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PEACTICAL NUESING

■i

PRACTICAL NURSING

ISLA STEWART

MATRON OF ST BARTHOLOMEW'S HOSPITAL, LONDON
AND

HERBERT E. CUFF, M.D., F.R.C.S.

MEDICAL SUPERINTEXDEST, NORTH-EASTERN FEVER

LONDON

BUM jiaiai

IN TWO VOLS.— VOL. I.

WILLIA^[ BLACKWOOD AND SONS
EDINBURGH AND LONDON
MDCCCXCIX

All liiglita reserved

PREFACE.

In the following chapters we have dealt with the
nurse's work from a general point of view. In another
volume we hope to consider in detail the nursing of the
various medical and surgical ailments, and also devote
some space to special branches of nursing.

Our great aim in writing this book has been to make
the practical part of it as thorough as possible, and to
give every step in the performance of the various nurs-
ing operations. Not that we for one moment believe
that book-work can ever take the place of, or even
compete with, ward-work ; but we do hold that a pre-
cise and complete account of an operation, such as a
vapour bath, will aid a nurse in the giving of it, par-
ticularly if she should be doing so in private, after
having had but little experience of it during her

PKEFACE.

hospital career. It seems to us that the descriptions
given in books on nursing are, as a rule, too sketchy,

Further, we have endeavoured to make clear the
reasons for what a nurse does when carrying out the
treatment that has been ordered. This should increase
her interest in the work, and lead to a more intelligent
performance of it.

We have to thank Dr W. T. G. Pugh for his very
careful reading and correction of the proof-sheets.

. I. S.
H. C.

CONTENTS OF THE FIEST VOLUME.

CHAP. PAQE

I. NURSING AS A PROFESSION 1

II. THE HYGIENE OF THE WARD 16

III. WORK IN THE WARD AND PRIVATE SICK-ROOM . . 30

IV. PERSONAL CARE OF THE SICK 44

V. OBSERVATION OF THE PATIENT 61

VI. OBSERVATION OF THE PATIENT — continued . . 75

VII. DIET IN DISEASE 93

VIII. COLD BATHS AND PACKS 110

IX. HOT BATHS AND PACKS 125

X. HOT AND COLD APPLICATIONS 138

XI. COUNTER-IRRITANTS — SYRINGING THE THROAT, NOSE,

AND EARS 154

XII. ENEMATA, ETC 167

XIII. MEDICINES AND THEIR ADMINISTRATION . . . 181

XIV. THE NURSING AND FEEDING OF SICK CHILDREN . 198
XV. CONTAGION AND DISINFECTION 211

XVI. ON THE PRODUCTION OF SURGICAL CLEANLINESS . 221

XVII. SURGICAL NURSING 235

INDEX ■ . . 248

PEACTICAL NUKSING.

CHAPTEE 1.

NUKSING AS A PROFESSION.

Et is only of late years that a coiirse of systematic
training has been deemed necessary for the woman
who wishes to become a nurse. Even now, what that
training is to consist of, its method, its length, and
its minimum standard of efficiency, are matters of
dispute rather than agreement. While this is so, it
cannot be said that any material step has been taken
towards the organisation of the nursing profession.
Yet, the fact that many of the public, as well as the
more thoughtful among nurses, feel the necessity for
such organisation, is some small advance in the right
direction.

It seems strange that the need of training was not
earher recognised by members of the medical profes-
sion ; for the sufferings of patients at the hands of
incompetent and often worthless women, and the

VOL. I. A

PRACTICAL NURSING.

inconvenience to both physicians and surgeons, must
have been very great. Without doubt there were
some good nurses in the first half of this century;
but the efficiency and morahty of a class of Avomen
who are now chiefly represented by the Sairey
Gamp and Betsy Prig of Dickens and the ]\Irs
Horsfall of Charlotte Bronte, cannot have been
very conspicuous.

In recognition of her great services during the
Crimean War, the nation presented IMiss Florence
Nightingale with the sum of £52,000, with which she
founded the Nightingale Training School for Nurses
in connection with St Thomas's Hospital. It is now
nearly forty years since the Home was opened, and
during that time almost every hospital and infirmary
in the kingdom has begun to train nurses on some-
what similar lines.

