygen with matter.  When oxygen
unites with compounds they are decomposed and heat is produced.
  2 Space will not permit description of radiation further than to
state that it is one of the ways in  which heat passes from hot
matter, the term is used because what is called heat passes outward
from the body in  which it originates in straight lines or rays.
     2 
18          Nursing Methods

tion  of  the  brain's blood supply a sensation of
drowsiness and inability to fix the attention are
experienced  and, especially if one tries by volun-
tary  effort to overcome the inattention, headache
is likely to result.  When the atmosphere, either
in doors or out of doors, is both hot and humid the
body temperature may rise to a degree that is in-
compatible with life.  Such a condition is known as
heat prostration and as sun-stroke.
  The reason for the heating of the skin and the
rise of body  temperature is that the heat which is
formed in the body by the oxidation of material
derived from food is not gotten rid of when radia-
tion  and the evaporation of  sweat are interfered
with, for these are  the two ways in which most of
the heat is lost from the body.  Heat is lost by
evaporation  of sweat because evaporation is only
brought about by heat and that required is taken
from the body.  Heat radiates from the body in the
same manner as it  does from a stove or any other
heated object.
  As the conditions  in  a badly  ventilated room
interfere with the circulation of the blood, it can be
readily appreciated that people who spend much
of their time  in places where the ventilation is
defective are not  likely to be really healthy and
they become very  susceptible to  changes in  tem-
perature and "take cold easily."
  The odor  commonly perceived in a badly ven-
tilated room is not, as is commonly supposed, due
to carbon dioxid, for C02 is odorless.  Ordinarily, 
   Care of Sick-Room and  Utensils 19

it is from the sebaceous1 matter and perspiration
on the skin and gaseous matter from the stomach
and mDuth.  If the teeth are not in good condition,
or if diseases of the digestive canal  or the respira-
tory tract exist, substances with a  very foul odor
may be  eliminated with the breath.   Other not
uncommon  sources of unpleasant odors that may
be present, even when there is  good ventilation,
are:  Dirty garbage pails;  improperly flushed
toilets, or hoppers; defective sewers, gaspipes or
stoves; and, in a sick-room, an odor that is very
difficult to get rid of will arise if: (i) The bedpan
is not properly covered immediately after it has
been used and thoroughly cleansed as soon as it is
emptied; (2) the bedclothes2 are allowed to remain
over the patient while she is having a defecation;
(3)  the patient is  not properly cleansed after a
defecation,  or (4)  she is not bathed sufficiently
often;  (5) the bedclothes are not  changed when
soiled.
  As previously stated, gases from defective sewers,
gaspipes, and furnaces may be injurious, but ex-
periments have shown that the substances usually
responsible  for odor in badly ventilated  rooms are
not  harmful.  Nevertheless, if  there is an  un-

  1 Fatty matter secreted by the sebaceous glands in the skin.
It helps to keep the skin soft and pliable. When present in excess
it gives the skin a greasy appearance and that from the sebaceous
glands in the scalp makes the hair oily.
  2 They should be folded down to the foot  of the bed as de-
scribed later and a sheet and, if necessary, a blanket kept for the
purpose substituted. 
20          Nursing Methods

pleasant odor in a room,  the ventilation of the
latter is to be rectified for, even if the cause of the
odor is harmless, its  presence indicates that less
easily  detected, but possibly harmful, conditions
probably exist.
  An important point to remember in this respect
is that the olfactory nerves (those connected with
the sense of smell) very quickly become accus-
tomed to a stimulus and then cease to be affected
by it,  so  that, after  being in a room for  a few
minutes, one may cease to perceive an odor, even
when it seemed particularly strong and obnoxious
at first.  For this reason, those responsible for the
ventilation of a sick-room should accustom them-
elves to detecting an  odor,  if present,  on first
entering the room.
  From what has been said, it will be realized that
to obtain good ventilation:  (i) The incoming air
must be pure.  (2) The air in the room must be
kept as active as possible without creating a draft.'
(3) If it is so cold out of doors that the windows can-
not be opened widely it is better to lower the top
sash, than to raise the bottom one, or else to have
a small opening both at  the top and at the bottom
of the  window.  (4) If  there are two windows in
the room one should be  opened at the top and the
other at the bottom, so  that the openings will not

  1 It is now generally believed that unless a draft is cold enough
to make a person feel chilled it is not likely to have a bad effect
and that more people are injured by remaining where the air is
stagnant than by drafts. 
Care  of Sick-Room  and Utensils 21
be directly opposite each other nor on the same
level.
  In  very cold weather there may be enough
difference between the temperature of the incoming
air and that in the room to allow of an arrangement
such as is  shown in Figure 2,  inducing sufficient
movement in the air to obtain fairly good ventila-
tion. This illustration shows
a narrow board placed be-
neath the  lower sash;  the
upper edge of the lower sash
is thus raised above the bot-
tom of the upper one.  This
deflects the cold air, which
enters   between  the  two
sashes, upward and  thus it
does not blow  on  the in-
mates of the room.
  Even in very cold weather
the sick-room should,  as a
rule, be  thoroughly venti-
lated, at least twice daily by
opening the windows widely.
If necessary, before doing so,
extra covers should be put
over the patient and a screen placed between the
bed and window.
  The best temperature at which to keep the sick-
room depends upon  the patient's condition.  As
a rule, about 66° to 700 F. is advisable in the day-
time and between 6o° and 650 F. at night.  Some-
  Fig. 2.  Method of venti-
lating a room by raising the
lower sash on a board.  The
arrows indicate the direction
taken by the incoming air. 
22          Nursing Methods

times, however, especially if the patient has a high
temperature, the doctor may require the room to
be kept at a lower temperature.

Necessity for Cleanliness  in the Sick-Room and
     Causes of the Transmission of Disease

  After it was discovered that a large number of
diseases were  caused by  the  minute organisms
known as bacteria, which are almost omnipresent,
it was thought that the air and dust fairly teemed
with disease producing germs, but  it has been
found that the organisms which cause disease are
not nearly as prevalent as was supposed, because
most of these species are readily killed by sunlight
and by drying and they  depend upon  material
that they find in the animal  body for subsistence.
Nevertheless, though  dust may  not in  itself be
quite the source of danger that, until recently, it
was supposed to be, its presence is likely to protect
and hide what is a source of danger.   For example,
the germs that cause many of the infectious diseases,
such as tuberculosis, measles, scarlet fever, menin-
gitis,  infantile  paralysis,  diphtheria, influenza,
some types of pneumonia and colds, are  in  the
secretions of the nose and mouth of a patient who
has any one of these diseases.  Therefore, the drops
that are  ejected when the  patient coughs may
contain millions of  the bacteria.   As  patients
suffering  with these diseases often have consider-
able trouble breathing,  and are not  always  con- 
   Care of Sick-Room and Utensils 23

scious of what they are doing, they are likely to
cough frequently and with  force and  drops of
sputum may go a considerable distance. Now, if
the room is dirty and dusty, the lodging plane of
the virus may not be perceived and, the dirt may
protect  the substance from air currents and light
and thus retard its drying and the destruction of
the germs,  and,  if the  infected place is not well
cleansed it affords a source of infection for anyone
who touches it and  later puts her hand  to  her
mouth or touches food or some other object that
is put in the mouth or that comes in contact with
food.
  The germs causing typhoid and certain types of
diarrhea and some other less common diseases are
present in the feces and sometimes in the urine and
anything becoming soiled with these excreta will
be a source of infection.  With care, however, it is
easier to limit the danger of infection by these or-
ganisms than by those that are contained in the
mouth  and nose  secretions.  Care implies  the
immediate  disinfection of anything that becomes
soiled with the excreta.
  Flies, it is believed, form one of the most com-
mon vehicles for the transmission of infection when
excreta of any kind is  not properly removed and
disinfected,  because, when  they  alight on such
material, their feet and wings become soiled with
the virus and they carry this to whatever they
alight on next, and this may be food or something
that will come in contact with food.  Therefore the 
24           Nursing Methods

fly that is allowed to enter and escape from the
environment of a person suffering with an infec-
tious disease is a menace.  It is said that if flies
could be exterminated one of the greatest causes
of the spread of disease would be eliminated.
  Mosquitoes  also are  a menace,  especially in
localities where malaria and yellow fever are pre-
valent, because certain species,  a different one for
each of these diseases, will absorb  the organisms
causing the disease when they bite a person who
has been already infected and they afterward inject
them into the blood of another victim.
  Thus it can be seen that the room occupied by a
sick person must be kept particularly clean and it
should be screened, so that flies and mosquitoes
will not be able to enter and, if they do, they should
be killed.
  There is another cause for the spread of com-
municable diseases,  knowledge  of which  is so
important that a few words regarding it will be
inserted here, though it is not especially connected
with the care of the sick-room.  It is that bacteria
may live as .parasites1 within the body of an  indi-
vidual without, at least at once, making the host2
actively ill, but, though not ill, or only very slightly
so, the individual may infect towels, drinking cups,
or other utensils that she uses and,  if the bacteria
  1 Bacteria that cause disease are called parasites because they
derive their sustenance from the tissues of the individual whose
body they invade.
  2 Any animal or plant within or upon which another organism
lives parasitically, is termed a host, 
   Care of Sick-Room and Utensils 25

are harbored in the mouth or nose, eject the germs
if she coughs or sneezes.  The reasons for this are:
(1) It takes some time  after a  person  becomes
infected with bacteria for the latter to multiply and
induce a sufficient amount of toxin1 to poison  the
individual and thereby produce the conditions and
symptoms of disease.   This interval between  the
time  that the person  becomes infected and  the
appearance  of the acute symptoms of the disease
is known as the period of incubation.  (2) A person
may have such a slight attack of a disease that the
symptoms are not recognized and yet the bacteria
given off from the body may, if they invade  a
person more susceptible to their influence, cause a
virulent  and possibly fatal infection.  (3) Some-
times a person, after recovering from an infectious
disease,  even an unrecognized  attack,  becomes
what is known as a carrier, that is, she continues to
harbor the germs in her body but, because she is
immune, their poisons no longer affect her.
  To understand what is meant  by immune and
why some people are more susceptible to infection
than others, it must be known that the  body is
provided with several  means  of  protecting itself
against bacteria,  some of  these are classed as anti-
  1 Bacteria, like all other living organisms, require food to main-
tain their life and those which cause disease in man get their food
from material in the human body. In the assimilation of their
food chemical  substances are formed which are poisonous to
human beings and are therefore termed toxins. The toxins pro-
duced by different species of bacteria are dissimilar and therefore
they produce different symptoms. 
26          Nursing Methods

bacterial substances, because they destroy or lessen
the vitality of bacteria, and others are known as
antitoxins, because they unite with substances usual-
ly spoken of as toxins formed by bacteria and there-
by prevent them injuring the body cells.   Some of
these substances are natural constituents of the
blood, others are only evolved as the result of an
attack of  a disease or by vaccination.  The pro-
tective substances formed in the body as the result
of bacterial invasion are more or less specific, that
is, they can only be depended upon to protect the
individual from the same species of bacteria, or
their toxins, as those which caused their formation,
though, it is now thought, they may possibly have
some slight restraining  effect upon some others.
For  example, if a person has had typhoid fever,
she is not likely to have a  second attack but the
substances in her body which serve to prevent the
second attack cannot be relied  upon to protect
her  from  any other disease,  though,  it  is just
possible,  they may do so to a slight extent,  es-
pecially diseases caused by bacteria that resemble
the typhoid bacillus, which is the cause of typhoid
fever.
  The amount of natural, as well as acquired, pro-
tective substances in the blood varies in different
individuals and even in the same individual at
different  times, and  the former are likely to be
diminished when a person is in ill health.   Natur-
ally, a person who has a relatively large amount of
protective substances in her system is not as likely 
   Care of Sick-Room and Utensils 27

to contract infectious diseases as an individual who
has a smaller supply.

    Important Points to be Considered and the
     Methods Used in Cleaning Sick-Rooms

  1.  It is to be remembered that scattering the
dust from one place to another will  not make a
room clean.   Therefore, when sweeping, keep the
broom close to the  floor.  Sweeping the floor,
however, is not the best way of cleaning it.  Prefer-
able methods are to take up the dust with a vac-
uum cleaner, or, if this cannot be obtained, and
the floor, is carpeted, to sweep the dust out from
around the walls and the corners and then  take it
up with a carpet sweeper or, if a polished floor and
rug are the problem, to use an o'cedar or  similar
mop on the floor and the carpet sweeper on the rug.
If the baseboard is painted white the mop  should
be covered with a duster while dusting the floor
near the wall because the oil on the mop is likely to
discolor the  white paint.  As previously stated, it
is well, when possible, to have a rug that is small
enough to be removed without disturbing the bed
or other  heavy furniture and in such case, when
there is no vacuum cleaner  (if the patient has not
an infectious disease) the rug should be taken from
the room occasionally and vigorously brushed or
beaten.
  To avoid scattering dust while dusting, be care-
ful not to flick the duster around and it is well to 
28           Nursing-Methods

use a moist duster on articles that will not be injured
by the moisture.  Those which are likely to be are:
Lacquered metals and surfaces, as walls,  that are
colored with water paints or kalsomine; and water
will dull varnished or waxed surfaces, but for these
the duster can be slightly moistened with  the
various preparations,  such as o'cedar oil,  that are
intended  for  the purpose.   Only  the  minutest
amount of oil is required and more should not be
used for, if the wood is left greasy, dust will stick
to it and may be hard to remove.
  2.   Do not use a dirty duster or dirty water for
dusting and cleaning.
  3.   Dust higher shelves, etc., before lower ones.
  4.   When  dusting,  for  example,  a  bed do
not forget the bar and shelves that are out of
sight.
  5.   Form the habit of removing dust with one
firm stroke, it is waste of time and energy to move
the duster back and forth over a surface unnecessa-
rily, as is very commonly done.
  6.   Do not  use alkaline soaps and cleansing
powders1  on  painted  surfaces and  enamel bath-
tubs,  sinks,  etc.  Bon ami is good for these  pur-
poses, except for colored  walls,  which it is very
likely to  streak, because the powder is not easily
removed  from between the granules of plaster;
  1 Most of the laundry soaps and  the cleansing powders used for
cleaning tiles, cement, and  unvarnished wood contain some free
alkali.  This increases their  detergent powers and makes them
valuable for these purposes, but alkali tends to dull and roughen
enamel ware and glass. 
   Care of Sick-Room and  Utensils  29

neutral soaps, as ivory,  and warm water are the
best detergents for this purpose.

            Care of Cleaning Utensils

  Wash dusters after use and, when possible, hang
them in the sunlight to dry.  Wash brooms and
brushes in soap and water when they look dirty
and remove dust from  brushes with a metal comb,
which should be kept for the purpose.  If there is
no suitable place in  which to shake the dust off a
dusting mop, or when it has been used in the room
of a patient suffering  with an infectious disease,
put a rubber glove or an old kid one on your hand
and pick the dust off  the mop, then  put the soft
part of the mop in a paper or thick muslin bag,  tie
this tightly around the handle and shake the mop.
When the mop is dirty, soak it  in kerosene  or boil
it in water and soda (about one teaspoon of soda
to a quart of water).  After it is  dry  sprinkle a
small  amount  of o'cedar or other polishing  oil
over it.

          Care of Sick-Room Utensils

  After emptying a  bedpan or sputum  cup1 rinse
it with cold water until every  particle of the ex-
  1 When possible paper sputum cups, which are not emptied,  but
burned, should be used. A patient with any of the diseases men-
tioned on page 22 should use  paper napkins for handkerchiefs
and these, when soiled should be put in  a paper bag which, with
its contents, should be burned. 
30          Nursing Methods

creta has been removed and then scald it with hot
water.  If it is not easily cleaned use a small sink
brush to rub off adherent matter.  After using the
brush for this  purpose,  do not  use it for any
other, but keep it for similar use in a disinfectant
until all likelihood of its being again required has
passed.
  Rubber articles, as hot-water bags, ice-caps, and
rubber tubing and syringes are easily ruined if they
are not cared for properly, because rubber is rotted
if it is exposed to a high temperature (as that of
boiling water) for a  long time; if it is put  away
moist, and if it is left in contact with oils, acids, and
alkalies.  Therefore,  clean  such articles carefully
before putting them away and do not use alkalies,
as ammonia and soda, or strong laundry  soaps
(which contain free  alkalies)  for cleaning them;
use a neutral soap, as ivory. If they require  to be
disinfected, boil them, but not longer than five
minutes and when filling a hot-water bag for use,
do not use water that has a higher temperature
than 1800 or 1900 F.   Be sure that rubber articles
are dry before putting them away; to dry the in-
terior of a hot-water bag or rubber tubing hang the
article where it will drain and stretch tubing  occa-
sionally ; dry the interior of an ice-cap with a  towel
or soft muslin and let it stand for some time with
the cover off.  When putting  on  the cover  of an
ice-cap or inserting the stopper of a hot-water bag,
leave enough air in the articles to keep their sides
from sticking to each other and put them away in 
   Care  of Sick-Room and Utensils 31

boxes, for the rubber is easily punctured and even
a pinhole will render them useless.
  The bed linen, table covers, and the like used in
the sick-room are so frequently stained that  it is
well to remember how to remove the stains  that
most commonly occur.
  A rule that holds good for all stains is, if possible
to avoid it, do not let a stain dry; if means to erase
it cannot be taken at once, place the stained article
in warm water and later use the special reagent for
removing it.
  To remove stains made with coffee and  tea,
soak and  then  wash  the stained part in boiling
water and soapsuds.
  To remove ink stains soak the stain in warm
water then cover it with lemon juice and salt and
place it in the sunlight; when dried, wash it in
warm water, if  the stain has not been  removed,
repeat the procedure.
  Stains made with most medicines can generally
be removed by soaking the stain for  some time in
alcohol and then washing it with soap and hot water.
  Iodine stains  are most easily removed by soak-
ing them in ammonia water and then washing the
material in soap and water.  Sometimes soap and
water or alcohol alone  will remove the stain, if it is
treated as soon as it is made and the iodine is not
allowed to dry.
  Silver nitrate stains  can be removed by covering
the stain with iodine and then removing the latter
as just described. 
32          Nursing Methods

     The Disinfection of Sick-Room Utensils

  By disinfection is meant the destruction of bac-
teria.  As stated in the first part of this section,
anything that becomes soiled with material con-
taining bacteria must be disinfected.
  The surest way of destroying bacteria is to boil
the contaminated article.  If this consists of metal
or of porcelain or other hard substance that bac-
teria cannot penetrate, five minutes boiling will be
sufficient,  but more time  must be allowed if the
bacteria are not likely to be at once exposed to the
heat, as, for example, if bundles of sheets are boiled
in a receptacle that is so small that the sheets are
pressed together, or if the sheets are soiled with
feces or sputum  which are hardened  by heat and
may therefore protect the bacteria for a short time.
When heat is used to destroy bacteria, the process
is usually spoken of as sterilization.
  For  many reasons,  it is sometimes  impossible
to make use of heat to destroy bacteria, and then
chemicals, known as disinfectants or germicides, are
employed.  There are a number of good disinfec-
tants to be had, there are also a number, widely
advertised, that are practically useless, and many of
those that are efficient germicides will stain linen,
or corrode metal, or have other undesirable quali-
ties which limit their usefulness.
  Naturally, for home use, disinfectants that can
be employed for the largest number of purposes are
to be preferred.  Lysol and iodine are good ones to 
   Care of Sick-Room and Utensils 33

have in the emergency chest (this will be referred
to again in the chapter  describing  the care  of
wounds) and lysol and chloride of lime are two of
the best ones to have when caring for a person with
an infectious disease.
  Lysol is a mixture of soap and of the chemicals
known as cresols which are similar to carbolic acid,
but they are stronger germicides.   Because of its
soap, lysol cleans, as well  as disinfects, and thus it
is particularly good for the disinfection of the skin
and  of instruments and utensils.  It can also be
used for the disinfection of linen, excreta, and
toilets,  but  for the two purposes last mentioned
cheaper disinfectants, such as chloride of lime, will
answer equally well.
  For  the disinfection of the skin, utensils, and
linen, a  i per cent, solution of lysol is  generally
used, that is, 2^ teaspoonfuls (approximately  10
c.c.) of the  concentrated  lysol is used to make i
quart  (approximately iooo c. c); warm water is
used as the  diluent.   For  the disinfection of uten-
sils,  the solution is generally prepared once a day
in a pail and, after a used  utensil has been cleaned,
it is put into the solution and left for about an hour
or until it is needed again, when it is  dried with a
towel kept  for the purpose.  A solution for dis-
infecting the hands is usually prepared in a toilet
basin  and  kept  where it can be conveniently
reached, for the hands should be well  rubbed with
it after doing  anything for the patient.  Unless
it becomes soiled, the same solution  can be used
4 
34          Nursing Methods

repeatedly, but a fresh supply should be prepared
at least once,  and usually  twice, daily.  For the
disinfection  of feces and sputum, enough  of the
concentrated lysol is used to make the mass about
4 per cent., that is, if there seems to be about one
cup full of excreta (approximately 250 c. c.) about
2Y2 teaspoonfuls (10 c.c.) of lysol is used.  Enough
lysol to make urine 1 per cent, is generally sufficient,
as it comes more readily in contact with the bac-
teria. After the addition of the lysol, the excreta
should be allowed to  stand for fifteen to twenty
minutes before being emptied.  Lysol, however, is
not as good a disinfectant for  excreta as chloride
of lime.
  Chloride of lime (bleaching powder), in the same
percentages  as lysol, is about the best disinfectant
for excreta,  toilets,  and privy vaults.  It can also
be used in a  1 per cent, solution  for the disinfection
of linen, but  the latter must be well washed  in
several waters after removal from the disinfectant
or it may be destroyed.
  Unslaked lime is a cheap and efficient  disin-
fectant  for excreta that is to  be emptied  into a
privy vault and for the vault, but it has to be used
with caution for, if it comes in contact  with the
flesh, it is likely to cause severe burns and it will
destroy linen  and corrode metal. The  chemical
reaction that  occurs  when the lime  is added  to
excreta is  attended with  the  evolution of such
intense heat that disinfection occurs very quickly.
   Chlorine  and lime  disinfectants must be kept 
   Care of Sick-Room and Utensils 35

tightly covered, or their efficiency will be reduced.
  Some important rules to remember in connec-
tion with disinfection:
  I.   Only  use  disinfectants  that  are recom-
mended by competent authorities.
  2.   Always use the full amount of disinfectant
that you are told to and let the article remain in the
disinfectant the time advised.
  3.   Be sure that the disinfectant can penetrate
contaminated material, if this is of a nature to be
penetrated by bacteria, for disinfectants have to
come  in  actual contact with  bacteria in  order to
destroy them.  For example, if a typhoid patient
passes hard masses of feces and the disinfectant is
merely poured over the mass, millions of bacteria
may remain alive and active in the interior. There-
fore, hard masses of feces should be broken.   The
disinfection of excreta emptied into privy vaults is
particularly important, because, when in the ex-
crement, the bacteria have the material they need
for their sustenance and will multiply enormously,
and the ground water percolating through the soil
may wash bacteria into the wells, streams, etc., in
the neighborhood.  Several epidemics of typhoid
have been traced  to this source.
  4.   Disinfectants are poisonous to human be-
ings,  some of them extremely so and, therefore,
bottles containing them should always be clearly
labeled and kept in a locked receptacle.
  5.   Proper disinfection of the hands is extremely
important and,  as they cannot be kept in the dis- 
36          Nursing  Methods

infectant long enough to insure the destruction of
the bacteria,  they must be  well rubbed  and
scrubbed. Also, to prevent the contamination of
the hands as much as possible, rubber gloves should
be worn  when cleaning infected utensils and  the
like.   Cold cream or other lubricant should be used
freely to prevent the hands being roughened by
the disinfectant and frequent scrubbing, and  the
nails should be kept short—long nails and rough-
ened skin hinder disinfection.
  6.   Whenever possible infected bed linen and
the like should be boiled, rather than disinfected.
The linen can be put into a pail when it is removed
from the bed and covered with water, and the boil-
ing done when convenient. 
CHAPTER  II
Methods  of  Moving,   Lifting,  and Carrying
                      Patients1

  Important points to remember when moving, lifting, and carry-
ing people. Demonstration 2:  How to:  Raise a patient's head;
turn a patient on her side; draw her to the side of the bed; move
her up in bed; raise her to a sitting position; lift her from the bed;
carry her.

   Equipment for demonstration:
   A  bed with  the ordinary  bedding,  the  upper
covers folded back to the foot of the bed.
   A  subject:   It will  probably be advisable  to
have a small child act as subject for the last proce-
dure—carrying the patient—but  the pupils should

   'To the Teacher:  The procedures of  this lesson have been
arranged separately, instead of, according to the usual custom, in
connection with bed-making  in  order (1) that  the  pupils may
appreciate that they are to be carried  out whenever a helpless
person is moved, and not only when making the bed;  (2) to afford
a means of drill and of focusing the pupils' attention  upon what
are often the most important and difficult procedures in the care
of a sick person and, though few of the pupils of a high school are
likely to be called upon to care for a helpless patient, if they study
nursing procedures at all they should learn to do work of this kind
well, if only because such ability  will do much to remove the fear
of doing anything for a sick person which so many people have, and
which makes it so difficult for a nurse to get members of a patient's
family to help her when she needs assistance,
                           37 
38          Nursing Methods

take turns being "the patient" for the other proce-
dures of this lesson, because experiencing the sen-
sations produced helps them to appreciate how the
movements should be made.
  Points to be considered in moving a patient:
  i.  When a patient is very ill, especially when
her heart action is rapid or weak, moving must be
done without her assistance.
  2.  It is often important that a patient be moved
as little as possible.
  3.  Do not attempt to move a patient until you
are sure that there is nothing {e.g., bedcovers) to
hamper her movements.
  4.  When two or more  persons are moving a
patient, they must work in unison, and  in order
to do so one must take the lead and give necessary
directions and the word to move when  all is ready.
  5.  When necessary to lean forward while mov-
ing or lifting  a patient,  bend from your hips and
keep your shoulders thrown back.
  6.  When necessary to lift a patient's thighs, as
when passing a sheet under her, except when she is
very weak or has some injury of the legs, flex her
knees, and have the soles of her feet flat upon the
bed.  When in  this position a patient  can usually
help to raise herself and, even if she is unable to
do so, it is easier to lift her if her thighs are raised
from the bed as they are when her knees are flexed.
  7.  When lifting a patient's shoulders, support
her head.   To do this, bend your elbow slightly,
pass your arm behind the patient, place your hanc] 
             Moving Patients           39

firmly under her far shoulder and your fingers in
the axilla, let her head rest  in the bend of your
elbow, see Fig. 3.  When passing your arm behind
the patient raise her head with your free hand.
  Fig. 3.  Method of supporting head and shoulders while ad-
justing pillows, etc.
  Important points to consider when lifting and
carrying a patient are:
  1.  Before lifting a patient from the bed draw
her to the edge in order to minimize the necessary
degree of stooping.
  2.  When  stooping is  unavoidable,  bend the
knees and hips  and  keep the shoulders thrown
back; do  not bend the back, especially when you
have a weight on your arms.
  3.  When lifting or carrying a patient do not let
her put her arms around your neck, but have her
put them across your chest and back  (under your
arm nearest her)  and clasp her hands on your far 
40          Nursing Methods

shoulder.  More weight is thus thrown on  your
shoulder, and less upon your back; the shoulders
are not easily strained by a weight and the back is.
  4.   Before lifting a conscious patient, tell her to
hold herself as stiffly  as possible while you  are
lifting and carrying her.
  5.   If a patient is to be carried, before lifting her,
see that there is no obstruction between you and
your goal.
  6.   When two or more persons are carrying a
patient in their arms  they should step in unison,
but not with the same foot; i.e.,  when  one  steps
with the right foot her neighbor should  step with
the left.

              Demonstration 2

     Moving, Lifting,  and Carrying a Patient

  To turn a patient on her side:  By methods 1, 2,
and 3 the patient is turned with her face toward the
person moving her, by method 4 she is  turned with
her back to the mover.
  Method 1.  If the patient is not helpless all that
is usually necessary is to place one hand on  her
back between the shoulders  and the other behind
her thighs.  Pass your hands behind her on  the
side farthest from you and press upward.
  Method 2.  To turn a weak or  helpless patient,
slip one arm under her far shoulder and obliquely
across her back, so that your hand  comes under the 
             Moving Patients          41

side nearest you; pass your other arm under her
hips, also from the far side, raise her slightly, and,
drawing her somewhat backward, turn her toward
you.  (See Fig. 4.)  It may be necessary to make
Fig. 4.  Turning a patient.
some  change in  the position  of her shoulders  or
hips.  If so, to  move  her  shoulders,  place your
arms, one on either side, around her body with
your hands under her lower  arm, raise her slightly,
and move her as required.   Have the pillow under
her head while doing this. The hips can be moved
in the same manner.
  Method 3.  To turn  a heavy patient loosen the
draw  sheet1 on  one  side and, reaching over the
patient, grasp the loosened  end of the sheet on a
line with the patient's  shoulders and thighs and,
by pulling it toward you, turn the patient.
  1 See foot note page 47. 
42          Nursing Methods

  Method 4.  Slip one arm under the patient's
shoulders from the near side, getting your hand
as far as possible under her far side.  Pass your
other arm under the hips until your hand comes
well under the far thigh.  Raise her somewhat and,
drawing her slightly backward, turn her.
  To move a helpless patient to one side of the
bed:  If alone and the patient is small, pass one
arm under the upper part of her back and the other
under her thighs and draw her toward you.
  // the patient is tall, put one arm back of her
neck and far shoulder and the other under the small
of her back and move the upper part of the body;
then slip one arm under the small of the back and
the other  under  the knees and move the lower
portion of the body.  It may be necessary to repeat
the procedures once or twice  in order to  get the
patient as far over as required, but it is not essen-
tial to carry them out in the same order;  in fact,
it is better to move first the part of the body by
which you are standing.
  // the patient is very ill  and  heavy, assistance
should be had.  In such case, support the patient's
head and shoulders with one arm and slip the other
arm under the small of her back.  Have your assist-
ant stand beside  you and pass one arm under the
upper part of the patient's thighs and the other
under her knees.  Draw the patient toward you.
  To move a patient up in bed:
  Method 1.  Flex the patient's knees so that her
feet will rest firmly on the bed.  Pass one  of your 
             Moving Patients           43

arms behind her and, supporting her head in the
bend of your elbow, grasp her under her far arm.
Put your other arm under her thighs.
  If the bed is supplied with a pulley, have the
patient  grasp this; if it is not, have her place her
hands, palms downward, firmly on the bed and, in
either case, have her raise herself slightly while you
draw her upward.
  Method 2.   If the patient is heavy and cannot
help herself it will require two people to move her
and, unless the bed is a wide one, it is better to
stand on opposite sides.
  If possible,, flex the patient's knees, even though
she cannot help herself; grasp her under the far arm
as when lifting her alone and place your other arm
under her back.  Have your  assistant place one of
her arms  near yours and  the other  under the
patient's thighs  or, if the latter's knees are not
flexed, under them.
  Method 3.   Loosen the draw sheet and roll this
to the patient's side.  Take hold of  the roll on a
line with her shoulders and thighs; have an assist-
ant do likewise on the other side, taking  hold of
the roll directly opposite you.  Move the stretcher
thus made, and with it the patient, upward.
  To raise  a patient into a sitting position:  Pass
your  arm  nearest the  head of  the bed  behind
her as in Fig. 3, if necessary and possible, have the
patient  place her hands palms downward on the
bed and, by pressing  upon them, help  lift herself
as you raise her into a sitting position. 
44          Nursing Methods
  To  carry a patient  on a chair made  with the
hands: If the patient is in bed, draw her to the
edge,  and then raise and turn her so that she will
sit with her legs over the side.
  Grasp your left wrist with your right hand and
have  your assistant clasp  her left  wrist in  like
manner.
Fig. 5.  Carrying a patient.
  Both pass your hands under the patient's thighs
and each clasp the other's right wrist with her left
hand.  Have the patient place one hand on your
far  shoulder  and the other on your  assistant's.
Raise her and walk to your destination.
  To carry a  patient as shown in Fig. 5:   If the 
             Moving Patients          45

patient  is  in  bed,  pass  your arm diagonally
across her back, placing, if possible, your hand in
her axilla.  Pass your other arm under her knees.
  Have the patient clasp her hands  on your
shoulder, putting her arms across your back and
chest, never around your neck because this throws
more weight upon your back. 
CHAPTER III
                 Bed-Making

  Important points to be considered when stripping and making
a bed. Demonstration 3: Stripping a bed and making a closed
bed.  Demonstration 4:  Making a bed with the patient in it,
including changing the nightgown and turning the pillows.

  Equipment for Demonstration 3:
  A bed.  Small table.  Two chairs.  Two pillows
and their covers. Mattress and mattress protector.
Rubber sheet or quilted  pad.   Three sheets and
two blankets.

               Demonstration 3

Stripping a Bed, Making a Closed Bed.  Stripping
                and Airing a Bed

  The important points to be considered are:  To
save time and energy  by doing the work in an
order that will  entail going around  the  bed  as
seldom as possible.
  Not to soil the clothes by dragging them on the
floor.
  To so arrange the clothes after they have been
removed from the bed that they will be all exposed
to the air.
                       46 
                Bed-Making              47

  Procedure: Place two chairs back to back two
feet apart.
  Place the pillows upon the table or the seats of
the chairs.
  Fold the spread in its creases and hang it where
it will not get crushed.
  Loosen the clothes all around the bed.  To do
this raise the edges of the mattress by passing one
hand along under it, and draw out  the clothes with
the other hand.
  Remove the clothes, one at a time, taking hold of
each  article in the center (this will prevent  their
ends  dragging on the floor), and place them over
the back of the chairs.  Hang the rubber sheet
over a bar of the bed.
  Turn the mattress over from top to bottom1 and
stand it, arched, on its upper and lower ends.   The
bed should air for at least twenty minutes.

              Making a Closed Bed

  Points to be remembered when making a bed
that is to be occupied by a sick person are:
  i.   Protect the mattress.   A quilted pad, put on
under the under sheet,2 will be sufficient protec-

  1 The mattress should not be turned from side to side, for, if
it is, the same part will again bear the heaviest weight of the
patient and the mattress will become dented sooner than it will
if properly cared for.
  2 The sheets are usually spoken of as the under sheet, the draw
sheet, and the upper sheet.  The under sheet being the one used
to cover the mattress.  The draw sheet is thus named because it is 
4$          Nursing  Methods

tion when the patient is convalescent, but, when a
helpless patient has  to  use the bedpan, further
protection is advisable and either an extra quilted
pad or a rubber sheet should be put on over the
under sheet, before the draw sheet.1   Ordinarily,
this extra protector and draw sheet are not used
when the patient is well enough to be up, but they
are shown in this demonstration because it is easier
to learn how to adjust them when there is nobody
in the bed.
   2.   Fix the sheets  that will be under the patient
so that they will  remain without  wrinkles.   This
requires:  (a) That the sheets be put on perfectly
straight, otherwise, the material is,  as it were, on
the bias and when this is  the case, if the sheets
become at all loosened they will wrinkle; (b) the
sheets must be stretched tightly before they are
tucked under the  mattress; (c) the sides of the
sheets must be  tucked under the mattress to the
center of the  bed so that the patient's weight
will  be  over them and help  to keep  them in
place.
  3.  Do not tuck the upper clothes far under the
so arranged that when the part the patient is lying upon gets un-
comfortably warm, it can be drawn forward and a fresh part
provided. In hospitals long narrow sheets are usually provided
for the purpose but, in the home, an ordinary sheet can be doubled
lengthwise and adjusted with the length across the bed.  Another
reason for the use of this sheet is that it can be tucked farther
under the mattress than the under sheet and therefore it does not
wrinkle as easily.
  'See foot note page 47. 
Fig. 6.  Mitenng a corner of the under sheet. 
 
                Bed-Making             49

mattress for,  if you do,  the under ones will be
loosened when the bedcovers are turned down.
  4.  Avoid wasting time and energy.   In order
to do so collect everything that you will need for
your work before you begin and do your work in an
order that will necessitate going round the bed as
seldom as possible.
  5.  Keep the surroundings neat while you work,
and do not consider that you have finished making
the bed until you have put the chairs and table in
place and removed  everything that should not be
left on the table.
  Procedure: Put the mattress in place and cover
it with the protector.
  Cover this with a sheet.  Let the sheet extend
about eighteen inches beyond the mattress at the
top to allow for tucking in and leave exactly the
same length on either side.   Be sure that the sheet
is straight.  There  are two  methods of arranging
this sheet, in one  method  the envelope  corners,
which help to hold the sheet in place, are made at
the sides and, in the other, the corners are made at
the top and bottom.  For method 1, i.e., with the
corners at the  sides:   Tuck the sheet under the
mattress at the top, go to the foot of the bed, pull
the sheet firmly and tuck it in there.  Miter {i.e.,
fold like an envelope) the upper and lower corners
(see Fig. 6) and then tuck in the sheet along the
side on which you  are standing.  For method 2:
Tuck in the sheet along the side on which you are
standing, but leave it loose at the top and bottom. 
50          Nursing Methods

  Put on the extra protector, placing it where the
lower part of the back, buttocks, and upper part of
the thighs will rest.
  Cover  this with the draw sheet.   Leave the
latter a little bit longer on the side at which you
are standing than the other.  Tuck it in on this side.
It should extend from slightly under the  pillow  to
about the same level of the patient's knees and  at
least two inches beyond the top and bottom of the
protector.
  Go to the opposite side of the bed.  Turn back
the draw sheet and extra protector, so that they
will be out of your way while you first stretch, and
then tuck the  under  sheet beneath the mattress.
To do  this for method i miter the corners on the
side at the top and bottom, as on the other side,
stretch a portion of the sheet as forcibly as you can
(Fig. 7, in which the sheet is being pulled with one
hand while the edge of the mattress is pushed back
with the other, shows a good way  of  getting the
sheet tight) and then tuck it as far under the
mattress as possible.  For method 2, treat the sheet
in the  same manner,  but begin to work about the
middle and proceed first toward the foot  and then
toward the head of the bed.  Fold  the top  of
the sheet like an envelope and tuck it under the
head of the mattress and then do likewise at the
foot.
  See that the protector is in place and  free from
wrinkles, if it is so wide that it has to be  tucked in
treat it in the  same manner as the draw  sheet. 
Fig. 7.   Method of adjusting the under sheet tightly when the corners are mitered at
                   the foot, instead of the sides of the mattress. 
 
               Bed-Making             51

  Stretch and  tuck the draw sheet  under the
mattress in the same way as the under sheet.
  Put on the top sheet with the hem wrong side
up, so that the right side will be uppermost when
the sheet is turned down over the blanket and
spread.  Have the upper edge of the sheet on a line
with the rim of the mattress.  Tuck  the sheet
under the mattress at  the  foot,  miter  the lower
corners, as in the under sheet, the sides may be
allowed to hang or they may be tucked  under the
mattress, but not as far as the under sheets.  Neat-
ness is the main consideration in the arrangement
of the upper bedclothes.
  Put  on the blankets, have  their upper edges
about eight inches from the top of the mattress,
tuck them in at the bottom and arrange the sides
in the same manner as the sheet.
  Put on the spread, have its upper edge on a line
with the top of the mattress.  Tuck it in at the
bottom, fold the corners neatly.
  If necessary, put  clean  cases on the  pillows,
shake them, get their corners  into those of their
cases, press them with your arms, on a table, until
they are perfectly flat and  then put them on the
bed.
  To turn down the upper covers, when the patient
is ready to go to bed:  Turn the top edge of the
spread over the blankets and the top of the sheet
over this.  If the covers have  been tucked under
the mattress, set them free and to do this, without
loosening the under sheets, keep one hand grasping 
52          Nursing Methods

them  and the edge of the  mattress, raising the
latter very slightly, while you pull out the upper
covers with the other hand.  Then turn down the
covers; there are two common methods of doing
this: (i)  Grasp the upper edge of the clothes on
each side of the bed between your  thumbs  and
fingers and fold them down to the center of the
bed, draw the upper half of this fold upward,
making a double fold with the upper edge of the
clothes facing the head of the bed.   (2) At  one
side turn back the upper half of the clothes in a
triangular fold.  This will mean  that the upper
edge of the clothes will lie along  the edge of the
mattress at the side farthest from you.

              Demonstration 4

  Changing the Sheets with the Patient in Bed

  Equipment for demonstration:
  The same  as for Demonstration 3 plus two ex-
tra sheets, two nightgowns and a "patient."  The
doll may be  used for the patient, but it is very
much better  for the pupils to take turns being
patient for demonstrations of this kind. Have the
"patient" in bed.
  Procedure:
  1.  Be sure that everything necessary for the
work is at hand and arrange the table and chairs,
as in Demonstration 3, for the reception of clothes
taken from the bed. 
                Bed-Making              53

  2.  Take off the spread, fold it, and put it where
it will not get crushed.  If there are two blankets
on the bed, remove the upper one.
  3.  Loosen the bedclothes on all sides.  To do so,
raise the mattress with one hand and draw the
clothes out with the other, so as to avoid risk of
jarring the patient and tearing the clothes.
  4.  Change the top sheet.  To do this, place a
clean sheet over the blanket that  remains  on the
bed, cover this with the other blanket; turn about
ten inches of the sheet over this blanket at the top;
if the patient is not too ill she can usually be asked
to hold the upper edge of these, otherwise they can
be tucked under her shoulders or under the pillow
to retain them in place; then, standing near the
foot of the bed, pass your hand under the clean
sheet, take the covers that are to be removed near
their center and draw them out.  Never expose
the patient while doing  this.  Separate sheet and
blanket and place them  across the chairs.
  5.  Fold the sides of the blanket and top sheet
up  over the patient, leaving the  fold just long
enough to cover her if she is turned. This answers
a threefold purpose: it  gives a neat appearance;
the clothes are not in your way while you work;
it keeps the patient as warm as before the upper
blanket was removed.
  6.  Draw the patient  to one side of the bed.
  7.  Arrange the pillows. To do this:   Slip one
arm under the patient's neck and far shoulder,
letting her head rest on your arm (see Fig. 3); raise 
54          Nursing Methods

her slightly and with your free hand remove the
pillows, pulling them outward.  It is usually easier
to remove them one at a time.  Before replacing
the pillows, shake them and see that their corners
fit into those of the cases.  Do not let them rest on
the bed while doing this.  To replace them, put
them one on top of the other,  at the head of the
bed close to, but  on the far side of, the patient;
raise the patient  as when removing the pillows;
pass your free hand back of her and, taking hold
of the lower pillow, draw both pillows into place.
Arrange them so  that the patient  rests comfort-
ably.   Do not allow an unconscious or helpless pa-
tient's head to be thrown forward on the chest, for
such a position will interfere with proper breathing.
  8. Change the nightgown.   Important points
to remember when doing so are:
  (i)  When a patient is weak or helpless, if the
sleeves of the gown do not slip off readily, slip one
of your hands  through an  armhole, grasp the
patient's arm about the  elbow, and,  bending  it
slightly, draw it backward while, with your other
hand, you pull the sleeve either at the armhole or
the wrist.
  (2)  Get a weak patient's arm into the sleeve of a
gown by putting your arm through the lower open-
ing, grasping her hand, including her thumb, and
drawing the arm through the sleeve.
  (3)  If an arm is injured, remove the sleeve from
that arm last, but put the sleeve of the  clean gown
on it first. 
               Bed-Making             55

 (4)   Be sure that the gown is well pulled down
and free from creases.  If the gown opens down the
back, it is usually better, especially if the patient
is weak or helpless, not to put the lower ends under
her as they are likely to become wrinkled.
  Procedures in changing the nightgown:
  Method 1.  If the gown opens down the back,
remove one sleeve of the gown to be discarded and
put on the corresponding sleeve of the fresh one.
Slip  the fresh gown  across the chest, under the
soiled one, to prevent exposure, and change the
sleeves in the same way as the first ones.
  Method 2.  To remove a closed gown, have the
patient lie on her back with her knees flexed; pull
the gown up as far as possible, then, if the patient
is strong enough, have her raise her thighs slightly;
if she is not sufficiently strong, place one of your
hands under her buttocks and raise her while you
draw up the gown with the other hand;  raise her
shoulders if necessary.  When the gown  has been
gathered up to the shoulders, slip one of your hands
through the upper armhole of  one of the sleeves,
grasp the patient's arm  below  the elbow, bend it
slightly while, with the other hand, you draw off
the sleeve; slip the gown over the head and off the
other arm.
  The best way to put on the gown depends upon
its make.  If it is narrow at the top and does not
unbutton it can sometimes be put on most easily in
about the same manner as the soiled one was re-
moved except that the order of things is reversed; 
56          Nursing Methods

thus one arm is drawn into a sleeve, then the gown
is put over the head and the other arm drawn into
its sleeve and  the gown pulled down, raising the
patient while doing so in the same manner as when
removing the gown.
  Method 3.  If the gown is loose at the top and
the opening is a fair size, it is best put on by gather-
ing it up loosely and slipping it over the head and
then drawing  first one and then the other arm
through a sleeve.  The gown is pulled down as in
Method 2.
  9.  Sweep all crumbs from the bed on the side at
which you are  standing, using either your hand or
a folded towel. Do likewise on the other side of
the bed when  you go there to adjust the sheets.
Look for crumbs between the sheets.   This  proce-
dure should be carried out even when the sheets
are changed, for  otherwise the crumbs may  be
scattered on the mattress.
  10.  Change the under and draw sheets.  To do
so go to the side  of the bed farthest from the
patient.
  Turn back the draw sheet and protector, so that
they will be out of your way while you adjust the
under sheet, if they are  wide, turn  down their
upper ends so  that they  will not come near the
patient's face.
  Roll one side of the under sheet close  to the
patient's side.
  Gather one side of the  fresh sheet to about its
center (let it rest on a table or chair while doing so, 
               Bed-Making              57

not on the patient's bed) and place the gathered
portion next the roll of the soiled sheet.  Be sure
that the sheet is perfectly straight and that you are
leaving an equal amount to tuck in on both sides.
  Tuck in the sheet on the side at which you are
standing.
  Adjust the protector on this side.
  Treat the draw sheet in the same manner as the
under sheet with the exception of leaving it longer
at one side than the other.
  Turn the patient and draw her on to the fresh
sheets and go to the other side of the bed.
  Remove the soiled sheets.
  Stretch the under sheet until it is perfectly free
from  wrinkles and then  tuck the side  and  ends
under  the mattress in the same manner as when
making a closed bed.
  Adjust the protector on this side and treat the
draw sheet in the same manner as in Demonstra-
tion 3.
   11.  Draw the patient to the center of the bed.
   12.  Arrange the upper sheet and blankets in
position.  Have the upper edges of the blankets
under  the patient's chin and leave enough of the
sheet to turn eight inches over the blanket. Tuck
in first the top sheet and then the blankets at the
foot, being  careful to keep them, especially the
sheet, loose over the patient's feet.
  13.  Arrange the pillows so that the patient lies
comfortably.
  14.  Put on the spread.  Arrange it at the foot 
58          Nursing  Methods

and sides as when making a closed bed, but. fold it
back under the blankets at the top and turn the
sheet over it.
  (N. B.  These details should be carried out in
the order in which they are given, since, if there are
crumbs in the upper clothes, nightgown, or pillows,
they are likely to be left in the bed if these articles
are changed after the under sheets.)
  15.   Remove all soiled clothes and the appli-
ances  used for the work. Replace anything that
has been moved from its regular place.  Be sure
that the surroundings are in order and that the
"patient" is comfortable. 
CHAPTER  IV
    Preparation of a Patient for the Night

  Demonstration 5: Preparation of a patient for the night, in-
cluding rubbing the back, cleaning the teeth, and doing the hair.
How to give and remove a bedpan.

               Demonstration 5

      Preparation of a Patient for the Night

  Equipment for demonstration:
  Toilet basin containing hot water.  Soap. Hand
towel and bath towel.  Washcloth.  Tooth paste.
Toothbrush, or substitute;  a strip  of whalebone
covered at one end with absorbent cotton is an excel-
lent substitute for a toothbrush when the patient is too
ill to clean her  own teeth, because the whalebone can
be bent to follow the contour of the mouth.  Alcohol,
50 per cent.  Talcum  powder.  Either the doll or,
preferably, a pupil in bed to  act as  patient.
  Procedure:
  1.   Place a chair at the foot of the bed.
  2.   Draw the patient to the side  of the bed.
  3.   Loosen the nightgown at the neck.
  4.   Place the towel under the chin; wash and
dry the face, neck, in and around the ears.
                       59 
60          Nursing Methods

  5.  Place the towel so that one end will be under
the basin when it is placed where one of the pa-
tient's hands can rest in it.  Arrange the basin in
such position and wash her hand, squeezing water
from the cloth through the fingers.  Dry this hand
and then treat the other one in like manner.
  6.  Place the towel under the chin and clean the
teeth.  To do  this, moisten the toothbrush with
water, put some paste on it, move the brush back
and forward over the teeth, then tell the patient to
hold her teeth apart and brush from the gum down-
ward on the upper jaw and from the gum upward
on  the  lower  jaw {never brush toward the gum)
in front and at the back of the teeth. Wet the
brush as often as necessary by pouring  water over
it, letting the water run into the empty bowl.
Brush off the paste. If the patient is strong enough
to rinse her mouth and gargle her throat raise her
head and let her take a mouthful of water, lower
her head, place the small basin where it will be
convenient for her to eject  the water into  it.  If
the substitute for a toothbrush suggested with the
equipment is used, wash your hands before putting
the cotton on the whalebone and, when removing
it, do not touch it with your fingers; you can cover
it with a piece of paper and then draw it off.
  7.  Turn down  the spread and upper blanket
over the foot of the bed and chair.
  8.  Turn the sides of the remaining blanket and
upper sheet over the patient as in Demonstration
4- 
       Preparation for the Night     61

  9.  Wash and then rub with (a) alcohol, and (b)
powder the axillae, back, and hips, and any other
parts necessary for the prevention of pressure sores
or chafing.
  To wash the back:  If possible have the patient
on her side; if she is weak turn her toward you as
you can then support her with one arm while you
work.  Turn back the upper corner of the bed-
clothes enough to have them out of your way but
not  enough to expose the patient unnecessarily.
Protect the bed by putting the bath towel close to
the patient's back.  Wash first with soap and then
clear water.  Do the neck and shoulders first. Dry
each part as soon as you finish washing it.
  To rub the back: Pour a little alcohol on your
hand and rub it  on the back around the shoulders
and neck, then place your hand firmly on the skin
and move the flesh on the bone, repeat until you
have gone over the entire  back and hips; pay
special attention to any parts that look red.  Pour
a little powder on your hands and rub it over the
back; do not use much.
  10.  Shake  the  nightgown to make sure that
there are no crumbs caught in it.
  11.  Go to the side of the bed farthest from the
patient.  If there are crumbs in the bed brush them
out with  a folded towel.
  12.  Loosen the draw sheet and, if it is wrinkled,
the under sheet.  If the  under sheet has been
loosened, stretch it and tuck it under the mattress
again.  Tuck the end of the draw sheet under the 
62           Nursing Methods

mattress but leave a portion loose and move this
up against the patient's back or, if possible, some-
what under her.
  13.  Draw the patient to the center of the bed.
  14.  Go to the other side of the bed.  If there
are any crumbs, brush them off with the folded
towel.
  15.  Raise the mattress with one hand and, with
the other, draw  out  the sheets.   In turn  stretch
each sheet until it is perfectly free from wrinkles
and then tuck the free portion under the mattress.
  16.  If necessary, tighten the under sheet at the
top and bottom of the bed.
  17.  Arrange the nightgown so  that it is free
from wrinkles and fasten it.
  18.  Arrange the  upper covers in  the usual
manner.
  19.  Comb and brush  the  " patient's" hair.
To do  this:  Place a towel under the "patient's"
head and across the shoulder nearest to you. Set
the hair free, part it in the center from the forehead
to the nape  of the neck and  be sure to make the
part clear.   Comb and then brush the strand  of
hair on the side at which you are standing.  If it is
tangled, begin to comb at  the free end and, while
you are loosening the snarl, hold the hair between
the tangle and the head.  Braid this strand, be-
ginning close behind the ear;  be sure that the hair
between the part and the braid is loose enough  to
avoid pulling the hairs, but not more so.  Go  to
the other side of the bed and repeat the procedures. 
       Preparation for the Night     63

If the "patient" does not wish to have her hair
done in two braids, instead of braiding the second
strand, undo the first and dress the hair as required.
Two reasons for arranging the hair in two braids
are (i) it is more comfortable for the patient if
she has to lie on her back; (2) it is then easier to
brush and comb it and to keep it free from tangles.
  20.  Be sure that the patient is comfortable.
  21.  Remove all appliances used and tidy the
surroundings.
  22.  Make sure that the ventilation is adequate
and the temperature of the appropriate.