The divergence of method, which has of late years
increased, was originally small. At first, twelve
months of actual work in the wards was considered
sufficient to qualify any woman for the responsible
post of matron, assistant - matron, or ward sister.
Now the time of training at the different schools
varies from one to three years, the majority pre-
ferring the latter. This only quahfies for the post
of sister, or for private nursing ; for the higher
appointments a long period of experience and super-
vised authority is required. When it is borne in
mind that this varied period of training is given to
women of every degree of inteUigeuce and education
in hospitals and infirmaries ranging from 10 to 800
beds; that in some it is methodical and careful,
while in others the probationer merely learns what

NURSING AS A. PROFESSION.

she can at the expense of the patients, it will not
appear strange that even now there exists a. prej-
udice aeainst trained nurses

Curiously enough the medical profession seems to
hold over-training to be the greater evil, as tending
to the production of a lower order of practitioner;
whereas, it is those who have been insufficiently-
trained and disciphned who fail to recognise the
grave responsibility of disobedience, and who take
upon themselves to criticise the doctor's treatment,
or even to suggest what form it should take. Such
an entire misconception of the duties of a nurse does
not spring from an excess of Imowledge but from
the reverse. It is the well-trained, carefully taught
woman who recognises the limitations of her pro-
fession, and is careful never to overstep them. A
minimum standard of knowledge should be laid down,
and a definite length of time prescribed during which
that Imowledge could be obtained in hospitals large
enough to ensure that it would be sufficiently varied.
Finally, there should be some method of testing this
knowledge by examination. Such a scheme would
tend to sweep out of a grand profession the half-
trained and untrained women who now peril its good
name, and often bring disgrace on its ranks.

In many hospitals of the present day candidates
present themselves to the matron, and she in an in-
terview of a few minutes is supposed to discriminate,
by some fine intuitive process, between the fit and
unfit. This method of selection is too often found
inadequate, admitting, as it does, into the wards too
many incompetent candidates, wlio liiave to be dis-
charged after a month's trial.

PEACTICAL NURSING.

An increasing number of hospital authorities are
beginning to feel the necessity for some little prepara-
tion hi the way of special study, both practical and
theoretical, leading up to an examination, by which
the candidate's intelligence is tested, while at the same
time her physical fitness is proved. It certainly seems
desirable that probationers should begin their work in
the wards with some knowledge of elementary anatomy,
physiology, and hygiene, together with experience of
dusting, bed-making, and other domestic work. How
this is to be obtained is a difficulty that will not
be easily overcome, since it entails a question of
expenditure which must be borne by the candidates.
The London Hospital and the Royal Infirmary at
Glasgow have organised in homes connected with,
but apart from, the hospitals, training-schools where
candidates are taught anatomy, physiology, and
hygiene from lectures by the physicians and surgeons,
and practical work by the matron and her assistants.
A better plan, perhaps, would be a central training
home, where each hospital could choose its own pro-
bationers from among those who had attained its
standard of preliminary knowledge as proved by ex-
amination. When this preliminary training becomes
more general, it vidll lessen to a great extent the
influx of unsuitable women into the wards, and will
therefore materially increase the efficiency and use-
fulness of the nursing staff'.

There is still abroad the idea that a nurse is born,
not made. A woman may possess all the qualities
which go to make a good nurse, but until she has
developed and strengthened them by experience and
discipline, and by hard work has mastered the techni-

NUESING AS A PROFESSION.

oalities and difficulties of her profession, she cannot in
any sense be considered a nurse.

To become a good nurse, a woman must possess
considerable intelligence, a good education, healthy
physique, good manners, an even temper, a sym-
pathetic temperament, and deft clever hands. To
these she must add habits of observation, punctuality,
obedience, cleanliness, a sense of proportion, and a
capacity for and habit of accurate statement. Train-
ing can only strengthen these quahties and habits ;
it cannot produce them.

Of the necessary habits which a nurse should cul-
tivate that of observation is the most important. A
hospital ward is the only jDlace where she can be
taught what to see, and the value of what she sees.
Her usefulness as a nurse depends so much upon
the possession of this habit, and her ability to use it
accurately, that she should lose no opportunity of
improving it. With carefully cultivated observation
comes a sense of the relative proportions of things
seen ' and heard. Obedience is the first duty of a
nurse and the best test of her training. It must
not be the dull mechanical obedience of the ignorant
or uninterested. To be effective, it must be whole-
minded, intelligent, and loyal. The necessity and
importance of punctuality and cleanliness should be
obvious to every one. Accuracy implies more than
the mere desire to be truthful. In social life this
is not always easy ; in official life the difficulty of
conveying impressions, so as to place them before
the mind of your hstener in the light in which
you yourself see them, seems at times wellnigh im-
possible. It requires a fairly extensive vocabulary,

PRACTICAL NURSING.

a knoivleclge of the relative value of the facts re-
ported on, and a certainty of observation which can
only be acquired by long and inteUigent attendance
on the sick. Accuracy is not limited to words, but
embraces the conscientious performance of duties.

The Lords' Commission on Hosj)itals recommended
that the training of nurses should occupy a period of
not less ,than jthree years. In a few of the larger
hospitals such wasalready the case, and since then
many more have made their arrangements conform
with this ruling.

During her first year the new probationer should
make herself well acquainted with the elements
of anatomy, physiology, and hygiene, and gain a
thorough knowledge of the technical part of her pro-
fession. This will include the making of beds, with
or without a patient ; the care and use of linen ; the
moving of patients ; the administration of enemata ;
the use of the catheter, and how to clean it ; the
composition, value, and administration of food. She
should learn, in addition, how to give medicines, with
their possible results ; how to pad spHnts, bandage,
make and apply hot and cold apphcations and coimter-
irritants ; how , to dress wounds ; the principles of
aseptic surgery, the personal care of patients, and
the prevention of bed-sores. These subjects, which
should be taught cliiefiy in the wards, but also in
classes by the matron or her assistant, wUl fully
occupy the first year of training, during Avhich the
probationer should in no way be placed in a position
of responsibility. At the end of this time an exam-
ination will demonstrate the extent of her knowledge,
together with her fitness, or unfitness, for promotion.

NU USING AS A PllOFESSION.

The second and third years will be profitably spent
in gaining experience of disease and its treatment,
and in learning the relation of nursing to the work
of the physician and surgeon. The nurse should now
be intrusted with some little responsibihty and au-
thority, that she may learn to use both judiciously.
Duruig this time she should attend lectures by the
medical staff, who will explain the causes and symp-
toms of the more common diseases and accidents, the
object of treatment, and the proper course for her to
pursue in the event of her being left in a position
where she must act on her own judgment pending
the arrival of medical assistance. The most diligent
and inteUigent of probationers will find two years
all too short a time in which to learn as much as
a nurse ought to know of disease and its treatment,
in order that she may become a real assistant to both
the physician and surgeon.

At the close of her three years' training the proba-
tioner should be able to pass an examination, which
ought to be as practical as possible. It should mainly
be directed to findmg out whether she has gained
sufficient knowledge by observation and experience,
and has become deft enough in the use of her hands,
to be capable of performing the duties of a nurse.
The information which she has acquired from books
alone should count for very Httle in comparison with
vvliat has been gained in the wards. Examinations,
at the best, can only demonstrate that the candidate
has learnt enough to enable her adequately to exer-
cise her profession ; they can never prove that this
or that woman is a good nurse.

The nur.se in charge of a case has a threefold duty

PRACTICAL NUilSING.

to perform. She has her duty to her patient, her duty
to her medical officer, and her duty to herself.

(a) The patient must always be her first care ; she
must ever be on the alert to anticipate his wants and
needs. She must be gentle but firm, striving to gain
his confidence, and not fearing to use her authority
when necessary. No two patients are exactly alike,
therefore no actual rules can be laid down ; but the
nurse will not greatly err who always remembers the
humanity of her patients, and makes their comfort
and wellbeing her first thought. ^

Her manner towards her patients should be charac-
terised by dignity and gentleness. The presence of
a refined and courteous woman is sufiicient imder
ordinary circumstances to maintain order in a ward.
If reproof must be given, let it be done as quietly and
briefly as possible, and not referred to agaia. Famili-
arity must always be avoided ; but the nurse should
show her patients, as she can in many little ways,
a sympathetic willingness to help them, that her work
is a pleasure, and that it is done ungrudgingly. She
should be particularly gentle in her dealings with new
patients, who often suflfer much from nervous shyness
and dread of the unknown when they first come to
a hospital. This feeliag is naturally increased by a
hard business-like manner in the nurse who receives
them, while a gentle remark or kindly inquiry -rtII
do much to remove it. A new patient should not be
allowed to sit for some time unnoticed, even if all the
nurses are busy : a kind word from one of them in
passing will show him that he is not uncared for.

The friends of patients are often some\\diat of a trial
to a nurse ; but she must remember that then' anxiety

JMURSING AS A PEOFESSION,

and their apparently needless and troublesome ques-
tions are the natural result of untried cii-cumstances.
She should make them feel that they are worthy of
consideration, and that they will receive kindness and
attention from her. She should endeavour to win
their confidence by listening attentively to whatever
they have to say, as far as it bears on the patient's
condition. At the same time, she should never give
them her opinion of the case, but always refer them
to the sister of the ward, or the medical officer, for
information.

As a private nurse she should be thorough but not
fussy. She must remember that she is engaged as
a help in time of distress, and should therefore be
willing to perform duties in a small house which it
would be quite unnecessary for her to undertake in
a larger establishment. She must, in a word, suit
herself to the needs of the case. She ought never to
talk to one patient of the affairs or illness of another,
but bear in mind that she has xmusual and unavoid-
able opportunities of becoming acquainted with the
private affairs of her patients, and that it would be a
gross breach of confidence for her to make use of this
knowledge. When her patient is visited by friends,
she should, when possible, leave him alone with them,
remaining within call, and intervening when she
thinks the visit has lasted long enough.