       To Give and Remove the Bedpan

  Another item that is usually essential in  the
preparation of a patient for the night's  rest is to
give her  a bedpan.   This procedure cannot very
well be demonstrated in class but,  some idea of
how to carry it out  can be gained from the follow-
ing description:
  If the pan is cold, warm it.  This is usually done
by letting hot water run over it.  Be sure that it is
dry before you take it to the patient.  Take with it
a cover (this is usually either double-faced rubber
or heavy washable  material), toilet paper, and, if
the patient  expects to have a defecation, a sheet
that is kept for this purpose.
  If possible, flex the patient's knees and place
her feet firmly on the bed.
  Place the  pan on  the bed near the patient. 
64          Nursing Methods

  Put your hand which is nearest the head of the
bed under the buttocks (stand, if practicable,  at
the side of the bed which will allow of this being
your left hand); raise the patient and slip the pan
into position. Make sure that it is well placed.
  If the patient expects to have a defecation put
the sheet, folded, under the upper covers, over the
patient's legs and around the sides of the bedpan
(this helps to prevent an odor permeating the bed),
and get two compresses of gauze or soft, old muslin
and a basin of hot water.
  When the patient is ready to have the pan re-
moved, if her knees  are not  flexed,  flex them;
arrange the bedcovers so that they will be out of
your way, but do not expose the patient.  If the
patient is not able to use the paper, do so for her.
Put one hand under the buttocks and raise the
patient as when giving her the pan.  It is most
important to do this  for, if you neglect it, even
when the patient can move without your help, the
pan may be jerked and some of its contents spilled.
Cover the pan at once.
  If the patient had a defecation put a compress
under the rectum  and  then wash around this part.
Use the compress placed under her for drying.
  If the defecation is  very odorous it is better to
remove the  pan before washing the patient, but,
otherwise, as the washing need only  take a few
seconds, it can be done first.
  Wash the compresses used and keep  them for
the same purpose. 
         Preparation  for the  Night      65


   Never empty a bedpan without  noting its con-
tents and if this has the slightest unusual appear-
ance empty it into a vessel in which it can be kept
tightly covered and show it to the  doctor.1
   After emptying the pan flush it  first  with cold2
and then with hot  water and  be  sure that it is
absolutely clean.

   1 Feces represents (i) the food material that has escaped diges-
tion; (2) secretions from the glands and lining membrane of the
digestive tract and associated organs; (3) bacteria that have been
in the alimentary canal and their products; thus abnormal condij
tions of digestion and of the lining of the canal and  of the liver
and pancreas  can often be ascertained  by examination of this
excreta.  The liver and pancreas manufacture secretions  neces-
sary for digestion and, therefore, if they are diseased digestion
will not be normal.
   The urine contains  the greater part of the waste products of
metabolism, except the C02,  and changes  will  occur in the
nature of these when  metabolism is defective; also, if there are
foreign substances in the blood,  such  as  medicine, toxins of
bacteria, etc., they will be eliminated chiefly  in the urine, as will
be also material normal or abnormal, thrown off by  the cells or
membrane lining the urinary  tract  (kidneys, ureters, bladder,
urethra).  Thus the physician can often obtain valuable informa-
tion regarding the patient's condition by examination of the urine.
   2 Both urine and feces contain material that is coagulated by
heat and thus if hot water is poured into the pan first the latter
will be harder to get clean and  to free from odor.
s 
CHAPTER V
      Essentials for a Patient's Comfort

  Principles involved in making  a  patient comfortable under
varying conditions, including when she is out of doors in cold
weather.  Causes and prevention of pressure sores and chafing.
Demonstration 6: Methods of making  a patient comfortable
when: (i) Lying in different positions;  (2)  sitting up in bed.
Demonstration 7: Preparing a patient to get out of bed and
making her comfortable in a chair.

  The equipment for Demonstration 6 is given on
page 82, and for Demonstration 7 on page 86.

        Essentials for a Patient's Comfort

  People,  when ill,  are,  as a  rule, more easily
irritated and worried by trifles than when they are
well, because, normal brains possess the power of
directing thought so as to restrain  any tendency
to be too easily influenced by slight annoyances,
but the conditions existing in illness will affect the
brain as well as other organs  and  it  is  just as
impossible for a brain that is in an abnormal con-
dition  to function  properly as, for examples,  a
muscle or the stomach.  Unfortunately, there are
few things worse for the brain than mental irrita-
tion and worry  and, especially as all the organs of
                        66 
 Essentials for a  Patient's Comfort 67

the body are more or less under the control of the
nervous system and their functioning thus likely
to be interfered with when this system is abnormal,
the prevention of anything that will induce mental
irritation is one of the very essential principles of
nursing.
  For this reason (i)  a sick person should not be
told anything that will be likely to annoy or worry
her; (2) her wishes should be complied with as far
as possible and, when they clash with what seems
right, the decision should be left to the doctor or
nurse;  (3) all sources of  physical irritation are to
be avoided, examples of these are:
  1.  Excessive heat or excessive cold.
  2.  Annoying noises and lights.
  3.  Lack of comfortable support with pillows,
or when being moved.
  4.  Crumbs in the bed.
  5.  Wrinkles in the sheet, nightgown, etc.
  6.  Being obliged to remain too long a time in
one position.
  7.  Weight of the bedcovers upon the feet or a
painful part.
  8.  Dampness of the bedclothes or skin.
  9.  Excessive pressure upon a part by a splint,
bandage, or other appliance.
  Pressure sores: The causes of discomfort just
mentioned, with the exception of the four first ones,
are also to be avoided because of their tendency to
induce ulceration or breaking down of tissue known
as  pressure   sores or bedsores.  They do  this 
68            Nursing Methods

because the  cells of  body tissues depend  upon
material derived from the lymph1 for their nourish-
ment and repair2 and, when the blood is not being
forced through the blood-vessels as vigorously as
under normal conditions, even slight pressure will
interfere with the flow in the small vessels of the
skin, consequently, the blood remains in the vessels
of the  area after it has lost  its nutritive supply
causing congestion  and hindering the inflow of
fresh blood.
  Crumbs and wrinkles in the sheets, etc., may not
only cause pressure, but  they  also rub  or chafe
the skin and may cause it to break, and moisture,
even such as may be present as the result of ex-
cessive perspiration, tends to help this effect.  If
the skin breaks, bacteria, which are always present,
will get into the deeper tissues of the part  and help
in its disintegration.
  The parts of  the body in which pressure sores
  1 Lymph is the name given to the fluid which passes from the
blood through the  small  blood-vessels  known  as capillaries.
Lymph contains (i) the water and food material (absorbed  from
the intestines)  which the cells need for their nourishment; (2)
the oxygen (absorbed while the blood circulates  in  the lungs)
which is required for those chemical changes in material brought
by the lymph, that give rise to heat and energy and produce the
C02  and other waste matter that passes into the lymph vessels
and blood-vessels and is carried to the lungs and kidneys to be
excreted; (3) substances manufactured in body glands and ab-
sorbed by the blood which promote the chemical changes that
occur in the tissues;  (4) substances that protect the body from
bacteria and their toxins.
  2 Material of the tissue cells is being constantly destroyed and
must be replaced by substances from the lymph. 
Fig. 8.   Changing the under sheet. 
 
 Essentials for a Patient's Comfort 69

will form most rapidly are the buttocks and over
bony prominences, such as the end of the spine,
the heels, shoulder blades, elbows, and, on children,
the back of the head.
  Chafing—i.e.,  friction—will cause breaks in the
skin very readily, even when there is no pressure,
if the skin is allowed to  remain damp.  It occurs
most frequently in parts  where two surfaces of the
body come in contact, as between the buttocks or
under the breasts.   It is most likely to occur in
stout elderly people and young children.  A similar
condition  will occur on the buttocks of infants
whose diapers are not properly attended  to, this
will be discussed in Chapter IX.
  One of the first signs that harmful pressure is
being made  upon a  part is a deep redness of the
skin. This is due to the  congestion resulting from
the interference with the circulation in the area as
described above.  There is  also likely to be pain,
especially when  the  pressure is due to a  tight  or
improperly adjusted bandage  or splint,  but the
pain does not always persist,  either because the
pressure  interferes  with the  passage of nerve-
impulses1  or because the nervous mechanism in-

  1 Sensations are perceived or  interpreted in the brain and not
at the outer surface of the  body, if, for example, a person cuts her
finger, the sensation produced is not really in the finger, but in
the brain.  A proof of this is that when either the sensory nerves
leading from (for example) a person's legs to the spinal cord, or
the fibers extending up the cord to the brain are destroyed, pain
in the legs will cease to be felt, the legs could even be amputated
without causing pain. 
 70           Nursing  Methods

 volved becomes accustomed to the stimulus and
 ceases to be affected by  it.1   Therefore, if a part
 remains red, even though there is no pain, means
 must be taken to reduce pressure.  Redness of the
 skin is also characteristic  of chafing, because irrita-
 tion of a part,  from any cause  results in dilation
 of the blood-vessels2 in the  area affected,  which
 interferes  with the flow  of  blood through  these
 vessels and congestion and, consequently, redness
 of the skin results.  Other common consequences
 of chafing are eruptions of pimples and itching of
 the skin.
  The means of preventing pressure  sores and
 chafing are:  To  protect  threatened  parts  from
 pressure and to keep the skin clean and dry.
  Excessive  bed-pressure can  be  relieved by
 changing the  patient's position frequently and by
 putting pads or rings under areas which show the
 effects of pressure and, when a  patient has to lie
for a long time in the same position, an air-mattress3
  1 Mild stimuli often cease to  be perceived after a time.  A
common example of this is the rapidity with which we cease to be
aware of an odor that we perceived on entering a room, except
when the odor is very strong.
  2 It is not always known why irritation causes dilation of blood-
vessels because local dilation can be induced in  at least three
ways, namely: (i) Depression of the walls of the vessels by chemi-
cal substances formed in the tissues when they are active; (2) de-
pression of the nerves which carry the  impulses to the blood-
vessels that keep them in a  state of contraction; (3) stimulation
of those nerves which transmit  the impulses to the blood-vessels
 that cause their dilation.
  3 A sack that when air is pumped into it assumes the shape of
 a mattress. 
 Essentials for a Patient's Comfort  7*

should be  obtained if possible, for this, if it is
properly prepared,x will yield to the weight  of the
body and thus make less pressure against it than
an ordinary mattress.
  Pressure and friction by splints and the like will
be avoided by padding the appliances and adjust-
ing them properly, this will be described in a sub-
sequent  Chapter XIV.  Of course any appliance
put on by a doctor is not to be changed without his
permission, but it must be realized that a bandage,
etc., may become too tight or too loose even when
properly applied because of increase or reduction
of inflammation in the part to which it is applied.
  The usual means employed to keep the skin in
good condition are: (i) Washing it very gently at
least twice  a day with warm water and a little pure
soap, using a  very soft  cloth  and patting, not
rubbing, red areas; (2) applying alcohol2 and, after
this has  evaporated, a little powder to all threat-
ened parts  after they have been washed and, if the
areas are very red, as often as every two or three
hours; (3) massaging the parts—this is done while
the  alcohol is evaporating.   While massaging,
keep the fingers still on the part and  move the
tissues, on  no account rub the skin either when
massaging or washing it, for doing so may break it.
  Adequate support, as stated on page 67, is very

  1 Enough air is to be  pumped into it to keep the patient from
touching the springs of the bed, but not so much that the mattress
becomes firm or inflexible.
  2 Alcohol tends to dry and harden the skin. 
72           Nursing Methods

essential for comfort when a person is ill.  It is hard
for a person who has never been ill or observed very
ill patients to realize how thorough support must
be to prevent a sense of strain and tiredness.   It
may, for example, be almost impossible for a weak
person to  lie  on her side unless pillows are so ar-
ranged  that  she  can rest  against them and,  in
almost any position, small pillows may be needed
under the curve at  the waistline.  If the legs are
flexed, support will be required under the knees
and, even  when sitting up in bed, a patient is likely
to want her legs flexed a great part of the time for
this relaxes the muscles of the abdomen and thighs.
Support may also be required to keep the patient
from slipping down in bed, this is especially likely to
be the case when she is sitting up or when her condi-
tion makes it necessary to raise the head of the bed.
  It would be quite impossible to give exact de-
scriptions  of arrangements of pillows that would be
comfortable to all patients for so much depends
upon the  patient's  condition and the size of the
pillows. The accompanying illustrations give some
idea of methods of  arrangement with the patient
in different positions.  In most of these, it will be
noticed, there is only one pillow under the head for,
except when the patient is suffering from a disease
that is associated with difficult breathing or other
condition  requiring  some special position, she,  if
very ill, is usually kept in as nearly a horizontal
position as possible  for, as will be seen in Chapter
VII, this minimizes the work of the heart.  Most 
 Essentials for a  Patient's Comfort 73

convalescent patients, however, especially during
the daytime, prefer to have a second pillow and,
X    |  T^    if-----y     ~  f  -v
   Fig. q.  Dorsal or supine position.  With Die knees raised to
 relax the tension of the abdominal muscles.

in such case, the lower one should be placed further
under the patient's shoulders than shown in Fig. 9
and the upper one in about the position shown in
this illustration.
  Fig. 10.  Prone position.  The bedclothes are folded down to
show the arrangements of the pillows.
  Fig. 9 shows the position a very ill patient will
lie in the greater part of the time when a special
one is not necessary.  In Fig. 10 the patient is lying 
74           Nursing Methods

prone with a pillow under the head and one under
the chest, such a position is sometimes necessary
after surgical operations,  otherwise, it is usually
only a temporary one, but it may afford relief to a
patient who has been lying on her back for a long
time.  In Figs,  n and  12 the pillows are placed
Fig. 11.  Lateral (side) position.
behind the patient's shoulders and thighs and a
small one under the curve at the waistline.  The
main difference in the  two illustrations is the pa-
tient's position, and they are both shown in order
to emphasize the fact that even such slight change
of position will afford relief to a patient who is rest-
less and tired of staying in bed.  In Fig. 13 the two
lower pillows are  placed obliquely, one on  each
side of the patient, with a corner fitting into the
curve of the back at the waistline and the greater
part of each pillow affording a  support for her
arms, another pillow, a small one, is placed at the
patient's back and another behind her head.   See 
Fig. 12.  Same as Fig. ii but showing different arrangement of pillows. 
 
 Essentials for a  Patient's Comfort 75

Fig. 14.  The back-rest in Fig. 13 is an adjustment
that is attached to the bed and that in Fig. 14 is a
  Fig. 13.  Patient supported in silting position when the bed
has an adjustable back-rest.
very commonly used variety,  but a chair with a
wide, flat back, placed upside down, with the upper
  Fig. 14.  Suitable arrangement of pillows wlien a sepa-
rate back-rest is used.
edge of the back and the outer edge  of the seat
resting on the mattress, as shown in Fig. 15, will 
76
Nursing  Methods
make  a fairly good  substitute.   A  large  pillow
should be placed lengthwise against the back of the
chair and the other pillows  arranged in front of
this.
   The support under the  patient's knees in  Fig.
13 is what is known as the Meinecke  non-slipping
knee brace, it has rough rubber pads on its under
surface which  inhibit its  slipping.  A pillow is
usually placed between the brace and  the patient's
thighs.  As  a  substitute for such a support,  a
folded pillow can be used and, if necessary to keep
it from slipping, it can be doubled and tied  over a
piece  of strong,  heavy,  preferably white  twine,
                          and  the ends of  the
                          twine passed through
                          interstices of the wires
                          and tied to the bars at
                          the sides of the bed on
                          a  line with  the  pillow
                          and,  if  the  patient is
                          heavy, to  a  bar  at the
                          head  of the  bed,  as
                          shown in Fig. 14.
                            A  pillow  or  brace,
                          secured in  place as just
                          described,  is  a  great
                          help  in preventing a
                          patient  slipping down
in bed  and,  sometimes, either in addition  to, or
instead of this, a brace is placed at the feet, and,
in this location,  a wooden box  such as can be
  Fig. 16.  Suitable table for use
as described on page 81. 
^ 
 
 Essentials for a Patient's Comfort 77

purchased for a few cents at any grocery store,
will  answer the  purpose.  If the box is  large
enough to extend from the patient's feet to the
foot  of the bed, it will probably not be necessary
to do anything to secure it in place, otherwise, a
small hole can be made in each side, twine passed
through these and tied to the bed as just described.
A pillow or folded pad will be needed between the
box and the patient's feet.
  A  method of supporting an injured leg is shown
in Fig.  17; the leg is resting on a padded splint,
which consists of a piece of board a little wider than
the leg and the length  of the leg from the knee to
the foot with a piece of board the size of the foot
nailed to the longer piece in position to support the
foot; the splint has a hole in each corner through
which twine is passed and the latter is tied to the
cradle.   Pillows and small pads are so arranged
that thigh and leg are well supported.  Having the
splint tied in  this way to the cradle and the leg
slightly raised allows  of  changing the patient's
position, changing the sheets, etc., without moving
the injured leg.
  The weight of the bedcovers, as  previously
stated, may be a source of discomfort to a patient.
Conditions in which this is most likely to be the
case  are: (i)  When the covers rest upon a part of
the body in which there is  pain; (2) when they rest
on the toes, as when  a patient is lying on her back
without her knees flexed; (3)  when  very  heavy
covers are used, as when the patient is sleeping out 
7*          Nursing Methods

of doors in cold weather.  There  are  supports
commonly known as bed-cradles that are put under
the covers over the part that is to be relieved from
their weight, but, if a cradle cannot be obtained,
a wooden box with two ends removed will answer
the purpose.
  When a patient is sleeping out of doors in cold
weather it is often quite a problem to  keep  her
warm  without using  excessively heavy  covers.
Some helps to doing so are: To put a hot-water
bottle or bottles in the bed (for care when filling
bags, see page  179), to provide flannelet sheets and
nightgown, instead of  cotton ones, and  to put a
large, thick, colored blanket (or two sewed together
if one large enough cannot be obtained) under the
mattress and fold its sides and lower end over the
mattress as shown in Fig. 18.  If the weight of this
blanket annoys the patient put a large  cradle or
other support under it.   This  blanket  must  be
large enough for the sides to overlap each other for
a considerable distance, its main purpose being to
prevent cold air getting under the  covers.  The
bed is made in the usual way, except that, as a rule,
the covers are tucked  under the mattress at  the
sides.
  The proper support of a patient while she takes
a drink is another item to be considered in connec-
tion with a patient's comfort. A patient who is at
all weak should not be expected to hold the glass or
drinking tube.  If a glass or tube cannot be ob-
tained from which she can drink without effort 
 
 
                        FULLY ADJUSTED.
  Fig. 18.  Arrangement cf blankets when patient is out of doors in
cold weather.
                               79 
80          Nursing Methods

while lying down she should be raised as shown in
Fig. 20.  It is to be noticed that the nurse has her
arm under the pillow.
  Amusement during convalescence  is  a very
important item to  be considered  in  connection
with a patient's comfort.  The most appropriate
form of amusement will depend, of course, upon
the invalid's age and disposition and, if convales-
cence is at all prolonged, it will have to be varied,
e.g., work, games,  and  reading.  Children  es-
pecially like to make things and it will be well for
those who may have to amuse them to purchase
one of  the many books now to be had describing
work that can be done  in bed, such  as making
paper articles, basket work, and bead work.
  Nearly everyone that is old enough likes to be
read to or to  read.  There is, however, a very
important objection to the latter form of amuse-
ment and to any kind of fine work, for a person
who has been ill for a long time, namely, strain on
the eyes.  In order to see things near at hand,
especially small things such as letters and stitches,
a change has to be made in the shape of what are
known  as the crystalline lens of the eyeballs (see
page 166) and this  change is  brought about by
very small and delicate muscles that are attached
to the lens and to the walls of the eyeballs.  These
muscles, after a person has been ill for any length
of time, are likely to be weak and, if kept in a state
of contraction (as they are when a person is read-
ing) for a long time,  they may be injured.  Also, 
Fig, IQ.  Holding glass and drinking tube while patient takes a drink. 
 
 Essentials for a Patient's Comfort 81

unless the book or work is held about on a level
with  the eyes, the muscles that rotate the eye
downward are under constant strain and this, and
the bent position in which the head is generally
kept when a book is held too low, tend to promote
congestion in the eyes.  Because of  the danger of
eyestrain, and  consequent  injury  to  sight,  a
patient who has been ill for  any length of time
should  not be  allowed  to read or sew  until the
doctor gives permission, and when she is allowed to
read, her book is to be placed where it will be nearly
enough on  a level with her eyes  to make it un-
necessary for her to  bend her head  and it should
be  supported on an  adjustable  table  or  a sub-
stitute1 so that she will not have the exertion of
holding it.
  If artificial light is necessary it should be on a
level with the top of the head or slightly higher and
should shine over the left shoulder.
  The patient should positively not  be allowed to
read or work after she becomes tired and drowsy,
for in these conditions there is a natural tendency
for the muscles of the eye to relax and prevention
of this by mental effort induces very harmful strain
upon the muscles.
  1A good substitute for a reading-table when a person is in
bed is a wooden box, the required height, with enough of both
sides removed to allow of placing the box across the patient's
thighs. The required tilt can be obtained by placing magazines
under the far edge of the book and the latter can be kept open by
driving a couple of nails into the edge of the box where the free
ends will hold the pages.
     6 
82          Nursing Methods

               Demonstration 6

Methods  of Making a Patient Comfortable in
              Different Positions

  Articles required:  i.  A bed made in the usual
manner.
  2.  An  air-ring or a substitute.   A commonly
used substitute consists of a pad made of several
thicknesses of  wadding or cotton waste stitched
between two pieces of soft, old muslin, with a hole
in the center slightly larger than the part which is
threatened with a bedsore.
  3.  Four pillows in  addition  to the two on
the bed.  Two  of  the pillows should be  small
ones.
  4.  A back-rest and a chair with a wide flat back
to use as a substitute.
  5.  A shoulder wrap.
  6.  About four yards of heavy, preferably white,
twine.
  7.  A knee support, see page 76.
  8.  A wooden box about one foot high and two
feet long.
  9.  A bed-cradle  and a  box with its two ends
removed to act as a substitute.
  It is well for the pupils to alternate being subject
for  this demonstration.
  Procedure: Make the patient comfortable, (1)
lying on her back; (2) turned on her side; (3) lying
prone; (4) sitting up in bed.  Put the  air-ring 
Fig. 20.  Supporting patient while she takes a drink. 
 
 Essentials for a  Patient's Comfort  83

properly inflated1 or a substitute under the spine
when the patient is on her back and under her hip
when she is lying on her side.  In each of the posi-
tions in which the patient is lying down place the
bed-cradle or substitute over some part of the body
and  arrange the covers over it in such a manner
that they have  a neat appearance. After placing
the patient in the sitting position take measures,
such as  described on  page  76,  to  prevent  her
slipping down in bed.
  Procedure: Arrange the articles that you  will
need for the position in which you are to place the
patient where you can reach them and in the order
in which you will require them.
  For the prone and lateral positions  turn the
patient on her side as directed on  page 41, put the
pillows in  place, and then turn the patient on or
against them as the desired position requires.
  To sit a patient up in bed, when there is no ad-
justment as shown  in Fig. 13 on the bed,2 raise
patient by passing  your arm that is nearest the
head of the bed  behind her as described on page 43;
have the patient place her hands palms downward

  1 Small bulbs can  be bought for inflating such rings, but it can
be done equally well by blowing into the valve on the side of the
ring.  Put a piece of muslin around the valve before putting it
into the mouth and be sure and close the valve before removing it
from the mouth. Just enough air is to be put into the ring to keep
the affected part off the bed; if the ring is made too taut it will
cause as much pressure as the mattress.
  2 Such a rest is raised, and, with it, the patient, by turning a
lever  provided for the purpose. 
84          Nursing Methods

on the bed and, by pressing upon them, help to lift
herself as you raise her into a sitting position.  If
she needs to be supported,  put  your other arm
across her chest and, if necessary, let her head rest
on your shoulder.  Put the wrap around her shoul-
ders and make sure that it will remain in place.
Arrange the back-rest and pillows as described and
then take means  to prevent the patient slipping
down in bed.

              Demonstration 7

Preparing a Patient to Get out of Bed and Making
    her Comfortable  in  a  Chair.  Putting her
    Back to Bed

  Important points to  be considered: When we
are well and our  minds are  occupied we are not
usually conscious of  the pressure of our clothes
unless they are uncomfortably tight, but, when a
person is ill, the nerve  stimulation caused by the
pressure of corsets and skirt bands, even though
they are not actually tight, may give rise to a sen?e
of discomfort.  For this reason, as well as to avoid
tiring the patient by unnecessary preparation, she
is, as a rule, clothed only in a nightgown, wrapper,
stockings, and slippers when she gets out of bed, if
she is not well enough to walk around.  She should
be provided with round garters but they must only
be tight enough to prevent her stockings slipping
when she steps from the bed to the chair. 
 Essentials for a  Patient's Comfort 85

  As the patient's clothing is very scanty, wraps of
some kind must usually be provided.  The most
appropriate nature and arrangement of these will
depend  upon  the temperature of the  room, but
unless the weather is very warm there should be
one to put around  the shoulders and  another to
wrap about the legs and feet.  The latter cover can
be laid  across the patient and hang loose if the
place is warm, but if it is cold, especially if the
patient  is to sit out of doors, it is well to place
the center of this wrap1 under a pillow in the seat
of the chair and the lower part of a pillow placed
against  the back of the chair, it must extend far
enough  beyond the lower end of the pillow in the
seat to be turned up over the patient's feet to her
knees and to be wrapped about her legs and tucked
under the pillows.  If the patient sits in an up-
holstered chair and pillows are not used, the wrap
is placed  in  the chair and wrapped  about the
patient  as  just  described, it should extend well
above the  waistline.   The other wrap is pinned
around  the patient's shoulders.  If the weather is
cold and the patient is out of doors, a  soft cap or
hood will also be needed and it is well to place a hot-
water bottle at her feet.
   A comfortable chair must be provided.  A good
variety is that known as a steamer chair as it has a
foot-rest.  If the chair used has no such attach-
ment, a footstool will be needed.  If the chair is
  1A colored blanket or a steamer rug will, probably, be the most
suitable kind. 
86          Nursing Methods

not upholstered, a pillow should be put in the seat
and another against the back and, if  possible, a
small one over the top in position to form a support
for the head; a pillow for this purpose will probably
be needed even with an upholstered chair.
  Placing the chair is another important point to
consider when a weak patient is to sit up out of bed,
and, naturally, the first point to be considered,
unless  there  is  someone  present  who is strong
enough  to carry the patient, is to have the chair
where she can reach it without unnecessary walk-
ing.  There may, of course, be other points  to be
considered such as  having the chair near a  win-
dow, or out of a draft.  The means of making any
such requirement comply with the first-mentioned
requisite  should be decided  before   arranging
the pillows and wraps in the chair,  unless  the
latter can  be easily moved after the patient is
in it.
  To arrange the chair so that little walking will
be required place it either parallel with the bed,
facing the head; or else at right angles with the bed
facing it, if it is near the  head, but with its back
against it, if near the foot.
  Articles required:
   I.  Bed made in the usual manner and with a
patient (preferably  a pupil) in it.
  2.  Wrapper.  It is well to provide and use, in
turn, both a closed wrapper and a kimono.
  3.  Stockings and round garters.
  4.  Chair, for demonstration it is better to use 
 Essentials for a  Patient's Comfort 87

a chair that requires to be made comfortable with
pillows.
   5.   Footstool, unless there is a foot-piece to the
chair.
   6.   Pillows, two large and one small.
   7.   Two wraps and a safety pin.
   Procedure:
   1.   Arrange the chair, i.e., put it in position, put
a wrap in the seat and against the lower part of the
back, as described on page 85,z put a pillow in the
• seat and one  against the back, but do not put the
small one for the head in place until the patient is
in the chair.
   2.   Put on the patient's wrapper.  If this is  a
closed one put it on in the same manner as a closed
nightgown; if it is a kimono pattern and the patient
is well enough let her sit up in bed and hold the
wrapper while she slips her  arms into the sleeves,
do not draw  down its skirt  until the patient gets
out of bed.  If the patient  is not well enough to
sit up, spread the kimono out on the side of the
bed, under the top covers, draw the patient over
until she lies  on its back width and put her  arms2
into the sleeves, fasten it in  front.
   3.   Draw the patient to the edge of the bed.
   4.   Put  on her stockings: to do this,  turn the
part of the stocking foot below the heel into the
   1 It is better, in demonstration, to arrange the wraps for cold
weather because there is no special point in their disposal when it
is warm.
   2 If time permits both methods of putting on a kimono and also
a closed wrapper should be demonstrated. 
88          Nursing Methods

leg of the stocking, slip the stocking foot over the
patient's foot and pull up its leg.  Put on round
garters.
  5.   Turn the bedcovers down to the foot of the
bed so that they will be out of the way.
  6.   Get the patient out of bed and place her in
the chair.  To do this, if she is well enough to take
a few steps, but needs help:  Raise her and turn
her so that her legs will be over the side of the bed.
Have her put a hand on your far shoulder, put your
arm around her waist and support her as she walks
to the chair.
  If the patient is not well enough for this exertion,
get an assistant, stand one on either side of the
patient, let one lifter put one of her arms around
the patient's waist and one under her knees while
the other  puts  one arm across her shoulders  and
the other under her thighs.  Have the patient put
an arm across  each lifter's  back and  place her
hands  firmly on their  far shoulders.  The  lifters
should stand on opposite sides of the chair while
putting the patient into it.
  7.   Arrange the wraps as already described.
  To put the patient back to bed, if she can help
herself, put your arm around her waist and have
her put her hand on your far shoulder, as when
you were helping her out of  bed.  If the  bed is a
high one, have the patient stand with her back to
it and place her hands upon it; put one arm around
her waist and one under her knees; tell her to raise
herself slightly by pressing her hands upon the bed 
Fig. 21.  Supporting patient while adjusting pillows. 
 
 Essentials for a  Patient's Comfort 89

and, as she does so, raise her on to the side of the
bed and then turn her into position.
  If the patient needs to be lifted into bed get an
assistant and, standing one on either side of the
chair, take hold of her as when lifting her out of
bed.  It is more difficult to raise the patient from
the chair than from the bed, and thus, if the pa-
tient is at all heavy, at least one of the lifters must
be quite strong.  Have the patient place her hands
very firmly upon your shoulders; straighten your
backs and take the other precautions mentioned on
page 40 before attempting to raise her.
  After the patient is  in bed, draw up the covers;
remove the wrapper in  the same manner as you
would a nightgown of similar cut, see page 55,
take  off the  stockings  by  slipping your hand
through the opening and drawing them down. 
CHAPTER VI
           Baths.   Care of the Hair

  Purposes of baths. Effects of cold, hot, and tepid baths and
how they produce these effects. What is meant by muscle tone.
Reasons for the necessity of cleansing baths.  Demonstration 8:
Giving a cleansing bath to a person in bed.  Care of the hair.
Demonstration 9: Cleaning  the  hair.  Demonstration  10 :
Washing the  hair. Demonstration n: Methods of giving  foot
baths.

  The equipment for Demonstration 8, is listed on
page  99; that for Demonstration 9, on page 107;
that for Demonstration 10, on page 108; that for
Demonstration 11, on page 111.

         The Uses and Effects of Baths

  The purposes  for which baths are most com-
monly used in the treatment of the sick are: To
cleanse the body; to stimulate the nervous system;
to lessen nervous irritability; to improve the circu-
lation of the blood; to lessen congestion; to reduce
excessive muscular contraction such as occurs in
convulsions; to cause sweating and thus rid  the
body of excess water and waste matter.
  Baths, with the exception of those used solely
for  cleansing, gain their results by the influence of
                        90 
Baths
91:
cold and heat upon the body and, though in. this
lesson only cleansing and foot baths will be dem-
onstrated,  it is well for you  to know something
of the effects of  different  external temperatures
upon the body.   To understand these,  you must
know that, just under the skin and in the muscles,
there are millions of nerve  endings which are the
termination of what are known as afferent1 nerve
fibers2 that extend to what are termed nerve centers3
in the spinal cord and  brain,  where they connect
with other neurones (efferent)4 which extend out-
ward to the muscles, and to blood-vessels, and to
glands, and other internal  organs.  Some of the
afferent nerve endings  in the skin are stimulated
by heat, others by cold,  others by pressure; endings
of afferent nerves in the muscles are stimulated by
the moving of the muscles and by chemical sub-
stances formed in the tissues as the result of their

  1 From the Latin ad  = to, and f erro = to carry =  to carry to.
  2 Groups of cell bodies and their uncovered processes form what
is known as the gray matter of the brain and cord.  Some of the
processes are short and branching and are known as dendrites,
others are straight and long, these are called axons.  Many of the
axons extend out beyond the  brain and cord to all parts of the
body and those which do so are  covered  with a  sheath. The
covered axons are known as  nerve fibers.  A bundle of nerve
fibers is called a nerve.  A cell body and its processes is called a
neurone or a nerve cell.  The cell body is sometimes likened to the
chemical battery and  the fibers to  the wires of  an electrical
apparatus.
  3 Masses of gray matter that are the origin of fibers over which
impulses pass to and from an organ and help to control its func-
tioning are termed nerve centers.
  * From the Latin ef  = out and f erro = to carry  =  to carry out. ■ 
92           Nursing Methods
activity; the optic nerve endings in the eyes are
stimulated by light, those in the ears by the vibra-
tions that we call sound, those in the nose by cer-
tain volatile substances, those in the tongue  by
compounds  that are bitter, sour, salty, or sweet.
When the nerve endings in the head are stimulated
impulses1 pass  to the brain; when  those in other
parts of the body are stimulated impulses pass to
the spinal cord  and, sometimes, up the cord to the
brain.  In the  cord  and brain the impulses pass
over to the  efferent fibers and along these to the
blood-vessels,  muscles,  etc.,  and these impulses
make muscle tissue  contract  or, if they pass to
glandular organs, they make the cells of the glands
secrete; an example of this is the flow of saliva that
is  induced when the nerve endings in  the  nose
(olfactory or sense of smell) and in the tongue are
stimulated by  the pleasant aroma and  flavor of
food.  Constantly, day and night, but,  of course,
to a much greater extent in the daytime when the
muscles are active, there are impulses passing from
the periphery (outer part) of the body to the brain
and cord  and efferent impulses (aroused by the
afferent ones) are as constantly coming out. These
impulses  help to maintain the muscles in a condi-
tion of slight contraction that is known as  tone.
This tone is very important for the well-being of

  1 The  nature of  nerve impulses,  the changes they induce in
nerve centers, and the reason for their results are unknown, but,
it is believed, every  impulse leaves some trace and it is such traces
that constitute our  memories and the basis for habits. 
Fig. 22.  Arrangement of wraps to keep a patient warm when she is in a chair. 
 
Baths
93
the body, for examples: (i) Tone is necessary for
the prompt  and smooth action of the skeletal
muscles  (the muscles covering the skeleton  and
moving the bones); (2) it is essential for the circula-
tion of the blood for, if the tone of the muscle tissue
in the blood-vessels is diminished, the vessels re-
lax and cannot then force the blood through the
body properly, in fact, if their tone is greatly de-
creased, death will result; (3) tone is necessary for
the normal action of internal organs that contain
muscle tissue,  as  the heart, stomach, intestine,
and bladder.  One very bad result of imperfect
action of the stomach and intestines is that food
remains  in these organs too long and  there,  es-
pecially  in  the intestines,  undergoes chemical
changes  which produce substances  that are very
injurious to  the body.  It is usually such sub-
stances that  are chiefly responsible for the head-
ache, sleepiness, and other indispositions that are
associated with constipation.
  Lack of muscle  tone is  common whenever ill
health exists  and,  ordinarily, exercise and cold
baths tend to increase it and warm and hot baths
to reduce it.  It is chiefly because of the influence
of baths upon this very  important body phe-
nomena—muscle tone—that  this  digression  from
the main subject of the chapter has been made.
  Action of cold baths: Cold stimulates the end-
ings of nerve fibers in the skin that are known as
cold-spots and impulses then go over the fibers to
centers in the cord and brain in which the impulses 
94          Nursing Methods

are transmitted to the muscles and to the muscle
tissue of the superficial blood-vessels.  These im-
pulses cause muscular contraction and drive much
of the blood from the surface of the body to the
deeper muscles and internal organs and this in-
creases the chemical reactions that yield heat and
energy to the body.  When a healthy person leaves
the bath, or, even while in it, if exercise is taken, as
when swimming, the  increased heat produced in
the system  induces certain reaction1 effects and
blood is  forced to the skin which  then becomes
warm and red, and, because there is more blood in
the skin, there is more  heat lost from the body2
and a rise of temperature from the increased heat
production is prevented,  in fact,  if  the  person
has fever, her temperature may be considerably
lowered by a cold bath.
  A cold bath will also stimulate the portions of
the brain that control thought —how many of you
have splashed cold water  on your face when you
have  wanted  to  study after you  have become
sleepy?   As cold stimulates the brain, cold baths
should not be taken at bed time by a person who
does not go  to sleep easily.
  Because  cold has these effects the practice of
  1 By  reaction is meant action in a contrary direction to that in
which advance has already been made.  The physiological processes
involved in the reaction to cold are only imperfectly understood
and space will not permit of giving the theories; pupils interested,
however, will find them under Heat Regulation in almost any
book of physiology.
  2 This will be further discussed in Chapter VII. 
Baths
95
taking a cold bath daily tends to render a person
sturdy and vigorous for, to summarize, a cold bath
acts as a nerve stimulant, it improves muscle tone
and the circulation  of the blood and, by these
actions, it increases  the chemical reactions upon
which the body's nutrition  depends and facilitates
the removal of waste matter from the body through
the bowels, kidneys, and lungs.  Also, a daily cold
bath  lessens a tendency to "taking cold" easily
because (i) congestion of the throat and surround-
ing parts  is likely to result from chilling of the
body when reaction does not follow and the results
of  this condition  favor the  development of the
bacteria that cause colds; (2) reaction to cold does
not occur readily until the body is trained  to  re-
spond to this stimulus (cold) in the right way.  For
all activities of the body that involve coordination
of a number of organs are only  carried out per-
fectly after some kind of pathway (the nature of
which is unknown) is formed through nerve cen-
ters, and  such a pathway,  whether it is for abso-
lutely involuntary activity (as  the response  to
cold)  or for voluntary acts {e.g., learning to swim),
is made only by repetition. Therefore, the person
who is  not accustomed to cold baths is likely to
shiver for quite  a time after such a bath or when
exposed to cold air, and will not have the pleasant
sensation  of glow, warmth, exhilaration, and mental
stimulation that cold gives a  person in  whose
nerve centers the proper pathways  have been
formed. 
96          Nursing Methods

  There is, however, a certain amount of danger
in the use of cold baths when people are ill, because
ill health often prevents reaction,  and thus cold
baths should only be given to  the sick by those
who have been trained to observe and understand
symptoms.
  Action of hot baths: A hot bath {i.e., one with a
temperature that  is  more than a  few degrees
higher than the normal temperature  of the body,
usually between  1030 and 1120  F.) will cause (1)
free  perspiration;  (2)  muscular relaxation;  (3)
dilation of  blood-vessels; especially those of  the
skin,  and,  consequently,  the flow of an extra
amount of blood to the surface  of the body, and
(4) as a result of the increased amount of blood at
the surface, lessening of congestion if this condi-
tion exists.   Congestion in internal organs can be
relieved even by hot baths that involve but a small
portion of the  body such as the feet,  and for this
reason hot  foot baths are often given  to relieve
congestion of the throat, lungs, or  other internal
organs.
  The effects produced by hot baths are of value
in many diseases but, even more readily than cold
baths, they may also have very bad effects and, for
this reason, they should only be given to a sick
person by someone who understands the symptoms
that may arise.
  The chief uses of  hot baths by healthy people
are: (1) For cleansing; (2) to lessen congestion in
the uterus  during menstruation, or that following 
Baths
97
chilling of the body.  In the latter case a hot bath
may,  by  relieving conditions  favorable  to the
action of bacteria, prevent a cold.  An important
point to remember after taking a hot bath for such
purposes  is that it  is necessary  to keep warm,
because exposure to cold air, by promoting  rapid
evaporation of the sweat, may chill the body and
increase the internal congestion.
   Hot baths should not be taken frequently except
when they are necessary for therapeutic purposes
for they cause exactly the opposite effects of cold
baths and these, it can be realized from what has
been said, are not conducive to health.  When they
are taken for cleansing they should be followed by
a cold plunge or spray.
   Action of warm baths:  A warm bath  {i.e., one
with a temperature about 990 F.) is ordinarily the
 best  for a cleansing bath and also to lessen fatigue,
 either muscular or mental. For the latter purpose
 it is customary to remain lying quietly in the bath
 for some time, about thirty minutes.  The reason
 for this is that, if the bathroom is quiet and dark,
 and  the water about the same temperature  as the
 skin, the stimulation  of superficial nerve endings
 will  be lessened and consequently the amount of
 impulses  passing  into  nerve  centers much de-
 creased and thus the latter have a chance to re-
 cuperate. As fewer nerve impulses pass into the
 centers,  fewer come out and  the  muscles become

   Taking baths of this kind before going to bed is 
98           Nursing Methods

often advisable while one is subjected to unusual
mental strain of any kind, but a cold bath should
be taken in the morning to counteract the effects of
the warm one upon  muscle tone.

                Cleansing Baths

  Baths are necessary, even when  a person re-
mains in  bed all day  and  does not look dirty,
because (i) the perspiration and sebaceous matter1
discharged upon the  surface of the skin from glands
in its deeper layer contain organic substances that,
if allowed to remain, decompose and give rise to an
unpleasant odor and are conducive to irritation of
the skin and chafing; (2)  bathing stimulates the
circulation of blood in the skin and thus aids in the
various  functions of the latter and lessens any
existing tendency to  the formation of  pressure
sores; (3)  a bath is  refreshing to the majority of
people who  must remain in bed.
  If possible a  patient should be  bathed daily,
preferably  about  an  hour after   breakfast  or
shortly before she is ready to go to sleep at night.
A bath should not be given  within about an  hour
after a meal, because, if given properly, it will, for
reasons  that have been already mentioned, cause
an influx  of extra blood to  the skin and  thereby
  1 The sebaceous matter or sebum consists chiefly of oily sub-
stances which serve: (1) To keep the skin soft and pliable; (2)
to prevent the  too rapid evaporation of perspiration; (3) to pro-
tect the skin from injury by excessive humidity or dryness of the
atmosphere. 
Fig. 23.   Helping a patient get into bed. 
 
Baths                 99
lessen the amount in the stomach and intestines
at a time when it is needed by the glands in these
organs for the manufacture of the juices required
for digestion.

               Demonstration 8

   Giving a Cleansing Bath to a Person in JJed

  Equipment: The doll in bed.  A cotton blanket.
Something to protect the  bed,  for  examples,  a
large  bath towel, folded sheet, or pad.  A bath
towel, face towel, and washcloth.  A foot-tub and a
basin each about one third full of water, the water
in the basin should be about no° F., that in the
tub somewhat warmer, about 1150 F., to allow for
cooling.  Manicure utensils.
  Procedure:  1.  See that the window is closed
and that the room is warm.
  2.  Collect  your equipment and  arrange  the
articles where you can reach them easily  as you
require them.
  3.  Put two chairs near the foot of  the bed.
  4.  Replace the top bedcovers with the cotton
blanket.  To do this, if the bath is given before the
bed has been made, remove the spread, fold it, and
place it where  it will not  get crushed.   Fold  the
blanket in four and place it across the patient's
chest with its ends facing her head. If the patient
is well enough she can generally be asked to hold
the lower end,  if she is not, tuck this end firmly 
ioo          Nursing Methods

under her shoulders or the pillow.  Then take the
upper end between your third and fourth fingers,
on either side of, and a little beyond, the patient.
Put your other fingers under the covers and your
thumb on top and draw the covers down over the
foot of the bed  and across the backs of the chairs.
As the blanket  is between your fingers it is drawn
QT'er';the patient at the same time as the covers are
removed, loosen your hold of it as soon as it covers
the feet.   Raise the foot of  the mattress and pull
out the covers and separate them so that they will
air while the bath is being given.
  If the bed has been made it will not be necessary
to remove the  spread but, so  that  it will not be
crushed, it is well to fold the covers neatly down to
the foot of the  bed.  A method that, after a little
practice,  allows of this  being  done very quickly
and deftly is as follows: Place  the blanket, and
take hold of it and the covers, as described in the
preceding paragraph, make a  fold  in the covers
about  twelve to fourteen  inches deep, then, still
holding the blanket,  and with your  thumb on top
of the covers, pass your free fingers under the upper
edge of the fold and  make a second fold.  Repeat
the procedure until the clothes are as far down as
possible to have them without loosening them at
the corners, then,  either leave  them folded1 and,
if they are not below the patient's  feet,  raise the

  1 The covers are  usually left folded if the bed has been made
recently but, otherwise, it is well to draw the folds out over a
chair as this allows the sheet to air. 
Baths
IOI
latter over the fold, or else draw out the folds, and
bring as much of the  covers over the backs ot the
Fig. 24.  Replacing bedcovers with blanket.
chairs as possible without disturbing them at the
foot and corners of the mattress.
  5.  Draw the patient to the side of the bed.
  6.  Remove the nightgown.
  7.  Proceed with the bath, washing in following
order: Face,  ears, neck, arms, hands, chest, ab-
domen,  back, thighs, legs, feet, pubic region.  Put
the protector under each part before you wash it.
While working remember the following points:
  (a) Make firm pressure.
  (b) Expose only the part that you are washing
at the time, and  even this much exposure is not
usually  necessary.
  (c) After washing a part, dry it before going
farther. 
 102         Nursing Methods

  (d) Wash and dry the ears, between the fingers
and toes, the axilla, and pubic region particularly
well.
  (e)  Use the water in the basin for the face, neck,
arms, and hands.
  (f)  Before washing a hand place the towel and
(on this) basin under it, then soak the washcloth
with water and squeeze the water through the
fingers;  repeat this procedure  after washing the
hand  with soap and then place the hand on the
towel, remove the basin, and dry the hand.  Treat
the other hand in like manner.
  (g)  If the knees can be flexed and there is no
reason why the feet cannot remain in water for a
few minutes, put them into the tub before begin-
ning to  wash the thighs and legs.  To do this:
Flex the patient's knees, put the tub on the side of
the bed near the feet, under the blanket;  place
your arm that is nearest the foot of the bed across
the tub—see  Fig.  26—this prevents the blanket
getting into the water; put your free arm under
the patient's legs and your  hand under her heels;
raise  the  legs  and feet; draw the tub  under
them  and lower  them  into the  water.   (This,
like the  rest of  the bath, can be done under the
blanket.)
  To  remove the feet: Fold the bath towel and
place it on the bed at the far side of the tub; take
hold of the feet and tub as before; raise the feet,
hold them over the tub for a few seconds until the
water stops dripping from them, place them on the 
Fig. 25.   Washing the hair. 
 
Baths                103
towel; remove the blanket from above  the tub;
take the tub from the bed; dry the legs and feet.
  (h) Turn the patient on her side before washing
her back.
  8.  Cut and clean the finger and toe nails if neces-
sary.   Have  a towel under them while you are
doing so.
  9.  Remove the upper blanket.  To do so, take
hold of the  upper edges of the bedcovers,  draw
them up to the foot of the bed, then include the
lower end of  the blanket in your grasp and draw
clothes and blanket upward, take out the blanket.
  10.  Put on the nightgown.
  11.  Remove all your equipment and put chairs,
etc.,  in place.

  Important points to remember when a conval-
escent patient takes a tub bath:
  1.   If a patient has been very ill she should not
be allowed to take a tub bath before convalescence
is well advanced without the doctor's permission.
  2.   See that the bathroom is warm before the
patient goes to it.
  3.   Be sure that the patient has everything that
she needs for her bath—bath towel, face towel,
washcloth, nailbrush,  soap, clean  clothing  if
necessary.
  4.   Fill the tub half-full of water about 960 F.,
usually not hotter.  Let the cold water  run into
the tub at the same time as the hot.  Never run the
hot water in  first, especially when preparing the 
 104          Nursing  Methods

 bath for a child, for this has been the cause of many
 accidents.
   5.   Do not allow the patient to lock the door nor
 leave her long  alone without  speaking  to  her  to
 ascerstain that she is all right.
   6.   If,  for any reason other than therapeutic
 purposes, the bath water is above 960 F., do not
 let the patient remain in it longer than ten minutes.
 For reason see page  97.
   7.  As soon as the patient leaves the bathroom,
 wash the tub and tidy the room.