(6) To the medical attendant a nurse's first duty
is obedience. In a hospital, where the services of a
resident stafi' are always at hand, obedience should be
absolute and unquestioning. A mental habit is thus
formed the power of which is never quite lost. In
private practice, where more responsibility nmst be

PRACTICAL NUKSING.

left to the nurse, and where altered conditions some-
times justify a modification of the doctor's orders, her
aim should be to proceed on lines Hkely to be approved
by him rather than on those she herself might choose.
Any deviation, however small, should always be at
once reported to him, that he may express his opinion
upon it ; while a niirse should never omit to acknow-
ledge any mistake she may have made in carrying out
his instructions. She should always do her utmost to
promote her patient's faith in his medical attendant.
Absolute candour, loyalty, and obedience will render
her a valued and trusted assistant.

(c) A nurse's duty to herself can be divided into two
parts — mental and physical. If she thinks, reads, and
talks about nothing but nursing, she contracts her
outlook on life, lessens her intelhgence, decreases her
capacity for assimilating new ideas, and becomes
somewhat of a nuisance to her friends. A nurse's life,
passed as it is amid scenes of sorrow and suifering —
often the result of what she has been taught to con-
sider sin — is naturally depressing, and she tends to
become morbid, introspective, and cramped. She will
do well, therefore, to seize every legitimate means
of relaxation. Her pleasures should be hghtly held,
tasted with enjoyment, and easily put aside ; her
duties grasped firmly, and unswerxdngly followed.
Besides obtaining what pleasure and relaxation she
can without detriment to her work, a nurse should
keep up her interest in literatiu-e, pubhc events, and
whatever is new in her own profession. Kelaxation is
necessary in all professions, but in none more than in
nm-sing, for which there are seven working days in
each week, and eleven, and sometimes twelve, work-

NUKSING AS A PHOFESSION.

ing hours in each day, A healthy miud is as neces-
sary foi- a niu'se as a healthy body, and that can only
be attained by giving it a varied diet, plenty of work,
and a sufficiency of play.

Nurses ought always to be most careful of their
own health. If they are not so, they are less likely to
be able to do their patients justice. They are very
hable to suffer from sore tliroat and fatigue, wliile
flat-foot and varicose veins are by no means uncom-
mon. These ailments may to a certain extent be
avoided by attention to a few simple rules of health.

Nurses should see that their bedrooms are well
ventilated, the windows being open from the top, not
only when they are absent, but also when they are
sleeping in them. They should never go on duty
fasting. They should scrupulously wash their hands
and faces, and clean their nails, before taldng food.
The latter should be kept so short that no extran-
eous matter can find a resting-place beneath them ;
and, that they may be easily cleaned, special atten-
tion should be paid to the bases of the nails. Any
wound, however slight, should be at once cleansed
and protected. Careful drying will help to prevent
chapped hands, and some emollient shoidd be rubbed
into them, not on them, at least twice a-day. Nurses'
clothes should be Hght, warm, and loose. Tight stays
and garters impede the cumulation, leading to indiges-
tion, varicose veins, and other discomforts.

The amount of standing which nursing necessitates,
particularly when the probationer has not been accus-
tomed to it, occasionally results in a tendency to
flat-foot. With a little care this may frequently be
avoided. Five or six tunes a-day the nurse should

PEACTICAL NUKSING.

raise herself on tiptoe, repeating the movement ten
to twenty times. The feet should be bathed in cold
water twice a-day, and when they feel tired or ache
the nurse should stand for a short time on the outside
of them. Pain in the arch of the foot should be
attended to at once, as flat-foot is not only disfigur-
ing, but may be so painful as to imfit a nurse for her
duties.

Serious illness may often be avoided by an early
attention to symptoms ; a nurse should, therefore,
neglect no sign, however slight, of ill-health or func-
tional disturbance. A sore throat should always be
reported at once, not only for the sake of the nurse,
but also for the protection of the patients, since there
is always a possibihty of its being dii^htheria. In
almost all hospitals nurses will fijid du-ections to be
observed when they are attending upon infectious
cases, such as typhoid fever and diphtheria. It is
their duty carefully and fuUy to carry out those
directions.

The new probationer should, for her own sake,
make herself early acquainted ^vith the etiquette of
hospital life, which is nothing more than common
poUteness ofiicially expressed. She ought never to
remain seated in the presence of a superior officer, nor
when visitors are in the ward. She should leai'u to
receive orders with deference and j^ohteness. She
should obey the written and unwritten laws of the
hospital, respect its traditions, and so order her ways
that no discredit may fall on it through want of
thought on her part At the same time, there is no
need for a nurse to be aggressively polite. She must
remember that the sister, when present, will take the

NURSING AS A PROFESSION.

lead in all things, and in her absence the senior nurse
will act for her. A cheerfully polite manner is all
that is required of a probationer, unless she is speci-
ally addressed.