                 Care of the Hair

   During and after  an illness of any  severity the
 hair is likely to fall out and the scalp to become
 covered  with dandruff, and these conditions are
 favored by lack of care of the hair and scalp.
   Dandruff  consists  of dried sebaceous matter or
 sebum and cells1 that have become separated from
 the scalp. The sebum is  a fatty substance that is
 secreted by  small glands similar  to  those in the
  1 The skin, including the scalp, consists of two layers, a thin
outer layer (known  as the epidermis or cuticle) consisting of dry
flattened cells that have  been pushed forward from the under
layer (the derma) where the production of new cells is constantly
taking place.  The outer cells of the  epidermis are being con-
stantly rubbed  off,  but, except  those of the scalp, they are so
minute that, ordinarily, they are not visible. Even those of the
scalp, when the latter is in a healthy condition and kept clean, are
hardly discernible.  The discharge of these cells, however, be-
comes  excessive when  conditions arise that interfere with the
 circulation of blood in the derma, 
               Care of the  Hair          105

skin of other parts of the body.  The glands dis-
charge their secretion into what is known as the
hair-follicles (small pockets or  inversions in the
derma1 in which the roots of the hair are situated)
and it passes out along  the  shafts of the hairs.1
It serves, when not in excess, to keep the hair soft
and pliable, but excessive secretion and the pres-
ence  of  dandruff  are  nearly always  associated
with falling of the hair.2  The reasons for the ex-
cessive secretion are not always discoverable and
some  physicians  consider that  some as yet un-
known  microorganisms  may be  sometimes the
active cause.  But, whatever the underlying cause
of  both the  excessive secretion  of  sebum  and
shedding of cells that give rise to dandruff and the
falling of hair, they are favored  by inefficient cir-
culation of the blood in the scalp.   Common causes
of poor circulation are: A thin, tight scalp; nervous-
  1A hair consists  of a small  bulbous  portion, known as the
root, and a straight extension, called the  shaft. There are three
layers to a hair, an outer one consisting of flat cells that overlap
each other like the tiling of a roof, a middle portion consisting
chiefly of elongated cells and of pigment to which the color of the
hair is due, and an inner layer of practically spherical cells. The
cells of the shaft grow out from the root and the root absorbs
nourishment from the lymph that comes from the blood-vessels
in the derma.
  The hairs, as can be seen from the above  description, are not
tubes, as is very commonly supposed, and thus there is no founda-
tion for the very prevalent idea that the ends of the hair should be
singed  after being cut to prevent the escape of oil and nutrient
material.
  2 It is probably the conditions producing the dandruff, rather
than the dandruff, that causes the hair to fall. 
106         Nursing Methods

ness;  general  ill  health;  wearing tightly  fitting
hats.   Conditions and treatments that favor free
circulation of blood in the scalp and, consequently
the nutrition of the hair, are: A thick, loose scalp,
brushing the hair thoroughly at least once daily;
massaging the scalp  and keeping it clean.  Some
physicians say that tonics are valueless and others
that certain ones are of use, especially those  con-
taining substances that promote a mild, temporary
irritation of the scalp and thus increase the amount
of blood around the roots of the hairs for, when
any part is irritated, more blood goes to it; this can
be seen by the redness that follows rubbing the
skin.  Also, tonics are of value because their use is
associated with  massage, and the alcohol which
they nearly all contain helps to  clean the scalp.
Care of the hair is particularly important when a
person is ill, but is very commonly neglected for
fear of tiring the patient. As a matter of fact, if
the hair is braided properly in two braids, as de-
scribed on page 62, its care will necessitate  very-
little, if any,  fatigue for the patient.   The  care
should consist in a daily, thorough brushing and
moving the scalp by placing the fingers firmly
upon  it and, keeping them in one place for a few
seconds, while moving the scalp back and forth in
all directions,  then moving them to another part
and repeating  the procedure until all the scalp has
been treated.  If the hair becomes oily it should be
either washed  or given what is sometimes called a
dry cleansing.  The latter is far less tiring  than a 
              Care of the Hair          107

regular shampoo.  Do not use a fine-toothed comb
to remove dandruff, for it only does so temporarily
and the pointed prongs scratch the scalp and may
cause harmful irritation.


                Demonstration 9

                Cleaning the Hair

   Articles  required: 1.  Orris  root,  about  one
tablespoonful tied in a small piece of gauze.
   2.   A hair lotion,1 about J^  ounce in a small
glass.
   3.   A medicine dropper.
   4.   A comb and a brush with stiff bristles.
   5.   A little absorbent cotton.
   6.   Two towels and a safety pin.
   Procedure:  1.   Put  one  towel under the pa-
tient's head and pin the other around her neck.
   1 A hair lotion commonly used in hospitals when the physician
does not prescribe a special tonic is as follows:
             R Sodium bicarbonate 150 gm.
              Ext. witch hazel]
              Alcohol 95%   j> a.a. 835 c.c.
              Water        J
This quantity is, of course, for the stock solution; only about
2 3 are used at a time, being poured when needed into a small
glass.
  If there is dandruff the following prescription is sometimes
substituted:
                 Resorcin 10 gm.
                 Alcohol 95% 40 c.c.
                 Water 50 c.c. 
 108        Nursing Methods

  2.  Undo one braid.
  3.  Separate a strand of hair, brush it well and
 then pat it on both sides, and also the scalp around
 it, with the sack of orris root.  Place this strand
 where it will not get mixed with the remainder of
 the hair, separate  another strand and repeat the
 procedure, do this until all the unbraided hair has
 been so treated. Then put a thin layer of absorb-
 ent cotton over the brush and press it in with the
 comb, brush a strand of hair with this (it takes up
 the orris root and with it oily matter that was on
 the hair); fill the medicine dropper with lotion and
 run it along the scalp (squeezing the lotion from it
 at the same time), where the orris has been re-
 moved. Take another strand  of hair and repeat
 the procedure, do this until all the unbraided hair
 has been  treated.   Then rebraid this.   If  the
 patient is tired leave the other braid until later or
 even the next day; if she is not too tired, turn her
 head and repeat the procedure.

              Demonstration 10

    Washing the Hair with the Patient in Bed

  Equipment:  1.  Two small  rubbers, pieces of
old blanket, paper, or bath towels may be  sub-
stituted.
  2.  A piece of rubber about a yard wide and long
enough to  cover the pillow and extend into a basin
or foot-tub placed on a chair at the side of the bed. 
Care  of the  Hair          109
  3.   Three face towels and one bath towel.
  4.   A safety pin.
  5.   A quart pitcher of hot soap solution (about
1 io° F.), any good soap can be used, but the liquid
green soap used in surgery for cleaning the skin is
particularly  good, it can be bought at any drug
store.  Enough soap should be used to make a good
lather.
  6.   A large pitcher of water about I io° F.
  7.   Something to protect the table if it is likely
to be injured by the hot pitchers—a towel or paper
will answer the purpose.
  Procedure:
  Arrange the equipment: Put a protector on the
table under  the pitchers, place the foot-tub on a
chair or stool near the head of  the bed at the side
at which you will stand  while washing the hair,
hang one face towel where you  can reach it easily.
  Draw the patient to the side of the bed and turn
her on her side with her back toward you.
  Loosen  her nightgown  at the neck and turn it
down.
  Double a  towel over one edge of a rubber, put
these around the  neck and pin the towel in such
fashion that it will hold the rubber in place.
  Move the top  pillow from under, but just in
front of, the patient's head.
  Cover a small rubber with the  bath towel and
this with the large rubber arranging the latter so
that it will extend  about  twelve inches above,
below, and in front of the patient's head. 
 no         Nursing  Methods

  Put these under the patient's head with the small
 rubber undermost and covering the pillows; roll up
 both sides of the large rubber so that it forms a
 trough with one roll under the patient's neck, have
 one end covering the near portion of the  pillow
 which was moved, and which serves as a wall for
 the trough, and the other hanging free over the
 side of the bed.
  Put  one  corner of  a  face  towel  between the
 patient's face and the  roll of rubber and leave the
 rest of it free to wipe her face with, if necessary,
 during the shampoo.
  Undo the hair and spread it out in the trough.
  Draw the chair with the tub into position and
 put the free end of the trough rubber into this.
  Pour the soap  solution  slowly over the head;
 turning the latter as required, rub the soap into
 the scalp and through the hair as you proceed and,
occasionally, discontinue pouring  while you rub
 the scalp.  When the soap solution is finished,
pour some of the water from the large pitcher into
 the small one—as the latter is more easily handled
 —and pour this over the head, rubbing the latter
with one hand as you do so.
  When the soap has all been removed, squeeze
 the water from the hair, wipe the patient's face,
neck, and ears with the towel that you placed under
her face, moving back the rubber at this  point
when you take away the towel; gather the hair into
 the towel, remove the trough rubber, letting  it
 down into the foot-tub. 
Care of the Hair          111
  The patient's head is then on the bath towel.
Dry the hair with this and the face towel.
  When the hair is as dry as you can get it, unpin
the towel that is around the  patient's neck, re-
move this and the rubber and use the former to
replace the bath towel unless it is wet; in such case,
use the towel that yo,u hung at the top of the bed.
  Fasten the nightgown, place your patient in  a
comfortable position,  spread out her hair to dry.
Fan it.
  Put everything around the bed in order and re-
move your equipment.

                  Foot Baths

  As  previously stated  a foot bath is very fre-
quently used  to relieve  congestion.   It does  so
because, by  dilating the blood-vessels  in the feet
and legs, it increases the amount of blood in these
parts and, therefore, of course, lessens the amount
in other parts.  Mustard is sometimes added  to
the water, because, by  its irritant  action, it in-
creases the effects of the  heat.

              Demonstration n

Giving a Foot Bath to a Patient (i) in Bed; (2)
                  Out of Bed

  Equipment: 1. A foot-tub half full of  water,
usually uo° or 115° F.
  2.  A bath blanket. 
n2         Nursing Methods
  3.  A bath towel.
  4.  A face towel.
  5.  A covered hot-water bag.
  6.  A bath thermometer.
  7.  Mustard dissolved in  cold water.  For an
adult, one  tablespoonful and,  for a child, half a
tablespoonful for each gallon (four quarts) of water.

  Procedure when the patient is in bed:
  Loosen the upper bedcovers at the foot of the
bed.
  Double the  bath blanket  lengthwise and then
fold it in four with the two ends one on each side
of the central fold.
  Place this across the foot of  the bed, under the
loosened covers  with the ends toward the foot.
Stand near the foot of the bed, take the upper fold
of blanket between your third  and fourth fingers
and the bedcovers between your other fingers and
thumbs and turn the covers back to  above the
knees, carrying up the blanket over the legs at the
same time.
  Add the  dissolved mustard to the water in the
bath.   The reason why it should  not  be added
sooner will be found on page  183.
  Flex the patient's knees.
  Turn back the lower portion of the blanket so
that it will cover the part of the bed on  which the
tub is to rest.
  Place the tub on the bed, near the feet over the
lower fold of blanket. 
Care of the Hair          "3
  Put your arm that is nearest the head of the bed
under the patient's legs and your hand under her
heels.
  Put your other arm across  the tub, grasping it
on the far side, and move it forward into position
while, at the same time, you raise the patient's feet
  Fig. 26.  Foot bath.  The blanket has been drawn up to show
the manner of holding the feet while putting them into the tub,
ordinarily they should not be exposed.
and legs from the bed.  This is done under the top
layer of  blanket, the arm being kept across the
tub to prevent the blanket getting into the water.
  Before lowering the feet into the water, tell the
patient that it is hot, but that it cannot possibly
burn her. Put the feet in slowly and, if the patient
objects to the heat, raise and lower them alter-
nately for a short time until she becomes accus-
tomed to it.
  Put the edge  of  a  folded towel between the
     8 
114         Nursing Methods

patient's legs and the rim of tub; be sure that it is
not near the water.
  Take hold of the upper edge of the blanket and
hold it in position, while with your other hand you
draw down the covers.
  Roll the hot-water  bag in  the bath towel
(to warm the latter)   and place  it  under  the
covers.
  The feet are kept in the water for from twenty
to thirty minutes.  If it is necessary to raise the
temperature of the water, bring some water that is
about 1500 F., in a pitcher, and pour it in slowly,
keeping your hand between the patient's legs and
the stream. This can be done without  uncovering
the tub except at the point where you are pouring
in the water.
  To  remove the  tub:  Turn  the bedcovers back
above the knees, but leave the blanket covering
the legs.  Take the bath towel from the hot-water
bag and place it on the far side of the  tub. Take
the towel from behind the patient's legs.
  Put your arm under the legs as when putting
them  in the tub, raise  them from the water and
hold them over the tub for a few seconds, that the
water may drain from them, then put one side of
the layer of blanket  that is covering them around
them and lower the feet on the bath towel.
  Remove the tub.  Dry the feet and then remove
the blanket from underneath them.
  Put the hot-water bag at the feet.
   Draw down the  covers and, with them, the 
Care of the Hair         115
blanket.  Remove the latter and tuck the covers
under the mattress as usual.
  Procedure when the patient is not in bed:
  Provide a comfortable chair and over the outer
edge of the seat and the floor spread a heavy
colored blanket.
  Have the patient sit on the chair,  remove her
shoes and stockings and turn her skirts up above
her knees.
  Put the tub in position, place the patient's feet
in the water and envelop her legs and the tub with
the blanket.
  Add hot water, if necessary, in the same manner
as when the bath is given in bed.
  After about twenty minutes, remove the  bath
and dry the feet thoroughly. 
CHAPTER VII
Temperature.  Pulse.  Respiration.   Records

  Heat production, elimination, and regulation. Fever. Nature
and care of thermometers.  Demonstration 12: Procedure in
taking the temperature.  The nature of the pulse.  Conditions
that cause changes in the rate and character of the pulse.  The
nature of respiration and of breathing.  Factors controlling these
functions.  Demonstration 13: Counting the pulse and breathing.
Some important reasons for keeping records of a patient's con-
dition. Nature of records.

  The equipment for Demonstration 12 is listed on
page 125 and that for Demonstration 13 on page 136.

                Heat Regulation

  Temperature  has been denned as  the  degree of
hotness of a  body measured by a chosen standard.
  In referring to  measurements of heat two ex-
pressions are  used, viz., amount and degree.   An
example of the difference between the two measure-
ments is as  follows: The temperature  of eight
ounces of boiling water is the same as that of two
thousand ounces of boiling  water, but there is a
much larger amount of heat in the vessel holding
the two thousand  ounces than in  that containing
the eight ounces.  The degree of heat is ascertained
                       116 
               Temperature            117

with a thermometer and recorded in degrees; the
amount of heat is ascertained by the use of a calori-
meter and recorded in calories.  Unfortunately,
two standards are used and expressed in terms of
calories.  In Physics, the calory is said to be the
amount  of heat necessary to raise the temperature
of a gram of water one degree centigrade and in
Physiology and  Dietetics a Calory is considered
as the amount of heat required to raise the temperature
of a kilogram of water one degree centigrade.  The
former is sometimes termed the small calory and
the latter the large calory and a capital C is  com-
monly used when the large Calory is referred to.
   The amount of heat produced  in  the human
body varies considerably under different  circum-
stances,  but,  nevertheless, there  is very  little
fluctuation in the degree of heat (commonly desig-
nated the  temperature) of a healthy individual.
The reason for this is that the body is provided
with a mechanism to control the rate of heat pro-
duction and elimination.  The details of the action
of this mechanism  are  as yet but  imperfectly
understood but, experiments seem to show, that
there are small masses of gray matter in the brain
that are influenced by the temperature of the blood
as it passes through them and, as the result of this
influence, send impulses to nerve centers control-
ling  organs that influence heat production and
elimination.  The portions of  gray  matter  that
are affected by the temperature of the blood are
termed heat regulating centers, 
118          Nursing  Methods

  Heat is produced chiefly in the muscles as the
result of the oxidationl of substances derived from
food.  The amount  of material oxidized  depends
largely upon the amount of muscular contraction
that occurs and thus  oxidation  goes on  more
rapidly and, consequently, more heat is produced
when a person  is active, than when at rest, and
convulsions, which  consist of intense muscular
contraction may cause  a very  excessive rise of
temperature.   The underlying reasons for the in-
crease of oxidation by muscular contractions are
unknown.  Very  important  requisites   for the
maintenance of oxidation in the tissues are certain
chemical   substances manufactured  by  special
glands and brought to  the tissues  by the blood.
Thus, it may be said, that the chief requisites for
the maintenance of body heat are food, oxygen, and
chemical  substances that promote oxidation, and
the rate  of oxidation is  chiefly dependent  upon
the amount of muscular contraction that occurs.2
Other less important sources of body heat are:

  1 The union of oxygen with matter. When oxygen unites with a
compound it decomposes it into simpler substances and liberates
the energy (power to do work) that held its molecules together.
Some of this energy is manifest in the form of heat.  The muscles,
heart, and lungs and other organs of the body are just as depen-
dent upon the energy thus liberated for their power to do work as
the machinery of a ship is upon the  energy liberated from the
coal burned in its furnace. When oxidation takes place rapidly
enough to induce fire it is spoken of as burning or combustion.
  2 Some physiologists consider that  there may be  differences
either in the amount or nature of the chemical substances pro-
moting oxidation that also determine  the rate of its occurrence. 
               Temperature            119

The friction within the body caused by the move-
ments of the muscles, circulation of the blood, and
other internal activities; the hot foods and drinks
that are taken; the heat received from such ex-
ternal sources as the sun and fires.
  Heat is lost from the body chiefly through the
skin but also, to a slight extent, through the lungs
and with the urine and feces.  Its loss through the
skin is affected by conduction and radiation and
by  the evaporation of sweat.  The amount lost
by conduction and radiation depends chiefly upon
(1)  the amount of blood near the surface of the
body,  being  greater,  of course, when there  is a
large amount of blood in the skin vessels; (2) the
temperature of the environment, hot surroundings
interfere with the passage of heat from the  body
(the reasons for this were given in Chapter I), and
cold, by contracting  the superficial muscles and
blood-vessels, forces much of the blood to the in-
terior of the body.  Loss of heat by evaporation of
sweat  occurs because heat  is essential for evapo-
ration  and that required is taken from the body.
536 small calories  or  0.536. of a large Calory are
necessary  for the evaporation of one gram of water
and approximately nine hundred (about one quart)
grams  of perspiration are secreted daily.
  Ordinarily we are unconscious of this secretion
because the rate of evaporation keeps pace with
that of secretion and, on a hot day, if the humidity
is not high, a much larger quantity can be secreted
without becoming visible or being  felt, because 
120          Nursing Methods

heat hastens evaporation, but, humidity interferes
with evaporation (for reason given in Chapter I)
and, consequently, with loss of the heat from the
body by evaporation.
  The heat lost through the lungs also is largely
due to its use for vaporization, for during twenty-
four hours as much as a pint of water leaves the
body as vapor in the breath.
  To summarize the process of heat regulation:
Cold causes muscular contraction, drives the blood
from the surface of the body, and lessens perspira-
tion;  thereby, it increases  heat  production and
lessens heat loss.   When the temperature of the
blood is raised, either as  the result  of increased
oxidation or from hot surroundings, the skin vessels
dilate and more blood flows to the exterior, the
secretion  of perspiration  is  stimulated  and the
muscles relax; therefore, loss of heat  is promoted
and its production  decreased. Consequently, the
temperature of a healthy person remains normal,
regardless of changes in the external temperature,x
unless the change is excessive.

                     Fever
  Fever is defined as abnormally high body tempera-
ture.  The rise of temperature is brought about by
  1 The body temperature of some of the lower forms of animal life
varies with that of their environment; thus a frog's temperature in
winter may be five degrees centigrade and in summer twenty-five
degrees centigrade or over and the vitality of its tissues will not be
impaired by this wide fluctuation.   In higher forms of animal life,
however, such a fluctuation would be incompatible with life. 
                Temperature             121

disturbance between the production and loss of
heat.  The nature of this disturbance varies some-
what as in some cases it is due chiefly to over pro-
duction and in others to interference with loss of
heat.  This derangement in heat regulation, how-
ever, only lasts for a short time for the heat regu-
lating center eventually again assumes control but,
as long as there  is fever,  the center is set for a
higher scale of temperature so that,  instead of
responding to a temperature between 990 and ioo°
F. (the ordinary actual temperature of the blood),
it is only called into action by  a higher tempera-
ture, z the degree  depending upon the cause of the
fever and the patient's condition, but, even in fever
there  is adjustment.  This is  much less  stable,
however, than  in  health for there are often wider
variations in the  diurnal fluctuations and changes
of external temperature and other stimuli more
easily depress or increase the temperature than in
health.
  The cause for  the heat-regulative upset is  not
definitely known; one of  the theories that has been
advanced is that the heat centers are depressed by

  1 The heat regulating center is often likened to the adjuster of
an electric oven.  If the indicator of the adjustor is set, for ex-
ample, at ninety-eight, so soon  as the oven reaches ninety-eight
degrees the electric connection  is automatically severed by the
adjustor and remains  so until the temperature falls, when it is
again remade by the adjustor, and thus  a constant temperature
of ninety-eight is maintained in the oven; but if the indicator is
set for, say, four hundred, this will be the  temperature maintained
in the oven. 
122         Nursing  Methods

the action upon them of bacterial toxins, or in non-
bacterial diseases, the conditions causing the ill-
ness ; but it is now thought that there are also other
factors involved; these, however, are too compli-
cated to be discussed here.
  Fever, though a  symptom of abnormal body
conditions,  is now thought to be one of nature's
methods of protecting the body from such condi-
tions.  An experiment  that  has  been tried  re-
peatedly has consisted in putting rabbits, or other
small animals, into  hot  surroundings  until their
temperature rose to about  400 C. and  then  in-
jecting them, and also similar animals that had not
been heated, with bacterial toxins.  In almost all
instances all the animals that were not heated have
shown bad results and died from the effects of the
toxins before those who had the high temperature
at the time of injection.   Nevertheless, fever can
become so high that it will add to the danger of the
patient's condition.
  The toxins produced by the various species of
bacteria and diverse  abnormal body conditions
differ one from the other  and they induce different
conditions or symptoms in the body, including the
course of the temperature, and therefore knowl-
edge of the changes in the temperature helps the
doctor to decide what is the matter with the patient
and the progress  of the disease.
  The terms used  in  describing different de-
grees of temperature  are shown in the following
table: 
Temperature
123
	Fahrenheit	Centigrade
Hyperpyrexia	1060 and over	41°
High fever	103° - 1060	39° -4i°
Moderate fever	ioi° - 103°	38° -39°
Subfebrile	990 - 1010	37° -38°
Normal	98° - 99°	36.5°-37°
Subnormal	96° - 97°	35-5°-36°
Collapse	95°" 96°	35° -35-5°
Algid collapse	Below 95°	Below 35°
        Nature and Care of Thermometers

  The thermometers  used  for  ascertaining  the
body temperature  are  known as clinical1  ther-
mometers.  A clinical  thermometer consists of a
glass tube of capillary2 bore with a bulb, filled with
mercury, on  one end.   When a thermometer is
made the bulb and part of the tube are filled with
mercury  and the instrument is  heated until the
mercury boils over and thus forces the air from the
tube.  The open end of the tube is then sealed.
When the tube is cold it is placed in boiling water
and the point to which the mercury rises is marked
212,  if the thermometer is to be marked according
to the Fahrenheit scale, or 100, for the centigrade
scale. The bulb is next placed in a vessel of melt-
ing ice and the point at which the mercury stops
is  marked 32 for the Fahrenheit scale and o for
the centigrade.  The space between the boiling and
freezing temperatures is then marked at regular in-
tervals, the number and size  of the divisions made
  1 From a Greek word signifying at the bedside.
  ' From the Latin capillaris = hair-like. 
 124         Nursing Methods

 depending upon which scale is used.  The value of
 the thermometer depends upon the expansion of
 the mercury by heat which causes it to rise in the
 tube and, as the expansion is always in proportion
 to the degree of heat, to which  the mercury is
 subjected, the height to which it rises in the tube
 shows the temperature.
  When not in use a thermometer is best kept in a
 case but, when it is being used for a patient, it is
 more hygienic to keep it in a glass of water or, if
 the patient has an infectious disease or the ther-
 mometer is used for more than one person, in a
 disinfectant.  A pad of soft material, as cotton,
 gauze, or muslin, should be kept in the bottom of
 the glass, because the bulb is likely to be broken if
 it comes in contact with anything hard.  The glass
 should be kept covered with a compress of gauze
 or muslin and the thermometer  wiped on  this
 before use.  A thermometer should be well washed
 with alcohol or other disinfectant before  it  is
 returned to its case.
  Clinical thermometers are self-registering—i. e.,
 the mercury stays at the height to which it ascends
 until it is shaken down.  Therefore, before using
 a thermometer, it is necessary to see if the mercury
is down to 950 F. and if not to shake it down to that
point.
  To shake down the mercury, hold the thermome-
 ter between the thumb and the first and second
fingers of the right hand, with the bulb pointing
downward,  flex the hand somewhat and give it a 
               Temperature            125

quick, sharp jerk.  Be careful not to shake the mer-
cury below 950 for if it all gets into the bulb it may
not be possible to make it rise again.  To try and
make it do so, put the bulb into water about 1080 F.
  The temperature is taken in  either the mouth,
rectum, or axilla, for these locations form more or
less  closed cavities in which large blood-vessels
approach  the  surface.   For obvious reasons, the
temperature taken by rectum  will be registered
about a degree higher,  and that taken by axilla
about 3^ degree lower, than that taken by mouth.
It is necessary to leave  the thermometer in place
for a longer time when it is put in the axilla than
when it is inserted in the rectum or mouth.
  There is less chance of error when the tempera-
ture is taken by rectum and thus it usually is taken
in this way when a patient is very ill, except when
there are abnormal conditions of the rectum; also
the temperature of a young child is best taken in
this way.  As this will probably be the only rectal
temperature that the students of this class will be
likely to take, unless they receive further instruc-
tion, it will be described in the chapter dealing with
the care of children.

              Demonstration 12

 Taking the Temperature by Mouth and by Axilla

  Equipment: 1.   Clinical thermometers in a glass
containing a disinfectant and a soft pad in the
bottom. 
126         Nursing Methods

  2.   Several small pieces of soft, clean muslin or
gauze on which to wipe the thermometers.
  3.   A few towels.
  4.   A clock or watches.
  5.   Pad on which to record the temperature.
  6.   Pens.
  Procedure when  taking  the temperature by
mouth: Take the thermometer from the solution,
wipe it, shake  it down if necessary, as described
on page 124, place it, in a slanting position, under
the tongue.  Tell the patient to keep her mouth
tightly closed.  Leave it in place three minutes.
Remove it, wipe it, read it, put it in the solu-
tion.
  Record the temperature.
  Points  to remember: A  mouth temperature
should not be taken within ten minutes of the time
that  the patient has had anything hot or cold in
the mouth.
  The temperature is  not to be taken  by mouth
when the patient is coughing, has dyspnea, is un-
conscious, delirious, insane, or too young to under-
stand what she is to do.
  Do not leave the thermometer in  the mouth
longer than three minutes.
  Should a patient bite the bulb off the thermome-
ter, make her at once  spit out the glass and mer-
cury and be sure that no particles are  left  in her
mouth.   The physician should be notified.  The
danger attending this  accident is that  small par-
ticles of glass may be swallowed. Mercury in its 
Pulse
127
metallic form is inert and, therefore, would prob-
ably do no harm, even if swallowed, but white of
egg, which contains albumen, the chemical antidote
for mercury, is usually given as a precautionary
measure.
  Procedure in taking  the temperature by axilla:
Wipe the axilla with a towel.  Shake down the
mercury.
  Place the bulb of the thermometer in the hollow
of the axilla with the  stem pointing  toward the
chest, bring the arm across the chest, and instruct
the patient to hold it pressed closely to her body;
unless she  can do so without undue effort, keep
your hand upon her arm.
  Remove, wipe, and read the  thermometer, put
it in the disinfectant, and record the temperature
at once.

                    Pulse

  By the pulse is meant the  distention  of the
arteries that occurs  when blood is pumped into
them from the heart.
  This distention or pulsation may be felt where-
ever an artery approaches the surface of the body
over a bone, the latter is necessary to afford a firm
background against which to make pressure.  For
convenience, however, the pulse is usually counted
on the radial artery1  where it comes near the sur-
face at the wrist.
  1 The large artery on the thumb side of the forearm. 
128         Nursing Methods

  There are a number of things that a nurse is
taught to observe when "taking the pulse," but as
to be able to recognize  most of them, requires
considerable experience with sick people, the rate
and force or  strength will be  the only ones dis-
cussed here. To understand even these it is neces-
sary to know the following facts  regarding the
structure of the heart and functions of the blood-
vessels :
  The heart is a hollow muscular organ with a
muscular wall dividing its interior into two distinct
cavities and each of these two cavities is separated
by movable flaps of  membrane, known as valves,
which open when blood is flowing from the upper
to the lower divisions.  The upper divisions, i. e.,
the part above the valves, on each side of the heart,
are known as the right and left auricles, and the
divisions  below  the  valves as the right and left
ventricles.  The blood enters  the auricles from six
large veins, two of which open into the right auricle
and four into the left.  The blood entering the right
auricle has come from all parts of the body  to
which it has given much of  its oxygen and from
which it  has received  carbon dioxid and  other
waste matter.   That entering the left auricle has
come from the lungs,  where it has given up a large
proportion of carbon dioxid and received oxygen.
From the auricles, the blood flows into the ven-
tricles and from the right ventricle it is forced into
the pulmonary artery from which branches extend
to the lungs, and from the left ventricle it is forced 
Pulse
129
into the large artery known as  the aorta  from
which  branches extend to all parts of the body.
Thus, to summarize, the blood flows from the left
auricle into the left ventricle, from the left ventricle
          EXTERIOR                INTERIOR OF RIGHT SIDE
Fig. 27.  The Heart.  Showing cavities of the right auricle and right ventricle.
into the aorta, and thence all over the body; from
arteries the blood passes into capillaries and from
these into veins, and veins in all parts of the body
communicate  directly or indirectly with  one or
other of  the  two large veins that enter into the
right auricle.  From this the blood is poured into
the right ventricle  and, at the  same time as the
blood in the left ventricle is being forced into the
     9 
130          Nursing Methods
aorta, that in the right is forced into the pulmonary
artery from which it flows to the lungs to get rid
of carbon  dioxid  and  obtain a fresh supply  of
oxygen for the body.  From the lungs it is returned
to the left  auricle.
  From the time that the organs concerned with
the circulation  of  the  blood1 are formed,2 until
death, the heart is constantly alternately contract-
ing and relaxing with a very short period of rest3
between the relaxing and subsequent contraction.
When the heart is beating more rapidly than usual
it is chiefly the rest period and time of relaxing
that are  shortened.  Thus  when the pulse is ab-
normally rapid, the heart is losing its rest and also
its nutriment, for the heart muscle gets its blood
supply from small vessels  that run through its
substance and these, like the cavities, are emptied
when the heart contracts.
  The normal rate  of the heart can be seen by the
following table. As shown  there,  sex and  age are
responsible for a certain amount of difference.

  In men....................     60- 70 beats per minute
  " women..................    65- 80    "   "    "
  " children above 7 yrs......     72-90    "   "    "
  " children 1-7 yrs..........     80-120    "   "    "
  "infants..................    110-130   "   "    "
  At birth...................    130-160   "   "    "
  1 Heart, arteries, capillaries, veins.
  2 Some months before birth.
  3 About 0.1 to 0.2 of a second when the pulse rate is 72 per
minute. 
Pulse
131
  The rate  of  the heart  action is controlled by
impulses coming from the brain over two different
sets of nerve fibers and when one of these, known
as the cardiac1 accelerator, is stimulated, it makes
the heart beat faster while stimulation of the other
group, known as the cardiac inhibitory mechanism,
slows the heart action.
  Some of the common causes of stimulation of
the accelerator mechanism and,  consequently, of
increase in the rate of the pulse are: Fear, anger,
excitement, or any other strong emotion, bodily
activity, fever.  The rate of the pulse is also in-
creased by depression of the inhibitory mechanism
and by conditions  that prevent the heart contract-
ing firmly, such as a diseased or weakened heart,
relaxed blood-vessels, a deficiency of blood in the
vessels, such as is the case after hemorrhage or
when the blood-vessels become so relaxed that the
arteries do not force enough blood onward through
the capillaries and veins to  the  heart.  Also  a
person's position,  lying, sitting, standing, causes
some change in the pulse rate, partly because in
the two  postures last mentioned the blood has to
be forced to  the  parts above the heart against
gravity.   Even in health, the pulse may  be -as
much as five beats more per second when a person
is sitting up than when lying down and  thus  a
patient's heart may be spared at least 21.600 beats
a day if  she is kept lying quietly in bed.  This is
very  important when  the heart  is beating  too
  1 From the Greek, kardia = the heart. 
132          Nursing Methods

rapidly and thereby losing its chance  to  get suf-
ficient rest and nutriment.
  For two reasons it is very important to remember
that excitement increases the heart  rate (i)  in
order to realize the importance of shielding the
patient  from  undue excitement and  annoyance;
(2) to appreciate that if a patient's pulse is counted
while she is excited the count will not show the
ordinary rate of the heart action at the time, and,
as relative changes in temperature and pulse are
an important guide to the physician in judging of
a patient's  condition, when there  is any known
cause for increase in the pulse rate at the time it is
counted the fact should be stated.

           Breathing and Respiration

  By breathing is  meant the movements of the
chest walls, diaphragm, and lungs which result in
the inspiration of fresh air and expiration of that
not used and, with it, the gases brought from the
tissues to the lungs by the blood.
  Respiration1 implies (1) the interchange of gases
that takes place in the lungs—this is known as
external respiration—and consists in the passage
of oxygen from the inspired air into the blood and
its union there with what is known as hemoglobin
(which is contained in the red corpuscles2) and the
  1 This is now considered the correct significance of the term
respiration, but the word is very commonly used as a synonym
for breathing.
  2 If not understood, see footnote on page 135. 
                  Respiration              133

passage of water and carbon dioxid from the blood
into the air sacs1 of the lungs from which it is ex-
pelled in expiration; (2) the interchange of gases
between the blood and  the tissues (known as in-
ternal  respiration)  in  which oxygen  leaves the
blood and passes into the tissues and carbon dioxid
passes from the tissues into the  blood.
  The  principal  factor  maintaining breathing is
the carbon dioxid in the blood which stimulates a
small mass of gray matter contained in a  portion
of the brain known as the medulla oblongata.  This
is connected by nerve fibers with the  spinal cord
from which fibers extend to the muscle tissue of the
diaphragm2  and  to muscles of the  chest.  It is
stimulated by the carbon dioxid in the blood pass-
ing through it and the impulses thus evoked con-
tract the muscles involved in breathing and, as a
consequence, the  diaphragm is pulled  downward
in the center and the ribs are pulled upward and
outward, thus the chest cavity is very considerably

  1 The lungs consist chiefly of air-passages which end in minute
sacs of exceedingly thin membrane, and of blood-vessels held
together with a very thin, elastic fibrous tissue.  The walls of the
air sacs and of the capillaries upon their surface are exceedingly
thin and gases can pass through them readily.  At the rate at
which  the blood ordinarily flows through the body it takes less
than a minute for the entire amount of blood in the body to flow
to and through the lungs.
  2 The dome-shaped partition between the thoracic (chest) and
abdominal cavities. Its central portion consists of non-contractile
fibrous tissue and this is surrounded with muscle that is attached
to the ribs, vertebrae,  etc., forming the  lower  boundary of the
thoracic framework.  See Fig. 28, 
134         Nursing Methods
enlarged and, as the lungs expand in keeping with
the chest wall, there is a partial vacuum created
in the air passages and sacs which the outside air is
pressed in to fill.  This constitutes what is known
Fig. 28.  Diaphragm, viewed from the front.  (Gerrish.)  The ribs
              have been cut away in front.
as inspiration.  It is, as stated above, followed by
the recoil of the muscles involved and relative com-
pression of the lungs which constitute expiration.
When anything interferes with the normal aeration
of the blood, more muscles are brought  into play
than are used in ordinary breathing and expiration
has a more forceful character.
  The  rate of breathing can be controlled for a 
                 Respiration              135

few minutes by voluntary effort, but not for long.
It is determined chiefly by the amount of carbon
dioxid in the blood and, therefore, it will be in-
creased by anything that accelerates the oxidation
in the tissues, and also by anything that tends to
hinder the  blood getting its required amount of
oxygen,  and getting rid  of  surplus carbon dioxid.
Such interference with the  proper aeration of the
blood may result from1 any congestion or obstruc-
tion in the lungs or the upper air passages leading
to them; (2) a lack of red corpuscles or of hemo-
globin in the blood2; (3)  interference with the cir-
culation of the blood  in  the lungs  as may occur
when the heart is diseased  or the nervous system
is depressed.
  Also,  the  depth  of  breathing movements influ-
ences  their  rate,   relatively  slow  movements
being associated with deep breathing and rapid
movements with  shallow inspirations.  Common
causes of shallow breathing are: Thoracic or ab-
dominal pain, lack of oxygen in the room,  reduced
air pressure (as in high mountains), tight clothing,
and habit,  the latter being probably often the
result of tight clothing or of a lazy disposition.
  1 The coloring matter in the red blood corpuscles.
  2 The body's oxygen supply is very greatly influenced by the
amount of hemoglobin in the blood and by atmospheric pressure,
and, when people go up high mountains, they are likely to suffer
from  air-hunger for the first few days.  Usually, however, this
stimulates the formation of  hemoglobin and thus more oxygen
can be absorbed at the low atmospheric pressure. This stimula-
tion of hemoglobin formation u largely responsible for the benefit
anemic people gain by sojourn in the mountains. 
 136         Nursing Methods

   As the rate of breathing is increased when it is
 shallow, if there is nothing to interfere with the
 aeration of the blood, as much oxygen will be ob-
 tained with superficial as with deep breathing but,
 nevertheless, the  former is not thought to be as
 conducive to good health because the lower areas
 of the lungs are not expanded as they should be
 and, as the circulation of blood in the lungs  is
 helped  by the respiratory  movements, the un-
 expanded  areas are not properly nourished  and
 thus are less able to resist  invasion by bacteria.
  As can  be seen by  the  following table which
 shows the average normal frequency of breathing
 there is some difference in  the rate that is  normal
 for children and adults and men and women, the
 latter difference however is thought to be  largely
 due to dissimilarity in dress.
     Men.....................  16 to 18 per minute
     Women...................  18 to 20  "   "
     Children..................  20 to 25  "   "
     Infants...................  30 to 35  "   "

              Demonstration 13

        Counting the Pulse and Breathing

  Articles  required: 1.  Watches  with   second
hands.
  2.   Writing pads and pens.
  The pupils can act as subjects for each other.
  Precautions: Do not "take the pulse" when the
patient  is  excited  or other conditions exist which 
Fig. 29.   Counting the pulse and breathing. 
 
                Respiration             137

will cause temporary changes in it, except for the
purpose of noting the results of  such conditions
upon it, see page 132.
  Do not use your thumb to feel a patient's pulse
for there is a superficial artery in it and you might
feel your own pulse instead of the patient's.
  Do not make too strong pressure when counting
the pulse  for,  if the  pulsation is weak,  strong
pressure will obliterate it—this is a common fault
of beginners.
  When taking the pulse at the radial artery, let
the patient's arm rest on the bed or a table.
  When taking the pulse of a patient for the first
time always take it in both wrists to ascertain if it
can be  felt equally well in both for, sometimes,
owing to an unusual distribution of the arteries, or
of some pathological condition, there is an appre-
ciable difference in the quality of the pulsations in
the two arteries.
  The method and frequency of breathing can be,
to some extent, controlled voluntarily and some-
times, possibly without intention, it will be done
when the individual knows that her breathing is
being counted; therefore, do it, if possible, without
the patient's knowledge.  A good way of doing so
is to count the breathing either before or after the
pulse and to pretend to be counting the latter while
you are counting the breathing movements.  When
the patient is in bed her hand may be held as shown
in Fig. 29, for the chest movements can then be felt
as well as seen which facilitates counting them. 
138         Nursing  Methods

  Procedure when " counting the pulse ": See that
the patient is resting comfortably.
  Take your watch in one hand and place two or
three fingers over the  artery, making slight pres-
sure; observe the general character of the pulse.
Count  the number of  beats  occurring  in one
minute.
  Procedure when counting the breathing:  Place
your fingers as when counting the pulse, hold your
watch where you can see its second hand and the
patient's chest at the same time.  Count an in-
spiration and expiration as one breath. Count for
one minute.

                   Records

  When a person is at all seriously ill a written
record  should be kept,  for otherwise something
that  the doctor should be told at the time of his
visit  will be  forgotten.  The record should in-
clude :  The doctor's orders; records of the patient's
temperature,  pulse,  and breathing; the hours at
which medicines are given and the amounts ad-
ministered ; pain or other distress that the patient
complains of and the results of treatments used for
relief; the number of bowel movements. 
CHAPTER  VIII
     Medication.  External Applications.
                    Irrigations

  Method of administering drugs.  Bad effects that may arise
from the unadvisable use of drugs. Important points to be re-
membered  regarding  the care and  administration of drugs.
Measuring  medicines.  AppUcation of medication to the nose,
throat, ears, eyes, and skin.  Demonstrations 14 to 21, including:
Measuring medicines; application of medication to the throat and
steam inhalations; irrigation of the ear; appUcation of medicine
to the eyes; making poultices and sinapisms; applying ointment,
liniments, iodine, fomentations, hot-water bags and substitutes,
ice-caps  and  substitutes.  The nature  and  uses  of  counter-
irritants.

  The  lists of equipments for the demonstrations
are on  pages 145, 154, 162, 167, 175, 182, and 192.
  Medicinal substances are used to cause both
local  and general or systemic effects.1   For local
effects  they must be so applied that they will come
in contact with the part that they are to act upon:
for systemic effects they must be either absorbed
by the blood or act upon nerve endings and thus
obtain  results  through  the  nervous system  as
described under counter-irritation.

  1 Those acting upon the whole body or at least a number of
organs, especially those concerned in a common function.
                         139 
Uo         Nursing  Methods

  Drugs may be  given: by mouth; through the
lungs; by rectum; as subcutaneous, intramuscular,
and  intravenous  injections;  and they  may be
applied externally; but only the means of giving
them by mouth and applying them externally will
be considered here, because the other methods of
administration require more knowledge and prac-
tice than can be gained in a short nursing course.
  Before learning how to administer medicines it
is well to realize that drugs should neither be taken
nor given inconsiderately because there is hardly a
drug that  has not some bad effect.  This is true
even of drugs that are very commonly taken with-
out consulting  a  physician, viz., drugs used to
relieve headache and to induce sleep, cathartics,
and tonics.  Other reasons why it is unwise to take
even such drugs frequently without consulting a
doctor are: (i)  the symptoms that the drugs are
taken to relieve may be due to serious conditions
and, though a drug may temporarily relieve the
pain or discomfort that the condition produces, it
does not cure the cause and this may continue to
grow  worse.   For example,  common causes of
frequent headache are: (a) Abnormal conditions
of the eyes;  (b) collections of pus in bones behind
or at the side of the nose, or at the roots of the
teeth, or in the tonsils; (c) constipation; (d) disease
of the kidneys; and the drugs commonly taken to
relieve headache cannot improve such conditions
though, usually by depressing the nervous system
and thus lessening the appreciation of pain, they 
Medication              141
may alleviate the headache.   (2)  A number of the
drugs which  alleviate pain  (including  headache)
and induce sleep do so by uniting with constituents
of the nerve tissue, especially that of the brain, and,
if they are used frequently they may cause de-
terioration of the  tissue, and the person's mental
capabilities and will-power will then decline, and
any or all of the organs of the body may cease  to
function  properly, because,  as previously stated,
their functioning is  controlled by the  nervous
system.   Even  cathartics and tonics, if taken too
frequently, may  cause  trouble.   Cathartics  so
accustom the intestine to abnormal irritation that
the contraction of its muscle tissue, which propels
the waste from food through the organ, does not
occur properly without the extra stimulus.  There-
fore, taking cathartics  too frequently  may be a
cause of chronic constipation.  Thus it is infinitely
better to  try  and overcome any tendency to con-
stipation  by natural means,1 e. g., eating food that
has a considerable amount of cellulose2 which is not
digested,  e. g., fruit  and  green vegetables.   The
food supply should also be considered when a tonic

  1 Constipation, when not due to intestinal disease, is generally
the result of (1) a diet lacking in substances that are not digested
and thus provide the bulk necessary to stimulate and distend the
intestine and thereby produce the nerve impulses that induce de ■
fecation; (2) lack of tone of the intestinal or abdominal muscles,
see page 93; (3) failure to respond to the sensation arising when
the rectum  is ready to discharge its contents, this is  further
described on page 216.
  2 The fibrous part of vegetables, fruit, and grain. 
142         Nursing  Methods

seems needed, for fresh vegetables, fruit, eggs, and
milk contain many of the constituents of tonics
and have not the bad effects of drugs.  Dried and
most canned vegetables and fruit are not as good
as fresh, because the means taken to preserve them
destroys some of their vital principles.
  Some important  points to remember regarding
the care and administration of medicines are:
  i.   Never leave medicines where children can get
them.
  2.   Do not keep highly poisonous drugs, such as
disinfectants, on the same shelf as others unless the
bottles are of very  different size.
  3.   Never have medicines in unmarked bottles.
  4.   Keep oils in a cold place.
  5.   Do not use a drug that  has  been  kept  for
any length of time if  its  appearance is  at  all
changed, for many  drugs deteriorate with age.
  6.   Give medicines  on time and be especially
particular about the relative  time of meals and
medicine because, for  examples, some drugs that
are ordered given before meals are to induce  the
secretion of gastric  juice and, for various reasons,
may be about useless if given while the stomach is
full of food or if it contains acid, as it does during
digestion; on the other  hand  many of the drugs
ordered to be given after meals would be exceed-
ingly irritating to the lining of the stomach if  the
latter were empty.
  7.   Use graduated glasses and pipettes  (medi-
cine droppers) not spoons for measuring medicines, 
Medication            H3
for few of the latter are of standard size and quite
a number of medicines will stain metal.
  8.   Measure exactly, never give a patient a drop
more or less than the doctor orders.
  9.   If there is more than one medicine on hand,
read the label on the bottle twice, before and again
after pouring the drug.
  10.  Shake the bottle before pouring out a medi-
cine  that is not perfectly clear or that has a sedi-
ment.
  11.  While  pouring a medicine, hold the glass
with the mark of the quantity required on a level
with your eye; if the mark is above your eye, you
will give too little, if below,  too much.
  12.  To avoid defacing the  label on a bottle
while pouring the medicine, hold the bottle so that
the label will be on the upper side, but do not let
your hand come in  contact with it, and, before
putting away the bottle, be sure that there are no
drops on the rim.
  13.  Always recork a bottle  immediately after
pouring out the drug for many medicines  contain
■volatile substances and may thus become either
stronger or weaker if left uncorked.
  14.  Always follow  the instruction regarding
the dilution of drugs, because some drugs are very
irritating and may do great harm to the membrane
lining of the stomach and intestine if not very well
diluted, while the effect of others will be minimized
if much water or other diluent  is added to them;
certain medicines, especially  syrup cough mixtures 
U4         Nursing Methods

are not to be diluted at all for the syrup lubricates
the irritated membrane of the throat.
  15.  A certain class of drugs, known as bitters,
produce their  effect (stimulation of  the  appetite
and secretion of saliva and gastric juice) by virtue
of their bitter taste and thus nothing should be
done to alter this further than diluting the drug
with cold water.   Other  drugs, however, should
be made as palatable as  possible.  Powders and
also  liquid preparations of which only  a  small
amount is  ordered  can be given in capsules or,
especially for children, in syrup or jam.  Castor
oil1 is probably the medicine  that has most fre-
quently to have its taste disguised and a good way
of doing this is to put some lemon or orange juice
and a small piece of ice in a medicine glass, add the
oil and then some more fruit juice and, just before
the patient is ready to drink it, some Vichy or other
effervescing water.   The  piece of ice should be
about the size  of a pea when the patient takes the
dose, that is it must be small enough to swallow
easily.   Have  a glass of  lemonade or orangeade
ready for the patient to take as soon  as she swal-
lows the oil.  Some people object to the mineral
oils which are now  much  used as cathartics, and
for those who  do, it is well to add a  little lemon
or orange  juice  or  peppermint  water  or  some
flavoring extract.   Holding a  small  piece of ice
in the  mouth before  taking  a  distasteful  dose
  1 N.B.  Never give castor oil in milk, especially to children,
for it may cause the recipient to dislike milk. 
Medication             145
may be of help for cold depresses the taste nerve
endings.
   16.  Give acids and medicines  containing iron
through a tube,  because  acids may corrode and
iron discolor  the teeth.  The mouth should be
thoroughly rinsed after taking such medicines.


              Demonstration 14

              Measuring Medicine

   Equipment: 1.  Ordinary  graduated medicine
glasses,  minim   glasses,  medicine droppers  (pi-
pettes) .
   2.  A pitcher of ice water.
   3.  Some bottles of water or other substitute to
represent medicine.
   4.  Small trays.
   5.  Small pieces of old, clean muslin or gauze.

   Procedure: Take  a medicine  glass in the left
hand and  (after reading the label), the medicine
bottle in the right.
   Shake the bottle if necessary.
   Take the cork  between the third and  fourth
fingers of the left hand and hold it thus (with
the part that goes in the bottle  projecting from
behind  the  hand)  while  you  pour  out  the
medicine.
   Raise the glass until the mark representing the 
146
Nursing  Methods
amount of drug that is to be given is on a level
with your eyes.
  Pour in the drug until it is on a line with this
mark.
  Put the glass on the tray.
                      Recork the bottle, read the
                    label, wipe the  rim of the
                    bottle if necessary, and put
                    the bottle away.
                      Pour  some ice water into
                    the medicine.
                      Fill a medicine glass with
                    ice water and put it on the
                    tray, carry the tray and its
                    contents to the patient.
                      When the medicine  is
                    to  be measured by  drops,
                    proceed  as  just  described
                    with  the   following  excep-
tions:  Leave the bottle on  the table and, after
removing the cork,  fill the pipette,—to do this,
put its point into the medicine, expel  the air from
its tube by pressing the bulb, and then release the
pressure, whereupon the medicine will be forced
into the  tube (because the air  having being re-
moved, there will  be  no  pressure  within the
tube to oppose  the  pressure of  the liquid in the
bottle).
  Wash the glasses,  etc., and put  them away.  If
the glasses are dried, the drying  should be done
with either a special  towel or a dish towel.
  Fig. 30. Method of hold-
ing cork and glass while
pouring medicine. 
Medication             147
              Local Applications

  Local applications are made to wounds, the skin
and cavities that communicate with the exterior;
e. g., nose, throat, eyes, ears.
  Applications to the nose are usually made either
by spraying, douching, painting, or inhalation.
  The two methods of treatment first mentioned
are attended with considerable danger and should
only be given to patients by those who thoroughly
understand the technic.  There is somewhat less
danger in their personal  use but  even thus they
must be used with caution and under the direction
of a doctor.  The chief dangers attending the treat-
ments are: (i) If liquid is sprayed from an atomi-
zer into the nose with force, infective material in
the nose may be forced through the minute canals
that lead from the nose into cavities that exist in
some of the bones of the face and thus cause a seri-
ous infection; (2) unless  the solution used in the
spray or douche is of the right concentration and
alkalinity, it may  irritate the lining of the nose
injuriously;  (3) in the use of the nasal douche
infected matter may be driven into what are known
as the Eustachian tubes, two  small  canals  that
lead,  one  on each side,  from  the throat  to the
middle cavity of the inner ear.  The result of such
infection may be very serious indeed.
  Thus, to repeat,  these treatments should not  be
used unless prescribed by the doctor and only the
solution prescribed is to be used and the tempera- 
148         Nursing Methods

ture of the solution  is to be exactly as ordered.
The spraying is done with a special atomizer simply
by pressing the atomizer bulb, after the point of
the atomizer has been inserted in a nostril.  The
pressure on  the bulb is to be slow and without
force.  The  safest form of  appliance to use for
douching the  nose is a fountain syringe  bag or
           irrigator  can with  tubing  attached
           and  a nasal tip inserted in the free
           end of the tubing.   Also, there must
           be a  clamp  on the  tubing to check
           the flow of liquid until it is required.
           To use this appliance: Put the solution
           prescribed by the doctor into the bag
           or can; hang this about twelve inches
            (not more) above the head, bend the
Glass nasal tip. latter over a basin,  insert the point
           of the nasal tip in  the nostril that
the doctor has specified, open the mouth, let the
solution run.  It  will run in one nostril and out
through the other nostril and the  mouth.  The
chief precautions to be observed are:  (1) not to
have the reservoir higher than stated above, not
to cough, sneeze, swallow, or talk while the liquid
is running through.  If necessary  to do any of these
things, shut off the flow, for the three first men-
tioned may  force fluid, etc., into the Eustachian
tubes and the other two draw  the tissue away
from the openings of the tubes and  thus facilitate
the entrance of solution and infective matter into
them.
 
Medication             149
   Painting the membrane lining the nose is usually
 done by wrapping a small piece of absorbent cotton
 around a wooden toothpick, dipping this in the
 solution or ointment and rubbing it gently over
 the affected part.
   Local applications are made to the throat in the
 same way as to the nose  and, in  addition,  by
 gargling.
   Less  danger attends  the  use of sprays in the
 throat than in the nose, but too much force should
 not  be used as it  is possible  to drive infective
 material into the Eustachian tubes.
   The chief points  to remember  when painting
 the throat are:  (1)  that the back of the tongue
 must be held down so as to  afford a  good view of
 the tonsils and surrounding  parts; (2) as a rule it
 is only the most inflamed  parts that are to  be
 painted and, as the drugs generally used for such
 purpose are very irritating,  care should be taken
 not to include unnecessary  parts in  the applica-
 tion ; be careful not to touch the back  of the throat
 with the tongue  depressor and only if necessary
 with the applicator, because this causes gagging
 and even vomiting; (3) never dip a used applicator
 into the solution; (4) do not touch the point of the
 applicator that has  been in the mouth, roll the
 applicator in paper and have it burned as soon as
 possible for inflammatory conditions of the throat
 are often  caused by germs  that are very easily
 transmitted to others and cause very serious ill-
nesses, 
150         Nursing Methods

  Inhalations intended to produce external  local
effects usually  consist of steam either alone or
with the vapor of certain volatile drugs that are
added to the boiling water and vaporize with the
steam.  The purposes for which such inhalations
are commonly used are: To  relax spasmodic con-
tractions of the muscles of the throat, such as occur
in croup, and  to  soothe irritated membrane and
congestion  of  the throat.   The first mentioned
result is effected chiefly by heat and the other two
both by heat and the drugs used. Drugs are also
given by inhalation to produce effects after absorp-
tion either upon distant or local parts.  Examples
of those affecting  distant parts are the anaesthetics
such as chloroform and ether.
  Steam inhalations may be given either with the
apparatus so arranged that the exit for the steam
is in as close proximity to the patient's mouth as
the heat  of the steam will permit or a large kettle
may be used and placed at a slight distance and a
so-called canopy  or tent so  arranged that the
steam is  directed  toward the patient  in a manner
that will allow of its being inspired.
  There are a number of appliances sold for giving
steam by close inhalations—most of them contain
alcohol lamps  for keeping the water boiling and
are thus dangerous.  What is known as the Maw's
inhaler has no stove but  is so made that it re-
tains heat for a  considerable  length of  time
and  is thus one of  the best varieties to use.  A
pitcher is usually used in emergency but it does 
Fig- 33-  A method of giving a steam inhalation. 
 
Medication             151
not retain the heat as long nor does the steam
rise as well.
  To get the best effects when a canopy is used it is
well to have an inhalation kettle which has a long
spout and a small opening in
the cover through which  air
enters and forces the  vapor
through the spout.  If an  or-
dinary kettle is used, the cover
must  be raised at one corner
for the same purpose as this
opening.  An electric stove is
the safest variety to use and,
next to this,  a gas  one.  If
obliged to use an alcohol stove
—place it  in a  deep basin. Fig. 32.  Maw's inhaler.
When the canopy is arranged
as in Fig. 33, only an electric stove should be used
as the canopy comes  in too close contact for any
other  variety to be safe.
  The foundations of the canopies shown in Figs.
34 and 35 consist of frames that are attached to
the bed,  and that in Fig. 33 is an ordinary bed-
cradle, but a screen  can be used as a foundation
for canopies arranged as Figs.  34 and 35,  and a
wooden box such  as canned  goods and other
grocery supplies are bought  in  will  answer as a
substitute for the cradle.  The canopy consists of
a piece of old blanket pinned over the top of the
frame (this is to absorb moisture which otherwise
may condense and drop on the  patient and bed-
 
i52         Nursing Methods

clothes) and sheets.  In Fig. 34 the  sheets are
pinned together in the center and then each sheet
is folded back upon itself so that there is a seam
in the center between which the spout of the kettle
Fig. 34.  A canopy arranged for steam inhalation.
is fitted and the steam thus enters at the back
above the patient's head.  In Fig. 35 one sheet is
folded and pinned over the top of the  frame and
the other is pinned to this around  the back and
sides.  The only essential difference in the two
being that in the former, owing to the seam in the
back, it is possible to let the steam enter from the
back.  When a cradle is used, as in Fig. 33, it is
well to put a rubber between the blanket and sheet.
otherwise, the kettle  being so near the canopy,
much of  the steam escapes.  The rubber and,
perhaps, the blanket, will not be needed if the box 
Medication             153
is used, but if the steam condenses and drops as it
probably will be if the inhalation is continued for
any length of time a folded piece of old blanket can
be tacked inside the box.  The box should have a
Fig- 35.  A canopy arranged for steam inhalation.
depth of about twenty-four inches and one end has
to be removed.   In arranging  the  sheet,  which
should be doubled, leave a fold in front so that it
can be drawn down over the patient's face from
time to time, if desired, and thus the patient will
get more vapor.
  Some important points to remember when using
steam inhalations are:  i.  They will probably do
more harm than good unless the patient remains in
bed,  or at least in one room, during the entire time
that  the treatment is used. 
 154         Nursing Methods

  2.  The volatile drugs used for such purpose are,
 almost without exception, inflammable, and thus
 the bottle containing the drug used should not be
 brought near the flame.
  3.  The stove is to be placed where there is no
 danger of the bedcovers coming in contact with it
 or else a guard must be placed around it, e. g., it can
 be placed in foot-tub or deep granite basin.
  4.  The spout of the  kettle must not project
 far  enough under the canopy for it to come in con-
 tact with the patient.
  5.  A small child should not be left alone while
 receiving such treatment, for it may easily upset
 the kettle or otherwise burn  itself.

              Demonstration 15

     Application of Medication to the Throat

  Requisites for painting or  swabbing the throat:
 1.  Tongue  depressors.  Small  strips  of wood,
made for the purpose, can be bought at any drug
store and are the best things to use for this purpose.
In emergency, however, the handle of a spoon can
be used.1
  2.  Applicators, the best kind, consist  of  a
slender strip of wood with a piece of  absorbent
cotton, about one inch wide and two to two and a
half inches  long  wound  around  one end.   The
  1 If a spoon is used it must be boiled after use.  The wooden
strips are burned. 
Medication              155
cotton should be left loose at the point and wound
very tightly at its upper end so that it will not fall
off.  Strips of wood intended for this purpose can
be bought at most drug stores, but, in emergency,
the cotton can be wound around a pencil or pen-
holder. x
  3.  A paper  bag  or folded paper  into which
the depressor  and  applicators  can be  put after
use.
  4.  The drug, a small bottle with water can be
used for class.
  5.  A small glass.

  Requisites  for  spraying  the  throat: 1.  An
atomizer.
  2.  A handkerchief.

  Requisites for giving inhalations:  1.  A Maw's
inhaler and a piece of flannel or old blanket or a
bath towel.
  2.  A foundation for a canopy, see page 152.
  3.  Two sheets and a piece of old blanket.
  4.  A paper of pins.
  5.  A kettle.
  6.  A stove.
  7.  A stand for the stove and, if necessary, some-
thing to protect this from the heat.
  1 After an apphcator has been used it must not be dipped into
the solution.  If more solution is needed, take a fresh apphcator
or, if a pencil or penholder has been used, wind fresh cotton around
it. When removing the cotton, do not touch it with your fingers,
to avoid doing so you can cover it with paper. 
156         Nursing Methods

  Procedure  when  painting  or  swabbing  the
throat1: Wash your hands.  Arrange the applica-
tors as directed on page 154.  See that the subject
is where the light will fall into her throat.  Pour a
small amount of the liquid to be used into the glass.
  Place this where you can reach it easily.
  Depress the tongue by  placing the point of the
depressor upon the highest part of the curve of the
tongue (which hides  the part of the throat  that
is usually most affected)  and press it downward.
Do not let the depressor touch the  back of the
throat.
  Dip the cotton of the applicator into the solution.
  Swab the affected parts of the throat with this.
  Procedure when spraying the throat: Place the
subject2 where the light will shine into her throat.
  Place the handkerchief where she can reach it.
  Depress her tongue as described in the preceding
section, but it can be done with the stem of the
atomizer, press the bulb and be sure that the solu-
tion reaches all  congested  parts.
  Procedure when arranging steam  inhalations
with a Maw's inhaler: Heat the utensil by pouring
water into and over it.
  1 The procedure for nasal treatments will not be described.
They were mentioned merely to tell the pupils of the dangers
attending their use.  This seemed advisable, because they are so
commonly used unnecessarily and with harmful results.  As pre-
viously stated, they should only  be used when prescribed by a
physician and his instructions should be accurately followed.
  2 The students may act as subjects for each other or they may
stand in front of mirrors and carry out these treatments on
themselves. 
                 Irrigation              157

  Pour out this water and  then  pour in enough
boiling water to reach the level of the opening of
the air channel (see Fig.  33) and  add the drug, if
one has been prescribed.
  Insert the cork with the  mouthpiece attached
and wrap the inhaler,  except the tip of the mouth-
piece, in flannel or a bath towel.
  If the water is boiling when it is used and the
inhaler is properly heated before the water is put
into it, vapor will continue to arise for at least
twenty minutes.
  Procedure when arranging for steam inhalations
with a canopy: Secure the foundation in place and
cover the top of this with a piece of old blanket.
  Drape the sheets around the foundation and pin
them in place.   The manner of doing this will
depend upon the foundation.  The way in which it
has been done in the accompanying illustration
has been already described.  If screens are used
the sheet around the back and  sides should be
pinned on the  inside so as to protect the screen.
  Put the stove in place.   If necessary protect the
stand.
  Fill the kettle to about  three fourths its capacity
with boiling water, add the drug, if one has been
prescribed, and put this on the stove.

              Irrigation  of the Ear

  Earache  is a trouble for which home remedies
are often used  and, if they are successful, no medi- 
158
Nursing  Methods
cal advice is sought.  To show the error of this
and of the danger of ill-advised treatment a few
words will be said here regarding the anatomy of
the ear and the physiology of hearing.
  The ear consists of three distinct parts termed
the outer ear, middle ear, and inner ear.
  The outer ear consists of the auricle (the part
outside  the head) and the  auditory canal.  The
                             latter in the adult
                             is about i}/£ inches
                             long and is curved
                             so that its central
                             portion  is  higher
                             than the  opening
                             or terminal.  The
                             outer portion of the
                             canal is of cartilage,
                             the  remainder  is
                             hollowed out of the
                             temporal bone.  In
                             small children  the
                             bone is less formed
                             and the  canal  is
  Fig. 36.   Vertical section through the straight.  This dif-
external auditory meatus and tympanum, r      •  ,,  ,
passing in front of the fenestra ovalis.                 "
Note shape of auditory canal.         of the Canal must
                             be  remembered
when irrigating the ear.  The canal is lined with a
membrane in which  there are cells that7 secrete a
sticky substance, known as cerumen or wax, which
is intended to keep foreign substances from enter-
 
                 Irrigation             159

ing the ear.  Normally, only a small amount of
cerumen is secreted, but, if the canal is irritated,
the cells may become overactive and  secrete so
abundantly that hard masses of wax. are deposited.
  The middle ear is a cavity hollowed  out of the
temporal bone.  It  is divided from the canal of
the outer ear by a very thin membrane, known as
the tympanum or drum.  Three small bones called
because of their shapes, the hammer, anvil, and
stirrup stretch across the cavity.  One end of the
hammer is attached to the drum and the other to
the anvil.   The free end of the anvil is attached to
the stirrup and the free end of the latter to a mem-
brane that is stretched across one of the two open-
ings that lead into the inner ear.  In the back part
of the middle ear there is a minute passage into the
part of the temporal  bone known as the mastoid,
and there  is also a canal leading into the throat.
This is known as the Eustachian tube and its pur-
pose is to equalize the  air pressure on both sides of
the drum.
  The inner ear consists of three cavities, known
as the vestibule, the  cochlea or snail shell, and the
semi-circular  canals.  In each of  these cavities
there is a membranous bag, and the spaces between
the bone and bags  and within the bags contain
fluid.  That  surrounding  the bags is  known  as
perilymph,  and that within the bags as endolymph.
The fibers constituting a portion of the membrane
within the cochlea are connected with processes of
the auditory nerve,  this is also the case with the 
160         Nursing Methods

membrane in the semicircular canal, but the nerve
fibers extending from this portion of the ear only
go  for a  short distance into  the brain with the
fibers from the cochlea and then they  branch off
and connect with portions of the brain that help to
control the coordination of certain muscles. Thus
the semicircular canals are  not concerned with
hearing, but with maintaining balance.
  Sound consists of wave-like vibrations in matter
(usually the air)l that affect the auditory nerve.
When the waves enter the ear they make the drum
membrane vibrate in like  manner,  this induces
similar vibrations in the small bones of the middle
ear and, in turn, the lymph and membrane of the
inner ear.   It is thought that the fibers of the mem-
brane in the cochlea that are connected with the
auditory nerve are held at different tensions  and
are thus affected by waves with different rhythms
(just as, if the cover of a piano is left open and a
note struck on another musical instrument in the
room the same string in the piano will vibrate), and
that the interpretation  in  the brain depends at
least partly upon the nerve fibers over which the
impulses come.2

  1 Sound is transmitted through liquid and solid matter even
more readily  than through air, for example, the vibrations pro-
duced in water by the paddle wheel of a steamer can be heard a
mile away if the ear is held near the water.
  2 It is to be realized that we do not actually hear with our ears
or see with our eyes or feel at the exterior of  the  body. These
parts being merely the portion of the various mechanisms that
receive and transmit the external stimulus to the brain. 
                 Irrigation              161

  The most common abnormal conditions of the
ear and their causes are:
  I.   The collection of wax in the auditory canal.
  2.   The  formation  of pimples or boils in the
canal.
  The most common cause of both of these condi-
tions is irritation of the canal in  the endeavor to
clean it with pins and the like and by putting irri-
tating liquids into it in the treatment of earache.
It is usually unnecessary to clean the ear further
than the tip of the small finger can reach and, if
so much wax is being secreted  that further means
are necessary, a doctor should be  consulted.   The
tip of  the finger should be covered with a clean,
soft cloth before being put into the canal.
  3.   Blocking of the Eustachian tubes.  This is
usually the result of inflammation in the throat,
or enlarged tonsils, or the presence of adenoids.
It interferes with the passage of air into and out of
the tubes and, therefore, the air pressure on the two
sides of the drum becomes unequal and the normal
vibration of the  latter is interfered with.  This
interferes with hearing and it  is likely to cause
ringing and buzzing sensations, because the audi-
tory nerve  endings are stimulated.
  4.   Inflammation of  the middle  ear.   This  is
usually due either to the extension of inflammation
from the throat {e.g., tonsillitis) or to forcing virus
from an inflamed throat or nose into  a tube by
improper irrigation or  spravine  of the nose or
throat.
11 
 162         Nursing Methods

   Thus it can be appreciated that earache is not a
 condition to be left to home treatment.  If it occurs
 when it is not convenient to consult a doctor, as at
 night, heat can be sometimes applied in the form
 of a hot-water bag or an irrigation, as described
 later, but, even if the pain ceases, the doctor should
 be consulted as soon as possible so  that the cause
 of the earache can be found and removed.
   If, however,  the pain is behind the ear, heat
 should not be used without first consulting a doctor,
 even if it is at night, especially if the sufferer is a
 child, because pain behind the ear is often due to a
 dangerous condition known as mastoiditis.


               Demonstration 16

              Irrigation of the Ear

   Equipment:  i.  A fountain syringe bag or other
 type of irrigator with a clamp on its tubing and, if
 possible, a return flow aural nozzle1 in its free end;
 a piece of rubber tubing between twelve and four-
 teen inches long on  the  side  projection  of the
  *Fig-  37 shows a return flow aural nozzle.  The dotted line
indicates a small tube inside the nozzle through which the water
flows from the reservoir into the ear.  As can be seen in the illus-
tration, there is room for the water flowing from the ear to re-
enter the nozzle around this tube and it flows from the nozzle
through the side projection.  This is about the best appliance to
use for irrigation of the ear because, if the reservoir is not raised
more than about twelve inches the water will flow in and out of the
ear without making any pressure on the drum. 
Irrigation                163
nozzle.  About one quart of water with a tempera-
ture between 1060 and no0 F. in the reservoir.
  2.   A rubber
ear bulb* and a
basin  contain-
ing water with
the    tempera-
ture mentioned
above.
  3.   A   ther-
mometer  to
,  .     .,                    TJP FOR CONNECT/ON tV/Tft
take  the  tern-            tubing for return fuqw
perature OI trie    p{gt j^  Glass return-flow car nozzle.
water.
  4.   A  basin with a capacity  of  about  one
quart.
  5.   A bath towel and pin.
  6.   Pledgets of absorbent cotton made by taking
pieces of cotton about i^ inches square and twist-
ing one end of each piece into a point that will allow
of its ready insertion in the ear; the twist must not
be very tight or the power of the cotton to absorb
the moisture from the ear will be  lessened.   If
cotton cannot be obtained pieces  of soft, clean
muslin can be used  but, as they will not remain

  1 Rubber bulb ear syringes are cheaper than the above appara-
tus and are therefore more commonly used, but they do not allow
of the steady,  constant flow of water  provided by the other
appliance and, unless care is taken not to squeeze a bulb quickly
or forcibly, enough pressure will be made on the drum to cause
pain.
 
164         Nursing Methods

twisted, they are only prepared when needed.  On
no account should any hard pointed implement
be put into the ear by anyone but a doctor.
                 7.  A receptacle for used pled-
               gets.
                 Procedure when a return flow
               nozzle  is used: Hang the  reser-
               voir about twelve inches above the
               patient's ear.
                 Have her lie  or  sit with  the
               affected ear uppermost.
                 Put the towel  around her neck
               and,  unless  she  is  lying  down,
               pin it.
                 Hold the  nozzle over the basin,
               open the clamp on the tubing
               and let enough water run through
the tubing to heat it and expel the air.  Check the
flow and place the basin the same distance below
the ear that the reservoir is above it.  Put the free
end of the tubing for the return flow into the basin.
Insert the tip of the nozzle in the auditory canal
and let the water flow.  While it is doing so pull
the auricle of the ear backward and, if the patient
is an adult, upward (the reason for this was men-
tioned on page 158).
  If  pain  or dizziness  are  occasioned,  lower the
reservoir as these sensations are usually occasioned
by too much pressure on the drum.
  Shut off the current before the solution reaches
the lower exit of the irrigator.
 
. Cornea
     Anterior chamber
chamber
 .Conjunctiva
"». Choroid
Fig- 39-   Diagram of the right eye in horizontal section, showing the upper
                        surface of the lower segment. 
 
                  Irrigation              165

  Remove the basin, etc., and, if necessary, dry
the neck and around the ear.
  Insert the pointed edge of a pledget in the ear,
while doing this hold the auricle in the manner just
described so as to straighten the canal.
  Change the pledget  after a few  minutes and
continue doing this until the pledget removed is
dry.  Do not rub the walls of the canal.
  If the irrigator is used without a nozzle make the
following differences  in  the procedure: Hold  the
basin for the return  flow pressed tightly against
the neck under the ear being treated.  Put the free
end of the tubing at, but not actually in, the orifice
of the canal; that is, space enough must be left for
the exit of the water.
  When a bulb syringe is substituted for the irri-
gator, fill it by holding its  tip in the water and
pressing the bulb.  To use it hold the point at, but
not in, the opening of the auditory canal and press
the bulb gently and slowly.  Otherwise, the proce-
dure is the same as when an irrigator is used.

       Application of  Medicine to the Eyes

  There is, probably, no part of  the body more
easily injured than the eyes and no attempt should
be  made to  treat  abnormal conditions of these
organs without first consulting an oculist.1
  Two particularly important reasons for this are:
  * A physician who specializes in the treatment of diseases of the
eyes, 
 166          Nursing Methods

 (i) Redness of the lids, styes and the like, which
 people are so prone to treat according to the advice
 of their friends, are very often the result of eye-
 strain, i.e., of forcing certain small,  and  exceed-
 ingly  delicate, muscles within the eyeballs to do
 more work than they are fitted to perform. Their
 work is to so adjust a part of the eyeball, known
 as the lens, that the light rays entering the pupil'
 from different angles are brought to a focus on  a
 certain part of the inner wall or retina2 of the eye-
 ball.  When we are looking at things in the distance
                                these muscles are
                                at rest, but, when
                                we look  at  any-
                                thing  near  at
                                hand, the muscles
                                contract and this
                                makes  the  lens3
                                become more con-
                                vex and the rays
 Fig. 40.  Muscles that move the eyeball.  °f llght Ere then
           (Gerrish.)              brought to a focus
                                sooner than  they
otherwise  would be.   Quite  a number  of ab-
normal conditions may exist  in the eyeball that
  1 The hole in the iris, which is the colored portion in the front
wall of the eyeball.
  2 The retina consists chiefly of a portion of the optic (sight) nerve.
  3 The lens is a transparent jelly-like body that is surrounded by
a thin transparent membrane.  The latter is attached at either
side of the eyeball to the ciliary muscles and is held suspended
behind the iris and pupil and in front of the retina,
 
                 Irrigation              167

will make it harder for these muscles to do their
work effectually or the defect may be in the muscles
themselves.  In either case, the muscles are likely
to be injured if they are not helped by the use of
glasses that will give the required aid in refracting
(bending) the rays  of light entering  the pupil.
The local irritation arising when these muscles
are undergoing strain, for reasons given on page
80, may induce congestion  and  consequent ab-
normal conditions of the eyes and lids.  It can be
appreciated from what has been said, that treat-
ment which temporarily relieves congestion and
its  external  results,  but  not the conditions pro-
moting the strain, are not to be relied upon.
  2.  The other particularly important reason for
consulting an oculist if the eyes become at all in-
flamed is that they are subject to infection by a
number  of organisms that may speedily cause
severe inflammations and even blindness.
  The treatment of the more serious inflammations
requires  an expert and those described here are
only such as are  frequently prescribed for simple
congestions and the like, such as are promoted by
eyestrain; they should, however,  only be  carried
out upon the advice of a doctor.

              Demonstration 17

  Irrigating and Putting Medicine in the  Eyes

  Articles required for an irrigation: 1. A small
clean basin containing about one half to one pint of 
168          Nursing Methods

whatever solution is ordered (warm water—about
ioo F.—will answer for class)  and some pledgets1
of absorbent cotton.
   2.  Dry absorbent cotton pledgets.1
   3.  A towel and safety pin.
   4.  An empty basin.
   5.  A receptacle for used pledgets.
   Articles required when an eye-bath is used for
cleansing or  the application  of medication:  (1)
an eye-bath, about three quarters full of the solu-
tion prescribed (the eye-bath  is a small oval cup
that fits around the eye).
   (2) A towel and pin.
   Articles required for putting drops of medicine
in the eyes:   1.   The drug that is to be used (for
class clean warm water in a small bottle).
   2.  A medicine dropper.
   Important  precautions to be taken  when giving
these treatments are:  (1) Do not let the tip of the
medicine  dropper come in contact  with the eye;
(2) avoid making pressure upon the eyeball when
separating the eyelids; (3) when irrigating the eye,
direct the current toward the outer  angle  of the
eye and away from the nose, because  there is a
small duct leading from the eye into the nose2 and

  1 Pieces of cotton about an inch or an inch and a half square.
  2 This duct is intended as a passageway for the tears which are
being constantly secreted by glands at the upper  and outer angles
of each eye.  These tears are intended to keep the surface of the
eye moist.  Unless they are secreted in unusual amount (as when
the person is crying) their presence is not marked, for their evapg- 
                  Irrigation               169

if any foreign substance is washed into it serious
trouble may result; (4) do not use anything rough,
as gauze, for wiping the eye—absorbent cotton is
particularly good  for the purpose; (5) be careful
to have the solution the strength and temperature
prescribed by the physician.
  Procedure when irrigating  an  eye: Pin  the
towel around the patient's neck.
  Scrub your hands.
  Have the patient sit or lie with the head thrown
back and so tilted that the eye to be treated is
slightly lower than the  other (in  order to  avoid
washing discharge into the well  eye) and place or
have patient hold the empty basin where the solu-
tion will flow into it.
  Wash any adherent discharge from the lids with
pledgets moistened with solution.   Do not  put a
used pledget back into the solution.
  Separate the lids by making traction upon  the
flesh above and below the lids with the  thumb and
first finger of your left hand,1 making all necessary
pressure upon the lower ridge of the forehead and
upper part of the cheek bone, never on  the eyeball.
  Squeeze  the solution  over the  eye from  the
pledgets in such a manner that it will be directed
away from the inner angle of the eye.  During the
treatment have the patient look upward and down-
ward, making the change by moving the eyeball,

ration or passage into the ducts leading into the nose keeps pace
with the rate of secretion.
  1 Each pupil should practice doing this  on herself. 
170
Nursing Methods
not the head, so that as much of the eyeball at
possible will be subjected to the irrigation.
                                At the conclu-
                               sion of the treat-
                               ment dry the eye
                               by gently patting
                               around it with a
                            '/  pledget  and  dry
        ^  ^              i'""-   the face with the
                               towel.
                                P r ocedur e
                               when using   an
                               eye-bath: Pin the
  Fig. 41.  Drawing the eyelids apart by towel around the
making traction on the flesh above and below rmTiprit'<; n ppV
the eye, exerting necessary pressure on the ^\              '
bones of the forehead and cheek.         glV^  tier trie  cup
                               and  instruct  her
to  (1)  bend  her head forward  and  press  the
cup firmly around  the eye,  keeping  the  eye
closed  while  doing so,  and  (2)  (pressing the  cup
in place) to throw her head backward and, for the
length of time prescribed, which is usually two to
five minutes,  to  keep  alternately  opening  and
closing her eye and  moving  the  eyeball;  (3) to
bend her head  forward and remove the glass.
   Procedure in  dropping medicine  in  the eye:
Place the patient with her head tilted slightly back-
ward ; take up as much of the drug in the dropper
as  required,  but  leave  the latter  in the bottle.
Draw down the lower eyelid with the first finger of
your left hand and tell the patient to look upward. 
         External Applications       171

Take the dropper in your right hand and, holding it
slightly above, but not touching the eye, make very
slight pressure on the rubber nipple of the dropper
so that the number of drops prescribed will fall on
the inner surface of the lid.  Release the lid slowly
and  tell the patient to close her eye. When the
medicine is applied in this way it enters the eye
quite as well as when it is dropped directly on the
eyeball and it causes less irritation.

            Applications to the Skin

  The purposes for which applications are  most
frequently made to the skin are:  (1)  To overcome
abnormal conditions of the skin itself or of the
tissues situated directly beneath it; (2)  to lessen
congestion and pain in the internal organs and (3)
to cause the expulsion of gas from the  stomach
and  intestines.   Also, there are a few drugs that
can  be absorbed through the skin and these are
sometimes administered  by a process known as
inunction.
  Examples of the uses of applications to  cure
external  abnormal conditions are:  (1) To lubri-
cate or soften  roughened skin  or mucous mem-
branes; (2) to dry moist surfaces, especially those
denuded of skin;  (3) to act as astringents, that is,
to cause contraction of tissue and thus lessen the
amount of blood  in the part and check secretion;
(4) to depress sensory nerve endings in the part and
thus alleviate local pain;  (5) to kill or render inert 
172          Nursing Methods

organisms causing skin lesions; (6) to soften tissue
and increase the amount  of blood in an infected
part and  thus get a local increase in the amount
of white corpuscles and other substances that the
blood contains for fighting bacteria—heat1 is the
agent most commonly employed for this purpose;
(7) to lessen the amount  of blood in an area and
thus relieve pain due to congestion;2  cold2 and
drugs, which act as astringents described above, are
generally  used for this purpose and, when they are
employed, the inflamed part is usually raised for
this  favors the flow  of blood  away from  it and
slightly impedes the flow toward it.
   The  external applications  used  to affect the
internal organs are:  Irritant substances such as
mustard,  turpentine, and  iodine; heat; cold.  Irri-
tant substances used to relieve pain are known as
counterirritants  because  they counter or  relieve
pain already existing.   Heat also induces irritation
and thus acts as a counterirritant and, as it induces
a  particularly  marked dilation of  blood-vessels
and  softens and expands  tissue, it is often a par-
ticularly  valuable one.   The  relief  of pain and
   1 As previously stated, when a part is congested the local blood-
vessels are dilated and distended with blood, this results in an
increased exudation of lymph into the tissues of the part and this
sometimes induces pressure on nerve endings thereby causing
pain.
   2 Heat or  cold should not be used without a doctor's order for
these purposes, because heat tends to promote suppuration (the
formation of pus) which under some conditions may be harmful,
and cold, by forcing the blood  away from a  part reduces the
amount of protective substances to fight the bacteria. 
          External Applications      i73

congestion in the internal organs by counterirri-
tants and cold depends upon the fact that nerve
fibers extending from the skin connect in the spinal
cord with fibers  that  transmit impulses to the
viscera (internal organs).  Neither heat nor cold,
in degrees that can be used on the skin, penetrate
the tissues, but irritation on an area of skin will
give rise to nerve impulses that pass to the cord
and are discharged over the connecting fibers to
the muscle tissue in  the organs and  blood-vessels
situated  below  that  area of skin.  The impulses
contract  the blood-vessels  and, thereby,  force
blood from the area so that congestion and pain
due to it are lessened and when, for  example, hot
fomentations are  applied  to  the abdomen the
muscle tissue in the  walls of the stomach and in-
testines contracts and forces gas from the organs.
  If too severe irritation is produced by any means
blisters are likely to  form because extreme irrita-
tion increases the amount of blood in the irritated
part to such a degree  that there is excessive transu-
dation of fluid from the vessels and this separates
the outer from the  under  layers of skin,  which
constitutes a blister.   Certain irritants, especially
cantharides, are used purposely to produce blisters,
and, if properly applied, they will do so without
injuring the underlying tissues but, when irritation
severe enough to cause blistering is  produced by
the majority of irritants, lesions that are very hard
to cure may be caused.
  The medicated preparations most commonly 
174         Nursing Methods

used for external applications are: Solutions, lini-
ments,  ointments,  plasters,  pastes,   poultices.
Articles commonly used for hot applications are:
Hot-water bags, electric  pads, the flatiron, salt,
fomentations or compresses, poultices; also, there
are electric baths and ovens but these are seldom
available for home use.  Articles commonly used
for cold applications are: Ice-caps and compresses.
  Solutions are liquids containing dissolved matter.
Most of those used for external applications are
disinfectants1 and some of them are also astrin-
gent, 2 and the so-called tincture of iodine is both
a disinfectant and a counterirritant.
  Liniments are liquid or semi-liquid preparations
the majority of which contain irritant substances
in an oily or alcoholic medium.  They are used
chiefly to, by counterirritation,  relieve pain in
superficial tissues.
  Ointments are soft  preparations of fatty  sub-
stances in which, as a rule, a drug is incorporated.
Drugs with various actions  are used in this way
and therefore ointments are employed for a num-
ber of different purposes.
  Plasters are preparations of drugs  combined
with a resinous substance that is spread  upon and
adheres to  a  foundation of  muslin or similar
material.

  'Substances that kill bacteria.
  2Substances that cause the contraction of tissue. Many as-
tringents also lessen the sensitiveness of nerve endings and these
lessen pain. 
          External Applications       175

  Pastes  are soft viscid substances.   Mustard
paste and mustard plaster are known as sinapisms
from the Latin name for mustard, sinapis.
  Poultices are soft, hot, moist pastes.  Anything
that can be made into such a paste and that retains
heat well  can be used for the purpose, but flax-
seed or, as it is generally  called, linseed, is usually
preferred  as it is inexpensive and answers these
requirements particularly well.  Antiphlogistin or
clay poultice, which consists of kaoline (a form of
clay), glycerine, and several drugs with mild coun-
terirritant properties, is also considerably  used
and, for small poultices, bread.
  Stupes  or fomentations  consist  of  flannel or
compresses of gauze or other soft material wrung
out of very hot water.

              Demonstration  18

Methods of Using: Iodine, Liniments, Ointments,
     Plasters and Articles Employed for Hot and
     Cold  Applications1

  Equipment for demonstration:
  A bottle of tincture of iodine and some applica-
tors (matches with small pieces of absorbent cotton
twisted around one end can be used), a receptacle
for  used applicators (a paper bag will answer the
purpose).
  1 Most of these procedures are so simple that, if time is limited,
a few questions regarding necessary precautions and methods will
be as valuable as a demonstration. 
176         Nursing Methods

  A  jar of ointment, a spatula (a knife  can be
substituted), compresses of gauze or soft muslin,
a bandage.
  A piece of a plaster such as cantharides or bella-
donna, if it can be obtained, but this is not impor-
tant.
  A hot-water bag and cover.
  An electric pad, if one can be obtained easily.
  A bag of salt, a pan, spoon, and stove.
  A  flatiron and a piece  of flannel or flannelet
about half a yard.
  An ice-cap and cover (a piece of thin soft muslin
will answer the  purpose), ice  and appliances  for
cracking it.
  Arrange the articles required for cold compresses
on a small tray,  such compresses are most com-
monly  used for the eyes and on the forehead to
relieve headache. The articles required are:  Two
small bowls, one enough smaller than the other
to be inverted  in it.  A lump of ice placed on top
of the  inverted bowl, a little water in the other
bowl, compresses for the eyes which should consist
of small squares, about an inch, of absorbent cotton
or folded pieces of soft muslin.  Compresses for
the forehead, viz., pieces of gauze  or muslin or a
handkerchief folded to fit the forehead.  A recep-
tacle for used compresses, a towel.
  Procedure:  The demonstration  doll  for   the
patient.
  To apply iodine: Dip the covered  end of  the
applicator in the iodine and then rub this on  the 
          External Applications       177

skin, let the application dry, if the skin does not
become a deep brown color, repeat the procedure.
When it is employed to produce counterirritation,
enough iodine must be  used to produce a fairly
deep brown color and induce a slight stinging sensa-
tion that  will be felt for a few minutes, but too
much  must not  be used or blisters  will result.
Other  precautions necessary  are: The skin must
not be moist and thus iodine should not be applied
soon after the part has been washed, for moisture
increases the irritant action of the iodine; the part
should be left exposed for a time.  If too much irri-
tation is induced the iodine can be easily removed
by washing the part with ammonia water or strong
soapsuds or alcohol.
   To apply a liniment: Place the patient  in a
comfortable position; pour a little liniment on the
part (do not let  the rim of the bottle touch the
patient's skin) and rub the liniment into the skin,
exerting as much pressure as the patient can toler-
ate.  Continue to do this for from ten to twenty
minutes; use more liniment  if necessary to main-
tain a slight stinging sensation.
   Ointments are applied in  two different ways:
(1) They are rubbed into the  skin;  (2) they are
spread on some soft material as muslin or a gauze
compress and bandaged over the part. Ointments
are applied in the manner first mentioned both for
local effects and in order that the drug contained
in the preparation may be absorbed.  Especially
when the  ointment is used for  the latter purpose 
178         Nursing Methods

it is  important that the skin be first washed with
soap and hot water and, if possible, alcohol so as
(i) to remove the sebaceous  matter,  which is
always present on  the skin  and interferes with
absorption, and (2)  to make the skin soft and red,
the redness is due to an increased supply of blood
in the part and this  favors absorption.   When
ointment is rubbed into the skin to promote the
"absorption of a drug the process is  known  as
inunction.
  When ointments  are used  on sores or wounds
the  second  method of application  is  generally
employed and the following precautions must  be
observed: (1)  The gauze or muslin must be sterile,
if there are no sterile supplies at hand a piece of
clean muslin can be sterilized by passing a hot iron
over it several times.   (2) The ointment must be
taken from the jar and spread with a spatula or a
suitable substitute as a knife and this should  be
boiled before use.   (3) Enough ointment must be
used to prevent the dressing sticking to the sore
or wound.
  Plasters, with the exception of sinapisms, are
usually prepared for use by warming them, which
softens the resinous substance; this can be done by
putting it in a warm oven for a few minutes or
under the lighted jets of a gas stove; the skin should
be prepared in the same manner as for an inunction
and it should be warm when the plaster is applied.
The latter is laid on the skin and pressed slightly
with the hand which makes it adhere to the skin. 
         External Applications      179

If necessary it  is covered with a bandage.  The
method of  using sinapisms  will be described  in
Demonstration  19.

Methods of Using Articles Employed for Applying
             Dry Heat to the Body

  To fill a hot-water bag, remove the stopper and
roll the bag from the bottom  upward so as to expel
the air, otherwise, the hot water is likely to spurt
out over your hands, being forced  out by the ex-
panding air.1  Let the water flow  in,  this should
not be hotter than about 18o° F.   If the bag is to be
put on the body do not fill it to more than about one
quarter to half its capacity, or it will be too heavy;
if it is to lie on the bed, you can put more water in,
but do not fill it to its full  capacity.  Insert the
stopper and, after doing  so, hold the  bag upside
down to ascertain if  there is leaking, this most
frequently occurs around the stopper as the result
of an absent or defective washer. Put the bag in a
flannel or flannelet  cover,  stopper first, so that if
the cover becomes loosened the  metal stopper will
not come near  the  patient, for, as metal absorbs
and parts with  heat more readily than rubber, it
is much more likely to cause  a burn.
  It is  to be remembered (1) that a patient's word
is never to be relied upon as to the suitability of
the temperature of  a  hot  application,  because if a
person  is in pain  a burning sensation may not be
  1 It will be remembered that air is expanded by heat. 
180         Nursing Methods

perceived or it may be a relief.  (2)  The hand is
not as sensitive to heat as other parts of the body
and therefore when testing a hot application hold
it against your arm or cheek.   (3) Some people
are more easily burnt  than others and therefore
when a hot-water bag or other hot application is
placed directly on the skin look at the latter after
a few minutes and see if it is a deep red, if so, the
application is probably too hot; this care is es-
pecially necessary with small children and the aged.
  Warm salt is sometimes used as  a  hot applica-
tion when a hot-water bottle cannot be obtained.
To heat the salt, empty it into a  pan  and place it,
preferably, in a hot oven, though it can be heated
on top of the stove.  Stir it occasionally, and when
hot enough pour it into a muslin bag.
  Two important things to remember about elec-
tric pads are:  (1) The insulating material wears
off in the course of time and thus old pads should
be inspected before use; bedclothes have caught
fire from defective insulating material.   (2) Pads
may become dangerously hot after they have been
in use for some time.
  Ironing the affected part with a flatiron will often
afford great relief in conditions such  as stiff neck
and lumbago.  To do this, dry the skin thoroughly,
cover it with a piece of flannel, and pass a heated
iron back and forth over the latter for about twenty
minutes.   Have the iron as hot and make as much
pressure as the patient can endure.   It may be
necessary to press lightly at first and increase the 
         External Applications       181

degree gradually.  Raise the flannel from time to
time to see that the skin is not too deep a red.

Methods of  Using Articles Employed  for Cold
                  Applications

  The special points to remember in connection
with the use of ice-caps are: i.   To break the ice
into pieces about the size of a walnut; if the pieces
are larger than this the cap is not likely to fit over
the part well, if smaller they will melt too quickly.
  2.  Let some hot water run over the ice to blunt
the sharp edges which might pierce the rubber.
  3.  Roll up the sides of the cap before putting in
the ice, and,  after doing so, squeeze it above the
ice, to expel the air.
  4.  Do not fill a cap  more than three quarters
its capacity and not even this much when its weight
will cause discomfort.   Cover it with a piece of
thin muslin.
  5.  If the weight of a  cap annoys the patient tie
the cap to some support such as a bed-cradle or the
substitute mentioned on page 78, and place  this
so that the cap will barely rest upon the part.
  The care of ice-caps after use was  described in
Chapter I.
  Cold compresses are sometimes used as  sub-
stitutes for ice-caps as a means of applying cold to
the forehead.  To use them, arrange the tray as
described on page  176 (the ice is raised above the
water because this retards the melting).  Saturate 
182         Nursing Methods

the compresses in the water and then place them
on the ice.  When one is thoroughly chilled squeeze
the water from it  and place  it on the forehead.
When it becomes warm replace it on the ice and
put the cool one on the forehead.
  Cold compresses for the eyes are used in  the
same manner except that, as  a rule, a number of
them  are provided for they need to be changed
more frequently and, if there is any discharge from
the eyes, the same  one should not be used twice.
Separate compresses should be used for each eye if
both eyes are being treated.
  A very important thing to remember about  the
use of cold is that as long as the treatment is con-
tinued the  use of the cold must be constant for,
otherwise, the reaction effects described in Chapter
VI will occur during the intervals that the cold is
reduced and this is likely to be harmful in some
conditions  for  which  local cold  applications  are
prescribed.

              Demonstration 19

Preparing,  Applying,  and  Removing  Sinapisms

  Equipment:  1.   Mustard plaster.x
  2.   Mustard.
  3.   Flour.
  4.   Tepid water.
  5-   Oil.
  1 Mustard plasters are commonly called mustard leaves. 
External Applications       183
6.	Bowl.	
7-	Spatula.	
8.	Tablespoon.	
9-	Plate.	
10.	Gauze.	
11.	Two towels.	These will not be
12.	Basin of warm water.	needed until the
13-	Washcloth.	paste is to be re-moved.
  Some important facts  to remember regarding
the use of mustard are: The counterirritant action
and flavor  of  mustard are due to a volatile oil
which is developed by the action of a ferment that
is contained in the  mustard and  becomes active
when  the mustard  is wet. This  ferment is de-
stroyed by a temperature exceeding 1400 F. (6o°C.)
and its action is inhibited at considerably lower
temperatures so that, if the liquid with which the
mustard is mixed is hotter than about 1060 F. the
amount  of  oil  developed  (and hence the counter-
irritant  action of the mustard)  will be  limited.
Nevertheless, mustard is considerably used in hot
poultices and baths because, if it is only added to
the heated substance just before the latter is used
it will have a slight counterirritant effect for a
short time and thus increase the effects of the heat,
but when the  counterirritant  effect is to depend
solely upon the mustard the water used must not
be hotter than 1060  F.  The ferment becomes less 
184         Nursing Methods

active  when mustard is kept for any length of
time, especially in hot weather, and thus in summer
time and in hot countries it is usually necessary to
use relatively more mustard.  When preparing a
mustard  paste for  a child or an aged person it is
well to add a little oil, because this softens the skin
and thus lessens the tendency of the outer layer to
separate from the derma as described on page 173.
The skin should be washed when a sinapism is re-
moved because particles of mustard are likely to
adhere to it and cause blistering.
  Procedure in the use of mustard plasters:
  To prepare a leaf for use, dip it in tepid water,
fold it in a gauze  compress,  arranging the latter
with only one thickness over the mustard surface.
Lay the  leaf,  mustard  surface uppermost,  on a
folded towel.  Leave this towel in place when you
apply the leaf as it will protect the patient's night-
gown and the bedcovers from the moisture.   It is
rarely necessary to secure a sinapism in place and,
usually, it is better not to do so as, if it is loose, the
color of the skin can be more easily watched, which
is imperative, for mustard blisters some skins very
readily.
  Remove the leaf when the skin is well reddened.
This is usually in about twenty minutes, but, some-
times,  in ten or even less.   Wash the skin  with
warm water and dry it.  Make sure that  no par-
ticles of mustard adhere to the skin.  If the skin is
very red, apply some oil or other lubricant.
  Mustard pastes are made of mustard, flour, and 
         External Applications      185

tepid water and, for the reason given on page 184,
oil is sometimes added.   The relative proportion
of mustard to flour required varies for the reasons
given  on page  184.  Ordinarily, in a temperate
climate, about one part of mustard to three or four
of flour is necessary for an adult and one to six or
eight for a child. About five tablespoons of mate-
rial are needed to make a paste six inches square.
  Procedure: Put the mustard in a bowl; crush all
lumps.
  Add the flour  and mix the  two ingredients
thoroughly.
  If oil is to be used, add about two teaspoonfuls.
  Add enough tepid water to make a paste that can
be spread easily, but that will not run.
  Lay  a gauze compress on a plate and spread the
paste in the center of the former, about one eighth
inch thick. Fold the edges of the gauze over the
back of the paste.
  Place the paste, the side  with single layer of
gauze uppermost (this is the side that goes next
the skin), on a folded towel.  Put it on the patient.
Take the same precautions while it is on and when
removing it as for a mustard leaf.

              Demonstration 20

        Making and Applying Poultices

  Requisites for demonstration:  1.  Flaxseed.
  2.  Baking powder or  sodium bicarbonate. 
186
Nursing Methods
3-	Mustard.
4-	Boiling water.
5-	Cup measure.
6.	Utensils provided for cooking poultices in.
7-	Stove.
8.	Spatula or knife.
9-	Tablespoon.
10.	Towel.
n.	A piece of board or large platter.
12.	Flannel cut the size and shape required for
the poultice.
 13.  Binder and pins.
 14.  Gauze  or  thin  muslin on which to spread
the poultices.  For a square or oblong poultice this
can be cut twice the size that the poultice is to be,
NECK
ARMHOLE              ARMHOLE
          Fig. 42.  Shape of poultice to cover chest.

plus about three inches to allow for turning over
the edges of the paste, which is spread on one half
of the material and covered with the other half, but
when  any complex shape is  needed {e. g., for the
chest) it is well to have fairly  firm muslin for the
foundation and gauze or thin muslin for the cover,
and to cut these the required shape.  See Fig. 42. 
          External Applications       187

Cut the foundation two and the cover three inches
larger on all sides than the finished poultice needs
to be.

        /  ^^>  <\     BACK     \   S^ \

      r-Rom   v_y              \^J  FR0Nr
            ARM HOLE             ARMHOLE
       Fig. 43.  Shape of binder to retain poultice in place.

   15.  A doubled piece of flannelet the shape of
the poultice with which to  cover the  part after
the removal of the poultice.
   16.  Oil  or vaseline, a gauze  or cotton sponge
with which to apply it, and a dish to put the latter
in after use.
   17.  Antiphlogistin and a small empty bowl or
jar.  A saucepan containing water.l
   18.  Some stale bread.1
   19.  The demonstration doll.
   20.  A stove.
   The points  of special importance  to Consider
when making a poultice are: To have it as light2

  'These need only be provided if desired for, if  the pupils
are shown how to make  a linseed poultice, they should, at any
time, be able to make any other kind by following  printed or
verbal instruction.
  2 A poultice to cover the chest should not be more than half
an inch thick, for a weight on the chest may interfere with breath-
ing. A small poultice can be about  three quarters of an inch 
188          Nursing Methods

as possible and as hot as it can be used without
burning the patient; to make it of a consistency
that will allow of its being spread easily, but not so
thin that it will spread of itself and thus run from
the covering.
                Flaxseed Poultice
  Procedure: Put the water to boil (about one and
a half pints will be required for a medium-sized
poultice for the chest).
  Spread a towel on the board and on this lay the
oil muslin or flannel; cover the latter with the gauze
or muslin on which the flaxseed is to be spread.
  When the water is boiling forcibly, add flaxseed
to it slowly (do not allow the water to stop boiling),
and stir the mixture with the spatula as you do so.
  When the paste is  just thick  enough for  some
dropped from the spatula to retain its  shape for a
minute add about one third of a tablespoonful of
baking powder or sodium bicarbonate and beat the
mixture thoroughly.
  Turn the poultice on to the muslin  and fill the
pan with hot water.1
   Spread the  paste  on the muslin to within two
inches of the edges as quickly as possible.   Turn
up the edges of the muslin over the paste.
thick.  When baking powder and sodium bicarbonate are moistened
gas (C02) is liberated and, therefore if either one is added to a
poultice, it tends to make it lighter, and, as gas  is a poor heat
conductor, to assist in the retention of heat.
  1 If the flaxseed is allowed to dry in the pan the latter will be
much harder to clean. 
          External Applications       189

  Cover the latter and turn the edges of the cover
between the foundation  and  protector {i.e., the
flannel).
  Fold the poultice, including the protector, and
wrap the towel around it.
  Wash and put away the cooking utensils.1
  Carry the poultice (folded in the towel) and the
binder and pins to the patient.
  To apply the poultice:  Turn back the bedcovers
as much as necessary and slip the binder under the
part to which the poultice is to be applied
  Turn back the nightgown as much as required
and if the  patient is old  or  a small child rub  some
oil or vaseline over the area to which the poultice
is to  be applied.  Cover the part with the towel
that is around the poultice.
  Test the temperature of the poultice with the
back of your hand.
  Slip the poultice under the towel, but do not un-
fold it all  at once.  Keep raising and lowering it
until the patient becomes accustomed to the  heat.
Notice the color of the patient's skin and judge by
this, rather than  the patient's opinion, if the poul-
tice is too hot.  If it does not cause a very intense
redness,2 spread  it out over the part, remove the
  1 If the poultice is boiling when  turned on to the muslin and
spread  quickly and the utensil washed and put away speedily,
it is quite possible for this to be done before the poultice becomes
cool  enough to be applied.
  2 This should always be the  guide when making hot applica-
tions of any  kind, because some skins will blister much more
readily than others, and,  if a patient is in pain, heat, even in- 
190         Nursing Methods

towel, and secure the binder;  do not, however,
fasten it tightly,  especially around the chest, as
this may interfere with breathing.
  Fold the towel and keep it to roll the poultice in
when the latter is removed.
  A poultice should not be left on longer than three
quarters of an hour, for by that time it will be no
hotter than the skin and thus of no further value.
  To remove a poultice:  Take the flannelet pro-
tector or a fresh poultice, towel, oil, and pledgets
to the bedside. Cover the poultice that is on the
patient  with the towel, moving the bedcovers and
nightgown out of the way as you do so.
  Remove the poultice from under the towel and
dry the skin by rubbing your hand over the towel.
  Look at the skin and, if it is very red, rub some
oil over it.
  Put on the pad or fresh poultice and  when it is in
place remove  the towel  and  wrap it  around the
poultice that is to be taken away.

                Mustard Poultice

  To make a  mustard poultice: Proceed as for a
plain flaxseed poultice, but dissolve some mustard
in tepid water, using for an adult one tablespoonful
of mustard for each cup of flaxseed, and for a child
half this amount of mustard, and, just before add-
tense enough to burn, may be a relief, while on the other hand,
some patients will object to even a moderate degree of heat. 
          External Applications       191

ing the baking powder or soda, pour in  the dis-
solved mustard.
  For the reasons given on page 183, when mustard
is added to anything the temperature of a flaxseed
poultice, the counterirritant action of the mustard
is much diminished,  but it does add slightly to
that of the poultice.