The new-comer will find women of all kinds among
those who are to be her companions during her term
of training, and she Avill do well not to rush into
hasty intimacies which on further acquaintance may
prove undesu'able. It is not wise to lay aside all
reserve and be willing to be the comrade of any one.
At the same time, it is foolish to adopt a churlish
and repellent air, which may keep off a companion-
sln]^ that would prove both pleasant and profitable.
The middle course is always the best. An obliging,
courteous, slightly reserved manner will leave its
owner free to form suitable friendships. A matron is
equally suspicious of the nurse who at the end of her
first year has either no friends or too many.

In the matter of study probationers will do well
to act with discretion. Some nurses, after gaining
a superficial knowledge of anatomy and physiology,
discuss and study obscure questions, wasting their
time in the pursuit of knowledge which can be of
no use to them. Their reading during their term of
training ought to be kept strictly within prescribed
limits, covering efficiently a small portion of each
subject. The following, if really known, might safely
be considered sufficient : The bones of the skeleton,
with their articulations ; the large superficial muscles;
the skin and its functions; the circulation in the large
arteries and veins ; the alimentary canal, and the
process of digestion ; a general idea of the nervous
system and its functions ; and the same of the kidney

PRACTICAL NURSING.

and organs of special sense. If, in addition to these
subjects, a nurse learns all that her work in the
wards can teach her of surgery, pathology, and
medicine, she will have more than enough to study
during her three years' training. If she really aims
at being a successful nurse, she must work hard
with her hands as well as her head. In the hospital
she will find the material for study, and such aids
to it as lectures and teaching can give. But the
learning and application must be done by herself.
In nursing, as in all other professions, education
must be the work of the pupil, aided and guided
by the teacher.

At the close of her term of training the nurse
is a very different woman from the candidate who
entered three years previously. Her life in hospital
may have had one of two results. She has either
improved, or deteriorated. She is either more in-
telligent, sympathetic, and imselfish, or she has be-
come dull, mechanical, and self-absorbed. To some
extent the responsibility for the change rests with
the people under whom she has worked, but in the
main she must look to herself.

If she is willing to work mechanically, glad when
each day's work is over, learning only enough to
enable her to pass the examination, she will leave
her training-school fit only to work with the rank
and file — a mere drudge. This is the kind of niu>se
who so often brings her profession into disrepute ;
for to a curious ignorance she often unites a most
consuming confidence in herself. She it is who
criticises the treatment of the medical attendant,

NURSING AS A PROFESSION.

and presumes to disapprove of it. The profession
is indeed overstocked when it holds one such nurse.

But if during her probationship the nurse has
worked loyally, conscientiously, and intelligently,
using: to the utmost her enormous sources of in-
formation, recognising her responsibilities, and keep-
ins: herself at the same time ahve to outside interests,
she will be a more intelligent, capable, and sympa-
thetic woman. She will more readily assimilate
new ideas ; her grasp of hfe will be firmer, and her
mind will be broader. Recognising her limitations,
she will be averse to taking unnecessary responsibility
on herself. She is, in fact, the loyal assistant that a
nurse ought to be to her physician and surgeon.

CHAPTER II.

THE HYGIENE OF THE WARD,

Hygiene is " the science which treats of the preserva-
tion of health." As applied to any room, it includes
proper lighting, thorough ventilation, and sufficient
warming. Light, warmth, and fresh air are all es
sential to the maintenance of good health. How
necessary, therefore, must they be to those who are
ill!

One of the most important of a nurse's duties is to
keep a careful eye upon the hygiene of her ward.
More than that, her eye must be intelligent. It is
the want of this latter quality, combined with igno-
rance of the first principles of ventilation, that renders
so many nm?ses incapable of providing their patients
with a constant supply of warm fresh air. They fail
to realise the immense importance of a pirre atmos-
phere. Many a nurse thinks far more of keeping the
air away from her patients than of letting it get to
them. She has a righteous horror of draughts, and
iinfortunately, in her anxiety to exclude them, she
shuts out fresh air. She shares with the general
public the superstition that anybody who has a high

THE HYGIENE OF THE WARD,

temperatiire must be carefully guarded from the air,
or he will take a cliill. Experience teaches a very
dilFerent lesson.

In many a campaign it has been foimd that the
woimded who were crowded together in hospitals and
other buildings were decimated by pyaemia, erysipelas,
and hospital gangrene ; whereas those who were placed
in tents, or rough shelters hastily thrown up for the
purjjose, escaped these diseases. They did so because,
from the nature of their surroimdings, they were con-
stantly exposed to draughts of fresh air, which swept
away the germs and other impurities. On the other
hand, their better-housed but less fortunate comrades,
under the influence of deficient ventilation, fell easy
victims to the diseases just mentioned.