              Antiphlogistin Poultice

  To prepare an antiphlogistin poultice stand the
container in a pan of boiling water.  Keep the water
boiling until the antiphlogistin is considerably hot-
ter than could be borne by the skin (to  allow for
cooling), stir the antiphlogistin occasionally so that
it will be equally heated.  Either spread it direct-
ly on the skin or on muslin, if the latter,  place the
uncovered antiphlogistin next the skin, cover the
application with absorbent cotton and secure it in
place with a bandage  or binder.
  Remove the poultice when it is cooler than the
skin or if it becomes dried.  This may not be for
several hours.

                 Bread Poultice

  To make a bread poultice: Soak the  bread in
boiling water until  it is soft, beat it with a fork;
bring it to boiling point; pour off any water that
has not been  absorbed;  proceed as  for a linseed
poultice. 
192         Nursing Methods

             Demonstration 21
     Application of Fomentations or Stupes
  Fomentations, as  previously stated, consist of
soft material wrung out of boiling water.  Flannel
and, for the eyes, absorbent cotton are  the best
materials to use because they hold heat for a rela-
tively long time. Fomentations are most com-
monly  used  (1) on the abdomen  to cause  the
expulsion of gas and (2) on the eyes to overcome
certain forms of inflammation.
  Requisites for abdominal stupes, Method 1:
  1. A gas or electric stove and a tray on which
to stand it and, if the table on which these are
placed will be injured by heat, something  (as wood
or a folded towel) that is a poor heat conductor to
put under the tray.
  2.  Matches, if necessary.
  3.  A basin of boiling water.
  4.  Wadding or a  fold of flannelet the size of the
abdomen.
  5.  Two pieces of flannel twice the size of the
area for application.
  6.  A coarse towel.
  7.  A blanket or shoulder wrap.
  8.  The demonstration doll.
  Requisites for Method 2:  The same  as  for
Method  1  with the  following exceptions: No
blanket and stove are required; the boiling water is
to be in a pitcher and the basin empty, but warmed;
a binder and safety  pins will be needed. 
         External Applications      193

  Requisites  for  fomentations  for  the eyes: 1.
Compresses of absorbent cotton about one and a
half inches square,  the number depending upon
conditions, for, if there is suppuration, the same
compress must not be used twice; otherwise, five
or six will probably be enough.
  2.   A towel.
  3.   A bath thermometer.
  4.   A pitcher of boiling and one of cold water or
whatever solution is prescribed.
  5.   A dressing basin.
  6.   A  bag or other receptacle for used com-
presses.
  7.   If  the treatment is to be continued for any
length of time, a pail or jar and a stove.
  8.   If  the treatment is for a communicable in-
fection or following operation, gloves.   These must
be sterile for the latter condition.
  These  articles should  all be  arranged  in con-
venient order on a tray.

               Abdominal Stupes

  Procedure  for Method 1: Arrange the stove,
light the gas, put on the basin of boiling water.
  Double one  of the pieces of flannel.  Place it in
the center of the towel or wringer and put as much
of this as envelops the flannel in  the boiling water,
but leave the  ends  hanging over the  side of  the
basin.
  Put the blanket  over the patient's chest and
     13 
194         Nursing Methods

abdomen and  turn  down  the bedcovers  to  the
groin.
  Turn  the  nightgown up  above the abdomen.
Cover the latter with the flannelet.
  Wring the water out of the flannel by twisting the
two ends of the towels in opposite directions.  Do
this until it is impossible to wring out any more water.
  Remove the flannel from the towel;  give it  a
quick shake and pass it (doubled)  under the pro-
tector (be sure that it is not too hot); spread it out
over the abdomen.
  Place  the other piece of flannel in the towel and
this in the boiling water and, after three minutes
have elapsed, use this flannel to  replace that on
the abdomen.
  The stupes are to be changed without removing
the protector or blanket, but you must raise these
slightly each time you make a change to ascertain
the color of the skin.
  Continue the treatment the length of time pre-
scribed ;  this  is usually twenty minutes.
  Dry the abdomen.   Sometimes it is covered with
wadding or folded flannelet.
  Method 2: Prepare the patient as for Method I,
but it is not necessary to  replace the bedcovers
with a blanket on the upper part of the body, as
the covers can  be moved from over the  abdomen
sufficiently without uncovering any other part of
the body.
  Pass a binder under the patient in position to be
pinned around the abdomen. 
         External Applications      195

  Put the flannel in the towel or wringer and this,
except the two ends, in the basin.  Pour the boiling
water over the part containing the flannel.
  Wring the stupe and apply it as in  Method I.
Draw up the sides of  the binder and pin it.
  Change the stupe every ten or fifteen minutes.
The treatment is usually continued until it affords
relief.

               Eye Fomentations

  Procedure: Put  a  towel under  the patient's
head.
  Pour some water or solution into the bowl and
make it the required temperature; this is generally
about no° F.
  Put in some pledgets; squeeze the water from one
and put it on the eye.   Change this in two minutes
for a hot one.  If there is any suppuration a fresh
pledget must be used for each application.  Con-
tinue the treatment the required length of time and
keep the solution at the prescribed temperature.
  If both eyes are to be treated use separate bowls
and compresses  for each eye and  squeeze the com-
presses for each  eye with a different hand. 
CHAPTER JX
                Care of Children

  Normal development of children and measures to promote it.
Some especially important facts regarding mental development.
Requirements for health.  Method of taking a baby's tempera-
ture. Suitable clothing for an infant.  Care of diapers. Demon-
stration 22: Lifting, weighing and dressing a baby. Reasons for
the modification of milk.  Care necessary in the preparation of
an infant's food and in its feeding.  Care of feeding bottles and
nipples.  Demonstration 23: Preparation of an infant's food and
the care of utensils required for the purpose.


Normal Development of Children and Measures
                   to Promote It

  Knowledge  of  what constitutes a normal rate
of development is of great  assistance in taking
care of children and therefore some of the  more
important  facts regarding it will be  given  here
though space will not allow of going into detail.
  The table following shows the average relative
weight and height  of normal children at different
ages and is a good indication of what  the rate of
growth should be.
                        196 
Care  of Children         197
		Weight	Height			Weight	Height
Age	Sex			Age	Sex		
		Pounds	Inches			Pounds	Inches
Birth	Boys	7-5	20.1	5 years	Boys	41.4	41.7
	Girls	7-i	19.9		Girls	.0.2	41-3
6 months	Boys	16.0	254	6 years	Boys	45-i	44.0
	Girls	i5-5«	25.0		Girls	43-5	43-5
1 year	Boys	21.2	29.0	7 years	Boys	49-5	46.1
	Girls	20.4	28.2		Girls	47.8	45-8
18 months	Boys	22.8	30.0	8 years	Boys	54-5	48.5
	Girls	22.0	29-5		Girls	52.2	47.8
2 years	Boys	28.5	330	9 years	Boys	59-8	50.0
	Girls	27.8	22.7		Girls	57-4	49.6
3 years	Boys	33-5	36.0	10 years	Boys	66.0	52.0
	Girls	3i-5	35-5		Girls	63.0	5i-7
4 years	Boys Girls	36.4 35-i	38.6 38-3				
  During  the  first five months of life a normal
baby, after  the  first few  days, will gain on an
average about four and a half to seven ounces
weekly and, from this time until it is a year old,
about two and a half to four ounces weekly; after
this, as can be seen in the table, growth is less
rapid.
  The development of a normal infant's muscles
is about as follows: Those  of the neck are usually
sufficiently strong to allow  a baby to hold its head
up by about the end of the third month, those of
the back are strong enough to allow the child to
sit up unsupported by the seventh or eighth month
and soon after this it will be able to creep.  As soon
as it is, creeping should be encouraged because it
will  strengthen  the muscles  involved,  namely, 
198         Nursing Methods

those of the abdomen,  buttocks, and thighs.  An
infant's pen furnishes an excellent means of allow-
ing a child to creep about  without getting into
danger and one can be made with a packing case
that will answer the purpose as well as anything
that can be bought.  The case should be about
eighteen  inches high and large enough to allow
the child to move about freely.  A washable lining
should be tacked in it in such a manner that it can
be removed when soiled.  A baby's clothes must
also be  considered in connection  with  muscle
development because  exercise  is  essential for
proper development and  the clothing must there-
fore not  interfere with free movement, especially
that of the legs.
  The bones of  the legs and  spine  are  usually
strong enough for a child to stand and begin to
walk when it is about a year old, but a baby should
not be allowed to do so much sooner because, until
this time, the bones do  not contain enough mineral
matter to make them sufficiently firm to  bear its
weight without  bending and,  therefore,  a  baby
that is allowed to stand and walk too soon is likely
to become bow-legged and to acquire an abnormal
spinal curvature.  A child's legs are also likely to
become bowed if its diapers are so large that they
keep the legs in an abnormal position.
   The cutting of the first teeth is about as follows:
    Names of Teeth.
2 lower central incisors
2 upper central incisors
Month of Appearance
    6th- 8th
    8th-12th 
Care of  Children           199
        Names of Teeth.          Month of Appearance.
    2 upper lateral incisors             ioth-i2th
    2 lower lateral incisors             12th-15th
    4 anterior molars                  14th-16th
    4 canine                        i8th-20th
    4 posterior molars                 I2th~30th

  The incisors are the central teeth, there are four
in each jaw; the canine are the pointed teeth, there
are two in each jaw, one on either side of the in-
cisors;  the anterior molars (known  also  as bi-
cuspids) are behind  the  canine and the posterior
molars behind the anterior.
  Delay in the cutting of the teeth much beyond
the ages mentioned above  is usually indicative of
poor nutrition.
  The  appearance of the  second set of teeth is
usually as follows:
        Names of Teeth.            Age of Eruption.
  First molars                   6th- 7th year
  Central and lateral incisors        7th- 9th "
  Bicuspids                     9th-ioth  "
  Canr'nes                     I2th-i4th "
  Second molars                 12th-16th
  Wisdom teeth or third molars     I7th-2ist or even later

  A very prevalent, but mistaken, idea  regarding
the teeth is that care of the first set is not impor-
tant.   On  the contrary, if  these are not cared for
in the proper way, bacteria are likely to reach their
roots and bring about conditions which will injure
the permanent ones; it is to be remembered that,
though the permanent teeth do not appear through 
200         Nursing Methods

the gums until the ages specified above, they begin
to form in early infancy.  Also,  if the milk teeth
are lost too soon the shape and condition of the
alveoli (cavities through which the teeth come and
in which their roots remain)  may be so altered
that the shape and normal  condition of the per-
manent teeth will be interfered with.
  Proper care of the teeth (first or second) implies
having them filled if cavities  form and brushing
them at least twice a day  with (in  the  case of
children) a small, very soft toothbrush1 and a little
tooth paste  or  powder.   The brush  should be
moved backward and forward across the teeth, and
also downward  on the upper  teeth and upward
on the lower, in front and behind. It is important
that this direction be observed  because, moving
the brush upward on the upper  teeth and down-
ward on the lower tends to make the gums recede
from the teeth  and to brush  foreign substances
under the gums and this favors  the formation of
abscesses in the alveoli.  Some of the bad effects
that may result from such infection are mentioned
on page 147.
  Some of the body glands are  very  imperfectly
developed  at birth.   The  lacrimal glands2 (see
  1 The  prophylactic toothbrush is a particularly good  variety
because the brush is curved in a manner that allows it to follow
the contour of the jaw, and the bristles are so arranged that they
get between the teeth.
  2 The lacrimal glands are situated just above  the eyeballs at
their outer angles.  They secrete the tears. The  tears are neces-
sary to keep the anterior of the eyeball moist and free from dirt; 
               Care of Children            201

Fig. 44) are not sufficiently developed to  secrete
tears until the third or fourth month, and,  especi-
Fig. 44.  The lacrimal apparatus of the right eye.
ally during this time, a baby's eyes must be  most
carefully  protected  from  strong light, dust, and
all forms  of   irritation.    During  infancy  the
glands1 that  secrete  digestive  juices have  very
limited power to manufacture  the enzymes2  re-

they pass across the eyeball and, if not evaporated, into small
channels that lead into the nose.  Ordinarily, we are not aware of
this secretion because evaporation just about keeps pace with
secretion* but, irritation of the eyes or psychic stimulation of the
glands induces such excessive secretion that the tears flow  over
the cheeks and into the nose.  Injury to these glands which pre-
vents them secreting may result in blindness because the conse-
quent dryness of  the membrane covering the eyes  and its  irri-
tation by dust, etc., induces inflammation and thickening which
interferes with the passage of light rays to the retina, see page 166.
  1 These are (i)  the salivary glands, which  discharge their  con-
tents into the mouth; (2)  glands in the wall  of the stomach and
small intestine;  (3) the pancreas; (4) the liver.
  2 Chemical substances, made by certain animal cells and plants,
which assist chemical reactions. 
202          Nursing Methods

quired  for digestion.  Only those needed for the
digestion of milk are made at first and but  small
amounts of these.  The ferments necessary for
the  digestion  of starch are not secreted in any
amount until a baby is nearly a  year old  and,
therefore any starchy food given an infant  must
be   predigested.1    Also  the   functioning   ca-
pacity  of some of the  glands which  make  the
hormones2 necessary  for metabolism3 develops
slowly and thus infants are very dependent  upon
chemical substances known  as vitamines present
in fresh milk, and older children upon those in fresh
fruit, vegetables, butter, and meat.  Vitamines are
destroyed by a high  temperature and  by drying
and, therefore, if a baby is fed with sterilized milk it
is likely to develop a disease due to defective meta-
bolism such as scurvy or rickets.
  The mucous membrane lining the alimentary
tract4 is very delicate and easily irritated during
childhood, and foods containing spices and other
irritant condiments may cause harmful  conditions

  1 The same changes that are produced in starch  during diges-
tion can be caused by long-continued cooking and by a ferment,
known as diastase, which is obtained from malted barley.
  2 Chemical substances, some of which are enzymes, that are
absorbed from the glands in which they are secreted by the blood
and carried to other parts of the body where they  either hasten
chemical reactions or stimulate the activity of the organs.
  J The chemical processes involved in the growth and repair of
tissue and in the oxidation of material derived from food which
provides the body with heat and energy.
  * The mouth, throat, esophagus, stomach, and intestines. 
              Care  of Children          203

in the stomach and intestines.   Even the lactic acid
in sour milk is too irritant for infants, though it will
not harm older children, provided the milk is pure.l
  The action of  a baby's  bowels can usually be
regulated in three or four months if, as soon as the
infant is a week old, it is held on a small chamber
at the same hours each day, the best times being
after the first or second morning feeding and a late
evening feeding.  For the first  few times that this
is done it will probably be necessary to induce re-
latively strong irritation by inserting a small piece
of soap in the anus,2  but, in a day or two, moving
the  finger  around the rectum  ought  to induce
enough irritation to produce the reflexes that cause
the rectum to expel its contents.  Even this irrita-
tion should be discontinued as soon as  possible,
though, at  first, this  will mean longer waiting for
the reflexes to occur.
  The skin, like the mucous  membrane, is very
easily irritated in early childhood and thus rough
  1 The lactic  acid is derived by the disintegration of lactose (the
sugar of milk).  The change is produced by certain bacteria—
which are always present in the ducts leading from cows' udders
and thus get into the milk.  These germs, however, are not danger-
ous to human  beings, but, unless milk is kept out of contact with
anything dirty, it will become infected with bacteria that dis-
integrate other constituents of the milk and produce substances
that are very harmful, but  do not necessarily change the taste or
appearance of  the milk.  Also, if milk is not properly cared for, it
may become contaminated with germs that, though they do not
induce any  changes in milk, will  cause diseases.  Scarlet fever,
typhoid fever, and various forms of dysentery have frequently
been traced to infected milk.
  2 The external opening of the rectum. 
204         Nursing Methods

clothing or friction from any source will cause
chafing; and wind, the sun's rays and irritant sub-
stances, such as impure soaps, and even pure soaps
in excess, will cause roughening of the skin. Also,
for the same reason,  children  are very subject to
skin diseases.
  The special senses touch and taste are already
developed when  a child  is born but a few days
elapse before an infant appears to hear and about
three weeks before its sight is at all acute.
  At birth, the skull is relatively large in propor-
tion to other parts of the body and its size increases
considerably during the first year and then more
slowly up to the seventh year when it will have
nearly attained its full growth.  During the first
few  months of life the skull  bones are soft and
pliable  and are not firmly united  and,  to some
extent,  the shape of the skull may be modified by
the growth of the brain but, later, development of
the brain does not affect the shape of the skull.
  Actual  increase in  the size  of the brain ceases
about the same time as the skull but other physical
changes in  its structure  continue for a varying
number of years.   When a child is born the outer
part of its cerebrum, * which consists chiefly of what
is known  as gray matter, is smooth  but gradually
  1 The upper and front portions of the brain.  It is this part of
the brain that is concerned with consciousness, that instigates
voluntary movements and perceives and interprets sensations;
for example, our eye and ears are merely the parts that are stimu-
lated by  external influences but it is because these stimuli are
transmitted to the brain that we hear and see. 
Care of  Children          205
ridges of various depths are formed.  This  de-
velopment goes on more slowly in the parts of the
brain known as the association areas, which are the
parts chiefly  concerned with the higher  mental
activities such as reasoning, judgment, self-control,
and will power.   Other changes undoubtedly go
on in the brain from the time of birth until death;
changes which are responsible for memories, habits,
etc., but their nature is almost entirely unknown.

Some Important Facts  Regarding Mental De-
                    velopment

  The first  signs of anything like  real  mental
activity  are observed when a child is about three
months old.   Then  a normal child begins to hold
out its hands  to clasp things that attract its atten-
tion-—it  is generally bright things or those which
produce  sound as watches that do so.  Shortly
after this it begins to recognize those whom it sees
frequently. When it is about a year old, it begins
to try to talk and  to imitate the acts of others.
From the time that it does this its character begins
to be formed, and, in some ways, what happens in
the brain of a young child in this process and in its
results may be likened to the making1 and use of a
  1 An unmarked plate or cylinder is made to revolve under a
stylus and  the person making the record sings or speaks, as the
case may be, in front of a cone-shaped tube at the bottom of which
there is a membrane, or other appliance, to which the stylus is
attached and which is vibrated by the waves made in the air by
the vocal cords which produce the voice.  The stylus cuts lines on
the surface of the plate that correspond to the vibrations in the air. 
206         Nursing Methods

phonograph record.  In the making of the record
a smooth, unmarked cylinder or plate is marked
by a stylus or needle with lines that correspond to
the vibrations in  the  air produced  by the  (for
example) singer's voice and, when the record thus
made is again put under the stylus of a phonograph
and made to revolve beneath it this stylus, moving
in the marks made by the first one, will make the
mechanism to which it  is attached give rise to the
same kinds of vibrations and, consequently, sounds
as those by which the lines were produced.  Let the
cylinder or plate represent the child's brain; the
singer,  its parents, brothers, sisters, and other com-
panions; the stylus, the nerve impulses that these
arouse.   The nature of the marks made in the
brain are unknown,  but,  psychologists consider
that anything which attracts a  child's attention
(and thus arouses  nerve impulses) will  leave an
indelible  pathway  or mark, even as the stylus
leaves  marks on the phonograph plate.   After a
child is about five years old, any circumstance that
is very interesting or startling to it, or sight, sound,
act, or thought  that is frequently repeated may
make such a deep impression on the  brain that it
will remain as a more or less distinct memory, but,
especially during the earlier years, few marks do
this.  Nevertheless, the tracing is there and, just
as the  record reproduces the voice of the singer,
so the character of a  child is a reproduction of the
marks made upon its brain by its associates.  How-
ever, the results of  the marks on the human record 
             Care of Children          207

(the character) cannot be as accurately foretold as
in the case of the phonograph record because so
many people and circumstances, some good, some
bad, are concerned in the making of the human one.
Also, the child's response to the impressions make
a great deal of difference in the final results; if it
imitates what it sees and hears the impressions in
the brain will be deepened1 and each repetition will
intensify the effect until the grooves become so
marked that the nerve impulses evoked by similar
thoughts, sights, sounds, etc., are almost  sure to
pass in them and induce  like responses—i.e., to
make the child  think or act as  on  previous occa-
sions.  It is thus that habits are formed.
  A pleasing phonograph record can be made by
a good singer, even though there are a  few flaws
in the plate, though, of course it will not be perfect,
but a  poor singer  could not produce a pleasing
record on the most perfect plate. These facts, also,
are generally  true of the  human record.   If the
protoplasm of the brain is poor,  the best examples
and training  cannot produce the best possible
character, but those who understand the natural
human instincts and how these can be trained or,
on  the other  hand,  perverted  by  disease  and
example can do much toward overcoming natural
or acquired deficiencies, but poor training,  unless

  1 The  terms deepened and groove  are used because they so ade-
quately express the permanency of impression and the difficulty,
encountered in changing  fixed habits, but, as frequently stated,
the actual nature of the impressions is unknown. 
208          Nursing  Methods

very strong influences for good are made by some
of the child's associates, will, except in rarest in-
stances, spoil the best inherited material.
  To summarize: A child's character will depend
upon: (i) The nature of  the brain protoplasm1
inherited from its parents; (2) the degree of health
in which this protoplasm2 is maintained; (3) the
examples (good or bad) set the child by its asso-
ciates and  the nature of the teaching it receives;
(4) the degree  to which  the child imitates the
examples of  others and  the frequency of  seeing,
hearing, and doing the same things in the same way;
(5) the nature of the things in which an interest is
aroused.  The characteristics formed in early life
can never be entirely eradicated  for they are the
results  of  indelible  impressions  through which
nerve impulses pass and control action and thought
even  as the stylus of the phonograph follows the
traces on the record.  Some of the impressions re-
main so vivid that we call them memories, others
are so faint that they never call forth any definite
consciousness but  even  these subconscious  ones
are the foundation of character.
   It is the parts or qualities of the cerebrum that
govern the emotions (love, dislike, etc.), and the
senses (the perception of things seen, heard, felt,

  1 For definition see page 352.
  2 Poor circulation of blood in the brain, abnormal conditions of
the blood, the toxins of disease will all have an injurious effect
upon the brain, just as they have upon other organs of the body,
and a diseased, or even a tired brain, cannot function properly. 
Care of Children          209
etc.) that develop earliest in life.  Also, the world
is new to the small child and it is very curious and
wants to know the why and how of everything and
its desire to imitate all that it sees and hears is
strong.
  After about the sixth or seventh year, the parts
of the brain that more especially control judgment,
will  power, the faculty of associating ideas and
experiences that we call  reasoning develop more
rapidly.   The  degree  to  which they  will do  so
depends upon (i) the nature of the brain;  (2) the
degree to which these functions are exercised; (3)
how soon the individual begins to exercise them.
For example: The will power that is necessary  to
concentrate the  attention on one's lessons and,
later  on one's business or occupation will  not be
developed unless it is exerted to keep the attention
fixed when it wants to wander and, if the individual
begins to make such effort at the age of nine or ten,
she will have less trouble in  doing so than if she
starts at fifteen,  and it will be easier to do it  at
fifteen than at  twenty;  after  twenty, it will be
almost impossible to attain the power of concentra-
tion  to  any great degree  if previous efforts have
not been successful.  It is  the same thing with the
power of reasoning and all  other faculties necessary
for success.  They  must  be  trained in youth  if
they are to be developed to the individual's fullest
capacity.   The way to train them and also the
instincts and capacities that  develop in early life
are taught in psychology.
14 
210         Nursing  Methods

           Requirements for Health

  The main requirements for health are:  i.  All
the fresh air possible.  In fine weather in summer,
a healthy  baby can be  taken out of doors when
it is a  week old; in cooler  weather, such as is
common in spring and fall,  when it is about a
month old; in winter, when it is about three months
old.  In fine  weather, the longer children, even
infants, are out of doors the better, but the latter
must be protected from wind and their eyes from
the sunlight.   The rooms in  which children live
must be well ventilated.  This, it will be  remem-
bered, involves having as free currents of air as
possible without creating a draft.  The tempera-
ture of the rooms should not be below 66° F.  nor
above 68°  or 690 F., except when a child is being
bathed when the room should be  between  730 and
77° F.
  2. Suitable  clothing.   Children,   especially,
should never wear tight clothing nor bands.  Any-
thing tight around the chest interferes with free
breathing movements  and then the lower areas of
the lungs do not expand as  they should and the
circulation of blood  and  air through these parts is
sluggish.  This diminishes the vitality of the cells
and they are less able to resist the action of bac-
teria if infection occurs.  Tight  clothing around
the abdomen may cause misplacement of  the ab-
dominal organs and interfere  with the circulation
of blood through them.  Tight garters inhibit the 
Care  of Children         211
flow of venous blood from the legs and predisposes
to enlargement of portions of the veins thus giv-
ing rise to a condition known as varicose veins.  In
infancy clothing that is too loose is also to be
avoided because the undergarments are then likely
to become creased and the folds will irritate the
skin.  The clothing worn next the skin should be of
a nature (i) to absorb moisture readily, and  thus
prevent such rapid evaporation of sweat that the
skin is chilled, and (2) to hold air within its meshes
and thereby (air being a poor conductor of heat)
prevent the  too rapid loss of heat from the body.
To comply with these  requirements the material
must be loosely woven and, for the best results, its
threads of a loose or fluffy nature.  At one  time
wool was the only material that complied well with
these  requirements but cotton and silk materials
can now be had which are almost as good and are
more  easily  laundried.  The amount of clothing
put on children while they are too young to know
when they are too hot or too cold is often wrong.
A prevalent,  but mistaken,  idea is that children
should be kept very warm; on the other hand, some
people go to the other extreme and  in order, so
they say,  "to harden the child" they clothe it too
lightly. Both extremes may be harmful for reasons
given in Chapters I and VI.  The amount of cloth-
ing should be regulated by the conditions of the
child's skin,  this should be slightly warm and dry
and not either hot and moist or cold.  What is
known as the Gertrude pattern is one of the best for 
212         Nursing  Methods

infant's clothing because the several pieces can be
put on at the same time and drawn up over the
child's feet and there are no bands to restrict
breathing and the circulation.  In early infancy
the skirts should be long enough to cover, but not
to drag upon,  the feet.   Two articles of infants'
clothing  that need special attention are the ab-
dominal  binder and  diapers.  The binder was
formerly  generally used until a baby was at least
three or four months old in  order to support the
abdominal  muscles,  but  most  physicians  now
believe that, as a rule,  the binder is not  really
needed after the first two weeks and that, unless
there is some special reason for it, a baby is better
without it, for, it is quite a difficult matter to put
it on  tightly enough to  support the muscles and
to keep  it  from  wrinkling  without restricting
breathing.  The best  kind  of diapers to use is
mentioned on page 226.  Some especially impor-
tant  considerations in their adjustment and use
are as follows: A diaper  must never be drawn too
tightly around the body nor be put on in a manner
to bend the child's legs  nor keep them too far apart.
A diaper should be changed as soon as it is wet and
it must not be used again, even though  only wet
with urine, until it has been washed. Cheap soaps
must never be used for washing diapers and, even
when pure soaps are used, diapers must be very
thoroughly rinsed  in  clear water, for any  alkali
remaining in the diapers is likely to cause chafing
of the buttocks. 
Care of Children         213
  3.  Proper feeding.   This is too lengthy a sub-
ject to be considered here in detail and only a few
especially important points will be mentioned,
viz.:  Never give a  young infant food that has not
been prescribed a physician, if it  is fed with cows'
or goats' milk, the  proportion of the constituents
must  be altered (according to  the doctor's direc-
tions) to resemble that of human milk.  The milk
must  be kept in absolutely clean utensils, to pre-
vent its contamination with bacteria, and cold, to
prevent the multiplication and activity of bacteria
that may be in it.  It is to be realized that unless
milk is boiled it is likely to contain some bacteria,
even  after it has been pasteurized, and, as pre-
viously stated, boiling will destroy the vitamines
which are essential for  a child's  health.   Exactly
the amount of food and the number of  feedings
ordered by a doctor are to be given.  Even after
infancy, food should not be taken between meals.
In early youth and during illness, while the quan-
tity of food taken at a time is relatively small, more
than  three meals  a day are required,  but these
must  be given at regular hours so that the stom-
ach will have time to  digest one meal and rest
before it is given more  work.   Foods that should.
not be given children until they have attained the
stated ages are as follows: Until they are fourteen
years of age, children should not be given  pies and
other pastry, highly spiced foods  or drinks, coffee,
tea, cider, soda water, and other carbonated drinks1
  '^lost effervescent drinks owe their effervescence to carbon dioxide, 
214          Nursing Methods

or alcoholic drinks of any kind.   Children under
seven years of age, should not be given, in addition
to the articles just mentioned, pork, ham, sausage,
salt fish,  dried beef, game, kidney, liver, corn,
cabbage, beets, cucumbers, raw vegetables other
than greens,  fried fish and vegetables, hot bread,
griddle  cakes, nuts; and even  after children are
seven years of  age, such foods must be given in
moderation.   Children  between  two  and  four
years of age, in addition to the above articles, must
not be given corned beef, raw greens and raw toma-
toes, sweet cakes, bananas, uncooked berries and
cherries and even other uncooked fruits,  except
their  juices,  must  only be given in  very small
amounts,  for a considerable portion of their solid
material is not digested, and  is  likely  to  cause
diarrhea,  because, as previously stated, a small
child's  intestinal tract  is  very  easily irritated.
Fruit juices,  especially  orange  juice, are particu-
larly good for  children because they contain  a
liberal quantity, of the chemical substances known
as vitamines which, as mentioned on page 202, aid
metabolism.  Appropriate diet for children.
  Between twelve and fourteen months:
  6.30 or 7 a.m., 4 per cent, milk, 6 ounces, diluted
with 3 ounces of well-cooked, strained cereal gruel.
  9 a.m., orange juice,1 one or two ounces.
   10 a.m., same as 6.30  a.m.

  'When expense has to be considered, the juice of canned
tomatoes may sometimes be substituted.  Tomatoes, unlike other
vegetables, do not lose their vitamines when canned, 
Care of Children          215
  2 p.m., beef juice, 2 ounces, or strained chicken,
beef, or mutton broth, 6 ounces.  Well-cooked and
strained cereal jelly, about 3 to 4 ounces with milk.
  6 and 10 p.m., same as 6.30 a.m.
  Between fourteen and eighteen months:
  7 a.m., milk, 4 per cent., 8 ounces.
  9 a.m.,  fruit juice, preferably orange, about 3
ounces.
  10.30 a.m., unstrained, but  well-cooked, cereal,
about  3  ounces,  with cream  1  ounce or milk 2
ounces. A piece of dry toast or rusk or zwieback.
Milk about 6 ounces.
  2 p.m.,  meat broth, about 4 ounces.   Either a
small baked potato or well-cooked rice with a soft
cooked egg.  A small piece of toast. Water, no milk.
  6 p.m., same as 10.30 omitting the toast.
  10 p.m., milk, about 6 ounces.
  Between eighteen months and two  years:
  This should  be the same as the  previous diet,
with the occasional substitution  of finely minced
chicken, beef, or white fish for the egg in the 2 p.m.
meal and the  addition  of a small amount (about
a  level tablespoonful)  of mashed and strained
carrot or peas  or spinach and a dessert of either
custard or strained cooked prunes or  apple sauce.
Also stale bread or toast and milk is added to the
6 P.M. meal, and the 10  p.m. meal is omitted.  Very
little sugar should be  used in cooking fruit for
infants and a little salt, but no sugar,  should be
served with the cereal.  If a baby is accustomed to
eat things without sugar it learns to  like them in 
216         Nursing  Methods

this way and too much sugar is one of the common
causes of digestive  disturbances  in  childhood.
Water should be given between meals.
  4.  Prevention   of  constipation.  Important
measures for doing this are:  Training the infant to
use the chamber as described on page 203 and, in
later life, going to  the toilet at a regular hour, soon
after breakfast being a good time.   Going to the
toilet as soon as the desire to do so is felt.  Nothing
is more likely to produce constipation than failure
to do this for, though defecation is to some extent
under voluntary control, the actual act is a reflex
one produced by nerve impulses that are aroused
by irritation of the rectum by material entering
it from the upper  part of the bowel and this reflex
becomes  less prompt and powerful if  it is con-
stantly interfered with by conscious effort, as when
one resists the desire to go to the toilet.  If further
treatment is needed  for infants, a doctor should
be consulted, older children and adults should eat
fruit, coarse cereals, and vegetables, and take  all
the exercise possible.  Constipation is very harm-
ful because when food residue stays too long in the
intestine it is decomposed by bacteria into sub-
stances that may be very harmful to the body.
  5. Training the body  to react  to  differences in
temperature as described in Chapter VI and  on
page 221.
  6.  Freedom from  irritating conditions such as
are induced by adenoids,  eyestrain,  and  other
remedial body defects. 
             Care of Children         217

  7.  Care  against infection  by  bacteria.  To
avoid the contracting or causing infections children
should be taught to observe  the  following pre-
cautions: Not to spit on the  ground; to  hold  a
handkerchief in  front of the face  when sneezing
or coughing; not to use public drinking-cups or
towels; not to touch the spout of a drinking-foun-
tain when taking a drink; not to wet the fingers
in the mouth before turning the leaves of a book;
not to put the fingers, money,  or any unnecessary
article in the mouth; not to take a  bite of another
child's candy, etc.; not to eat anything that looks
dirty or upon which flies have  been seen to alight;
to wash food and raw vegetables before eating them.
  8.  Sufficient rest and sufficient exercise.  Exer-
cise is of primary importance for maintaining nor-
mal muscle tone and circulation  of the blood.
Therefore, as previously stated an infant's clothing
and surroundings must not be  allowed to interfere
with its movements. A certain amount of crying,
about thirty or forty minutes a day, is good for a
baby, it exercises its lungs and other parts of its
breathing apparatus.  The cry of a healthy baby
will be loud and strong.  When a baby cries it
should not be petted and taken up or it will form
the habit of crying and do so more than it ought to.
If it cries too long or frequently means should be
taken to ascertain the cause.
  The nature of a child's cry often gives some clue
to its cause,  for example, if the child is in pain, the
cry is sharp and is usually accompanied with draw- 
218          Nursing Methods

ing up of the legs and distortion of the features; a
fretful,  moaning cry,  indicates  illness; a strong
fretful cry accompanied with sucking of the fingers
usually indicates hunger; but, if it is not time for a
feeding the child should not be indulged.  If it is fre-
quently hungry, however, the doctor's advice should
be sought as it may not be getting enough food.
  If a child is fretful and does not sleep properly
or shows other signs of distress it is well to take its
temperature and an infant's temperature is best
taken by  rectum.  The means of doing this can
not be demonstrated in class but, if the method of
taking it by mouth is known, the following instruc-
tions can be easily followed:
  Shake down the mercury,  lubricate the  bulb
with vaseline, insert it gently in the rectum for
about one inch pointing it, if the child is lying on
its back, slightly backward and, if it is lying face
downward,  slightly forward.  Hold  the  thermo-
meter in place for three minutes. Fig. 45 shows
the way in which  a child  is usually held when
taking its temperature as, when it is in this posi-
tion, its movements are easily restrained.

              Demonstration 22
Lifting, Weighing, Bathing, and Dressing a Baby1
  Equipment:  1.  A large doll in a crib.
  2.  Scales.
  1 This description is for a baby over two weeks old.  An infant
younger than this should be bathed by a nurse or, if this is im-
possible, following the directions of a doctor or nurse. 
Care of Children           219
   3.   A  wrap,  a  square  (about one yard)  of
flannelet is a good kind.
   4.   Two soft warmed towels.
   5.   A rubber apron.
   6.   A bath thermometer.
   7.   A small tub  about  two thirds full of water
with temperature of, at the time of use:
  For an infant under three months.......     950 to ioo° F.
  For an infant three months and upward..     900 to  960 F.
  For an infant one year.................     850 to  90° F.
  For an infant two years................     750 to  8o° F.
   8.   Soap or, better, a small basin of hot soap-
suds.   Only the purest unscented soap, such as Cas-
tile, should be used,  cheap soaps and cold  process
glycerine soaps are likely to contain free alkali which
irritates a baby's skin.
   9.   Pure unscented toilet powder in  a can with
a  perforated cover.   Powder puffs should never be
used.
   10.   Clothing1  consisting of:  A  binder  (this
should be used in class in  order to  learn how to put
one on though,  as previously stated, binders  are not
generally used after a child is about two weeks old)
a shirt, a flannel petticoat,  except in warm weather;
a  white petticoat, if desired; a dress; stockings;
diapers, a small  one of stockinet  (about fourteen
inches square for a small  baby) and a larger one
(about half to three quarters of a yard square) of
heavier material, for example, Canton flannel.
  1 To the Teacher:   It is well to have samples of good and poor
styles of clothing to show the pupils. 
220         Nursing Methods

  II.   Safety pins.
  12.   Scissors, needle, thread, and thimble.
  Points of special importance to remember when
lifting, weighing,  bathing, and  dressing a baby:
Do not startle an infant by lifting it quickly and
suddenly when it is asleep.
  Do  not  undress a baby in a room colder than
about 750 F.
  Always support a young baby's neck and back
while lifting and holding it.
  If possible weigh a baby about once  a week for
the weight is, as a rule a good index of its condition.
  Formerly it was thought that the baby should not
be exposed while being weighed and bathed, but it
is now believed that, if the room is about 75° F.
and the baby is healthy, it is well to  expose the
body to the air for a short time, but a wrap should
be put about the baby after it  is undressed and,
though it  may  be thrown back while the child is
in the scales and being bathed, etc., it must be kept
where it can be drawn about the baby if the latter
appears cold.  The weight of a wrap that is about
a baby while it is being weighed must be  ascer-
tained and deducted from the total weight.
   Keep the tub used  for bathing an infant exclu-
sively for that purpose.
   Have the  temperature of the water  correct.
To have it unnecessarily  hot is bad for a child for
reasons given in  Chapter VI,  and temperatures
lower than those mentioned on page  219  for the
given ages may also be harmful because a small 
Care of Children          221
child's system will not have been trained to react
to cold.  After a child is about two or three years
old it is well to complete the bath with a spray of
cold water—about  7o°-65°  F.   While using the
spray have the child stand in water about  8o° F.
and, for the first few times spray only part of the
body for a minute or two and do it in a manner to
amuse the baby, for if a  child is frightened or al-
lowed to feel cold, it is likely to dread the spray
and cold baths, which  is  to  be deplored, because,
for reasons given on page 95, they are a great help
in maintaining good health.  Having a floating toy
or two in the bath water is a help in making a child
enjoy its baths.
   While  bathing a baby  notice its general  condi-
tion, look especially for signs of chafing and at the
condition of the eyes and mouth. Formerly it was
customary to wash the eyes and mouth with boric
acid solution,  but now, most physicians consider
this not  only  unnecessary, but  injurious and be-
lieve that, when these organs are in a normal condi-
tion, washing  around the eyes with a clean wash
cloth and warm water when washing the face is all
the cleansing that the  eyes  require  and that the
mouth seldom, if ever, needs any cleaning until the
teeth appear.  Of course  if a baby has fever or
digestive disturbances, just  as in the case of an
adult, the mouth will become dry and coated, and
if  anything unclean, for  example a soiled  bottle
nipple, is put in a baby's mouth a condition known
as thrush  is likely to develop.  Thrush is caused 
222         Nursing  Methods

by a very prevalent microorganism that multiplies
rapidly in decomposing milk and sugar substances.
The first signs of the infection are white specks in
the mouth and increased redness of the membrane.
In such cases the mouth must be washed often
enough  to keep it  clean,  but a doctor's  advice
should be sought.
  Observe the following precautions when wash-
ing a child's mouth:  Wash your hands thoroughly.
Use only clean, soft material, such as absorbent
cotton (gauze is too rough).  Do not make this
moist enough for the  liquid to  be  swallowed for
even though this is not poisonous  it is very un-
desirable for material  from an infected mouth to
enter the stomach.   Use the utmost gentleness
when washing  the  mouth  for  more than  the
slightest degree of rubbing is likely to break  the
surface of the membrane and a very serious deep
infection may follow.  Very frequently all  that is
required to clean the  interior of the mouth is to
put a wad of moistened  cotton in the mouth and
the sucking movements that the child then makes
will cause sufficient rubbing.  To clean the interior
of the cheeks, outer border of the gums and, if
necessary, within the mouth, wind a piece of cotton
around one end of a  thin strip of whalebone, as di-
rected in Chapter IV, or your little finger.  Moisten
the cotton and move it about the mouth very, very
gently.  Change the cotton as often as necessary, do
not reinsert a soiled piece in the mouth.  Though the
washing is to be done gently, it must be thorough. 
■ l^fcte
Fig. 45.  Position in which to hold an infant when taking
                    its temperature. 
 
             Care of Children         223

  When dressing a baby do not put  any safety
pins, knots, or buttons where the child will lie upon
them and  use as few of such things as possible.
Never put a straight pin in a child's clothing and
use safety pins only for the diapers.
  Procedures: See  that  the temperature  of the
room is about 750 F.
  Arrange the scales and articles required for the
bath and dressing where you can reach them easily.
If the weather is cold  have them near a radiator
if possible and hang the wrap and towels on this
that they may be warmed.
  Weigh the wrap.
  Put on your apron; take the weighed wrap and
lifting the baby gently, so as not to startle it, put
the wrap1 around it with the opening on the side
that will be nearest you  when you sit with the
baby on your lap.
  Undress the baby.   While doing so  sit with it
lying in your lap and draw its clothing off over its
feet.
  Put the wrap in the scales and the baby on the
wrap and note the weight.  Deduct the weight  of
the wrap from the total.
  Hold the baby in your lap with one  side of the
wrap covering your apron and the other ready  to
be drawn around the child if necessary.
  See that the temperature of the bath water  is
accurate.
  1 The wrap is put around the baby so that when it is undressed
it will not come in contact with your rubber apron. 
2^4         Nursing Methods

  Proceed  with  the bath.   An  infant may  be
bathed in the lap or sprayed or, after  it is three
weeks old, a healthy infant may be put into a small
tub.   As previously stated,  it is rarely necessary
to use soap more than once a week.   Wash first
the face, head, and neck and  then in turn the arms,
chest, legs,  back, buttocks, and between the legs.
Pay particular attention to  the eyelids, ears, but-
tocks and all parts where two surfaces of skin come
together.  When bathing a  baby in your lap, dry
each part before  proceeding  to another and, when
the bath is  completed, draw the wrap around the
child and by gently rubbing  over the former make
sure that there is no moisture on the body.  Then
put your left arm under the wrap in a manner to
adequately  support the baby, draw the dry warm
towel  over your lap, discard  the wrap and put the
baby  down on the towel.  When putting a baby
into a  tub bath, have your left wrist and hand under
its head and shoulders with  your thumb and little
finger extending  into  the axillae.  Hold the legs
with your right hand.  Keep your left hand in the
same position during the bath and wash with your
right hand.  Do not keep the baby in the tub more
than two or three minutes.   To lift it, take hold of
the legs in the same manner as when putting it into
the tub; raise it from the water and hold it for a
second or two above the tub, then put it on your
lap and bring the wrap around it; dry it by gently
patting over the  latter and with one of the warm
towels.  Then  replace  the wrap with a dry towel 
Care  of Children          225
as when giving the bath in the lap.  The method of
giving a spray bath is so dependent upon the kind
of apparatus used  that no adequate description
can be given.
   Powder the baby if necessary.  To do so, shake
a little over the parts where it is required and then
rub it gently with your hand.  The powder is used
to dry the skin  and thus prevent chafing and,
except in hot weather, all that is usually required
is a little between the buttocks, in the groins and
axillae and some babies do not even need this much.
   Dress the baby:  If a binder is to be used1 put
it around the abdomen, draw  it firmly enough to
keep it from wrinkling, but not so tightly that it
will interfere with breathing.  Sew it in front with
coarse thread.
   Put  the shirt on; if it is closed, draw it upward
over the feet.  To get the child's arms  into the
sleeves, put the  fingers  of your right hand  up
through a  sleeve and, taking  hold of the child's
hand, draw its arm down through the sleeve.
   Fold a small diaper cornerwise,  place it under
the child's buttocks with the  longest side at the
waistline, bring the three  corners together in front
and pin them with as small a safety pin as can be
used conveniently.   Fold a large diaper in  the
same  manner as the  small one,  pin  it  around
the waist and, with the small  one, to the tab on
the shirt that is intended for the purpose.   Do not
  1 The objections to its use when not needed were mentioned
on page 212.
    15 
226         Nursing Methods

bring the ends of the large diaper up between the
legs.
  If possible arrange the remainder of the garments
one inside the other so that they can be put on at
Fig. 46.  Shape of folded diaper.
the same time.  Draw them up over the legs and
draw the arms into the sleeves in the manner de-
scribed for the shirt.

              Demonstration 23

Preparation of an Infant's Food.  Care of Bottles,
          Nipples, and Other Utensils

  Articles required:  1.  Two bottles of 4 per cent.
milk.z
  2.  A prong for removing the cover.
  3.  Nursing bottles.  The standard graduated
Hygeia nursing bottle is the best type, for it can be
easily cleaned.  There should be a bottle for each
feeding that  the baby is  to have in the twenty-
four hours.
  1 Milk containing 4 per cent. fat. This is the amount usually
contained in good cow's milk in temperate climates. 
Care of Children           227
  4.  A basket with a handle in which to stand the
bottle.  There  are special wire baskets to be had
for this purpose, but a wicker one
that  has  fairly straight  sides  will
answer or,  if the milk is  not to be
pasteurized, a deep dish or bowl can
be substituted.
  5.  A granite pot large  enough to
hold the basket of bottles.
  6.  Absorbent cotton  or  rubber
corks1 to fit the nursing bottles.
  7.  A Chapin dipper.
  8.  An enamel quart pitcher.
  9.  A thirty-two ounce graduated
glass measure  or, if this  cannot be
obtained  a small  measure and an
extra enamel pitcher.
   10.   A teaspoon.
   11.   A glass rod2 about two inches longer than
the glass  measure.
   12.   A funnel to fit the nursing bottles.
   13.   A dairy thermometer, if the  milk is to be
pasteurized.
  1 Ordinary corks are so porous that germs can pass through
them.  Sterile absorbent  cotton  makes the best stopper but is
expensive and rubber corks answer the purpose if they are washed
and boiled daily.
  2 A glass rod is better than a spoon for stirring the milk mixture
because a spoon that has a small enough bowl to  fit into the
measure will not have a long enough handle to make it unneces-
sary for the hand to be within the circumference of the measure.
Such rods are inexpensive and can be bought at almost any drug
store.
Fig. 47.  Ideal
nursing bottle. 
228           Nursing Methods


   14.   Some sugar, either cane sugar or lactose.1
   15.  A   pitcher   of  boiled  water   or   cereal
water.2
   16.  Boracic acid powder.
   17.  Nipples, preferably one for each bottle.3
   18.  A small saucepan and 2 small covered jars
for the nipples.
   19.  A clean apron.
   20.  A piece of clean white oilcloth such as is
used for covering tables, or,  if this  cannot be ob-
tained, a clean towel.
   21.  Two clean towels.


   1 Lactose is the natural sugar of milk and is prepared from it—
it  is not as heavy as granulated cane sugar, two tablespoonfuls
of cane sugar and three of lactose weighing an ounce. This differ-
ence in weight must be remembered if necessary to substitute one
sugar for another when preparing a feeding.
   2 Specially prepared  flours are generally used for making cereal
waters for infants, as, if the untreated grains are used they must
be cooked for from three to six hours, the reasons for this were
mentioned on page 202.  To  prepare a cereal water,  make the
amount of flour prescribed into a paste with a little cold water
then, add (slowly to prevent lumping) the amount of boiling water
required, stirring the mixture constantly as you do so.  Cook this
in a double boiler the length of time specified; it will be necessary
to stir it constantly for a short time and occasionally afterward.
If the amount is reduced during cooking, add enough boiling water
to replace that lost, e.g., if the doctor told you to use two table
spoons of flour to a quart of water, if there is less than a quart of
cereal  water at the completion of cooking,  add enough boihng
water  to make this amount, otharwise, there will be more flour
in the water than the  doctor intended and it may be more than
the baby can assimilate.
  3 The reason for this is that  there is likely to be lack of care in
the cleaning of a nipple when it has to be done after each feeding. 
Care of Children           229
  22.   A  bottle-brush, for cleaning the  bottles,
and a small hand-brush for cleaning the nipples.
  Points of special importance in       q
connection with an infant's feed-
ing:  A young baby  should  not
be  given  any food that  has  not
been prescribed by a doctor.
  In preparing the food, the mea-
surements  must  be   absolutely       J§
                                          tit*1
correct.                            Fig 48  Brush jor
  Everything used for the prepara-   cleaning bottles.
tion must be perfectly clean.
  The  milk should be kept in the same compart-
ment as  the  ice and surrounded  by the latter,
nothing else should be placed near it.  If there is
not ice, each bottle should be rolled in  a layer of
wet cheesecloth  and  stood in  a pan  containing
water and this placed in a draft.
   If the milk is not certified or pasteurized1 when
obtained—it should be pasteurized after it is pre-
pared  and, after this  is  done, it must  be cooled
rapidly.2
  1 Milk obtained from dairies that are under the supervision of
the Board of Health and comply with certain rules made by the
Board which gives them the right to label their milk "Certified."
  * So-called after Pasteur one of the first bacteriologists to show
that spoiling of food was due to microorganisms.  Pasteurizing
'milk differs  from sterilizing  it in that the milk is  exposed to a
lower degree of temperature and for a shorter time  when  it  is
pasteurized than when it is sterilized, and thus fewer changes are
caused in the milk, but, though most of  the bacteria likely to
be in the milk are killed by the lower temperature, what are known
as spores, are not and these, if the milk remains warm, will de- 
230         Nursing Methods

  Fresh food must be prepared each day.
  The food for each feeding should be placed in a
separate bottle and, if any is left, it should be
thrown away.  Occasionally, even when the baby,
food, and nipple are all right, a baby will not take
the whole of a feeding, but when this happens it
should  be ascertained if  there is  any avoidable
cause; two common ones are: (i) too small a hole
in the nipple; (2)  the baby sleeps while it is being
fed.
  Bottles and nipples should be rinsed in (1) cold
water1; (2)  hot water as  soon  as they have been
used.  Each bottle should be kept filled with water
until it is cleansed. It is well to clean all the bottles
at the same time and, as they should be cold when
the milk is put into them, this  is best done in the
evening, if, as it usually  should be,  the  milk is
prepared in the morning.  However, some people,
for  convenience, prefer to  have two sets of bottles
so that those used one day can be cleansed at the
same time as the utensils used for the preparation
of the milk.  The bottles should be washed in hot
soapsuds, using a brush, and then very thoroughly
velop into bacteria.  Milk is a particularly favorable food for
bacteria and they develop very rapidly in it unless the milk is
kept at a temperature that is unfavorable for them, i.e., below
50° F.
  1 Milk contains a substance called albumin which is coagulated
by heat and, if hot water is used before all trace of the milk is
removed, this makes the glass look  smeared and it is difficult to
remove. 
Care of Children          231
rinsed and scalded with hot water.x  They should
then be inverted in the basket or a bowl so that
they  will drain,  and this stood  in  the pot and
covered.  Sometimes, especially in summer time,
it is well to boil the bottles.  To do this, fill the pot
sufficiently  to cover the bottles with cold  water2
and let this  come slowly  to boiling point and
boil for at least five minutes.  Let the water
cool and then pour it off and  invert the  bottles
to drain.
  It is well, if possible, to have as  many nipples as
bottles and to rinse each nipple after use in (i) cold
and (2) hot water and then  drop it into a covered
jar and wash  the entire supply  when washing the
bottles.  Wash  them with  a  brush  using  first
soapsuds and then hot water.  Wash both sides
of the nipples.   To turn a nipple, put the  end of
your finger against the point of the nipple, push it
upward and, at the same time, turn the open end of
the nipple down over  your finger.   After they are
washed, tie  the nipples in a  square of cheesecloth
and boil them for a minute—have the water boil-
ing before you put the nipples in and do not boil

  1 Always let the hot water run over as well as into the bottles so
that all parts of the glass will be expanded  at the same time by
the heat and then the glass will not break.
  2 If the bottles  are not in a basket something such as a piece of
wood or a folded towel should be placed between them and the
metal, because metal does not expand as readily as glass under the
influence of heat and it absorbs heat more rapidly than glass and
for these reasons, it is likely to crack the  bottles if it touches
them. 
 232         Nursing Methods

 them longer  than  necessary, as the heat  softens
 the rubber.  Pour off the water at once, expose the
 nipple to the air for a few minutes  (in the pan in
 which they were boiled) that  they  may dry and
 then  empty them into  a dry jar that has  been
 boiled and can  be tightly  covered.  After  they
 have  been boiled  the nipples must not come in
 contact with anything but the pan in which they
 were boiled and the sterile jar.
   If there is only  one nipple for use, wash  it  at
 once after use and  drop it into the solution.  Boil
 it once a day.
   If rubber corks are used boil them at the same
 time as the nipples.
   Especially  important  points  to remember re-
 garding the care of nipples are:  Always wash both
 sides of a nipple.
   After a nipple has been washed do  not touch the
 part that is to go in the baby's mouth.
   Always keep at least one new nipple in the house,
 for the hole in a nipple may become enlarged during
 the cleansing.
  Reason  for and nature of the modification  of
milk for infants: The milk of each species of animal
is suited to the requirements  and digestive capaci-
ties of its  young and, as the young of the lower
species of mammalia grow more rapidly than the
human infant, the  milks of these species contain
more solid matter than human milk; also, there is
some  difference in  the proportion of the various
solids as can be seen in the following table; 
               Care of Children           233

     Differences between Human and Cow's Milk

               Human Milk               Cow's Milk
  Protein,1    I to 2 per cent.              4   percent.
  Fat,        3  " 4  "  "            3 to  4   "  "
  Lactose,2    6  " 7  "  "                 4.5  "  "
  Mineral,    1  " 2  "  "                  .7  "  "
  Water,     87  " 88  "  "           86 to 87   "  "

  It is because of  these differences that milk ob-
tained from cows or other animals has to be modi-
fied3 before it is given to a young infant.
  The modification  of milk generally consists in
the addition of water and carbohydrate4 and some-
times lime water,s  and, for some infants, changing
the relative proportion of protein and fat.
  The carbohydrates generally added to milk are

  1 There are a variety of substances in foods that contain nitro-
gen and are classed as  proteins.   Two kinds found in milk are
albumin (this is coagulated by heat and appears as a scum on the
top of milk when it is heated) and caseinogen (this is curded by
acid and rennin).
  2 The sugar in milk.
  3 Changing the proportions of the constituents of milk from the
lower animals to resemble those of human milk is termed modi-
fication.  There are however other differences between the milks
that cannot be altered;  two important ones are: (1) if a child is
nursed it receives sterile milk, but other milk will only be sterile
if raised to  a temperature that causes other changes in it; (2)
human milk is likely to contain substances that protect the infant
from infection by bacteria.
  4 The principal foods classed as carbohydrates are: Starches,
sugars, cellulose (i. e., the fibrous portion of fruit, vegetables, and
other parts of plant) gums.
  s Lime  water  inhibits the formation of  hard curds in the
stomach and increases the body's supply of calcium, but it also
tends to retard digestion in the stomach and, therefore, it should
not be used unless ordered by the doctor. 
234          Nursing Methods

either lactose or granulated  sugar, and specially
prepared starch in the form  of cereal water.  As
previously mentioned starch that is subjected to a
high temperature or the action of certain ferments
will undergo the same changes as those induced by
digestion.
  The change in the relative proportions of protein
and fat is generally procured in either of two ways:
(i) cream is added to whole milk1;  (2) the milk is
allowed to stand until the cream rises to the top
and  then the number of  ounces  specified by the
doctor are removed.  The smaller the amount of
so-called top-milk removed, the more fat and less
protein will it contain because it is principally the
fat of milk that rises to the top.2  For examples, if
you  take the upper nine ounces from a bottle of
4 per cent, milk that has stood long enough for the
cream to rise it will contain 11.5 per cent, fat and
approximately 3.0 per cent, protein; while if you
remove  16 ounces you will have a top-milk con-
taining 7 per cent, fat and approximately 3.2 per
cent, protein.
  The easiest accurate way to remove cream from
a bottle of milk is with a  Chapin dipper (see Fig.
49).  This can be bought at almost any drug store.
The method of using it is described later.
  Care in the feeding of an infant is as important
as care in the preparation of its food.

  1 Milk from which none of the constituents have been removed.
  2 Milk containing 4 per cent. fat. This is the usual fat content
of good milk. 
Care of Children          235
  The points of special importance to observe in
the feeding  are: Make  milk lukewarm  before
giving it to an infant, but do not warm it until it is
required because germs multiply rapidly in warm
milk.  For this reason milk that is kept warm for a
number of hours in a  thermos bottle may be very
injurious to a child.  To warm the milk: remove
the stopper from the bottle, put a nipple on the
latter, being careful not to touch the part that is to
go in  the child's mouth, stand the bottle in a pan
containing enough hot water to reach beyond the
upper level of the milk.  To test the temperature
of the milk, invert the bottle and allow a few drops
to fall on the front surface of your wrist.J
  Ascertain if the hole in the nipple is the right
size at the same time  as you test temperature.  If
it is, when the bottle is inverted, the milk will flow
continuously in slow drops, but not in a continuous
stream.  If the hole is too small enlarge it by in-
serting a heated knitting needle in the hole.   If the
latter is too large the nipple should be discarded or,
if you have not a substitute, take special care to
regulate the flow of the milk by the slant of the
bottle.
  Always hold  the bottle  at a slant that will just
allow the infant to get the milk without undue effort.
  Do not allow a baby to sleep while it is being fed.
This will be more easily prevented if you hold it in
your lap during the process.
  1 The arm is more sensitive to changes of temperature than the
hand. 
236         Nursing Methods

  Do not allow a baby to suck the nipple after the
milk is finished, for by doing so it will get air into
its stomach and intestines and some physicians
believe  that all undue  sucking of nipples,  or
of the fingers,  or of pacifiers, by causing excessive
movement  of the soft  tissue  at the back of  the
throat, is  conducive to the undue development
of this  tissue  and  consequently of the growth
of adenoids.
  After a  feeding,  change the infant's diapers if
necessary  and  then put it in  its crib.  A baby
should never be played with  or rocked after a
feeding.
  Especially in hot weather,  infants need  water
between feedings, and water that has been boiled
for three minutes should be kept for the purpose.
A fresh supply should be prepared daily and kept
in a tightly corked bottle that has been boiled.
The  water  should not be actually cold when it is
given to the child and nothing should be added to
it unless prescribed by a doctor.   The baby will
usually take as much as it needs.   Restlessness is
apparently often due to thirst  for a baby is fre-
quently quieted when given a drink.
  Procedure in preparing a feeding: Roll up your
sleeves above  the  elbows  and scrub your hands
and arms.
  Put on a clean apron.
  Arrange  your equipment: Spread the oilcloth
where you  are to work; place the basket with the
inverted bottles at the left side; the pitchers and 
              Care  of Children          237

bottle of milk in the  center; the measures, spoons,
dipper, and other supplies at the right.
  Place your prescription where you can read it
easily.
  Take the cover from the milk bottle with  the
prong.
  If the prescription  calls for top-milk, remove the
number of ounces required.
  The two following  prescriptions, can be used for
class:
  ~Bf  i]/2 ozs. sugar;  12 ozs. of 7%  top-milk; 20
ounces of boiled water.J  Of this give 7 feedings of
4 ounces each.
  ]$  \}/2 ozs.  sugar; 30 ozs.  of 4% milk; 12 ozs. of
boiled water.   Of this give 6 feedings of 6 ounces
each.
  (The only difference in procedure in filling these
two prescriptions is in the preparation of the milk.)
  Put the  amount  of  sugar  required into  the
graduated measure and a little of the water.  Stir
the sugar until it is dissolved.
  For prescription 1, remove  the upper sixteen
ounces from a bottle  of milk.  To do  this open the
dipper as shown in Fig. 49, and lower it into  the
cream until its  upper edge is just below the upper
surface of the  cream,  then draw up the lower part
of the dipper until it is tightly closed; raise  the
  1 Plain water used to dilute milk for infant feeding should be
boiled, for three minutes, long enough before it will be required to
be absolutely cold when added to the milk. Recipes for preparing
cereal waters are printed on the packages of the cereal sold for
this purpose.  These also must be cold when used. 
233
Nursing Methods
dipper and, holding it over an empty pitcher, open
it again.  The Chapin dipper holds just one ounce
and therefore this procedure will have to be carried
                out  sixteen times, but, after the
                first ounce is removed, it will not
                be necessary to open the dipper
                when you lower it into the cream.
                Stir the top milk with the glass
                rod until it is thoroughly mixed.
                   For prescription 2, empty the
                whole bottle of milk into a pitcher
                and then either stir it  well or
                else pour it back into the bottle
                and again into the pitcher, for it
                is important that the cream  and
                milk be thoroughly mixed.
                   Hold the graduated measure
                with the line of the amount  you
                require on a level with your eyes
(be sure to notice how high the sugar solution comes
and allow for this), pour in the milk and then the
remainder of the water.
  Stir the mixture very thoroughly and then pour
it into the bottles; for prescription I, pour four
ounces into each of seven bottles, and, for prescrip-
tion 2, six ounces into each of six bottles.
  (When lime water is prescribed it can be added at
any time before the final stirring.  The ingredients
are usually mixed  in  the order  given above so  that
(i) the sugar may be thoroughly dissolved before the
milk is added; (2) adding the bulk of the water last is
   Fig. 49.
 Chapin dipper.
(a) Dipper closed
(b) Dipper open 
Care of Children          239
of help ift getting the ingredients thoroughly mixed.
It is important that the mixture be well stirred just
before it is put into the bottles, as otherwise the feed-"
ings may not all contain the same amount of cream.)
  Plug the bottles  tightly with absorbent cotton"
or rubber corks and place them in the basket.  If
the milk is not to be pasteurized put the basket
and its contents in the refrigerator amidst the ice.
  If the  milk is to be pasteurized have an extra
feeding  bottle and
put  some milk  or
water into it and a
dairy thermometer,
as in Fig. 50.  Stand
the basket of  bottles
in the pot and pour
enough  cold  water
around them to come
a  little  above  the
level of the milk in
the bottles.  Put the
pot on the stove and
let  the  water  heat
slowly  until the
liquid in  the extra
bottle  is  1400  F.
Then turn out the
flame, but watch the thermometer and, if necessary,
apply heat again.  The temperature of the milk is
to be kept at 1400 F. for thirty minutes.
  At the conclusion of the thirty minutes remove
Fig- 50.  Milk bottles arranged in
   basket for pasteurization. 
240         Nursing Methods

the basket of bottles, stand it in tepid water and
cool this as quickly as possible  without  breaking
the bottles.  This can be done by, at short inter-
vals, adding  small pieces of ice or cold  water to
that surrounding the bottles.
  As soon as the bottles are cool enough put them
in the refrigerator.
  Clean and put away the equipment: Wash all the
utensils in (i) cold water;  (2) hot soapsuds;  (3)
clear hot water.  Let the water run into and over
them; this is especially necessary in the case of the
glass utensils in order to keep them from breaking.
Invert the utensils to drain  and when they are dry
put them away.  It is well if possible to keep these
utensils solely for the preparation of the milk and
either in a covered  box or  rolled in clean towels.
If this is not done they should be scalded before
use.   The  method  of cleaning  the bottles  and
nipples has been already described. 
                 CHAPTER X

                   Bandaging

  Uses, kinds and sizes of bandages. How to make bandages.
Points to  remember when bandaging.   Demonstration  24:
Circular, spiral, spiral reverse, and figure-eight bandages.  Band-
ages for the leg, foot, heel, knee, arm, fingers, shoulder.  Tailed
and handkerchief bandages and slings.

  Equipment:  Bandages of different widths.
  A  bandage roller if possible.
  Pieces  of muslin  for  tailed and  handkerchief
bandages and slings.
  Bandages are used chiefly: To  keep surgical
dressings, splints, poultices and the  like in place;
to control the circulation of blood in a part when
there is hemorrhage  or swelling; to limit  motion
and  to afford support.
  Gauze  (cheesecloth) and muslin are  the materi-
als most commonly used for bandages, but various
others are also employed; e.g., crinoline impreg-
nated  with plaster which, when applied, consti-
tutes what is known as a plaster cast,  flannelet,
Canton flannel,  and rubber,  also bandages of a
special loose-meshed  material can now be bought,
at stores dealing in surgical supplies, that are par-
ticularly good for affording support to weak ankles
     16                241 
242         Nursing Methods

and  making  pressure  upon varicose veins  and
swollen parts.   Gauze bandages are usually  pre-
ferred to others for keeping surgical dressings in
place, because they are lighter and cooler and more
easily adjusted than those of other materials, but
the gauze is not firm enough to be used when pres-
sure and support are necessary.
  The average widths of bandages used for differ-
ent parts of the body are:  For the fingers, one inch
wide; for the head, arm, and foot, two to three
inches, according to the size of the patient; for the
thigh and trunk, three to four inches; for the heel,
three inches.
  Making bandages: When bandages are made in
large numbers they are rolled and cut by machin-
ery but,  for individual  use, the  material for  a
bandage can be cut or  torn and rolled by hand.
However, it must be properly rolled or the bandage
will be difficult to adjust.  The points  of special
importance are: The material must be smooth
(without wrinkles)  and  tightly  rolled  and  the
selvage and ravelings removed.   The selvage  is
removed before and the ravelings  after the mate-
rial is rolled.  The reason for the removal  of the
selvage is that it does not stretch as much as the
rest of the material and thus increases the difficulty
of getting uniform pressure.  To roll a bandage by
hand fold one end of the strip of material upon
itself several times until a small, but firm, roll is
formed.   Then hold the free part of  the strip
between the thumb and index fingers of the right 
Bandages              243
hand, hold the roll with the thumb of the left
hand on one end and the first finger on the other,
and rotate the roll until the bandage is completed.
Fig 51. Rolling a bandage by hand.
  Items of importance to remember when bandag-
ing are:  (1) A bandage must be put on tightly
enough to insure its remaining in place, but it must
never be so taut that it causes pain or, except when
prescribed for the purpose, interferes with the cir-
culation.  (2)  When there is a  wound or  acute
inflammation a bandage is generally put on par-
ticularly loosely, but, when it is intended to afford
support or pressure, it is usually put on as tightly
as possible without causing the effects mentioned
above.   In such case it is particularly important
that it be put on in such a manner that the pressure 
244         Nursing  Methods

is uniform over the entire part that is bandaged.
That it may be so, no one turn of the bandage must
not be tighter than another and each turn must
overlap the other  an equal distance.  The first
turn taken when starting the bandage is particu-
larly likely to be made too tight unless care is taken
to avoid it.  (3)  When bandaging a limb, the toes
or fingers are left uncovered if possible, even when
they are not to be moved, because their condition
shows if the bandage is too tight.  Indications that
it is are a deep red  or bluish color, and coldness of
the skin.  This precaution is especially important
when there is inflammation because,  even when
the bandage is loosely applied the swelling in the
part may increase and make it too tight.
                    When  bandaging, hold  the
                  bandage  roll side  upward in
                  your  right  hand,  begin  to
                  bandage  at the  distal  end of
                  the part  to  be covered and
                  work upward.  Always pin or
                  tie a  bandage so that the pin
                  or knot will not come in con-
                  tact  with any  part  of  the
                  patient's  body  or where  he
                  will not lie upon it.  To tie a
   Fig. 52.  Circular    bandage, tear a few inches of
      bandage.       the  material, twist the  two
                   ends  around each other, pass
them in  opposite directions around the limb and
then tie them over the twist.
 
Bandages              245
  The forms of bandages in most common use are
what  are known as the circular, spiral, the spiral
reverse, the figure of eight and the spica.
  The circular bandage consists of two  or three
turns made around a part, each turn covering the
preceding one.  (See Fig. 52.)
  The spiral bandage can be applied only to parts
of about uniform circumference.   It  consists of
Fig. 54.  Spiral reverse.          the reverse above.
circular turns, each one made higher than the pre-
ceding one, but overlapping it about one half its
width.
  The spiral reverse is similar to the spiral band- 
246         Nursing  Methods

age, but, in each turn, the material of the bandage
is reversed, i.e., turned over upon itself.  To make
the reverse, place the thumb of the left hand at the
point where the reverse is to be made, pronate the
right hand (in which the roll is held) and thus
double the bandage upon itself, as shown  in Fig.
54, and make sufficient traction on the bandage to
draw the turn into place.   Make each  reverse
directly above the  preceding one.  By thus re-
versing the bandage the turns can be  adjusted to
the contours  of the body;  this makes the spiral
reverse a particularly suitable bandage for the legs
and arms.
Fig. 56.  Figure-eight bandage.
  The figure-eight bandage consists of a series of
oblique turns alternately ascending and descending
and crossing each other in such a manner that they
form the figure eight around the part. This forms
the basis for many special bandages, such as those
used on joints. 
Bandages
247
Fig- 57-  Recurrent
    bandage.
  The recurrent bandage consists of a series of
turns passed back and forth across the part to be
bandaged, each turn overlap-
ping the other  one  half its
width.  The ends are secured
by  a circular  turn  around
them. The recurrent bandage
is used chiefly to retain dress-
ings in  place  on the  head,
ends of the fingers or toes.
  To bandage the foot, take
a circular turn around  the
ankle,  carry the roll  down
over  the top  of the foot
toward the toes, then  under
the foot near  the base  of
the toes and back over the top of the foot, cross-
                             ing the first turn in
                             the middle  line of
                             the  foot,  directly
                             above the toes; pass
                             the roll upward and
                             back  of  the ankle,
                             then  down  again
                             over and under the
                             foot as before. Con-
                             tinue the turns until
                             the foot is covered,
                             making  each  one
                             higher   than  the
other and covering  the preceding one about half
Fig. 58.  Foot bandage. 
248
Nursing Methods
Fig. 59.  Heel bandage.
its width.  It will be seen that this bandage is on
the principle of the figure-eight.
  To bandage the heel, use a three-inch bandage,
take a couple of turns around the heel  (1) then
                           carry the roll around
                           the ankle,  covering
                           the upper part of the
                           turns  around  the
                           heel for at least one
                           inch, pass obliquely
                           over the top  of the
                           foot;  (2) and then
                           under the foot (just
                           above the toes), up
                           over the top  of the
                           foot,  crossing  the
downward turn in  the middle of  the foot;  (3)
around  the  ankle  (covering half of the former
turn)  back again over the  top of the foot;  (4)
under the foot, and up around the  foot; (5) take
two turns around the ankle (6, 7).  The figures
refer to those in Fig. 59.
  To bandage the leg, take two turns around the
ankle and proceed up the leg with either reverse
or figure-eight turns. It is well, especially if the
patient is not confined  to bed after making three
or four turns (either reverse or figure-eight),  to
carry the bandage up and around the leg above
the calf then down around the leg to above the
regular turns and afterwards continue as at first.
The turn around the calf helps to keep the band 
                  Bandages              249

 age from slipping.  The knee is covered only when
 necessary, in which case proceed as for the elbow
 bandage.
   To apply a spica to the shoulder, fix the free end
 of the bandage by taking a couple of circular turns
 around the middle
 of  the arm of the
 injured side, make
 one  or  more re-
 verse   or   figure-
 eight  turns,  then
 carry the bandage
 across (for the right
 shoulder) the chest
 or  (for  the  left
 shoulder) the back,
 continue the  turn
 around   the  body
 (passing  under the
 armpit of the unin-    Fig% 6o_ Spica 0f the shoulder.
 jured side)  back to
 the injured side, pass the bandage obliquely around
 the arm on this side (forming the figure-eight) and
 then around the trunk as before.  Continue to make
 these turns until the shoulder is covered. Overlap
 the turns on the arm one half their width but con-
verge the bandage as it crosses the chest and  back
so that the fold under the armpit will be narrow.
  A spica for the thigh is put on in the same manner
as the shoulder spica except that the turns around
the trunk are carried upward to the waistline.
 
 250         Nursing Methods

   To bandage  the arm take one or two circular
 turns around the wrist and then  proceed up the
 arm with either figure-eight or reverse turns, do
 not cover the elbow unless necessary if the bandage
 is to be. continued up the upper arm, when you
 reach the elbow, carry the bandage up on the inner
                        side of the joint; take
                        a circular turn around
                        the arm  above the joint
                        and proceed  as on the
                        forearm.
                          When the elbow is to
                        be covered, discontinue
                        the figure-eight or re-
                        verse turns about two
                        inches below the joint,
                        flex the  forearm, carry
                        the  bandage  upward
   Fig. 61.  Elbow bandage.    and  around  the  el-
                        bow, in  a manner  to
have the point  of the latter in the center of the
bandage, bring the bandage downward inside the
joint and around the arm  (keeping the upper edge
of the bandage just below the point of the elbow),
pass upward  crossing the previous turn on the
inside of the joint, pass around the elbow (keeping
the lower edge of the bandage just above the point
of the joint), and then bring the bandage downward
again.  Repeat the turns, making that on the fore-
arm lower and that on the upper arm higher than
the preceding  ones,  then take a  circular  turn
 
Bandages
251
Fig. 62. Hand band-
age, fingers not in-
cluded.
around the upper arm and proceed with the figure-
eight or reverse.
  To bandage the  hand  without including the
fingers, take a circular turn around the hand at the
base of the fingers and, on reach-
ing the back of the hand for the
second time pass the bandage ob-
liquely across it and around the
front of the  wrist, then  down
across the  back  of  the  hand,
crossing  the former turn in the
              middle   of   the
              hand, around the
              palm   and   up
              across the  back
              of the hand again.
              Repeat  the  turns until the hand is
              covered, finish with a circular turn
              around the wrist.
                To bandage the hand when the
              fingers are to be covered put gauze
              or cotton  between the fingers and
              over the tops and, it is well to put
              powder on the cotton; these, if there
              is a wound, should be sterile.  Place
              the free end of the bandage about
              the middle of the palm  of the hand,
              in the center take a turn over the
              fingers, and down to the middle of
              the back of the hand, then take re-
current turns,  back and forth, across the tops of the
    63.  Hand
     ye. Fingers
covered with re-
current bandage.
Thumb  covered
separately   and
first with figure 8
or spiral reverse
turns. 
252         Nursing Methods

fingers, first on  one side and then on the other of
the first turn.  Hold these turns in place with the
thumb and first finger of  the left hand until the
fingers are covered, then secure them in place with
a circular turn  and bandage the hand as previ-
ously described.  If the thumb is to be bandaged
it is usually done before the hand.
  To bandage the thumb or a finger.  If the tip
is to be covered, take two or three recurrent turns
across the top and secure them in place with a
circular turn, otherwise begin with the circular
turn and proceed down the finger or thumb with
either figure-eight turns or reverse.  If more than
one finger is bandaged  and also the hand, it is cus-
tomary to, after getting to the base of one finger,
take a turn across the back of the hand, around
the wrist, up the palm of the hand, then make a
turn or two to carry the bandage to the top of the
next finger that is to  be bandaged and begin to
bandage as on the first finger.

     Slings, Handkerchief, and Tail Bandages

  The sling illustrated in Fig. 64 and the handker-
chief bandages  can be made by folding  a large
handkerchief or a  piece of muslin or other firm
material (about three quarters to one yard square)
diagonally, or the material can be cut diagonally.
The  result is a triangle as shown on Fig. 65.  For
the sling  shown in Fig. 66, either a triangular piece
of material with its central point folded in, or a 
                   Bandages                253

straight piece can be used.  The tail bandages con-
         Fig. 64.  Sling.  The two points are tied at
                  the back of the neck.

sist of muslin or similar material, long in  propor-
Fig. 65.  Shape of material for sling shown in Fig. 64 and
           for the handkerchief bandages.
tion to their width (the size depending upon the
part to be covered) split at each end.   The meth- 
254          Nursing Methods

ods of adjusting these slings and  bandages can*
be easily  learned  by studying and copying the
Fig. 66.  Sling.
illustrations and, therefore, space will not be taken
to describe them.
Fig. 67.  A handkerchief bandage for the head. 
Bandages
255
Fig. 68.  Hand-
kerchief bandage
for the liand.
Fig. 69.  Handkerchief bandage for the heel.
Fig. 70.  Handkerchief bandage for thefoot,
Fig. 71.  Four-tailed bandage     Fig. 72.  Tail bandage on
        of the head.                    back of head. 
256          Nursing Methods
Fig. 73-  Tail bandage on       Fig. 74.  Tail bandage for
      forehead.                     cyn^
Fig> 75.  Four-tail
  knee bandage. 
PART  II
                 CHAPTER XI

First Aid Treatment in Accident and Other
                 Emergencies
  The principles of first aid treatment. Nature, causes and first
aid treatment of: Unconsciousness; fainting or syncope; hysteria;
sunstroke; heat prostration; convulsions; chills.   Demonstra-
tion 25: First aid treatment in the above emergencies, including
lifting and carrying an unconscious patient who has fallen to the
ground.

  Equipment  for   demonstration:    Hot-water
bottles and some large glass bottles and corks to act
as substitutes.
  Covers for the bottles.
  Ice-cap and  cover and a basin of ice and com-
presses for the head as in Demonstration 21.
  Bath towel and hand towels.
  A foot-tub about three quarters full of water
105° F.
  A bath thermometer.
  A mouth thermometer
  The baby doll model.
  The  principles of first aid treatment:  In all
serious emergencies the following points are to be
remembered:
      1*                257 
258         Nursing Methods

  Do not get excited.
  Send for a doctor at once and, if possible, let
him  know what has occurred, but do not waste
time trying to get or give details.
  Do not, unless absolutely necessary, attempt to
give  treatment that can be only carried out prop-
erly by a physician or surgeon.
  Do not,  without a physician's advice, unless
absolutely necessary,  give drugs other than  the
simple remedies mentioned in the following pages.
  Do not molest  doctors  or  nurses with your
advice.
  If there is nothing for you to do keep away and,
if necessary, keep others away. A crowd around
a person who has met with an accident may be
very harmful for it is  likely to excite and disturb
her and to restrict her air supply.
  When an accident occurs out of doors it is well
to get the patient into a house as quickly as possible
but, before moving her, ascertain if there are any
signs of hemorrhage or fracture and if so take the
means described later to prevent harm being done
during the moving.  If possible, when the patient
is to be taken home, send someone ahead to notify
the family and  to give warning that the patient
is not to be excited and that a bed should be pre-
pared for her.  Naturally, endeavor must be made
not to alarm the family.
  If the patient is frightened, reassure her and, if
there is a severe wound or hemorrhage, take means
to prevent her seeing the extent of the injury. 
First Aid Treatment       259
  Keep the patient  quiet and lying down with,
unless there is apparently some injury to the head
or her face is flushed, her head as low as possible;
for  reasons given later, when  the conditions just
mentioned exist, the head is to be slightly raised,
though the patient is to be kept lying down.
  Loosen  the collar, tight bands, and corsets  for,
when the nervous system is depressed, even a very
moderate  constriction  interferes with  breathing
and the circulation of the blood and after a serious
accident there is always more or less  depression
of the nervous system.
  Do not try to give an unconscious person liquid
by  mouth for, when unconscious, a person is not
likely to be able to swallow and the fluid may get
into her trachea and  cause choking, but,  if the
person is  able to drink, and there is no reason to
suspect hemorrhage, give  all  the water possible
and hot drinks such as tea and coffee.
  If an unconscious  person vomits, turn her head
on one side so that the vomitus will run out of her
mouth, otherwise, it may get into the trachea.

                Unconsciousness

  Unconsciousness, known also as coma, is a state
in which an individual is insensible and cannot be
aroused.  It indicates  depression1  of  the  brain,
especially that part  known as the cerebrum.   It
results from  many causes, some of the  more com-
  1 Inability to function properly. 
260         Nursing Methods

mon ones being: Shock, collapse, fainting, apo-
plexy,  asphyxia,  sunstroke, poisoning either  by
poisons generated within the body, as described
under shock, or by drugs or alcoholic beverages.
  When a person is discovered unconscious it is
sometimes very difficult for even a physician to
determine the cause and, therefore, it is likely to
be quite impossible for anyone else to do so. En-
deavor should be made, however, to ascertain if the
condition is due to poisoning by drugs, sunstroke,
hemorrhage, or asphyxia, because these conditions
require  immediate  special  attention.   If this is
not the case and the patient is not having convul-
sions and her breathing does not show  signs of
ceasing, until the  doctor arrives, merely follow the
instructions given above, and, if the pulse becomes
weak and rapid, those given under Shock.

              Shock and Collapse

  Shock and a similar state known as collapse are
conditions in which the nervous system is depressed
and the blood is not circulating properly.  As de-
pression of the nervous system interferes with the
circulation of the blood and inefficient circulation
of blood in the brain and spinal cord will cause de-
pression of the nervous system, it is not always
known which of the two conditions is responsible
for the other.  In order to understand this and why
shock is produced by the causes mentioned later
it is necessary to recall the  following facts:  (i) 
First Aid  Treatment        261
The action of the heart is regulated by impulses
coming to it over nerve fibers extending from the
brain.  (2) The blood-vessels are maintained in a
state of partial contraction or tone  by nerve im-
pulses coming from the brain and spinal cord and,
if anything happens to depress (lessen the activity
of) any part of  the nervous mechanism concerned
in maintaining this state of tone, the blood-vessels
dilate and this not only interferes with the action
of the heart but with the power of the blood-vessels
to  propel  the blood  onward through  the body.
This is the state of affairs existing in shock.  (3)
If the heart muscle and the muscle tissue in the
walls of the blood-vessels are not in a healthy con-
dition they will not  respond properly to nerve
impulses.   (4) The action of the heart is also inter-
fered with if the amount of blood in the vessels is
reduced and this occurs when there is loss of blood
from the vessels, or excessive loss of fluid from the
body as the result of continued vomiting, diarrhea,
or profuse perspiration, also,  if the  blood-vessels
dilate,  practically the  same condition  will  be
present because, as just stated, the blood will not
pass onward through the veins.T
  No one of the above conditions can occur to a
marked  extent  without  inducing the  other nor
involving all other parts of the  body, because all
  1 The body can be likened to  a furnace, with machinery at-
tached.  The machinery will only work while the fire in the fur-
nace burns, and there will  only  be fire if coal or other fuel is
provided and also air and, consequently, oxygen, for burning con-
sists in the union of oxygen  with matter. 
262         Nursing Methods

the organs depend to some extent upon nerve im-
pulses to make them work, and they also need the
oxygen and fuel material brought to them by the
blood to give them the energy which they need to
carry on the work,  and the nutrient material to
repair the waste  which  the work entails.  The
nervous system, especially the brain, will be the
first  part of the  body depressed if its nutrient,
oxygen and fuel supplys are limited.
  To say that an organ is depressed implies that its
power to function (carry on its work) is reduced.
The  opposite of depression is stimulation.   Any-
thing which stimulates or excites an organ enables
it to work more  rapidly and strongly, but over-
stimulation ends in depression, because the organ
becomes fatigued. For this reason fright, severe
pain, intense anger will eventually induce a more
or less intense state of shock. You have all, prob-
ably, at times experienced a sensation of faintness
following pain or the emotions  just mentioned,
and  this sensation  is induced  by a  mild state
of the  conditions  described  in the  preceding
paragraphs.
  The common causes of shock are: Hemorrhage
or excessive loss of fluid from the body from  such
causes as those mentioned on page 261; exhaustion,
as from starvation, exposure to cold, severe mental
strain, or protracted illness (in the last-mentioned
case  the condition is spoken of as collapse); terror;
intense pain; poisons, either those taken into the
body or those formed within the body. 
First Aid Treatment       263
  Poisons will be formed in the body by: (1) Bac-
teria, (2) interference with the chemical processes
(known as metabolism) that are constantly taking
place and upon which life depends; (3) failure of the
body to get rid of waste matter, either food residue,
which should be eliminated through the bowels; or
the waste matter arising in  the course of metabol-
ism, which should be expelled chiefly through the
kidneys and lungs; (4) substances produced by the
chemical changes that  occur in tissues when they
are injured, especially when they are macerated or
acted upon by corrosive drugs.  The poisons may
cause shock by depressing the nervous system, or
by  weakening the muscle of the heart or dilating
the blood-vessels
  The symptoms of severe shock are: The pulse
is weak and usually rapid;  the breathing shallow
and feeble; the skin is pale, cold, and clammy; the
face has an anxious expression; the pupils of the
eyes are more or less dilated  and the body tempera-
ture falls; when the shock follows an accident, the
patient may be much excited for a time, but the
excitement will be followed by a stupid condition
and, very commonly, unconsciousness.  The symp-
toms of shock usually develop slowly and may not
be apparent for some time after an accident, par-
ticularly if the person  is excited,  but, it is to be
remembered, a  serious accident  will always  be
followed by more or less shock, especially if it is
associated with conditions  that cause fear or  in-
volve much destruction of tissue, 
264         Nursing Methods

  The symptoms of slight shock are similar to
those just mentioned, but less marked.
  Three important things to be considered in the
treatment of severe shock, and to prevent shock
are: To  keep the patient warm, quiet,  and in
a position to  favor the  flow  of blood  to  the
brain.
  For the first requirement—warmth—wrap the
patient in blankets or whatever suitable substitute
can be obtained and, as soon as possible,  surround
her with hot-water bottles, glass bottles  can  be
used in emergency.  To avoid breakage while fill-
ing them, pour water over, as well as into them.
It is to be remembered that, when the circulation
in the skin is poor, as it always is in shock, a patient
is very easily burned.
  Quiet is essential to lessen the work of the heart;
as previously  stated, the  action  of the heart is
greatly interfered with  and any extra strain  may
be more than it can withstand.  To insure quiet it
is important to  reassure the patient, for  fear is
likely to  make her restless and also to make the
heart beat more  rapidly.  Though all tight bands
and clothing are  to be loosened it is not,  as a rule,
advisable to undress a patient who is  suffering
from shock until her pulse improves, as this is likely
to entail  too much movement.
  The required position is most easily obtained by
laying the patient, without pillows under her head
(except in the conditions mentioned on page  259),
on a bed or couch and, if the symptoms of shock 
          First Aid Treatment       265

become pronounced, raising the foot  of the bed;
this can be done by resting it on a table or putting
stools or a pile of magazines, etc., under each of
the legs of the foot of the bed.  If the individual
is out  of doors and there is nothing at hand to
facilitate getting her into the required position,
any  unevenness of  the  ground  must  be  taken
advantage  of.  Also when  carrying the patient
her head is to be kept low, therefore, the  short-
est  carrier should support the upper part  of the
body.
  If the patient's pulse becomes very weak  before
the doctor arrives, she can be given half a teaspoon-
ful of  aromatic  spirits of ammonia or  even  am-
monia  water1 in about two to three tablespoonsful
of water, or the bottle of ammonia or smelling salts
can be held so that the gas will pass into her nose
and mouth.   It can be given in the latter manner
even when the patient is unconscious, but care
must be taken in such case  because the ammonia
is very irritating to the membrane of the nose and
mouth and to eyes.  The ammonia  must not be
given by mouth when the shock is due to poisoning
by irritant drugs.  The value of  the ammonia in
helping to overcome shock  is due to its irritant
action  which gives rise to nerve impulses that pass
to the  brain and cord and are transmitted thence
to the heart and blood-vessels.

  1 Only half to one eighth this amount is to be given to a child,
but, except in extreme emergency, ammonia should not be given
a very young child. 
266         Nursing Methods

              Fainting or Syncope

  Fainting is  a condition of temporary  uncon-
sciousness brought about by interference with the
flow  of blood to the brain.  It is in effect a mild
stage of shock or collapse and is brought about by
the same causes.  Some  people, however,  faint
very readily, the sight of blood, the slightest pain
or nausea being sufficient to  make them do  so.
Probably  the  two most common causes for this
are ill health and suggestion.  Examples of sugges-
tion  are:  (i)  Some people, especially those who
have little self-control,  having heard others say
that  they fainted  on seeing blood expect to  do
likewise and, therefore, do; (2) a person who faints
once, may fear that she is likely to do so again and,
if she does not overcome the belief, is likely to do
so if  the occasion she fears arises; and, if a person
faints frequently,  especially  in  childhood,  the
habit is likely to be formed for, as previously stated,
pathways are  formed in the nervous  system,  by
either the voluntary or involuntary repetition of
acts, which increase the facility with which a per-
son responds to any stimulus in the same manner
as previously.  Thus, it can be seen  that, while
fainting may be due to serious conditions, it may
merely indicate  a  lack  of self-control, or undue
susceptibility to suggestion.
  Symptoms:  Before fainting a person is likely to
experience sensations of nausea and faintness and
to be conscious of roaring and ringing sounds in the 
           First Aid Treatment       267

ears; her face becomes pale and covered with per-
spiration, her pulse grows  relatively  weak and
rapid and  she becomes  unconscious;  as a rule
however the condition is of short duration.
  Treatment: The essential feature of the treat-
ment is to facilitate the flow of blood to the brain
and, if a person, on first feeling faint, bends forward
until her head is about on a level with her knees,
loss of consciousness may be prevented.   If this
does not answer,  lay her on her back,  loosen her
clothing and if she  is indoors  open a window.
Sprinkling a little cold water on the face may be of
help because the cold gives rise to  nerve impulses
which  are  transmitted, via the spinal cord and
brain, to the heart and blood-vessels.  Ammonia
may be given by inhalation when the patient is
conscious or by mouth in the doses mentioned on
page 265.  A drink of hot tea may make her feel
better,  because the  heat is  stimulant  and tea
contains caffeine which  stimulates  the  nervous
system.  Coffee also contains caffeine, but some
people when nauseated are not able to take coffee,
because some of  its other ingredients  sometimes
tend to increase this condition.

                   Hysteria

  Hysteria is a term applied to various abnormal
nervous  manifestations.   It is  seen usually in
persons who have not much  will-power or self-
control,  though,  occasionally, following severe 
268         Nursing  Methods

strain, either mental or physical, even a person of
normal mental caliber may give way to emotion
of an hysterical nature, such as uncontrollable
laughing  and crying.  The other more  common
phases of hysteria are simulated fainting and con-
vulsions,  but the individual  does  not  lose con-
sciousness and, if she is left alone, she will usually
promptly  recover,  while, on the  other hand,
attention  and  sympathy are  likely  to make her
worse.
  Treatment: Leave the person alone and see that
others do  likewise.  In the case first mentioned a
dose of aromatic spirits of ammonia (see page 265)
may be given or a drink of hot tea or coffee.

                  Sunstroke

  This condition is produced by  exposure to the
rays of the sun or  to extreme heat from other
sources, especially when the humidity is high.  As
stated in the Chapter on Ventilation, heat is elimi-
nated from the body chiefly by radiation from the
skin and by the evaporation of sweat and, if both
processes are interfered with, as they are when the
atmosphere is both hot and moist, the body tem-
perature may rise exceedingly high.  The  author
has seen  patients with  temperatures of  1200 F.
and possibly over, as this was as high as the ther-
mometer registered.
  The  symptoms are: Unconsciousness, the face
is red, the skin hot and dry, the pulse full and slow, 
          First Aid Treatment       269

the breathing labored and sighing, the temperature
rises gradually and, unless preventative measures
are taken, may become exceedingly high and death
is then likely to occur.
  The usual treatment consists in  putting  the
patient into a cold bath with an ice-cap  or com-
presses that are kept very cold on the head, or if a
bath  cannot be obtained the patient is wrapped
in a sheet that has been wet with cold water and is
kept wet by sprinkling it with cold water.  It must
not be covered because it is only by the evapora-
tion  of the water that it  will be sufficiently cold.
A fold of the wet sheet or wet towel must be placed
wherever two surfaces of the body come together,
as between  the legs and between the arms and
chest. If the patient's temperature  is very high
the doctor is likely to order ice rubbed over the
sheet, but, except in extreme cases and when there
is  delay in getting  a doctor,  an inexperienced
person should not resort to such drastic measures;
in fact, if a doctor can be obtained within a reason-
able time it is better for any who is not likely to
recognize symptoms of shock, to merely put cold
on the head, bathe the neck and chest and get the
bath  or sheets, water and  something to protect
the bed,  ready for use when the doctor comes.
The  temperature should  be taken by rectum or
axilla about every twenty minutes and the condi-
tion  of the  pulse ascertained every few minutes.
The  bath is discontinued when  the  temperature
falls  or if signs of shock become evident. 
270         Nursing Methods

               Heat Prostration

  The term heat prostration is applied to a condi-
tion brought about, as in the case of sunstroke, by
exposure to excessive heat, but the symptoms are
somewhat different.  They are: The patient be-
comes very faint, but not unconscious; the face is
pale  and the skin covered with perspiration; the
pulse is weak and rapid, the breathing quick and
shallow; the temperature is likely to rise consider-
ably above normal but not as high as in sunstroke.
  For treatment have the patient  lie down in a
cool  place, put cold compresses or an ice-cap on
the head;  give the patient all  the cold water that
she can drink and, if they are  at hand a dose (see
page  265) of  aromatic spirits of  ammonia  and
inhalations of  ammonia or smelling salts.  If the
patient does not recover promptly or the symptoms
are at all severe a doctor should be notified.

            Convulsions and Chills

  Convulsions are commonly described as violent
involuntary  contraction of the skeletal muscles
(those covering the skeleton or bony framework of
the body), practically all these muscles may be
involved or only those on one side  of the body or
only certain groups of muscles.
  With the exception of those due to epilepsy or
hysteria, convulsions are almost always due  to
excessive stimulation of the nervous system. They 
           First Aid Treatment       271

occur more readily in childhood than in later life,
for the nervous system is then more easily in-
fluenced and very trifling  irritation, such as that
due to the presence  of worms in the intestine or
indigestible  food in  the stomach or intestine, or
intense emotion as anger  or fear may excite the
nervous system sufficiently to induce a convulsion.
Common sources of  nerve-excitement and conse-
quent convulsions, in both adults and children are:
(1) Pressure on some part of the brain or spinal
cord,  as when there  is a fracture of the skull or
spinal  column,  or when there is hemorrhage into
the brain and a clot  forms, as may occur from an
accident or in  the condition known as apoplexy;
(2) many  poisons, both those  ingested and those
formed within the body as described on page 263;
(3) anything that prevents the body getting suffi-
cient oxygen.
   It may be difficult for even a doctor to determine
the cause  of convulsions, but nevertheless  it is
important for anyone seeing a person  in convul-
sions to try and ascertain it for the first-aid treat-
ment required depends upon the cause.  The first
points to be considered are: Is there any evidence
that poison has been taken; is it known if the
patient has kidney disease (in which case the con-
vulsions are probably due to a condition known as
uremia); is there any history of previous convul-
sions, this would suggest hysteria or epilepsy; has
the patient been subjected  to unusual strain, either
mental or physical, this in an elderly person, and 
272         Nursing Methods

associated  with the  symptoms  described  later
would suggest apoplexy.  If the patient is a child,
further questions to be asked  are: What it has
eaten, if it has shown any evidence of having worms
or been exposed to an infectious disease recently.
  Also, there are certain differences in the symp-
toms produced  by  some of the  causes of convul-
sions, that may aid in determining the cause, for
examples:
  In hysteria the patient is not unconscious and
takes care not to hurt herself.
  Before a convulsion due to epilepsy the patient
generally gives  a sharp cry and falls unconscious.
The muscles are at  first stiff and rigid, but are soon
thrown into violent contractions,  the muscles of
the jaws are involved so that there is danger of the
patient biting her tongue and the excessive move-
ment stimulates the secretion of saliva to such an
extent that there is foaming at the mouth.
  When the convulsions are due to the conditions
existing in uremia  (in which the kidneys are not
eliminating  the waste products of metabolism),
there is usually an  odor of urine to the breath,  the
face is likely to be flushed, the  breathing is of a
snoring character, the pulse is full and strong.
  The symptoms of apoplexy1 are very similar to
those of uremia except that (i) there is no odor of
urine to the breath; (2) the pupils of the eyes  are
usually dilated and of unequal size and (3) there is
usually paralysis of the part of the body that re-
  1 Apoplexy is due to the rupture of blood-vessels in the brain. 
First Aid Treatment       273
ceives nerve impulses from the portion of brain
upon which the clotted blood is pressing.
  Convulsions due to injury of the brain as the
result of fracture of the skull are generally asso-
ciated with symptoms similar to those of apoplexy,
except that the face is likely to be pale and there
may be hemorrhage from the ears, eyes, nose, and
mouth,  and signs of injury to the skull.
  Convulsions due to ingested poisons are asso-
ciated   with  other  symptoms  induced  by  the
poisons as described under Poisoning.
  It is very important to notice if all parts of the
body are convulsed, and if  not, which parts  are,
for this knowledge often helps the physician deter-
mine the cause of a convulsion, and the convulsion
may cease before he arrives.
  Treatment: For convulsions due to the hysteria,
as previously stated, leave the patient alone, but
watch  to see that she does not injure  herself,
though she is not likely to do so. When the con-
vulsions are known to  be epileptic it is  usually
better to leave the patient on the ground and the
only treatment required is:  (i) To put something
soft, as the edge  of a folded towel  between the
teeth at one corner of the mouth, so as to keep the
jaws apart to prevent  the tongue being  bitten;
and  (2) to loosen tight bands.  Do not try to re-
strain the patient's movements, for, by so doing,
you may injure her, but see that she does not strike
against anything.   If it is not positively known1
that the convulsion is epileptic, or if it lasts much
18 
274          Nursing Methods

longer than preceding ones, or there are unusual
symptoms,  notify  the doctor.  For convulsions
due  to  other causes,  send for the doctor imme-
diately; take the means just described to prevent
the patient biting her tongue; loosen tight clothing,
remove the cause  of  the  convulsion, if possible;
keep the patient lying down with her head slightly
elevated; put cold compresses or an ice-cap on the
head and watch  that she does not  injure herself
by knocking against anything.   If the patient is a
child put her into a bath with a temperature about
1050 F.,1 keep the cold application on her head.
After about fifteen or twenty minutes, remove the
child from  the bath and  place her between soft
blankets; do not  use too many covers for the child
must not be too warm, but avoid any danger of
chilling. Keep the room fairly dark and the child
as quiet as possible.  If the convulsion was due
to anything that the child has eaten the doctor
usually prescribes a dose of castor oil and an enema,
and  only allows water, or possibly whey,  to be
given by mouth for at least twenty-four hours.
  Chills, like convulsions, consist of involuntary
contractions of voluntary muscles,  but the con-

  1 As a thermometer can seldom be obtained in emergency it is
well for the pupils to test water of this temperature with their
arms  for it is important that the  water used for a bath to arrest
convulsions should be about this temperature, for, if it  is much
below 1050, it is not likely to have much effect and, if it is much
hotter, it will interfere with heat  elimination and as, during con-
vulsions, there is excessive heat formation in the body, it is most
important not to hinder its loss. 
           First Aid Treatment       275

tractions are less intensive and the condition is not
necessarily associated  with loss of  consciousness.
Chills are due to the same causes as convulsions
and  to  exposure to  cold.  They occur most fre-
quently in adult life because a  degree of nerve
excitement that induces a chill in an adult is likely
to create a convulsion in a child and, the younger
the  child,  the  more  likely  is  this  to  be the
case.
  The symptoms vary somewhat with the intensity
of the chill: there may be merely chilly sensations
and  slight shivering or the teeth may chatter and
the shivering become  so intense that the move-
ments are almost convulsive and, in such case, the
lips will become blue and the skin pale because the
blood-vessels near the  surface of the body will be
contracted  and the blood thus forced to  the in-
terior of the body.  Following such a chill  there is
likely to be a  considerable rise  of temperature,
especially if it  occurs  in the course of an infec-
tious disease,  because muscular  contractions
increase the oxidative  processes which are the
chief source of heat   in  the  body  and,  also,
whatever causes  the chill is likely to affect the
temperature, especially if bacteria are the active
agent.
  Treatment: If the chill is at all severe,  get the
patient  to bed as quickly as possible, wrap her in
blankets and put  hot-water bags  around  her.
Remove the blankets and hot-water bags as soon
as she stops shivering and if, as is likely to be the 
276         Nursing Methods

case, she has a headache, put cold compresses or an
ice-cap on her head.  Take her temperature and
if it  is more than a degree or two above normal
notify a doctor, because a chill is one of the first
symptoms at the onset of a number of serious dis-
eases, such as pneumonia, influenza, scarlet fever,
and measles.
  The usual treatment for slight chilling, especially
following exposure to cold, is to take a hot bath and
hot drinks, especially hot lemonade, and a dose of
aspirin (five or ten grains for an adult, two or five
for a child between twelve and  sixteen  (children
younger than twelve years should not be given such
drugs without a doctor's order)  and go to bed.
Care must be taken to keep warm after this treat-
ment because the aspirin, hot bath, and drink will
cause free perspiration, and exposure to cold or a
draft may hasten the evaporation of sweat to such
a degree that the body will be chilled and the con-
dition which the treatment is used to cure made
worse.  This condition consists of congestion of the
membrane of the air passages and, possibly, of other
internal organs.  Congestion in the air  passages
(throat, nose, bronchial tubes, lungs) favors the
activity of  the  various  species  of bacteria that
cause colds and the treatment, by increasing per-
spiration (and thus taking fluid from the blood)
and increasing the amount of blood in the skin,
lessens the internal  congestion  and  is therefore
likely to abort the cold. 
First Aid Treatment       ^77
              Demonstration  25

Lifting an Unconscious Patient from the Floor and
    the Treatment for Fainting,  Shock,  Chills,
    and Convulsions

  Procedures similar to those for this demonstra-
tion have been described in previous lessons and,
therefore, with the exception of lifting a patient
from the ground, the pupils should be able to carry
out the instructions given in the preceding pages
without further explanation. The doll can be used
for the treatment of a child with convulsions but
some  of the pupils  should act as subjects for the
other procedures, one  pretending to faint, another
to be in shock, another to be having a chill, and
another a convulsion; those pretending to be in
shock and to be having a convulsion  should lie on
the floor that they may be lifted and carried to bed.
Other pupils should  demonstrate the treatment
and should  act as  though the  emergencies  were
real, putting into effect the instruction given under
principles of first-aid treatment, as well as that for
the special  emergency,  and also the instruction
given in Chapter II regarding lifting and carrying
patients.
  To  lift a patient from the ground: Two pupils
crouch by the patient, on the same side, your feet
planted firmly on the  floor, your knees bent suffi-
ciently to make you low enough to pass your arms
readily under the patient.  If the latter is supposed 
27%         Nursing Methods

to have convulsions or to be suffering from injury
to the brain, let the taller of the two lifters be the
one to support the head, but, for the patient in
shock let the shorter of the two take  the  head.
As usual, one lifter is to give directions.  Be sure
that your skirts will not be in your way when you
rise.  Let  the  lifter at the  head pass one of  her
arms under the patient's shoulders  to the further
armpit, and the other under the small of the back,
while the other lifter  passes one of her arms under
the patient's hips and the other under her knees.
At word from the director, lift the patient unto
your knees.  Readjust your hold, make sure that
there is nothing in your  way and, following  the
directions given in Chapter II, carry the patient
to the bed. 
CHAPTER XII
      Asphyxia or Suffocation.  Artificial
                  Respiration

  Mechanism of breathing.  Nature, common causes and treat-
ment of asphyxia. Demonstration 26.  Artificial respiration and
treatment of an individual rescued from drowning.