Changes produced In Air by Respiration. — Air-
consists almost entirely of two gases — oxygen and
nitrogen. Of the former there is rather more than
one-fifth ; of the latter shghtly less than four-fifths.
There is, in addition, a minute trace of a poisonous
gas called carbonic acid, and a small quantity of
watery vapour. Such is the composition of pure
air. We cannot improve on it. A nurse should
therefore endeavour to keep her patients constantly
siuTounded by an atmosphere which shall as closely
as possible resemble it.

The air which we breathe out of our lungs differs
very considerably in composition from that which was
taken in. A considerable proportion of the oxygen
has been absorbed by the blood-vessels of the lungs.
In exchange for it, they have parted with an equal
quantity of carbonic acid gas, a small quantity of
various other impurities, and some water which

VOL. I. B

PRACTICAL NURSING.

escapes as vapour. An atmosphere composed of such
an- as this is quite unsuited to support Ufe. It con-
tains far too little oxygen, and far too much carbonic
acid and other impurities. Every individual in a
ward is constantly engaged in removing oxygen and
adding carbonic acid to the air of the ward. The
atmosphere is rendered still more unwholesome by
emanations from the patients' bodies, their linen, and
excreta ; by any foul wounds or soiled dressings there
may be in the ward ; and by the bm-ning of gas.
Each jet of gas consumes many times as much oxygen
as a man. To counteract such a continual fouling of
the atmosphere, a frequent and thorough changuig
of the air is necessary. Merely diluting the bad air
with good is not enough : the former must be swept
out of the ward, and the latter allowed to take its
place. Ventilation should be sufficiently thorough to
completely renew the air in a ward at least three
times in every hour.

Principles of Ventilation. — It is highly important
that nurses should understand these principles, for if
they do not how can they intelligently regulate the
ventilation of their wards ? There are two simple but
all-important facts to be remembered.

(1) Air expands when it is heated. — From which
it follows that, as the hot an- in a room expands,
some of it escapes from the apartment by the
nearest outlet.

(2) As a Result of its Expansion, Hot Air is lighter
than Cold Air. — A balloon rises because it is filled
with a gas that is lighter than air. So hot air, being
fighter than cold air, will rise, wliile the latter, being
heavier, wUl fall.

THE HYGIENE OF THE WARD.

From these two facts we learn that in a dwelling-
room the hottest and foulest air must be situated
in the upper part of the room, close to the ceiling.
Further, that any cold air which enters the room
has a tendency to fall downwards towards the floor.
After being Avarmed, it in its turn expands and moves
upward.

In ventilation our object is to hasten the removal of
the hot foul air, and so to regulate the admission of
the clean cold air that it shall not fall directly upon
the occupants of the room, and thus lead them to
complain of a draught. If possible, the chill must
be taken off it before it reaches them ; at the same
time, an ample supply of pure air must be secured.
How to bring about this desirable result is the next
point for consideration.

Foul Air escapes from a Room —

(a) By the fireplace.

(b) 'By the windows.

(a) Bt/ the Fireplace. — In an ordinary dwelling-
house the chimney is the great place of exit for the
air of each room. Hot air, being lighter than cold
air, tends to ascend. Hence the air in the chimney,
being heated by the fire, moves upwards, its place
being taken by a fresh supply drawn from the room.
There is thus a constant current of air leaving the
apartment by way of the fireplace, which is conse-
quently a most important aid to ventilation.

(6) By the Windows. — The air which is in contact
with the ceiling, being the hottest in the room, has
a strong tendency to escape by any channel which is
open to it. Consecpiently, if the wijidows are o^n

PRACTICAL NDRSING.

from the top, this hot au" will stream out of them, its
place being taken by air from the lower and cooler
parts of the room.

(c) By Ventilating Outlets. — If these are to be used
for the removal of hot foul air they must be placed
in the uppermost part of the room, where that air is
situated — e.g., in the ceiling. A common and useful
plan in a ward is to have them directly over the gas-
burners, so that the stream of hot air which these
produce may move upwards into the outlet above.
In private houses an outlet for foul air, leading into
the chimney, is often made in the wall of the room
above the fireplace.

Fresh Air enters a Room —

(a) By ventilating inlets.
(h) By windows.

This is the more difficult part of the problem, since
a constant and thorough supply of fresh air must be
obtained, while draughts, if possible, must be avoided.
At the same time, nurses must remember that fresh
air is the prime consideration, and that it must be
obtamed at all costs. In a hospital it is impossible
altogether to avoid draughts, unless the air is warmed
on its way into the ward.