  Equipment for demonstration: (1) A lungmotor
if possible.
  (2) Blankets or old coats or other  substitutes to
put under the chest as in Fig. 76.
  Review of the mechanism of breathing: In the
portion of the brain known as the medulla oblon-
gata there is a  small area called the respiratory
center from which impulses pass over nerve fibers
to the muscle tissue in  the diaphragm and to the
muscles which move the chest wall.  These  im-
pulses are the result of the stimulation of the center
by  the carbon dioxid carried through it by  the
blood.  The carbon dioxid  is formed in the tissues
by the oxidation of substances derived from food
that has been eaten, digested,absorbed,and carried
to the tissues by the blood.  The  impulses  dis-
charged into the muscle tissue make it contract,
and  this results in the diaphragm being pulled
down and the ribs being pulled outward and  up-
                       279 
2S0         Nursing  Methods

ward so that the chest cavity becomes considerably
enlarged.  The elastic lung tissue expands in keep-
ing with the chest walls  and this causes a partial
vacuum in its little air sacs and in  the passages
leading to them'  (the bronchial  tubes and  bron-
chioles)1 and then the pressure of the air around
the body is much greater than in the air sacs and
passages and therefore, air is  forced  into the air
tubes and sacs.  The expansion of  the  chest is
immediately followed by its contraction and some
of the air is then pressed out.   The air forced into
the air sacs during inspiration (the period in which
the chest expands), contains more oxygen and less
carbon dioxid than there is in the blood and thus,
as gases always tend to spread  out  through space
and are able to pass through the very thin walls of
the air sacs and the small blood-vessels in the lungs,
oxygen passes into the blood and the carbon dioxid
brought from the tissues leaves the blood and is
exhaled during expiration (the period in which the
chest contracts).  The oxygen inhaled unites with
a substance, known  as  hemoglobin, that is con-
tained in the red corpuscles of the blood,2 but the
combination is not very  stable and as the blood

  1 If the pupils have not studied physiology, they should, if
possible, be shown the lungs of sheep or calves and allowed to
blow them up and dissect them.
  2 The combination of hemoglobin and oxygen is known as oxy-
hemoglobin. This is of a red color and, therefore, the blood in the
arteries is red but that in the veins has a bluish tinge, the color of
the hemoglobin when not combined with oxygen, because much
of the oxygen has left the blood before it reaches the veins. 
         Asphyxia of Suffocation     281

passes through the tissues where there is no free
oxygen that in the red cells passes out of the blood-
vessels into the tissues and is used for the oxida-
tive processes necessary to supply the body with
heat  and energy.  The compounds with which
oxygen unites are decomposed and one of the waste
products of the decomposition is the carbon dioxid
which passes through the capillaries and lymph
vessels and is thus taken to the veins and is finally
eliminated, as previously stated, through the lungs.
  Asphyxia or  suffocation is a condition induced
by  an insufficient supply  of  oxygen in  the body.
The insufficiency may  be due  to  many  causes,
some of the more common ones being:  (i) An
insufficient supply of oxygen in the air, as at high
altitudes and in improperly ventilated mines.  (2)
Obstruction to  the entrance of air to the lungs as
by  (a) swelling of the throat or other air passages
such as occurs  in many diseases, but particularly
diphtheria, and as the result of injury to the tissues
by  irritating gases or corrosive liquids;  (b) the
entrance of foreign substances into the air passages
or (c)  external  pressure upon the  trachea  (wind-
pipe).   (3) Inflammation  of the lungs.  (4) In-
terference with the circulation of blood through
the lungs.   (5) Water in  the lungs—as occurs in
drowning.  (6)  The  inhalation  of certain gases,
especially carbon  monoxid (one of the constituents
of illuminating  gases), which unite with the hemo-
globin of the blood and thus  prevent it absorbing
oxygen.  (7) The destruction of the red  cells of 
282         Nursing Methods

the blood by poisons.  It is by this means that the
venom of certain snakes  causes death.  (8)  De-
pression of the part of the nervous system which
moves the muscles responsible for breathing.
  The symptoms  of  asphyxia  vary  somewhat
according to the degree of suffocation and its cause,
but there will be discoloration  of the skin,  es-
pecially that of the face, it  may be of a bluish tinge
or, in extreme cases,  a deep reddish purple; the
breathing is likely to be labored and gasping but
when  the asphyxia is due to depression of the
nervous system, the breathing may become very
slow and weak and cease suddenly and, when the
condition is associated with drowning, or hanging,
or collapse it may be almost impossible to tell if the
individual is breathing; if the asphyxia is profound
there  will be loss of consciousness and probably
convulsions.
  The treatment consists in removing the cause if
possible,  placing the  patient where  she  will get
fresh air, but  keeping her warm; giving artificial
respiration if necessary. Needless to say a doctor
must be sent for at once and, if possible, a lung-
motor. Such appliances are usually obtained from
hospitals, stores where surgical  supplies are sold,
and the emergency stations at bathing  beaches.

              Artificial Respiration

  Artificial  respiration consists  in  making  the
chest  wall alternately contract and expand in as 
          Artificial Respiration       283

nearly the same manner as in natural breathing as
possible.  The easiest method of giving artificial
respiration when  a lungmotor cannot be obtained
is that known as the Schaefer method.
  To carry out the Schaefer  method proceed as
follows:  Lay the  patient prone on the ground with
a pillow  or substitute under the lower part of the
Pressure on expiration
Pressure off inspiration
      Fig. 76. Schaefer method of artificial respiration.

chest, her head turned on one side and her arms
stretched above  it.   Kneel  across the patient's 
284         Nursing Methods

thighs, facing her head; place your hands flat over
the lower part of her back, covering the lower ribs
with your fingers pointing toward  the sides; lean
forward forcibly, throwing the weight of your body
upon your hands, thus making all possible pressure
upon  the  patient's  back; do this  gradually and
slowly (this movement which is a substitute for
expiration will force air and, if it is present, water
from  the  lungs); then,  as  gradually, relax your
pressure by slowly  straightening your back, but
keep your hands in position. Repeat these move-
ments of  alternate  pressure and relaxation at a
rate that will allow of about sixteen  (the two move-
men ts being counted  as one)   being  made per
minute.
  Important points to remember  in connection
with artificial respiration are: (i) The movements
are not to be quicker than those of ordinary breath-
ing.   (2) Unless it  is positively known that the
individual is dead, artificial respiration should be
maintained  for  about an hour because,  though
recovery is hardly likely if  breathing has ceased
for more than five minutes, it has  occurred when
the person has been under  water  a much  longer
time and apparently has not begun to breathe for
a very considerable  time after artificial respiration
has  been commenced.   (3) Even  after natural
breathing has started, it may cease suddenly and,
therefore, the patient should not be left alone  for
an hour or more.   (4) Pneumonia is a very com-
mon  sequela of conditions necessitating  artificial 
          Artificial Respiration       285

respiration,  and anything (e.g., damp clothing)
that will also favor the development of this disease
should be removed as quickly as possible.  If after
a person  has been rescued from drowning it is im-
possible  to  undress  her at once, something dry
should be put over her to retard evaporation and
consequent  chilling of the body and, as soon as
help can  be  obtained, even while artificial respira-
tion is being given, she should be undressed and
rolled in  dry blankets or substitutes and treated
for shock.

              Demonstration 26

Treatment  of  a Person Rescued from Drowning
              Artificial Respiration

  Procedure:  Let  some of the pupils be subjects
and the  others give the treatment,  they should
act as though the emergency were reaf.
Fig. 77.  Emptying water from the lungs. 
286         Nursing Methods

  Let each one,  as quickly as possible (i) see if
there is any seaweed in her patient's mouth, and
pretend to  (2) loosen tight bands.  (3) Turn the
patient prone on the ground, pass the hands under
her abdomen and raise her as in Fig. 77, to further
the flow of water from the lungs.
(4)  Place the patient prone on the ground with her
head turned on one side; throw something dry over
her, your own coat if necessary, and proceed with
artificial respiration as previously described. 
CHAPTER XIII
                    Wounds

  The nature, classification, means of repair, and common com-
plications of wounds. Causes of, and means of preventing, the
infection of wounds.  First aid treatment of wounds.  Demonstra-
tion 27:  Dressing a wound.

  Equipment for demonstration: The first aid box.
  Boiling water.
  Clean towels.
  Toilet basin and water, hot and cold, for the
hands.
  Paper bag or other receptacle for soiled pledgets,
etc.

        Nature and Classification of Wounds

  A wound is usually defined as a break in the con-
tinuity of body  tissue caused by violence or inten-
tional cutting.
  According to their nature wounds are classified
as:
  1.   Incised wounds, i.e., those in which the edges
are clean cut and there is no tearing of the tissues.
Such wounds are made with a sharp instrument as
a knife.
                       287 
288          Nursing Methods

  2.   Contused wounds, i.e., those associated with
contusion1 or bruising of the tissues.  The edges of
such wounds are usually crushed and jagged.  A
wound of this kind is generally made by a blow
from a heavy object or a fall.
  3.   Lacerated wounds; in  these the  edges  are
torn and mangled.  These are the kind of wounds
likely to be produced in accidents caused  by
machinery.
  4.   Punctured  wounds; in these the wound is
deep in proportion to its diameter and it has but a
small  opening.   Such wounds are produced by
pointed objects as nails, daggers, etc., and, some-
times, by bullets.
  Wounds  are  also classified according to their
origin (e.g., operative wounds, gunshot wounds, etc.)
and depending upon their freedom from, or contami-
nation with, bacteria, asascepticand infected wounds.
  Aseptic wounds are defined as wounds which are
sufficiently  free from  microorganisms to show no
symptoms of infection, and infected wounds, as
wounds which are invaded by organisms sufficient in
number and virulence to produce pathological symp-
toms.
  Allied to  wounds, though not usually thus classi-
fied, are the open sores  such as ulcers, pressure
sores,  and those caused by some forms of eczema
and other skin diseases.

  1 A contusion is a wound, associated with rupture of blood-
vessels, beneath the skin. The discoloration is due so the extrava-
sation of blood into the tissues. 
Wounds
289
               Healing of Wounds

  Four processes by which the body endeavors to
repair wounds in its tissues are:  Fighting infection;
the disintegration and removal of debris, such as
blood-clots  and  destroyed tissue cells; the proli-
feration of new cells; and, when possible, the seal-
ing together of the walls of the wound.
  Conditions  favorable for  these processes  are
promoted by the injury;  three of which are:  (1)
Blood escapes from the severed vessels and this
helps to wash out foreign  substances, including
bacteria, that have entered the wound.   (2)  The
blood-vessels  in  the part become dilated and this
interferes with the passage of blood, consequently
an unusual  amount of blood-plasm passes through
the walls of  the capillaries and, with it, white blood-
cells known as phagocytes1 which can either dis-
integrate or demolish small blood-clots, dead tissue
cells, and bacteria remaining in the wound.  This
plasm or lymph also supplies the extra food mater-
ial2 necessary for the growth of the new cells re-
quired to replace those destroyed and, as the plasm
is of a glutinous  nature, it helps to hold the walls
of the wound together if they are brought into
apposition.   (3)  The third important effect of the
  1 From the Greek phagein = to eat and kytos = a hollow vessel.
  2 If the congestion becomes so severe that the flow of fresh
blood through the wound is interfered with, the food supply for the
cells is limited, therefore the prevention of all unnecessary irrita-
tion and interference  with the circulation, as by tight bandages,
is one of the very essential considerations in the care of wounds.
     19 
290          Nursing Methods

injury  is the  stimulation of  the  reproductive
faculty of the cells.
  Reproduction of cells: All the tissues of the body
are composed of cells and what is known as intra-
cellular substance,  which is secreted by the cells.
In the beginning of life the body grows because the
cells absorb nutriment from the lymph1 increase
in size and  then divide, thus  forming new cells.
The cells  of some tissues, especially those of the
skin, blood, blood-vessels  and fibrous tissue,2 re-
tain this power of reproduction all through life,
but others,  especially those of  muscle  and nerve
tissue, lose it to a great extent, even before body
development ceases, and  then their growth de-
pends upon increase in the size of the cells and the
deposition of intracellular substance.   Therefore,
when a wound is made in muscle tissue, except in
very early youth, the destroyed muscle cells are
not replaced, but new cells arise from the fibrous3
tissue that is present in the walls of the wound,

  1 The material which exudes from the blood-vessels into the
tissues.
  'Fibrous tissue,  in the form of bands (ligaments) and cords
'tendons) holds the bones together at their joints and the muscles
to the bones and, in the form of thin sheets, it exists to some ex-
tent in almost all the soft tissues of the body, either affording a
foundation for their cells or holding the substance of the tissue
together and different tissues to each other.  If the skin or fat is
raised from a piece of meat and the flesh of the meat pulled apart
this fibrous tissue will be seen as thin white strands.
  3 A form of fibrous tissue, known as areolar tissue holds the
muscle cells together.  Also it holds different tissues together
;md thus it exists in all parts of the body. 
Wounds
291
and from the cells of the skin around the edges of
the wound, and from the cells of the injured blood-
vessels.   The  new  cells arising  from the blood-
vessels form small loops of capillaries that extend
into  the wound and thus the new fibrous tissue
and  skin are  supplied with blood.  In an  open
wound the  new capillaries and cells give the walls
of the wound a rough  granular appearance and
they are therefore called granulations.
  During the first stages of healing the new fibrous
tissue cells  are relatively large and soft, but they
gradually contract and harden, and thereby  press
upon the newly formed blood-vessels  and cause
their obliteration.  These effects result in the new
tissue becoming hard and inelastic and gradually
losing the red color that is characteristic of new
tissue while it is plentifully supplied with blood.
Eventually the part becomes whiter than the sur-
rounding skin.  The mark thus left is known as the
scar or cicatrix.
  The amount and degree of  hardness of  scar
tissue that will form following a wound  depends
upon several factors; important ones are:
  I.   The nature of the wound:  Naturally a small,
aseptic, incised wound will heal more rapidly than a
large wound, or one in which tissue has been des-
troyed by the  processes  associated with infection,
or one in which the edges are torn or contused.
  2.   How soon the walls of the wound are brought
together: Immediately following injury the  con-
ditions are  more favorable for agglutination than 
292         Nursing Methods

later, and the more firmly the walls  adhere, the
less the amount of new tissue required.
  3.  The age of the individual:  In youth, while
tissue growth is still in progress, a wound, other
conditions being equal, will heal more rapidly than
in adult life, and there is always a chance of the
reproduction of some muscle cells and of the fibrous
tissue remaining relatively pliable.  In old age, on
the contrary, scar tissue  is likely to become very
dense and inelastic.
  4.  The vitality  of the part:  If the  person's
health is poor at the time the wound is received or
if anything interferes with the circulation of blood
to the wounded part, healing is likely to be delayed.
  The more common causes of interference with the
circulation are a tight bandage and excessive con-
gestion in the  wound.  Excessive congestion is
likely to occur if the wounded part is  not kept at
rest or if its position favors the flow of blood into
and not from the part, for example, if the wound
is in the hand and this is allowed to hang down-
ward.
  A large scar is unsightly and, furthermore, if it
extends deeply into  the tissues, it may, by its con-
traction, cause a deformity that  will  seriously
interfere with  the movement of the part, this is
especially likely to be the case if the wound is near
a joint.
  Another factor of importance in the results of
wounds is the presence or absence of injury to other
tissue  than  muscle, e.g.,  tendons or  nerves.  If 
Wounds
293
either a tendon or nerve is cut the severed ends
should be sewn together by a  doctor at once for,
if much time is allowed to elapse, the ends will re-
tract and then some part below the injury may be
useless for ever more.
  Thus, the chief points to be considered in the
first aid treatment of wounds are: (1) The preven-
tion of infection, this is important with the smallest
of wounds, even a pin prick.   (2)  If the wound is
at all deep1 it is to be inspected by a doctor, this is
especially important if it has been made by a dirty
object, or one that has been near a stable or man-
ured soil,2 or  if a tendon or nerve seems  to  in-
volve in the injury—this  is particularly likely to
be the case in deep wounds of the wrist, hand or
fingers.   (3) If  the  sides of the wound  gape, or a
part  (e.g., the tip  of a finger) is cut away, means
should be taken to keep the raw flesh together and,
especially in the latter case, a doctor  should be
seen immediately so that the parts can be sutured;
if  this is done soon after the  injury occurs and

  1 Deep wounds are always more likely to be infected than super-
ficial ones because:  (1)  They are harder to clean; (2) some of the
most virulent microorganisms that infect wounds  thrive better
when they are out of contact with air.
  2 The germ that causes tetanus (lockjaw) is a normal habitat of
the intestines of some animals, especially horses, and thus wounds
acquired under the conditions mentioned above are particularly
dangerous.  Wounds made with fire-crackers and toy pistols have
frequently resulted  in tetanus, because of the soil on the hands
when the wounds were made and, in the accident, the soil and
germs are driven deeply into the flesh, away from the air, which is
favorable for the tetanus bacilli. 
294          Nursing  Methods

there is no infection the severed parts are likely to
grow together readily.  The treatment of hemor-
rhage and other common complications of wounds
will be found in Chapter XIV.
  Important means of preventing  infection are:
(i)  To let the wound bleed freely.1   If it does not
do so the part should be held in a position to en-
courage bleeding2 and pressure made from above
downward, toward the wound; this  is particularly
necessary after pricks such as are made with pins
on needles, because in such cases it is generally the
only preventative measure taken, and exceedingly
bad  infections have been  contracted by pricks
from pins and needles infected with bacteria.  (2)
A little tincture of iodine diluted to half the usual
strength3 (which is 7 per cent.) painted over the
wound and surrounding skin is an excellent means
of inhibiting infection for, unlike most disinfec-
tants,  it  penetrates the skin.   It will  make the
wound sting for a few minutes but this disagree-
able sensation  soon passes.  As moisture on the
skin interferes with absorption, the iodine should
be applied before the skin is washed, if washing is
necessary.  (3)  If the skin around the wound  is
dirty it should be washed with boiled water and,
  1 Of course caution must be observed if the blood is coming in
spurts, as this would indicate arterial hemorrhage, or if the bleed-
ing is excessive.
  2 Holding the bleeding part lower than the heart encourages
bleeding and raising it above the heart is an important step in
checking bleeding.
  * See footnote page 3. 
Wounds                295
if possible, green soap before a permanent dressing
is applied.   (4) Everything  that  is  to  come in
contact  with the wound itself  or with  anything
that will touch such articles must be made sterile
and kept sterile.1
  Infected  wounds: Nothing will  be said  here
regarding the  treatment  of  infected wounds, for
this is too important to be left  to home  care, but
some knowledge  of the processes that  occur in
infection will, I am  sure, be found interesting.
  Infection  of  wounds  implies,  as  previously
stated,  the entrance of bacteria into  a wound in
sufficient numbers to produce abnormal conditions.
Only certain  species  of bacteria,  chiefly  those
classed as pyogenic (pus-producing) have any effect
in wounds, but some species  which enter  the body
through wounds, will have very serious systemic ef-
fects ; of this class are the organisms causing tetanus
(lockjaw) and hydrophobia.2  It is usually with
the pyogenic types of bacteria that wounds become
infected.   There are  several varieties  of  these
bacteria, some  of which are much more virulent
than others, but they all induce the following con-

  1 It is to be understood that this  description is merely for a
superficial wound in which there is no foreign matter. If any of
the conditions mentioned as needing  a doctor's inspection exist, a
sterile dressing (see page  301) should be  applied  and the doctor
seen at once.  If iodine can be obtained without loss of time, it is
well to paint the skin around the wound before putting on the
dressing.
  2 The organism causing hydrophobia is injected into the body
by the bite of an animal usually a dog that has the disease. 
296         Nursing Methods
ditions, the more toxic  species doing  so more
rapidly and intensely than others.  As the result
of their life and growth, they induce local irritation
and consequently cause the dilation of the blood-
vessels in the part. This results in the collection of
an unusual amount of blood and the exudation of
an extra amount of fluid from the vessels into the
tissues. Thus the part becomes red, hot, swollen,
and painful.   A mild  stage of this  condition is
known as congestion and an intense stage as inflam-
mation, and the symptoms of inflammation are said
to be redness, heat, swelling, pain, and imperfect
functioning. Under such conditions large numbers
of the white  corpuscles of the blood, known  as
phagocytes, force their  way through the walls of
the vessels and proceed to demolish the bacteria
and, if they succeed, normal conditions in the part
are restored.   This is  known  as resolution.   On
the other  hand, if the phagocytes cannot destroy
the bacteria  they themselves are destroyed  in
large numbers, and also cells in the tissue of the
wound and then what is known as pus is formed.
The process of the formation of pus is termed sup-
puration.  Pus consists of: Disintegrated  tissue,
the material which exudes from the blood-vessels
as the result of their congestion, living and dead
bacteria and their toxins, the phagocytes that have
been destroyed by the bacteria.
  When suppuration occurs an incision must be
made in the tissue (by a surgeon) to allow the pus
to escape, otherwise the toxins, and even the  bac- 
Wounds
297
teria, may be absorbed and a very serious condition
known as septicemia (blood-poisoning) result. Also
the tissue may  become  so disintegrated by the
suppurative process that pus-filled cavities, known
as abscesses, will form.
  The presence  of  bacterial  toxins in the body,
both before  and after suppuration, stimulates the
formation of new phagocytes.  If a person is in a
healthy condition  the  new  cells develop  more
rapidly then otherwise, therefore, in the treatment
of infections everything must be done to maintain
the patient's health.  Another important item in
the treatment is to keep the infected part quiet,
for the movement of the muscles in the area hastens
the absorption of septic material  and furthers its
spread through the  surrounding tissues.
  Though not connected with the care of wounds,
a few words will be said here regarding what are
sometimes called focal infections:  Especially in
certain parts of the body,  such as the sockets or
alveoli of the teeth, and the cavities in the bones
of the forehead, and cheeks and those behind the
nose, and the tonsils when they are not normal,
bacteria may enter and live for long periods and
their presence, at least in the bone cavities, may
not be recognized because, as there are few nerves
in these parts, pain will not be induced and, as
there are few blood-vessels, the absorption of toxic
matter goes on so slowly that the progress of the
conditions it produces may be very insidious, but
many diseases of the joints (usually, though often 
298         Nursing Meshods

erroneously, called rheumatism), and infections of
the heart, and other diseases have been traced to
this  source.  Infections in the tonsils are more
easily  discovered  because  tonsillitis  generally
occurs.

              Demonstration  27

           Dressing a Simple Wound

  Important precautions to remember when dress-
ing a wound: (1)  Watch  that  nothing  unsterile
gets near the  wound or near anything that will
come in contact with the wound.  (2) When you
are not using the scissors and forceps keep them
in the  dish in which you sterilize  them.  (3)
Handle the gauze and cotton with the scissors and
forceps, never with your fingers, for it is impossible
to make these  sterile.   (4)  Either wipe the rim of
a bottle before pouring out a liquid or, if the latter
is not expensive, discard the first portion that flows
over the  rim.  (5) Remember the instructions,
given later, regarding the  direction  in which  the
skin is to be rubbed when washing around a wound.
(6) If  sterile gauze and cotton are not at hand
substitute clean, soft,  white muslin, and make it
sterile by ironing it or if there is no iron, boiling it.
Prepare one piece to act as a protector for those to
be used for the wound.
  Procedure:  Let one of the pupils pretend to be
the wounded person and sit near the table on which 
Wounds
299
the supplies are to be placed, and let another pro-
ceed as follows: cover the point of the orange stick
with soap and rub it under your nails; scrub your
hands thoroughly with  soap and hot water, soak
them in the hot water,x rinse them in cold water.2
  In  the instrument dish,  boil  enough water to
keep the instruments covered while they are being
sterilized; add about a quarter teaspoon of washing
soda for each cupful of water3; put a small wad of
clean muslin4 into the dish; open the scissors and
put them and the forceps with their points on the
muslin pad.  Let them boil  for three minutes, not
more,  because boiling blunts the  scissors.
  If the skin around the  wound is dirty and, for
class, it had better be pretended that it is, also boil
the small bowl, a piece of clean muslin, a nail brush,
and some water.
  While  the instruments  are  being  sterilized,
spread a clean towel  over the table with the sur-
face that was folded inside uppermost.  Remove
the outer covers  from the  cotton and gauze, loosen
but do not  remove,  their  inner wrappers, place
them  on the towel.   Also,  get out  the adhesive

  1 This is to increase the activity of the sweat glands in the skin
so that the perspiration will wash  out bacteria from the ducts
leading from the glands to the skin.
  2 This is to check secretion and contract the muscle in the skin
so that any remaining bacteria will  not be washed to the surface
for the time being.
  3 This helps to  disinfect the  instruments and also  prevents
them from rusting.
  4 This is to protect the points which are  easily blunted. 
300         Nursing Methods

plaster, a bandage, ointment, if it will be required
(i.e., if there is so much abrasion of the skin that
the dressing would be likely to stick to the wound)
iodine and, if the skin is dirty, either green soap,1
lysol, or alcohol.
  As soon as the instruments are sterile  pour the
water from the dish, holding the latter so that their
blunt ends (and not the points) will touch the sides
of the dish if they move while you are doing so.
  Insert the points of the forceps under the cover
on the cotton  (do not let them touch the  outside),
open it enough to allow you to cut off a small swab
(about half inch square).  Dip this in the iodine
(remove and replace the cork in the bottle as de-
scribed on page 145); pass the swab over the wound
and surrounding area.
  If the skin  is very  dirty,  take the  small basin
from the boiling water  (you can use the forceps
for doing so), fill it with water and enough green
soap2 to make  a lather, or else put some alco-
hol into the bowl.   For the treatment of a real
wound about  fifteen minutes must be allowed to
elapse before the skin is  washed and the water can
be  cooling  sufficiently in the meantime,  however,
it should be used as hot as possible.  If practicable,
soak the part in the lather, if not soak some boiled
muslin or sterile gauze in the lather and cover the
  1 Other soap can be substituted, but this is better for surgical
purposes.
  2 Other soaps can be substituted, but these are better for surgi-
cal purposes for they are likely to be purer and they, especially
the lysol, are excellent disinfectants. 
Wounds
301
part with this.  When the skin and dirt are thus
softened take the forceps and scissors and, as pre-
viously directed, cut a  swab of cotton or gauze
about  two inches square and wash the skin sur-
rounding the wound; when doing  so, rub in the
direction of the axis of the wound, do not rub away
from  the wound,  because this draws  the edges
apart,  and do not rub toward it, because this may
wash foreign matter into it.  If necessary, the skin
at a distance from the wound can be scrubbed with
the nail brush  or boiled muslin.   Pour the clear
boiled water over the part and then dry it by gently
patting it with a fresh swab of cotton or of sterile
gauze.
  The dressing, unless there is much abrasion of
the skin, usually consists solely of gauze. Cut a
piece the size required and, touching it only with
the forceps and scissors, open out the folds and then
place it in a loose mass  over the wound.1 Use a
strip of adhesive plaster to hold it in place if the
bandage is not likely to make it sufficiently secure.
Put on the bandage.
  If the skin is abraided it will be better to use
something to keep the gauze from  sticking to the
wound.  In  hospitals, paraffin  preparations, that
are sprayed over the wound and become solid when
they dry, are much used for this purpose, for they do
not stick to the wound and can be readily lifted from it
when the dressing is changed, also caps made of wire
  1 When the gauze is arranged in this way it absorbs moisture
from the wound  better than when it is folded. 
302         Nursing Methods

and sterilized are used, the cap being secured over the
wound and the dressing put on over it, but such things
are not likely to be at hand in homes and sterilized
zinc oxid, purchased in a tube, is probably about
as good as anything that can be kept for emer-
gencies.  Do not use the portion of ointment that
comes first from the tube, remove it with the for-
ceps or a piece of sterile cotton, and do not let the
tip of the tube touch the portion of gauze that will
come next the wound. Leave the gauze  folded
when ointment is  used and let what will be the
outer surface of the gauze, when it  is over the
wound, rest on the clean towel while you are spread-
ing the ointment.   The scissors can be used for the
spreading if  there is no sterile spatula at hand for
the purpose.
  Procedure when changing a  dressing  on  a
wound: Prepare as for a first dressing, minus the
iodine and cleansing outfit, but, if the dressing has
stuck to the wound, provide  some warm  boiled
water and, if adhesive plaster was used, alcohol, if
possible, though the warm water will answer.
  Moisten the adhesive plaster where it is attached
to the skin, preferably with alcohol, then pull each
side in turn, quickly, toward the wound.  The re-
moval of the adhesive does not hurt as much when the
strips are pulled quickly as when they are dragged off
slowly.  If the dressing has stuck moisten it with
sufficient boiled water to allow of its easy removal,
but use as little water as possible and none  unless
necessary.  Wash away any dried blood from the 
Wounds
303
skin, preferably with alcohol, but  boiled warm
water can be used.  Do not touch the wound unless
you have been given special direction from a doctor;
the less a wound is touched or moistened the better.
Put on a fresh dressing. 
CHAPTER XIV
     Fractures.   Dislocations.   Sprains.
                 Hemorrhage.

  Nature of fractures.  How bone is repaired.  Symptoms and
first aid treatment of fractures.  Nature, symptoms, and treat-
ment of  dislocations and sprains.  Nature and  symptoms of
hemorrhage.  Natural resources of the body for arresting hemor-
rhage. First aid treatment of hemorrhage.  Demonstration 28:
First aid treatment of fractures and hemorrhage.

  Equipment for demonstration: Slings.
  Bandages.
  Splints and substitutes such as a cane, umbrella,
pieces of wood, thick cardboard.
  Charts showing the skeleton and the circulation.
  Material for  improvising tourniquets  such as
handkerchiefs, pieces of muslin, and stones, and
sticks.

                   Fractures

  A fracture  is what is commonly known as a
broken  bone.  A  fracture usually results  from
either a blow or fall.
  In old age  the bones break much  more easily
than in youth, and  in infancy they  are more likely
to bend than to break, or a bone may become bent
                       304 
Fractures             305
and  split  on one side,  a condition known as a
greenstick fracture, because it resembles the manner
in which newly  formed green twigs of trees  act
when endeavor is made to break them.
  The reason for this difference in fractures is that
at birth the bones  contain  very little  mineral
matter and resemble what  is known as cartilage,
a tough, but somewhat elastic substance that will
bend and stretch to some extent, but does not
break in the same manner as bone.  From the day
of birth, however, there is a gradual deposition of
mineral matter (obtained from food) in the bones
so that all through life they are becoming harder
but, as age advances, brittle.
  Sometimes, when a bone is broken, a wound is
also made in the soft tissues above the  bone so
that the latter is exposed to the open air. This
constitutes what is known as a compound fracture,
and it  is  a much more serious condition than a
simple fracture, as a break is called when  it is not
complicated with other injuries.  For one reason,
infection is very likely to occur and then the union
of the severed bones will be delayed and  possibly
prevented.
  Bones heal because new cells, derived from those
around the edges of the severed portions  of bone,
come into being and they, together with  material
which they excrete, and substances that exude from
the blood-vessels, soon form a tough, fibrous mater-
ial, known as callus that holds the severed ends
together.  Gradually, mineral matter, chiefly cal-
     20 
306         Nursing Methods

cium (lime) phosphate, is deposited in the callus,
and hardens it so that, in about ten days from the
date of fracture it will be fairly  firm and, at the
end of two months, if  the person is healthy and
there are no complications, the bone will probably
be as hard as before it was broken.
  The  special symptoms of  fracture are what is
known as crepitus, which is the sound heard when
the ends of the broken bone move against each
other and there is likely  to be  a false point of
motion, that  is, the bone moves at the point of
fracture.   Also, there will be  pain, redness, and
swelling (due to the increased amount of blood that
flows to the part as the result of the irritation) and,
sometimes, a purplish  discoloration  (due to the
extravasation of blood  into the tissues from rup-
tured capillaries).   Though the two symptoms
first mentioned are the only ones not present in
other injuries and, unless an X-ray picture is taken,
the only positive signs of fracture, no attempt is to
be made to discover them by anyone but a physi-
cian or surgeon for incompetent manipulation of
severed bones may cause serious injury to the sur-
rounding tissue.   To avoid any chance of trouble,
if the visible  symptoms are  pronounced, the part
should be treated as though the bone were broken.
  Treatment:  Even if a surgeon cannot get to the
patient for two or three days,  an incompetent
person should not attempt to  reduce a fracture,1
  1 The words reduce and set are used for  the restoration of the
pieces of the severed bone to their normal position. 
Fractures              307
con-
and
but should take means to keep the injured part
perfectly quiet in a firm, flat surface and, if possible
covered with an  ice-cap or iced compresses (the
cold tends to keep the local blood-vessels
tracted and  thereby  to lessen congestion
swelling), and, if the injured part
is a limb, bandaged to something
that will act as  a splint.   The
reason for the  splint  is  that,
even if the patient does not move
voluntarily, the nerve  impulses
induced by the irritation  cause
muscular contractions  that  are
likely  to  drag  the portion  of
the  severed  portions  of  bone
out of place, as shown in Fig. 78,
and it will then be more difficult
for the surgeon to set1  the frac-
ture properly.  A straight piece
of  board makes the best tem-
porary splint, and it will give the
greatest  degree  of support if it
is  attached to the under surface  ,. \g' 7 ' .   °™mz
                               displacement of bones
of a  limb, especially  if this is in a fracture.
a  leg, but the limb should  be
moved as little as possible when the splint is passed
under it and,  if necessary to raise  it, someone
should hold it above and below the point of frac-
ture so as to prevent movement of the severed bone.
If possible the splint should be covered with some-
  1 See note on p. 306.
 
308         Nursing Methods

thing soft and, it is even more important, after it
is in place, to fill hollow spaces, as under the knee
and ankle with something soft, even grass or moss
can be used.  If a board cannot be obtained any-
thing firm can be substituted, for example, several
layers of cardboard, or even a stick, cane, umbrella,
branches of trees can be used, and, if nothing suit-
able can be found, an injured leg can be strapped
Fig- 79-  A-n emergency splint for the leg.
to the uninjured one and a broken arm to the chest
or the arm can be held in a sling and a stick at-
tached as shown in Fig. 79 or if it is the forearm
that is injured the stick should be attached to it.

                  Dislocations

  A dislocation is an injury in which one of the
bones of a joint is out of its socket.  It is associated
with stretching and tearing of the ligaments (the
bands of fibrous tissue that hold bones together
at the joints).  A dislocation may be caused by a
fall, or blow, or strain due to a forcible movement. 
Dislocations            309
The joints most subject to dislocation are the
shoulders,  hip  joints,  lower jaw,  thumb,  and
fingers.
  The symptoms are: Deformity (due to the mis-
placed bone),  severe pain, inability  to move the
Fig. 80.  Temporary splint for the arm.
joint properly, and there is usually swelling, and
discoloration of the surrounding parts.
  Treatment: The  jaw  and fingers are  usually
easily put  into place and therefore if a surgeon
cannot be found within a short time it is permis-
sible to perform the operation, especially to get the
jaw into place, for, when this joint is  dislocated,
the mouth cannot  be closed and the pain is ex-
treme.  No attempt, however, should be made to 
310         Nursing Methods

put a large joint into place, even if it is necessary
to wait a day or two for a surgeon, for incompetent
manipulation is likely to result in severe injury to
the tissues which will make it more difficult  for
the surgeon to get good results and may cause per-
manent deformity and lack of mobility.  There-
fore, the first aid treatment is the same as for that
of fractures, namely, to immobilize the part with a
splint, sling, or bandage as required and apply cold.
  To reduce a  dislocation of the  jaw:  Have the
patient sit upright with a firm support at the back
                          of her  head; put a
                          compress or  several
                          layers of bandage or
                          other   protector
                          around your thumbs,
                          place  them, one  on
                          each  side, on the
                          patient's back teeth,
 Fig. 81.  Method of reducing a dis-
        located jaw.          Put Y°ur fingers under
                          and behind the jaw,
as shown in Fig. 81, and then press downward and
backward  while, at the same  time, you push the
chin  upward. Be prepared to remove your thumbs
the instant the  jaw moves,  because it is likely to
snap into place suddenly, it is for this reason that
the thumbs are protected.  When the  jaw  is in
place support it with a bandage such as shown in
Fig-  74-
  To reduce a dislocation of the fingers or thumb,
if a doctor cannot be found, make gentle traction
 
                  Sprains                311

(pulling) on the finger or thumb and at the same
time with the other hand move the bone into its
proper position.

                    Sprains

  A  sprain is an injury to a joint consisting of
more or less twisting or wrenching and, sometimes,
tearing of the tendons (the fibrous cords which hold
muscles to bones) and ligaments (the fibrous bands
which  hold the bones of a joint together), but,
unless the sprain is complicated by a fracture or a
dislocation, there is no break or displacement of a
bone.
  Sprains are caused by unnatural movements of
a joint and occur most frequently in the ankle.
  The symptoms are severe pain which is increased
by motion, swelling, and more or less discoloration
of the part and interference with movement.  It
will be noticed that the only symptoms of a frac-
ture that are lacking are those for which only a
surgeon should seek or even be likely to recognize.
Therefore, if there is much pain or swelling in the
injured part, treat it as if the bone were fractured
until it is seen by a surgeon.
  The first aid treatment  for sprains consists in
keeping the part quiet and elevated (i.e., with one
or two pillows under it) and covered  with either
cold or hot applications until the pain subsides, it
is then bandaged.  Moderate exercise is usually
allowed. If the sprain is a severe one the surgeon 
312         Nursing Methods

is likely to prescribe massage and to apply adhesive
strapping before the part is bandaged.

                 Hemorrhage

  The term hemorrhage signifies profuse bleeding.
According to the nature of the vessel from which
the blood escapes hemorrhage is known as arterial,
venous, or capillary.
  There are certain  differences  in  these  three
forms of hemorrhage, namely: When the bleeding
is from  an  artery,  the blood is a very bright red
and it is expelled in spurts, which correspond to the
contractions of the heart, and enough blood may
be lost from large arteries such as the femoral (in
the thigh) and the brachial (in the arm)  see Fig.
82,  in about five or ten minutes to cause death.
Blood from the veins is darker than that from the
arteries, because it contains less  oxygen, and it
flows more slowly and in a steady stream, because,
as the small capillaries  are between the  arteries
and the veins, the flow of blood in  the veins is not
as directly  influenced  by the contractions of the
heart as it is in the arteries.   In capillary hemor-
rhage the blood oozes slowly from the surface of the
wound or into the tissues.  The discoloration seen
in bruises is the result of capillary hemorrhage
under the skin.
  Symptoms of hemorrhage: Hemorrhage  from
small vessels, even arteries and veins, will usually
be  controlled  or even cease without treatment 
                Hemorrhage            313

before enough  blood is  lost to induce  systemic
symptoms, but if sufficient blood is lost to deprive
the tissues of their necessary oxygen and fluid and
to interfere with the action of the heart the follow-
ing symptoms  appear: Pallor of the  skin; weak,
sighing  breathing; thirst; restlessness; a longing
for fresh air; dizziness; rapid, weak, irregular pulse;
fall of temperature.  As a rule, there is also the
flow of  blood from the wound, but, occasionally,
even a  large vessel may be severed without the
production of an external wound.
  The body  is provided with certain natural re-
sources that are of great help in controlling hemor-
rhage, namely:  (i)  The elastic nature of the blood-
vessels  which,  when vessels are severed, causes
them to contract and thereby reduces the size of
the openings; (2) the blood tends to coagulate as
soon as  it  comes in contact with air, or the tissues,
or other foreign substance,  such as the dressing
of a wound, and the clots block the openings; (3)
the heart  action is weakened as soon as there has
been any considerable loss of blood and less blood
is then sent through the vessels.
  The principal points to be observed in the first
aid treatment of hemorrhage are:  (1) Keep the
patient  quiet and reassure her, for movement, fear,
or excitement will increase the rate of the  heart
action;  (2) raise the bleeding part higher  than the
heart, because, as  the blood must then flow to it
against  gravity, the force of the circulation in the
wounded vessels is reduced;  (3) if the  hemorrhage 
3H         Nursing Methods

is from a vessel in the leg below the knee or in the
forearm,  in addition to raising the limb, flex it at
the joint  (knee or elbow) for this interferes with the
flow of blood in the large vessels passing through
the joints and it is through these that the vessels
in  the lower part of the limbs receive their blood;
(4) expose  the wound to the  air, which favors
clotting of the blood; (5) make pressure either on
the bleeding vessels or on the large vessels of which
they are  branches, at the points indicated in Fig.
82. If the blood is coming from an artery make
pressure  between the wound and the heart; if the
hemorrhage is from a vein it may be also necessary
to  make pressure between the wound and the peri-
phery,1 to prevent the escape of the  blood that is
already in the veins.
  Pressure upon the bleeding vessels is spoken of
as  direct  pressure; that upon the main vessels as
indirect pressure.
  Whenever possible, direct  pressure  is  made,
because hemorrhage is  most easily  controlled in
this way.  To make it, put on a sterile glove or
encase your finger in a sterile compress and, putting
it into the wound, press firmly against the bleeding
vessels.   Hold it thus until a surgeon comes or the
bleeding  ceases.  In the latter case bandage tightly
folded compresses into  and over the wound.   If
the bleeding was at all severe,  do not  leave the
patient  until  the  surgeon  has  tied the  severed
vessels,  for the slightest movement, even excite-
  1 The end farthest from the heart. 
Facial
Innominate
.Jemporal
vUk
External Carotid
.Common Carotid
 .'Subclavian
     .-■'Aorta
       .-■■Axillary

          .'Brachial
          Heart,'' \
        Aorta......
  Common iliac----Jk

 External iliac.___;

Internal iliac''
,Ulnar
Palmar.'''
 arch
Radial
 \—Popliteal



  ...Anterior tibial



I—Posterior tibial

  .Dorsal/s pedis
Fig. 82.  Diagram showing plan of distribution of arteries and veins.   7 he
       arrows indicate the points where pressure may best be applied. 
 
Hemorrhage
315
  Fig. 83.  Improved tourniquet
made with a handkerchief, stick,
a nd stone.
ment, may  dislodge  the  clot  that  arrested  the
hemorrhage  and  the  bleeding  recommence.  As
stated in  the section
describing the treat-
ment of wounds, clean,
soft  muslin   pressed
with a hot iron can be
used as a substitute for
the  ordinary  surgical
compresses  used  for
dressing wounds.
   If  there is  nothing
sterile at hand, indirect pressure  must be  made
until sterile  supplies can  be obtained.  Indirect
pressure may  be  made with the fingers  (digital
pressure) or,  on the limbs, with  a tourniquet.  In
emergency a handkerchief, or a strip of muslin or
                               any  fairly strong
                               material   and  a
                               stick  and   stone
                               or  similar objects
                               can be utilized for
                               a tourniquet.
                                 To use such an
                               improvised  tour-
                               niquet put  the
                               stone in the center
                               of  the handker-
                               chief and this over
the artery supplying the  bleeding part, tie the
material, as shown in Fig. 80, place the stick over
Fig. 84.
Method of making digital com-
    pression. 
 316          Nursing Methods


 the knot,  tie it in place, and then twist the stiek
 until the bleeding ceases.
   The places on which to make pressure with the
 fingers or stone are  shown in Fig.  82 and the
 following table:

  To arrest bleeding from:          Make pressure on:

 The scalp                 The temporal arteries.
 The face                 The facial artery on the side of the
                      bleeding.
 The neck                 The carotid artery on the side of
                      the bleeding.
 The shoulder or axilla       The subclavian artery.
 The arm                The brachial artery.
 The wrist or hand          Either the brachial or the  radial
                      and ulnar arteries.
 The thigh                The femoral at either of the points
                      indicated in Fig. 82.
 The leg or foot            Either on the femoral artery,  as
                     for the  thigh, or on the popliteal
                     artery, by flexing the leg on a pad as
                     shown in Fig. 85 or on the tibial
                     artery.

  A very important point to  remember in connec-
tion with  indirect pressure  is  that it  cannot  be
continued for more than an hour without danger of
causing gangrene (death of the tissue) in the part
that is deprived of blood.   Therefore, it is most
important to get a surgeon  and sterile supplies as
quickly as possible.  If a surgeon does not arrive at
the end of an hour the pressure must be released,
very slowly, sufficiently to allow the blood to flow
into the part; if bleeding starts again, the pressure
must  be resumed after a few minutes, but it must 
                Hemorrhage            317

be released for at least a minute or two about every
half hour until help arrives.   As soon as sterile
supplies  are  ob-
tained  pack  the
wound  and  apply
a   tight  bandage,
then, with the part
in the proper posi-
tion, as described
on   page  313,  re-
lease the pressure
to some degree, but
very slowly, so as
not to risk dislodg-
ing clots that may
have formed by a
rush of  blood.
  Hemorrhage   Fig. 85.  Forced flexion of the knee to
from parts below arrest hemorrhage in parts below it.
the elbow or knee
if not severe, can usually be easily controlled by
placing  a thick wad, of soft, but tightly  rolled,
material in the bend of the joint as shown in Figs.
85 and 86 and  holding the arm or leg  in position
either with the hand or  a bandage.
  Heat  and cold tend to check hemorrhage, heat
because it hastens the coagulation of the blood and
cold because it induces nerve reflexes that con-
tract the blood-vessels.  Therefore hot irrigations
are  often  used to check  hemorrhage  in cavities
and  cold is  very commonly  used  externally, for
 
3*8
Nursing  Methods
example, an ice-cap is applied over the stomach
for hemorrhage in that organ.  A very important
                     point to remember regard-
                     ing the use of hot irrigations
                     is that they must be as hot
                     as can be employed with-
                     out burning, which is about
                     1200 F.,  for moderate tem-
                     peratures tend to dilate the
                     blood-vessels   and   favor
                     hemorrhage.
                      A  number   of   drugs,
                     classed  as  styptics,  are
                     sometimes  used to  check
                     hemorrhage,  which   they
                     may  do  by   contracting
                     the blood-vessels.  One of
these is acetic acid, which is contained in vinegar,
and another is tannin, a constituent of tea leaves,
therefore, either hot or iced vinegar or boiled tea
(for  which four or five times  the usual amount
of tea leaves are used) is very commonly employed
to check bleeding from cavities.
   For hemorrhage from the nose, make the person
keep  quiet with  the head hanging  backward,
never forward, put something cold, as a piece of ice
or a chilled door key at the back of the neck and
either hold the nostrils compressed tightly, or put a
wad of paper or cloth under the upper lip.   If this
treatment  is not effectual  plug the nostril from
which  the  blood is coming with cotton wet with
  Fig. 86. Forced flexion of
the elbow to arrest hemorrhage
in the forearm or hand. 
                Hemorrhage            319

either hot or iced vinegar or boiled tea.  If this does
not control the hemorrhage,  get advice from a
doctor.
  For  hemorrhage after  extraction of a  tooth,
place a plug of tightly wadded gauze or suitable
substitute in the cavity and press the teeth of the
other jaw upon it, if the hemorrhage is not checked
use a fresh plug moistened with vinegar or tea or
substitute a piece of ice for the plug. If the bleed-
ing is very  profuse and is not checked by these
means notify the dentist or a doctor.
  For hemorrhage from the internal organs there
is very little that a person not experienced  in the
care of the sick can do except send for the doctor,
keep the patient quiet and in a position unfavor-
able for the flow of  blood  to the  part, and, if
possible, put ice-caps over the bleeding organ, and,
if the hemorrhage is from  the stomach give small
pieces of ice by mouth, they must be swallowed as
ice and not allowed to melt in the mouth.  Ice is
also often given when the  hemorrhage  is from the
lungs, for, probably as  the  result of  reflexes in-
duced by the cold in the mouth, it sometimes has
a beneficial effect; at any rate it does no harm and
it helps to make the patient feel that something is
being done for her.  Blood coming from the lungs
has a frothy appearance because  of the air mixed
with it and,  therefore, hemorrhage from the lungs
is easily distinguished from that coming from the
stomach. 
320         Nursing Methods

              Demonstration  28

First Aid Treatment in Hemorrhage and Fractures

  Procedure: The pupils  should first study the
course of the blood-vessels  on the charts and prac-
tice stopping the pulse by digital pressure, this is
best  done on the  arm as follows: Make pressure
with the fingers of one hand on your neighbor's
brachial artery and keep the fingers of your other
hand on  the radial artery.  Make sufficient pres-
sure to arrest the pulse in the radial artery.  Cessa-
tion of pulsation of the artery shows that blood is
no longer flowing  into it and thus, where there is
a hemorrhage below the point of pressure, it would
be arrested.
  After  all the pupils have tried this and ascer-
tained how to manipulate an improvised tourni-
quet let  some  of  the pupils act as subjects and
pretend  to have, either a hemorrhage or fracture,
or both, and let others treat the subjects according
to the direction just given,  acting in all respects as
though the emergencies were real. 
CHAPTER XV
Fire.  Burns.  Scalds.   Frost-bite.  Chilblain

  How to put out fires. How to escape and help others escape
from  burning  buildings.  Demonstration  29:  Extinguishing
flames from the clothing and use of fire extinguishers.  Various
causes and treatments of burns.  Treatment of scalds.  Nature,
causes, and treatment of frost-bite and chilblain.  Other conse-
quences of exposure to cold.

  Equipment for demonstration:  Blankets or sub-
stitutes and if possible, different  varieties  of fire
extinguishers.
  Much unnecessary suffering, loss of life, and de-
struction of property is constantly  occurring be-
cause people do not do the  right things, when a
fire starts.  To realize what  should be done both
to put out fires and to escape from fires and their
consequences the following facts should be known:
  (1) Burning consists in the union of oxygen with
matter and, therefore, if air is excluded from burn-
ing material the fire will be extinguished. Air can
be excluded by pressing something hard or thick,
as wood,  rugs, blankets, tightly upon the burning
material, or by  covering the latter with carbon
dioxid,  which  is  heavier  than air and therefore
does not diffuse  readily.   This is what is done
     21               .  321 
322         Nursing Methods

when the majority of fire extinguishers are used,
for these contain  chemicals  .that interact when
poured over the flames and liberate carbon dioxid.
  2.  Movement of air, such as is created by a draft
or a person running, favors the spread of fire;  it
will also  hasten the diffusion of the carbon dioxid
poured over a flame.
  3.  Wet  material, provided the moisture is not
due to an inflammable substance, as ether or oils,
has a much higher kindling temperature than dry
and will not take fire readily.
  4.  Many of the deaths that occur when people
are trapped by fire, especially in crowded buildings,
are due to  asphyxia caused by the inhalation of
smoke.  As smoke is lighter than air it rises, there-
fore, there  is practically no smoke within about
six inches of the floor.
  5.  Another common cause of  death following
accidents due to  fire is shock, and death from this
cause has often occurred when there has been rela-
tively little external injury.  Probably the chief
reason for this is that the intense terror experienced
is conducive to shock, but also creates excitement,
which retards  the onset  of the  conditions con-
stituting shock, but increases their intensity later,
especially if the person is allowed to move around,
as is likely to be the case when  the internal injuries
are not extensive.
  Procedure in putting out a  fire: If anything in
the room catches fire, at once bang something hard
upon it or envelop it tightly in a rug, heavy coat, 
Fire
323
blanket, or the like.  If this is not effectual shut the
doors and windows (to prevent a draft); send some-
one to summon  the fire brigade and, if possible,
get and use a fire extinguisher, otherwise, except
when the flame is due to burning oil, get water and
pour it over the flaming material.  Water should
not be used to extinguish burning oil,  for it will
not do so and, as oil floats on water, it will spread
the flame.  Good things to use  to extinguish burn-
ing oil are the fire extinguisher, clay, sand,  ashes,
or wet blankets  pressed tightly upon the burning
mass.
  To avoid  becoming asphyxiated  when sur-
rounded with smoke tie something,  wet if possible,
over your nose and mouth and, if there is much
smoke, crawl to safety on your hands and knees,
keeping your face near the floor.  Try to make
others do likewise and do not get excited.
  If your clothes catch fire, do not run for help,
because this will favor the spread of the flames, but,
if  the ignited area is small,  immediately  make
hard pressure against it with something hard, as
wood or the wall, if this is not at once effectual lie
down on the floor and draw the rug tightly around
you, or, if there is  no  rug, anything that can  be
used as a substitute (e.g.,  bedclothes, or a heavy
coat, or blanket) and if, when lying  still, you  do
not press on a sufficient area  to smother all the
flames, roll slowly on the  floor in such a manner
that you  will press upon all  the  burning  parts.
It is most important to lie down because, as the 
324         Nursing Methods

flames and smoke rise, the fire will spread over
your clothing more rapidly when you are in  the
erect position.
  If anybody else's clothing catches fire help or
force her to carry out the preceding directions.
  When enveloping a person in a blanket, etc., or
when  drawing one  around yourself, put it  first
between  the flames and the face, otherwise, you
are likely to fan the flame toward the latter.


             Demonstration 29

              Extinguishing Fire

  Procedure: Some of  the pupils should pretend
that their clothes are on fire and others put  the
preceding instruction into effect.

                Burns.  Scalds

  A burn is generally defined as  a lesion of tissue
induced by heat, but similar lesions, also commonly
known as burns, are produced  by  other agents
such as the X-rays, the chemical rays of the sun,
various chemical substances such as strong acids
and alkalies (especially caustic soda and potash
and lime) and irritating substances such as mus-
tard and iodine.
  Burns  are usually classified according to  the
amount of tissue destroyed as being of the first
second, or third degree.  A burn of the first degree 
Burns.  Scalds           325
is one in which the skin is reddened,  because of
slight congestion in its blood-vessels,  but is not
actually injured.  A burn of the second degree is
one in which there is inflammation of the skin and
blisters.  Blisters are due to the exudation of fluid
from the congested blood-vessels which raises  the
outer layer of skin from  the underlying  tissue.
Burns of the third degree are those in which there
is charring and destruction of both the skin and
deeper tissues.
  The only treatment necessary for a  small burn
of the first  or second degree is to cover the part
with something clean and non-irritating that will
exclude the air and will not adhere to the skin.
Examples are:  A compress of soft muslin covered
on one side with an emollient such as boric acid
ointment, or zinc oxid ointment, or cold cream, or
the compress may be saturated with a bland oil
(such as  olive or Unseed oil) or with a solution of
sodium bicarbonate (made by dissolving about a
teaspoonful of baking soda in a cupful of water).
When the solution is used  the compress must be
moistened  at  intervals because the  liquid will
evaporate and the muslin will stick to the wound.
  If the burn is at all extensive send for the doctor,
if only because of the danger of shock.  Do not,
however, wait his arrival to cover the burned area,
because the destruction of skin leaves the nerve
endings exposed and, until they are covered with
something that will prevent their stimulation,  the
pain is likely to be excruciating.  A dressing such 
326         Nursing Methods

as any  of those mentioned may be used or the
burned  part may be immersed in cold water or a
solution of sodium bicarbonate made as described
in the  preceding paragraph.  When dressing  a
burn use small compresses so that when the dress-
ing is changed a large area need not be exposed at a
time for the pain is thereby increased.
  The term scald is applied to an  injury due to
moist heat.  The nature and treatment for scalds
are similar to those of burns.
  The treatment for burns due to other agents
than heat is the same as for the latter plus, in the
case of those due to a chemical, the removal of the
substance and, if the chemical is an acid or an
alkali, its neutralization.  To neutralize an acid,
use an alkali, such as a solution  of  sodium bicar-
bonate (baking soda) or sodium carbonate (wash-
ing soda)  diluted ammonia water, lime water, or
strong soap suds. For carbolic acid (which is not
a true acid) use alcohol.  For alkalies use a diluted
acid, preferably lemon juice or  vinegar.  If the
neutralizing agent cannot be obtained immediately
hold the part under running water, so that the acid
or alkali will be diluted and washed off and its
action thus  minimized,  but use  the neutralizing
agent as soon as possible.
  Burns from mustard are almost always due to
the improper use of  this substance  in pastes and
poultices, either too much  mustard is used, or the
application is left on too long, or the skin is not
washed  after the application is removed and the 
Frost-bite.   Chilblain       327
adherent  particles  of mustard  continue  to act.
The treatment consists in removing the mustard
by irrigating  and gently patting the part with
warm  dilute  soap  suds and  then warm  water,
drying it, and applying a dressing of bland oil or an
ointment such as those previously mentioned.
   Tincture of  iodine is most easily removed with
ammonia water, but alcohol or warm soap suds will
answer fairly well.  If the skin is blistered or seems
likely to become so apply a bland oil or ointment.

Consequences of Exposure to Cold, Freezing, or
             Frost-bite.  Chilblain

   Cold depresses living tissue, whether vegetable
or animal; it lessens the movement of the molecules
of which protoplasm is composed, and, thereby,
causes contraction of matter and inhibits all vital
(life) processes.  If the cold is not  excessive, how-
ever,  or exposure  too  prolonged, as stated in
Chapter VI, cold, by stimulating nerve endings in
the skin,  produces  conditions  that  protect the
body from its  depressant influence.  If, however,
exposure to intense cold is prolonged, the blood is
driven to the interior of the body; the surface of
the body becomes stiff, contracted, and pale, es-
pecially the more exposed parts and those in which
the circulation is first interfered with, namely, the
face, hands, and feet, if the exposure continues the
circulation of blood in the brain is inhibited and
the person becomes drowsy and finally unconscious, 
328         Nursing Methods

  Localized areas,  especially parts  of  the face,
hands, and feet may be severely frozen, however,
without the onset of symptoms of general depres-
sion, especially if the individual is exercising and
warmly clad.
  In the first stage of freezing, the affected part is
blue, numb, and stiff, later it becomes white and
rigid and, if this stage is allowed to progress, the
vitality of the cells may be  so reduced  that the
tissues will never recover, but gradually  slough
and die, that is, they become gangrenous.
  The walls of the blood-vessels in a frozen part
are in such a  condition that,  when the part  is
thawed, they  cannot respond to nerve  impulses
and contract, and this, as the circulation is restored,
interferes  with the  flow of blood  through them,
thus they  become congested and,  consequently,
the part becomes red and swollen,  and there  is
excessive exudation of fluid  into the tissues and
between the true skin and the outer layer of skin;
this separates the latter from the underlying struc-
tures and forms blisters.
  If the flow of blood to a frozen part is increased
quickly the conditions described in the preceding
paragraph  will be worse than if the  circulation is
restored gradually and the vessels are given time
to resume  at least a moderate degree of contrac-
tion.  Thus it can be seen that the severity of the
after-effects of freezing depend upon the intensity
of the freezing and the rapidity with which thaw-
ing is promoted, 
          Frost-bite.   Chilblain      329

  Chilblain: After a part has been frozen, exposure
to even a moderate degree of cold is likely to induce
a condition similar to the after-effects of freezing
in which  the  part becomes red or  mottled and
more or less swollen, and is intensely itchy and,
especially if the chilled part is  warmed quickly,
small blisters may form.  This condition is known
as chilblain.   People with poor  circulation may
suffer from chilblain even when the  affected part
has never been frozen.
  The aim of  the primary treatment of frost-bite
is to restore the circulation in the affected part
gradually.  Formerly it was customary to rub the
part with snow or iced water, but this is not now
considered the best treatment; instead, the person
is kept in a cool room (about 650 F.) and the frozen
area is very gently rubbed  and, if  possible, im-
mersed in water that has a  temperature of about
650 F. After a time the temperature of the water
is gradually increased, by the addition of slightly
warmer water; until it is about 900 F.  No definite
directions can  be given regarding the rate at which
the  temperature  is to be  increased, it depends
upon the severity  of the freezing and the way in
which the tissues respond to the treatment; severe
freezing and the onset of much congestion require
slow increase of temperature. If the frozen area is
at all large or  if there are symptoms  of general ill
effects from the exposures, a doctor must be con-
sulted and the  patient put to bed and, if necessary,
treated for chills and shock, except that heat must 
330         Nursing Methods

not be applied at first and, of course, it must never
be put near the frost-bitten areas.
  The after treatment of frost-bite is usually the
same as for burns, but, if the injury is at all severe,
a doctor's advice should be sought.  It is to be
remembered that the treatments mentioned in this
book are only those which  can be given by inex-
perienced  people  and that there are more com-
plicated,  but also more effectual, measures  that
are likely  to be needed  in serious cases of either
burns or frost-bites.
  To allay the unpleasant sensations induced by
chilblain rub the parts with spirits of camphor or
alcohol.  Denatured alcohol (that containing  sub:
stances which make it poisonous to drink) can be
used for this purpose, the poisons employed not
being harmful to the skin. 
CHAPTER XVI
Removal of Foreign Bodies and Treatment of
                   Poisoning

  Methods of removing foreign bodies from the eye, ear, nose,
throat, bronchial tubes, and alimentary canal.  Nature of poison-
ing and the first aid treatment for poisoning by some of the more
common poisons.

    Removal of Foreign Bodies from the Eyes

  Nature has provided the eyes with three very
effective means of protection from injury  by for-
eign substances;  these are the eyelids, eyelashes,
and the secretion of the lachrymal or tear  glands.
  These glands are in the bony cavities, known as
the orbits, that hold the eyes and are situated just
above  the eyeballs at  their  outer sides.   They
secrete  a  watery fluid known as the tears which
passes  through small tube-like  passages,  termed
ducts, to the free surfaces of the  eyeballs.  The
glands are constantly active  and  their secretion
keeps the eyeballs  moist.  Ordinarily we are not
aware of the presence of this fluid because it evap-
orates  very  rapidly and any  excess passes into
minute  ducts, at the inner side of  the eyeballs,
which lead  into  the nose.  When, however, the
                       33i 
 332         Nursing Methods

 glands are stimulated, as they are when any for-
 eign substance enters the eye, and  by psychic
 conditions, as anger, not only does a large amount
 flow across the eyeballs into the nose but overflows
 the lower lids on to the cheeks.
  If,  when anything  gets into a person's eye,
 nature's provisions, the tears, lids, and lashes were
 depended  upon for its removal, less trouble would
 be caused, but the almost invariable custom is to
 immediately  rub  the eye,  which treatment fre-
 quently either moves the substance further under
 the lids or embeds it in the conjunctiva (the mem-
 brane covering the free surface of the eye and lining
 the lids) and often gives rise to serious trouble.
  Therefore,  if dust,  a cinder, or other foreign
 substance  gets into the eye wink the lids briskly,
 for  this movement is likely to dislodge the speck
 and, at the same time, blow the nose forcibly, and,
if necessary, smell something, as pepper, that will
 make the eyes water.
  If these  efforts are not successful, and the speck
is under the upper lid,  grasp the lashes of this lid
 and draw  it downward so that  the lashes of the
lower lid will brush against its under surface.
  If this is not effectual either separate the lids,
as in Demonstration 17, or get someone to  evert
the lid, as  described later, and try to brush off the
speck,  with the corner of  a  clean handkerchief.
 If it does not come off readily irrigation of the eye,
as in  Demonstration  17,  can be tried.  If  these
measures are not effectual, a doctor should be seen. 
      Removal of Foreign Bodies  333

  To evert (turn back), the upper lid and expose
the under surface, have the patient sit with her
head tilted backward, stand behind her and hold
a match or similar article across the  lid  (do not
press on the eyeball), take the lashes between the
thumb and first finger of your hand and turn the
lid backward over the match.
  This procedure is quite easily done after a little
practice, though  it is rather difficult to  get the
knack, and the pupils should practice it.  They
can stand in  front of a mirror and each one do it
on herself.

    Removal  of Foreign Bodies from the Ear

  In the case of adults it is usually small flies or
insects that get in the ears, but children  are in-
clined to put such things as peas, buttons, small
stones, and the like in their ears.
  Filling the ear with liquid,  oil especially, will
usually kill an insect and it will then float to the
top and, if the head is bent so that the ear being
treated is downward the insect will be washed out.
The liquid can be poured into the ear from the
bottle or a medicine dropper.
  Hard objects can usually be picked out with the
fingers if they have not been  pushed in too far.
In the latter  case, syringing the ear can be tried
as described in Chapter VIII, but under no cir-
cumstances must the object be poked at  for the
membrane between the outer  and middle ear  is 
334         Nursing Methods

very easily ruptured.  In fact, unless it is difficult
to get a doctor,  it is better  for an inexperienced
person not even to try the syringing.  Alcohol
should be used instead of water or the solutions in
Chapter VIII,  when the foreign body is anything,
such as a pea or bean that will absorb water and
swell; alcohol tends to shrink such substances.

Removal of Foreign Bodies from the Nose and
              Other Air Passages

  Children quite frequently  poke hard  objects
into the nostrils.  To remove one, press your finger
on the empty nostril and make the child blow its
nose hard.  If  this is not effectual, unless there is
someone present who knows how to give a nasal
irrigation,  take the child to a doctor.
  The  entrance  of  foreign  substances into the
trachea (windpipe) is not an  uncommon accident.
The  usual causes are, vomiting while under the
influence of an anesthetic, and speaking or laughing
while there is something in the mouth. The reason
that  the accident occurs so readily is that the
esophagus  (the  tube-like  passage  leading from
the throat to the stomach) is behind the trachea
(the windpipe)  and therefore anything swallowed or
vomited has to pass over the latter.  The motion
of swallowing, however, draws a small membranous
cover attached to the  back of the tongue  (called
the epiglottis) over the opening of the larynx (the
upper distended part of the windpipe) and prevents 
      Removal of  Foreign Bodies  335

food getting into it, but the movements of the
tongue and throat muscles  when an individual is
laughing and talking are quite different from those
made when swallowing and the glottis (the open-
ing) is left exposed.
  The entrance of anything into these air passages
induces  such coughing that  the  object is likely to
be ejected without treatment, if it is not,  slap the
patient on the back, as this tends to dislodge any
foreign substance in the larynx or trachea and, if
this fails, invert the patient.  With an adult, this
is best done by laying  her across a couch or bed
with the upper part of her body bending over its
side, but a child can be taken by its feet or knees
and  held  upside down.  Continue to give  hard
slaps upon the back. If the trachea is sufficiently
blocked to cause symptoms of asphyxia  and the
object is not immediately coughed up,  a doctor
should be called at once and,  even though the
asphyxia is relieved, if the  object is not  coughed
up, a doctor should be consulted because the relief
of the asphyxia may be due to some change in the
position of the object  which lessens interference
with breathing and, if  left alone, the object may
pass down into the lung and cause serious trouble.

     Foreign Matter in the  Alimentary Canal

  Another not uncommon accident, especially in
childhood, is swallowing hard or sharp objects
which cannot be digested. The latter are the more 
336         Nursing Methods

dangerous as it is quite possible for them to pierce
the wall of the  stomach or intestines.  Even the
former, however, if large, may cause trouble by
blocking some of the constricted portions of the
alimentary canal, therefore, a doctor should be
consulted.  To lessen the danger of trouble from
sharp objects, large amounts of soft food, such as
mush, potatoes, and cornstarch preparations should
be given as soon as possible.  No cathartic should
be taken until ordered by the doctor.

Nature of Poisons and First Aid Treatment for
                  Poisoning

  A poison is generally denned as any substance
that, in relatively small amounts,  may cause death
or disease.
  As previously stated, poisons may be taken into
the body  (ingested)  or formed within the body.
Only the former will be considered here.
  Ingested poisons are usually  either chemicals
used as medicines or in industries, poisons, plants,
or toxic substances developed in food as the result
of decomposition.
  A poison may be taken by accident or deliber-
ately, with the  intent to commit suicide, also, it
may be administered by mistake or with criminal
intent.
  Poisons  are  sometimes  classified under  two
primary headings,  namely, those which  produce
harmful effects in the alimentary canal and those 
        Treatment for Poisoning     337

which act only after they have been absorbed by
the blood and carried about the body.  The latter
class is subdivided into (i) those which act as de-
pressants (drugs used to  induce sleep and to alle-
viate pain) and those which act as stimulants, but
even stimulants, in poisonous doses, usually cause
death by depressing  either the nervous system or
the heart muscle or both, because over-activity of
any part of the body is followed by its fatigue and
consequent inability to function properly and the
nervous system and in some cases, the heart muscle
are more easily affected by such drugs  than other
tissues.   Depression of these parts of course results
in shock.
   Death from poisoning is nearly always due either
to shock or to interference with breathing, and the
interference with breathing is usually the result
either of depression of the respiratory center or of
spasmodic contractions of the chest muscles during
convulsions.
   Irritant drugs (examples of which  are given on
page 341) will cause  shock by their actions in the
alimentary canal; these are: Intense inflammation
and, sometimes, corrosion of the membrane lining
the canal, excessive vomiting and diarrhea.  The
reasons  why such actions induce shock were men-
tioned in the section describing the causes of shock.
Some of them also depress the nervous system after
absorption.
   The local action of irritant drugs will be in pro-
portion to their strength; for example, a teaspoonful
     22 
 338         Nursing Methods

 of 50 per cent, hydrochloric acid will do infinitely
 more harm to the membrane with which it comes
 in contact than three times that amount of 10 per
 cent, hydrochloric acid, but a poisonous dose  of
 strychnine will be as poisonous in a quart of water
 as in a teaspoonful of water.
   Symptoms of  poisoning: It would  be  almost
 impossible for anyone not accustomed to observing
 the effects of drugs to  remember or recognize all
 the symptoms of poisoning produced by individual
 drugs and, therefore, only those characteristic  of
 the different types will be mentioned here.
   The characteristic  symptoms  of  poisoning by
 irritants  are: Intense  abdominal  pain,  nausea,
 vomiting, diarrhea and, after  a time, there will
 probably be blood and shreds of mucous membrane
 in the vomitus and feces and, later,  in the urine.1
 The mucous  membrane of the mouth and  throat
 will be intensely red and sometimes swollen and,
 especially if a  corrosive drug,  as a concentrated
 acid, has been  taken  the membrane may look as
 though it had been burned, and it may  be dis-
 colored.  Also,  the symptoms of shock mentioned
 on page 263 will soon be apparent.  There may be
 convulsions.
  The characteristic  symptoms  of  poisoning by
  1 Almost  all drugs and other poisonous substances are elimi-
nated chiefly through the kidneys, and even irritants that are too
thoroughly  diluted by the blood after they are absorbed to injure
other tissues may affect the kidneys and other urinary organs
because they are here once more present in concentrated amounts,
though, of course, not quite as much so as in the alimentary canal. 
         Treatment for Poisoning     339

the majority of depressant drugs  (those used to
relieve pain and induce sleep) are profound stupor;
slow, shallow breathing; the symptoms of shock;
and,  as  the breathing becomes insufficient, the
symptoms of asphyxia become  more or less pro-
nounced.
  In  poisoning  by opium and  its alkaloids1 the
symptoms  are  somewhat  different from  those
induced  by other depressants because these drugs
depress the parts of the brain concerned with sen-
sation and breathing more, and other  parts less,
than the other depressants.  The chief  differences
are: The breathing becomes excessively  slow in the
early stages of poisoning and, therefore, the symp-
toms of  asphyxia are especially  marked while the
symptoms of shock are not observed until shortly
before death; in fact many patients cease breathing
while the pulse is still fairly strong;  and if the
patient is kept walking about or otherwise aroused,
stupor is less profound than that induced by the
other depressants; the pupils of the eyes are con-
tracted until shortly before death when  they dilate
widely.
  Characteristic symptoms of poisoning by poi-
sons  that  cause death by overstimulating the
nervous  system  are:  Muscular twitching, convul-
sions, and, sometimes, delirium.   Finally there will
  1 Alkaloids are organic, nitrogenous substances  that combine
with acids to form salts. A large number of the most poisonous
drugs owe their effects to these substances. Well-known examples
are: Morphine and  codeine (derived from opium), strychnine
(from nux vomica), atropine (from  belladonna). 
34°         Nursing Methods

be stupor and the symptoms of shock but these will
not occur as quickly as in poisoning by depressants.
Commonly used drugs  which act in  this manner
are:  Strychnine,  nux  vomica,  belladonna, and
atropine.
  The symptoms of poisoning by poisonous mush-
rooms and some putrefied foods (ptomaine poi-
soning)  are:  Intense  abdominal pain,  nausea,
vomiting, purging, the symptoms of shock, thirst
becomes extreme, and,  especially if the patient is
a child,  there may be convulsions.
  There is also  a form  of food poisoning,  known
as botulism, * that is caused by eating food infected
with a microorganism, the bacillus botulus.  Sau-
sages and canned meats and vegetables, especially
peas and beans, that are not well sterilized when
prepared are common causes of poisoning, because
these foods are quite frequently infected with the
organism, and, if it is not destroyed, it multiplies
and increases in virulency  during the period that
the foods  are preserved.   The symptoms  do not
usually  appear  for some hours after  the infected
food is eaten and they vary considerably according
to the degree of infection.   They are likely to be
digestive disturbances  followed  by  collapse, ex-
treme dryness of the mucous membrane  of the
mouth and throat, dilation of the pupils, and there
may be  convulsions or paralysis.
  Treatment for poisoning: Send for a  doctor
instantly and, if anybody who knows  how to wash
  ' Latin botulus — sausage. 
         Treatment for Poisoning     341

 out the stomach can be reached quicker, get her
 or him, for lavage (washing out the stomach) is one
 of the first and most important things to be done
 in the treatment of practically all poisoning when
 the poison has been taken by mouth and, in the
 case of some drugs, especially opium and its alka-
 loids  and arsenic, even when  the drug  has  been
 taken in other ways, as by a hypodermic injection,
 because  these drugs are excreted into  the intes-
 tines, as well as through the kidneys.
  The treatment  that  an inexperienced  person
 should give while awaiting help is as follows:
  For poisoning by irritants:  (This includes some
 of the most common causes of poisoning, the chief
 ones are arsenic compounds; corrosive acids, in-
 cluding carbolic  and  oxalic;  corrosive alkalies,
 which includes many compounds of sodium,  po-
 tassium,  and calcium  or lime, and bichloride of
 mercury.)  Dilute the poison at once (it is to be
 remembered that the irritant action of these com-
 pounds is in proportion to their concentration and,
 if they are diluted promptly their ill effects will be
 minimized); if possible use the chemical antidote
 (mentioned  later) or milk or white of  uncooked
 egg for the dilution, but, if water can be  obtained
 quicker, give water and get the other liquids later,
 not a second must be lost.  The milk and  egg coat
 the surface of the membrane lining the alimentary
 canal and protect it from the action of the irritant,
also their albumin combines with a number of the
irritant drugs and reduces their irritant properties, 
342          Nursing Methods

Other good protectors for the membrane are starch
water1 and gelatine dissolved in warm water.  Give
as much of these protective fluids as possible, even
though they are vomited.
  By a chemical antidote is meant a substance that
will combine with a poison and change it to harm-
less or, at least, a less harmful compound.  There
are only certain poisons, however, for  which such
antidotes are known.
  The chemical antidote for acids (except carbolic
acid) are alkalies.2  The best alkali to use is milk of
magnesium  (one to two tablespoonsful, according
to the amount of acid taken), but, if  magnesium
cannot be  obtained,  sodium  bicarbonate  (baking
soda),  sodium carbonate (washing soda), (quarter
to half a teaspoonful  in  half a glass of  water),
ammonia water, soap, wall plaster, lime water (one
to two glasses full) can be used.  An objection to
the carbonates is that, when they come in contact
with acid, they liberate carbon dioxid gas and, if
the stomach is corroded by the acid, this may be
harmful.   Ammonia  is irritating and  therefore
should only  be used  if other alkalies cannot be
obtained, if necessary to use it, dilute it well, using

  1 To make the paste mix two teaspoonsful of cornstarch with
cold water, add about a cupful of boiling water  slowly, stirring
the mixture as you pour on the water; boil the mixture for at least
five minutes and then cool it and make it thin enough to drink by
adding cold water or, preferably, milk.
  2 Acids and alkalies interact and form salts. Carbolic  acid is
not a true acid and does not combine with alkahes but it does
with alcohol, 
        Treatment for Poisoning    343

about one teaspoonful in a glassful of water.  Do
not use the soda compounds for poisoning by oxalic
acid because the sodium oxalates (salts of oxalic
acid) are about as poisonous as the acid.
  The chemical antidote for carbolic acid is alcohol.
It is generally given in  the form of whiskey or
brandy, but wines can be used, though  they must
be given in larger amounts.  Though alcohol pre-
vents the local action  of carbolic it hastens  the
absorption of the drug and does not prevent  the
action of carbolic  after  absorption,  therefore, if
nobody to wash out the stomach can  be found,
after giving alcoholic drinks freely, and a protective
as white of uncooked egg, cause vomiting in one
of the ways described later, except by  the use of
mustard, which is too irritating to use in the treat-
ment of poisoning by an irritant.
  The chemical antidote for bichlorid of mercury
and other metal salts  is albumin, which is con-
tained in white of egg and milk.
  The chemical antidote for alkaloids  is tannin.
This is contained in tea leaves and, if the leaves are
boiled, a considerable amount can be  extracted.
As previously stated the  poisonous principles of a
large number of the vegetable drugs are alkaloids.
  When  the patient is discovered before she is
having convulsions or the symptoms  of shock are
pronounced, the first thing to be done in the treat-
ment for poisoning by drugs that act after absorp-
tion is to cause vomiting.  Vomiting can be induced
by tickling the back of the throat with your finger, 
344         Nursing Methods

a stick, feather, pencil, etc., or by giving an emetic
(i.e., a remedy that causes vomiting).  Mustard,
one teaspoon in half a glassful of water, is one of
the most  efficient emetics that anyone  not ac-
quainted with the use of drugs can use, but salt, one
teaspoon in a glassful of tepid water, or tepid water
alone will  often induce vomiting.  As soon as the
patient  has vomited give strong boiled tea, then
induce vomiting again and if the poisoning is due
to a depressant, give more tea and strong coffee
(for the  sake of their caffeine) but do not use these,
except the tea that is vomited (which is used for its
tannin)  when  the poisoning is due to  the nerve
stimulants mentioned on page 340, because they
contain  caffeine which is a nerve  stimulant  and
would therefore increase the harmful effects.  For
these give sodium bromide thirty grains in about a
quarter  of a glass of water.
  If the symptoms of collapse  are pronounced, or
the patient is having convulsions, except in the
case of poisoning by opium and  its alkaloids, do not
give an  emetic, for, as the drug must have been
absorbed if the conditions of  poisoning are pro-
nounced, vomiting will do little good and may do
harm.   Therefore, all that can be done until help
arrives,  in the case of poisoning by depressants, is
to treat  the patient for shock and give all the strong
coffee possible; if the patient  cannot take it by
mouth give it by rectum, you can do  so with a
long-nozzled  syringe,  or  by  inserting  a  rectal
tube, or, if one is not  at hand, a piece of rubber 
        Treatment for Poisoning    345

tubing about  four  to  six  inches in the rectum
(according to the size of the patient) and pouring
the coffee very slowly into this.  If possible put a
funnel in  the  free end of the tubing as this will
facilitate  pouring in the  coffee, or a fountain
syringe bag with its attached tubing can be used.
Grease the tubing with vaselin or cold cream or
other lubricant before inserting it in the rectum.
Do not hold the funnel or  bag more than twelve
inches above the rectum.  Give  artificial respira-
tion if necessary.
  If the patient is having convulsions as the result
of poisoning by nerve stimulants it is most impor-
tant to get help  immediately because, especially
in the case  of strychnine poisoning, the patient
usually has to be given an anesthetic before treat-
ment can be given,  for the  slightest stimulus, any
movement, a light, a noise, may cause a convulsion.
While waiting for help see that the patient is kept
very quiet in a darkened room.
  The principal items in the first aid treatment for
poisoning by opium and its alkaloids are: Empty
the stomach repeatedly, at intervals of about every
half hour (these drugs are alternately absorbed
and eliminated back into the intestines); give a
cathartic—magnesium sulphate (epsom salt), half
ounce (two tablespoonsful) in about half a glass of
water, is  generally  considered  one of the best
cathartics to use for the purpose; keep the patient
awake by, if possible, walking her  up and down
and giving her strong coffee.  If you cannot keep 
346          Nursing Methods

her awake until help  arrives, it will  probably be
necessary to give artificial respiration.
  The first aid treatment for poisoning by poison-
ous foods is  to  cause vomiting, as described on
page 343; to treat the  patient for shock; to give all
the liquid possible, including tea and  coffee, and a
large dose of castor oil.
  It is to be remembered that in all cases of poison-
ing, lavage of the stomach is better than an emetic
because it is less depressing to the patient and it
removes  material from  the stomach more thor-
oughly.   It is also to be realized that the treatment
described in these pages only includes the measures
that can be carried out by a person inexperienced
in the use of drugs and the care of the sick and that
a doctor, and, though to a lesser extent, a nurse or
druggist  can  give further treatment.  Therefore,
help must be sent for at once, but the measures
given here must be taken in the meantime, for every
second lost in diluting an irritant drug increases the
injury to the tissue and thus increases the chances
of death or, if the patient is saved, life-long trouble
from  the scars  that will form in  the alimentary
tract; and, if non-irritant poisons are removed by
lavage or vomiting before they are absorbed, the
individual may not be any the worse for having
taken the poison,  but, many of these drugs are
absorbed so  quickly that  the   conditions  of
poisoning will be present in from five to twenty
minutes.
  From  what has  been  said regarding the treat- 
        Treatment for Poisoning    347

ment for poisoning it can be seen that the aims
of the treatment are:
  (i) To dilute irritant drugs.
  (2) To remove the drug.
  (3) To use something that will render the drug
harmless or at least less harmful.
  (4) To take means to overcome the bad effects
that the poison has produced. 
 
GLOSSARY
Abnormal.   Not normal; not according to the usual condition.
Acute.  Short; rapid; having a short and relatively severe course,
    the opposite of chronic.
Agglutination.  Sticking or gluing together.
Alimentary Canal.  The canal through which the food  passes
    and is digested.  It consists of the mouth, pharynx (throat),
    esophagus, stomach, and intestines.
Alleviate.  To mitigate, to lessen.
Amputation.  The removal of a part of the body.
Analogous.  Having the same function or meaning.
Anemia. An abnormal condition of the body in which there is
    either a deficiency of blood—as following hemorrhage—or a
    deficiency of red blood corpuscles  or of hemoglobin.
Anesthetic.  A drug  that produces  anesthesia, i. e., lessened
    sensation.
Anterior.  In front of.
Antiseptic.   An agent that prevents the activity and multiplica-
    tion of microorganisms.
Antitoxin.   A  substance that will destroy the toxins (poisons)
    produced by bacteria.  Such substances are produced in the
    animal body as the result of infection by bacteria or their
    toxins.
Anus.   The opening to the external end of the rectum, i.  e., the
    lower part of the bowel.
Apposition.  The state of being fitted together.
Arteries.  The blood-vessels through which the blood flows from
    the heart to the capillaries.
Asepsis. Absence of septic matter, freedom  from infection.
Asphyxia.   Suffocation.
Assimilation.  To absorb  or incorporate;  the transformation  of
    food derivatives into living tissue, i. e., constructive metab-
    olism.
349 
 350                  Glossary

 Astringent.  A  substance  which produces  contraction of  the
     tissues and lessens secretions.
 Atrophy.   The wasting or diminution in the size of a part.
 Auditory.  Pertaining to hearing.

 Base.  The foundation; the chief ingredient of a compound; a
     metal element or compound that will unite with an acid to
     form a salt.
 Basic.  Pertaining to a base.
 Bronchi.  The bronchial tubes which extend from  the trachea
     (windpipe) to the lungs.

 Capillaries.  The small blood-vessels between the arteries and
     the veins; small lymph vessels.
 Complicated.  Complex;  associated  with  another disease  or
     injury.
 Condense.  To make more compact or  concentrated.
 Condiment.  A seasoning or sauce used to improve the flavor of
     food.
 Conduction.  The act of conveying or leading.
 Congestion.  An excessive accumulation of blood in a part.
 Contagion.  The contraction of a disease by contact with infected
     matter or with a person suffering with the disease.
 Contiguous.  Close together.
 Contused.  Bruised.
 Converge.  To come to a point or close together.
 Corrosion.  The  process or act of disintegrating or wearing away
     by degrees.

Defecation.   The discharge of feces from the rectum.
Demulcent.  Bland; soothing.
Dense.  Thick; compact.
Denude.  To lay bare; to remove the covering.
Depressant.  Anything that diminishes the force or strength of
     a body.
Detergent.  A cleansing agent.
Diffuse.  To spread.
Diluent.   An agent used to dilute or render a solution, etc., less
     concentrated.
Disinfectant.  An agent that will kill microorganisms. 
                        Glossary                   351

 Distal.  Remote from the center or origin.
 Drastic.  Severe; a powerful purgative.
 Duct.  A channel or tube for the passage of  secretions or ex-
     cretions from a gland.

 Eczema.  A non-contagious inflammation of  the skin charac-
     terized by lesions of various kinds.
 Efferent.   To carry outward.
 Eliminate.  To expel.
 Emetic.  A drug or other agent that causes eraesis, i.e., vomiting.
 Engorged.   Congested.
 Enzymes.  Organic substances that are produced by living cells
     and act as catalyzers, i. e., they hasten chemical reactions,
     but do not themselves enter into the reaction.
 Epidemic.   A disease that spreads rapidly through a community
     or becomes widely diffused.
 Epidermis.   The outer skin.
 Excreta.  Waste matter discharges from the body.
 Extravasation.  The escape of blood or fluid from a vessel.
 Exudation.  The passage of fluid through the walls of the blood-
     vessels.

 Feces. The waste matter that is discharged through the intestines.

 Gray matter.   The part of nervous tissue which contains the
     cell-bodies.

 Host.  Any organism  or plant upon  which another organism
     lives parasitically.

 Immune.  Protected against any particular disease.
 Incompatible.  Not suitable for combination.
 Infection.  The communication of disease from one person to
     another; the implantation of disease; contamination.
 Ingest. To take into the stomach.
Inherited.  Obtained from an ancestor.
Innervation.  The distribution of nerves in a part.
 Inoculate.  To introduce a virus into any substance.
Insidious.  Deceitful; lurking.
Lacerated.  Torn.
Lubricate.  To make smooth. 
 352                  Glossary

 Maceration.   The softening of a substance by soaking in a liquid.
 Medium.  An agency of transmission or communication; sur-
     roundings; any substance in which bacteria are grown.
 Mobility.  Capable of being moved.
 Molecule.  The smallest part of a compound that can exist and
     maintain its chemical features.
 Moribund.  In a dying state.
 Mucous Membrane.  The thin layer of tissue lining the canals
     and cavities of the body that communicate with the external
     air.

 Nerve Centers.  A rnass of nerve cells that control or help  to
     control some special function, as breathing, swallowing, etc.
 Nerve Reflexes.  Involuntary actions, movements, or secretion
     induced by the stimulation of sensory nerves which transmit
     the stimuli to  the efferent nerves and thus to the muscles  or
     glands.
 Neutralize.  To render neutral, i. e., neither acid nor alkalie; to
     render ineffective.
 Normal. Typical; healthy.

 Obliterate.  To wipe out.
 Omnipresent.  Everywhere.
 Oxidation.  The union of oxygen with matter.

Pallor.  Paleness.
Parasite.  An animal or  plant  that lives  at the expense or  is
     nourished by another animal or plant.
Pathogenic.  Producing disease.
Pathologic.   Pertaining to disease.
Periphery.  The outward part or surface.
Physiologic.   Pertaining to the functions of the body.
Protoplasm.  The essential constituent of the living cells of body
     tissues.

Radical. A group of elements common  to a series of allied
    compounds that act as a unit in a chemical reaction; extreme
    measures; the root or source.
Reaction.  The response which a part makes to stimulation.
Reproduction.  The production of offspring. 
                       Glossary                   353

Secretion.  A substance formed by secretory cells from material
    taken from the blood; the act of forming a secretion.
Sequela.  An abnormal condition following and, either directly
    or indirectly, caused by a disease.
Simulated.  To assume the likeness of; to pretend.
Sterile.  Free from microorganisms; barren.
Stimulate.  To excite or rouse.
Stimulus.  Anything which is capable of producing physiologic
    reaction.
Symptoms.  Signs.
Synthesis.   Building; putting together.
Systemic.  Affecting or pertaining to the whole body or a special
    system of the body, e. g., the respiratory system, the vascular
    system.

Tone.   The state of the body in which all of its parts are in a
    normal state of tension and vigor.
Transudation.  The passage of  matter though a membrane or
    other porous substance.

Urine.  The excretion of the kidneys.

Vaccination.  To inoculate with a virus so as to obtain immunity
    from a disease.
Vacuum.  A space from which all air has been  removed and
    which contains no material substance.
Virulent.  Poisonous; malignant.
Virus.  Poisonous matter produced by disease and  capable of
    propagating that disease.
Vital.  Pertaining to life.
Vitiation.  Impairment of a substance or process that lessens its
    efficiency.
Volatile.  Tending to evaporate rapidly.
       23 
 
INDEX
Air, how purified, 12
  impurities in, 11
Antidote for poisons, 342
.Antiphlogistin poultice, 191
Apoplexy, 271, 272
Artificial respiration, 282
Asphyxia, 281
Asphyxiated,  how  to  avoid
    becoming, 323

Back, how to rub, 61
  how to wash, 61
Bacteria, how to destroy, 32
  how transmitted,  32
Bandage, arm, 250
  circular, 245
  elbow, 250
  figure-eight, 246
  foot, 247
  hand, 251, 253
  heel, 247
  leg, 248
  recurrent, 247
  shoulder, 249
  spiral, 245
  spiral reverse, 245
Bandages, handkerchief, 256
  how to make, 242
  material for, 241
  tail, 256
  uses of, 241
Bandaging,  important points
    to remember when, 243
Bath, action of cold, 93
  action of hot, 91
  action of warm, 97
  cleansing, 98
  eye, 170
  infant's, 219
  points  to  remember  when
    convalescent takes, 103
Baths, uses of, 90
Bedclothes, how  to disinfect,
    36
Bedding,  suitable  for   sick-
    room, 9
Bed, ideal for sick-room, 8
  location of, 9
  making, 46-58
Bedpan,  how to clean,  29,
    65
  how to give and remove, 63
Bedsores, 67
Bottles, care of infant's feed-
    ing, 230
Breathing,  132, 279
Burning, nature of, 321
Burns, 324

Carriers of infection, 24
Carrying a patient,  methods
    of, 44
  after an accident, 265
Chair, making a patient com-
    fortable in a, 83
Chilblain,  329
355 
356
Index
 Children, appropriate clothing
     for, 24
   normal development of, 106
   proper diet for, 213
 Chills, 275
 Chloride of lime, 34
 Cold, action of, 327
 Cold compresses, 181
 Cold,  how  to avoid  taking,
     95
 Colds, causes of, 95
 Collapse, 260, 265
 Comfort,  essentials for a pa-
     tient's, 66
 Congestion, 68, 289
 Convulsions, 270, 274

 Demonstrations, list of, 359
 Diaphragm, 134
 Discomfort, causes of, 67
   causes of in badly ventilated
     rooms, 16
 Disease, how transmitted, 22
 Disinfection,  important rules
     to remember in connection
     with, 35
  nature of, 32
 Dislocations, 308
 Drowning, treatment of person
     rescued from, 285
 Drugs, how given,  140

 Ear, common abnormal condi-
    tions of, 161
  how to remove foreign body
    from, 333
  irrigation of, 162
  structure of, 157
Electric pads, 180
Epilepsy, 272, 273
 Equipment for demonstration
     room, 1
   for demonstrations, see list,
     359
 Eye, abnormal conditions of,
     165
   fomentations for, 195
   how to remove foreign bod-
     ies from, 332
   treatment of, 167
 Eyelid, how to evert,  333
 Eyestrain, 80

 Fainting, 266
 Fever, 120
 Fire, how to put out, 332
 First aid, principles of, 257
 Flaxseed poultice, 188
 Flies, how they transmit  dis-
     ease, 23
 Fomentations, 175
 Foot-bath, in
 Foreign body, removal of, from
     alimentary tract,  335
  removal of, from ear, 333
  removal of, from eye, 332
  removal of, from nose, 334
  removal  of,  from  trachea,
     334
 Fractures, 304
 Freezing, 328
 Frost-bite, 329

 Hair, care of the, 104
  how to comb  and brush the,
    62
  how to wash the, 109
Health, requirements for, 216
Heart action, how controlled,
     131 
Ind(
Heart, structure of the, 128
Heat, how formed in the body,
    118
  how lost from  the  body,
    119
  prostration, 270
Hemorrhage, how  to control,
    313
  symptoms of, 312
  where  pressure is made to
    control, 316
Hot-water bag, care of, 30
  how to fill, 179
Humidity, 15-17
Hysteria, 267, 272, 273

Ice-cap, care of, 30
  how to fill, 181
Immunity,  25
Incubation,  what is meant by
    the period of, 27
Inflammation, 296
Inhalation, 150
Iron,  how used to relieve pain,
    180

Lifting an unconscious patient
    from the floor, 277
  a patient, methods of, 37-43
Liniments,  174
Lysol, 33

Medicines,   important points
    to remember regarding the
    care and use of, 142
  methods  of giving, 139
  uses of, 139
Mental development, 209
Milk, modification of, 233
  pasteurization of, 239
5X                     357

Mosquitoes, how they transmit
    disease, 24
Moving patients, methods of,
    37-43
Muscle tone, 92
Mustard, 83
  pastes, 184
  poultice, 190

Nasal douche, 145
Nightgown,  how  to change,
    55
Nipples, care of bottle, 232
Nose, application of medicine
    to, 148
  removal   of  foreign   body
    from, 333

Odors, causes of, in sick-room,
    18
Ointments, 174

Pastes, 175
Patient, preparation of, for the
    night,  59
Plasters, 174
Poisoning,  symptoms of, 338
  treatment for, 340
Poisons, classification of, 336
  how formed in  the  body,
    263
Poultices, 175-185
Pressure-sores, 67
Pulse, how  to   count   the,
    138
  normal rate of, 130
  what  is  meant  by   the,
    127

Records, how to keep, 138 
358                     Index
Respiration, 132
Rubber, care of, 30

Salt,  external use  of  hot,
    180
Scalds, 326
Scars, nature of, 291
Shock, 260, 265
Sick-room,  desirable  char-
    acteristics of, 7
  how to clean, 27-29
  what is involved in the care
    of a, 10
Skin,  uses of  applications  to
    the, 131
Slings, 256
Solutions, nature of, 174
Sound,160
Sprains, 311
Stains, how to remove, 31
Stupes, 175
Sunstroke, 268

Tear ducts and glands, 331
Temperature, definition of, 116
  for infant's bath,  219
  how to take an infant's, 218
  how to take  by axilla, 127
  how to take by mouth, 125
  suitable for sick-room, 21
  terms  used  in  describing
    different degrees of, 123
Thermometers, 123
Throat,  application of medi-
    cine to the, 149
Trachea, removal  of  foreign
    body from the, 334

Unconsciousness, 259
Unslaked lime,  34
Uremia, 272
Utensils, how to clean, 29-31
  how to disinfect, 32

Ventilation,  10-22

Winds, causes of,  13
Wound, changing the dressing
    on a, 302
  dressing a simple, 298
  first aid treatment of, 293
  healing of, 289
  infection of, 294
  nature and classification of,
    287
Wrapper, how to put on, 87 
INDEX OF DEMONSTRATIONS
	Demonstrations	PAGE		
		List of Equipment.	Procedure.	
I.	Methods of ventilating and cleaning a sick-room. Care of utensils used			
	for the sick.	6	6-	36
2.	Moving,lifting, and carrying a patient	37	40- 45	
3-	Stripping a bed. Making a closed			
	bed.	46	47"	52
4-	Changing the sheets with a patient in bed. Changing a patient's night-			
	gown.	52	52-	58
5-	Preparation of a patient for the			
	night.	59	59	
6.	Methods of making a patient com-			
	fortable.	82	83	
7-	Preparing a patient to get out of bed and making her comfortable in a chair. Helping a patient get into			
	bed.	86	87	
8.	Giving a cleansing bath to a patient			
	in bed.	99	99	
9-	Cleaning the hair.	107	107	
IO.	Washing the hair.	108	109	
n.	Giving a foot-bath.	in	111-	H5
12.	Taking the temperature.	125	126	
13-	Counting the pulse and breathing.	136	138	
14.	Measuring medicine.	H5	145	
15-	Apphcation of medicine to the			
	throat.	154	156	
359 
360   Index of Demonstrations
INDEX OF DEMONSTRATIONS—Continued
	Demonstrations	PAGE	
			
		List of Equipment.	Procedure.
16.	Irrigation of the ear.	162	164
17-	Methods of irrigating and putting		
	medicine in the eye.	167	169
18.	Methods of using iodine, liniments, ointments, and articles employed for		
	the application of cold to the body.	175	176-182
19.	Preparing, applying, and removing		
	sinapisms.	182	184
20.	Making and applying poultices.	185	188-191
21.	Application of fomentations or		
	stupes.	192	r93
22.	Lifting, weighing, bathing, and		
	dressing a baby.	218	223
23-	Preparation of an infant's food. Care of feeding-bottles, nipples, and utensils used in the preparation of		
	food.	226	236
24.	Bandaging.	241	245-256
25-	Lifting an unconscious patient from		
	the ground.		277
26.	Treatment of a person rescued from		
	drowning. Artificial respiration.	279	283-285
27.	Dressing a simple wound.	287	298
28.	First aid treatment in hemorrhage		
	and fractures.	304	320
29.	Extinguishing fire.	321	324
 
   Jk Selection from the
       Catalogue of

G.  P.  PUTNAM'S SONS




    Complete Catalogue sent
        on application 
 
  " 1 consider It the best I have seen and shall recommend Its use
In our school."—Kate A. Sanborn, Supt. of Training School for Nurses,
St. Vincent's Hospital.
 Essentials  of  Dietetics

       In  Health  and  Disease

A Text-Book for Nurses and a Practical Dietary
             Guide for the Household
            By AMY ELIZABETH  POPB
 Instructor in the Presbyterian Hospital School of .Nursing;
         St. Luke's Hospital, San Francisco. Calif/
                         and
              MARY  L. CARPENTER
     Director of Domestic Science in the Public Schools
                Saratoga Springs, N. Y.

       Second Edition, Revised and Enlarged
              Crown 8vo.   Illustrated
   Essentials of Dietetics is primarily a text-book, intended to
facilitate the teaching of dietetics in schools of nursing.  Its aim
is  to furnish nurses with such information as is  indispensable,
and can be assimilated in the time given to the study of dietetics
in  the nursing-school curriculum.   It is also adapted to use as a
dietary guide for the home.  At least one-third of the •women
who enter the larger schools of nursing do  so with the desire of
being prepared  to take charge of  hospitals or to  do  settlement
work, and in both these branches of the nursing profession hardly
any one thing is more important than knowing how to direct the
buying, preservation, cooking, and serving  of food. To do this
intelligently it is  absolutely necessary to have some knowledge
of  the chemistry of foods, of the special uses of the various food
principles to the body, of the proportions in which they are con-
tained in the different foods, and of the effect on them of acids,
heat, salt, digestive ferments, etc.
       Q.  P  PUTNAM'S SONS
NEW YORK                            LONDON 
 For Those  Whose Work Is Among Children


   The   School   Nurse

                     By

       Lina Rogers  Struthers
          First Municipal School Nurse

             12°.   24 Illustrations

This Book  is a Survey of the Duties  and
        Responsibilities  of the Nurse

in the maintenance of health and physical perfection
and the prevention of disease among school children.
  The school nurse  has been a great factor in com-
munity  welfare and has strengthened the intimate
relations between the school and the home.
  School  nursing  is still in its infancy and many
changes in methods are to be expected, but the under-
lying essentials—child love and preservation of child
health—will exist as  long as child life.
  By  virtue  of her pioneer labor  in this  special
branch of nursing and also because of her subsequent
extensive  experience  and recognized position in the
field, Lina Rogers Struthers, R.N., First Municipal
School Nurse, is fitted as are few others  to counsel
and guide those who are engaged in or who contem-
plate pursuing school nursing.  Mrs. Struthers's book
is the result  of painstaking experience and  careful
study of the requirements of school nursing.
        G. P.  Putnam's Sons
New York                          London 
The    Home    Care   of



         Consumptives

                      By

              Roy L.  French

Former Secretary,  Kentucky Tuberculosis Commission

                 12°.

  The  successful home  treatment of  a consumptive
patient depends on the intelligent, hopeful, persistent
cooperation of the patient and family with the physician.
This cooperation must be based on  exact information as
to what to do and how to do it.  This book will not take
the place  of medical supervision, which is necessary in
every  instance.  But  it supplies a fund of information
which will make that cooperation possible.  Physicians,
social workers, nurses, and  teachers will also find here
much valuable material.

Suggestions to Physicians

  i. Leave a  reference  copy on  the reading table of
your dispensary or sanatorium waiting room.

  2. Provide visiting nurses with copies to lend to the
more intelligent patients.

  3. Patients in sanatoria and camps will learn much by
reading this volume.  A sufficient number of copies to
lend would be desirable.

  4. Many patients, discharged or arrested, lose in a
month  the gain of a year. Why? They forget your
instructions about exercise; or they do not know how to
arrange for themselves at home the same diet you take so
much  pains in preparing.  This book meets  that need.
Suggest that each discharged patient has a copy.
  5. No better use for a small fund can be found than to put a
copy of this  book into  the hands  of every  known tubercular
family in your territory, by gift or loan.


         G.  P.  Putnam's  Sons

New  York                            London 
 
 
 
% v
$
AUG 3< 1*1 
tM
WY 195 P825t 1921




54810170R-
Krv
NLN   DSaflTMTD  1
-^BsKs
NATIONAL LIBRARY OF MEDICINE
W:

*,v

S;f:'..'
tig* r-i
r ' ^..ox;:J

.-•"2y-i;.

. ~t ! *'■*/*£ "" '-v"'-'-■•T-" ■!>v^-^;>fej _i;'***$
4vo'#

•■.■•■J." i :.'?i\.~r + -

' j^£g-.~ 3^
"Y~ti <
££:

-Xi^1


"-jy
:-ki'.,'


:4^r^r^^1^^S^%*>^^^^
- ■ ■■ ■ -to-" ■-■ '1';-,iJ^.'i v*--i^.



NLM052894901