(a) By Ventilators. — If the air can be warmed on
its way into the ward, these should be placed near
the floor. In many of the more recently built hospitals
there is behind and below the bed of each patient a
large opening in the wall, leading direct to the outside
air. In front of the opening is a coil of pipes, con-
taining steam or hot water. As air enters the ward
by this opening, it is warmed by the pipes. Each
patient is thus enveloped in a constant stream of

THE HYGIENE OF THE WARD.

fresh air. This method of ventilation is only pos-
sible when there are hot pipes to warm the air as
it enters the ward, otherwise an intolerable di^aught
would be produced in cold weather. In the absence
of hot pipes the cold air must be introduced into the
ward above the level of the patients' heads, so that it
reaches them after mixing vnth the warm air in the
ward.

(6) By Windows. — The windows have already been
considered as an outlet for foul air ; they also act as
inlets for a large quantity of clean air, especially in
windy weather. At such a time air rushes in from
the side agaiBst which the wind is blowing, flushes
the ward, and then leaves it by the opposite windows ;
it is therefore most imperative that the windows
should be constantly open at the top, to allow of the
escape of bad and entrance of good air : opening
them at the bottom is not by any means so useful,
besides producing a veiy unpleasant draught. Fresh
air will also enter an apartment every time the door
is opened, and underneath it even when it is shut.
The door, however, should not as a rule be regarded
as a means of ventilation.

The Nurse's Duty with reg-ard to Ventilation. —
Having explained the principles of ventilation, and
the more common methods by which they are carried
out, we must now consider the practical application
of these principles by nurses in their difiPerent spheres
of work. The method of application will differ some-
what according as to whether that sphere of work is
in a hospital ward or a private sick-room.

(1) In a Hospital Ward. — Here the chief considera-
tion is the constant flushing of the ward with fresh

PRACTICAL NUESING.

air, so thut germs and other impurities may be swept
away.

We have seen that impure air escapes from the
ward by the chimney, through any windows which
may be open from the top, and by ventilating outlets in
the ceiling, while fresh air enters through the various
ventilating inlets and windows. We have also seen
that one of the best methods of supplying patients
with a constant supply of fresh air is by means of a
large opening in the wall at the back of each bed,
with a coil of hot pipes in front of it. This latter
method of ventilation is absent from many of the older
general hospitals. The only ventilators with which they
are provided are wooden tubes (Tobin's tubes, six feet
high, placed against the side of the wall, communi-
cating below with the outside air), and apertures in
the upper part of the walls. These furnish the wards
with a supply of fresh air which is quite inadequate
to the needs of its inmates. In such a case it is of the
highest importance that the windows should be con-
stantly open at the top, so that foul air may escaj^e and
fresh air enter to take its place. Tliis necessarily
entails a certain amount of draught, such a large
quantity of cold air being introduced that it cannot
be warmed before it reaches the patients.

In the absence of instructions from the doctor or
sister, a nurse must be very slow to close any of the
windows on account of a draught. If a patient com-
plains of feeling cold, she should give him another
blanket, a hot bottle, or a drink of hot milk, instead
of at once commencing to shut out fresh air.

A good fire must be kept constantly burning in
the cold weather, not only for the sake of warmth,

THE HYGIENE OF THE WARD,

but also for the help that it is in ventilation by
drawinw foul air out of the ward.

A nurse should not regard the door of her ward as
a means of ventilation. In many of the older hospitals
the only result of leaving the door open is to allow the
close atmosphere from badly hghted and ill-ventilated
passages to invade the ward. In the more recently
built hospitals, with broad stone corridors well pro-
vided with windows, this objection does not hold good ;
at the same time it must be remembered that an
open door is capable of producing a very unpleasant
draught.

In fever hospitals thorough ventilation is of even
greater importance than in general hospitals. Filled
as they are with cases of infectious disease, it is ab-
solutely essential that the wards should be constantly
flushed with fresh air, so as to ensure a frequent
changing of the germ-laden atmosphere. In these
institutions a nurse must pay even less attention to
draughts than she would in a general hospital. Be-
fore everything she must place ventilation.

(2) /n,a Private Sick-room. — In attempting to ven-
tilate a sick-room, a nurse frequently has to contend
with the prejudice of its occupant against anything
in the natvu-e of fresh air. This must be overcome
by carefully guarding against a draught, otherwise
the patient will begin to talk about taking a chill,
and insist on having every aperture by which fresh
air can enter closed up.

Ventilation must not be attempted by leaving the
door of the room open, since that will only admit
air that has already been used in other parts of the
house, whereas what the patient wants is the purest

PRACTICAL NURSING.

air that can be obtained. This refers more especially
to cold weather. In summer it is often impossible
to keep a room cool unless both door and window
are wide open. In such weather, however, windows
will be open all over the house, and plenty of fresh
air will be able to enter. Except for an odd ven-
tilator or two, the window is the only channel by
which the niu'se can introduce fresh air into the sick-
room. Unless the weather is very cold, or there is
much noise outside, it must be kept slightly opened
from the top, the patient, when necessary, being
shielded from a draught by screens. In summer it
can be opened top and bottom.

In cold weather fresh air can be introduced by
keeping the lower sash slightly raised by a long piece
of wood which fits closely between it and the sill, or,
if the sill is deep enough, the sash may be raised until
its lower margin is just covered by the upper edge of
the sill, thus dispensing with the strip of wood. In
this way a space is left in the middle of the window
between the tAvo sashes through which air can enter
in the upward direction, and pass all over the room
without causing a draught.

When possible, the patient should be covered up,
and the windows thrown widely open three times a-
day, so as to ensure a thorough changing of the atmos-
phere. This is esj)ecially necessary after the bowels
have been opened. To rest satisfied with the con-
cealing of a bad smell by means of perfumes is a great
mistake, and one that may be productive of much
harm.

If there is another room commimicating with the
patient's apartment, it can be filled with fresh air,

THE HYGIENE OF THK WARD. 25

and then the door between the two rooms opened to
admit it. This is merely an aid to ventilation: by
itself, it is quite inadequate.

A fire should, if possible, always be kept burning,
since we have seen how valuable an aid it is to efficient
ventilation, especially in a small room. In summer,
when it is too hot for a fire, a lighted lamp may be
stood in the grate. This will produce sufficient heat
in the chimney to start an upward current, and thus
draw away some of the impure air from the room.

Tempepature of the Ward.— In many of the older
hospitals fires are the only source of warmth in the
ward. In those of later date heat is also furnished
by pipes containing steam or hot water. In a few
hospitals these pipes are in separate coils, each of
which can be turned on or off by the nurse, who
should then be able to regulate the temperature of
her ward to a nicety. Particular care is needed in
the small hours of the morning, since that is the time
when the air feels most chilly, and when the vitality
of each patient is at its lowest.

The temperature of the ward should be kept as
nearly as possible at about 60°. This can only be
done by carefully watching the thermometer. Un-
fortunately, nurses are too fond of trusting to their
own sensations instead of consulting that instrument.
The consequence is that sometimes when they do
look at it they find the ward 8° to 10° hotter than
it should be. Doors and windows are instantly
thrown widely open, with the result of a sudden
fall in the temperature and a fair chance of some-
body taking a chill. It is this sudden alteration
in the temperature of the ward which is harmful.

PRACTICAL NURSING.

There is no excuse for it while the nurse has such
a thing as a thermometer.

The next point is to consider what a nurse should
do when she is unable to control the temperature of
her ward — i.e., when it persists in falling too low or
rising too high. She is told that to secure sufficient
ventilation she must have good fires, ^^dndows open
at the top, and doors shut — a very excellent rule,
but one that not infrequently requires modification.

In many of the older hospitals, where fires alone
provide warmth for the wards, one may sometimes
in the winter-time see all the v^dndows closed except
one or two, and yet the temperatiu-e of the apart-
ment below 60°. Under these circumstances it would
hardly be right to open all the windows from the
top, or the ward would quicldy become unbearably
cold. In such a case a nurse should obtain clear
instructions from the sister or the medical officer as
to the exact extent to which the ventilation is to be
sacrificed to the warming of the ward.

(a) Wlien the Temperature of the Ward is too
high. — This, of course, does not refer to the heat of
summer, but only to an excessive temperatm^e pro-
duced by artificial means. 60° has been laid down
as the proper temperature for a hospital ward.
When it begins to rise above that point we must
diminish the supply of heat. If the ward is warmed
by hot pipes, the circulation through them should be
partially or entirely cut o&. If all the A\TJidows are
open from the top, let them be lowered still more.
If after a tune the temperature shows no signs of
falling, the fires must be allowed to go down. This
should only be done after the other measui'es have

THE HYGIENE OF THE WARD.

been tried and failed. Too often a nurse, wlien she
finds her ward stuffy and hot, at once allows one
or more fires to go out. That is a mistake, since
the fire is helping to purify the ward by removing
foul air from it. On the other hand, a nurse should
burn as little gas as possible, since it quickly dimin-
ishes the purity of the suiTounding atmosphere. Only
as a last resource must the fires be allowed to go
down. Even then a small fire should be kept in,
since that, for the purpose of ventilation, is better
than none at all.

(6) WJien the Temperature of the Ward is too low.
— The nurse must not at once commence to shut
the windows. Let her remember that they are to
be used primarily for the purpose of ventilation, and
only secondarily for regulating the temperature. Let
her first make up the fires, and see that the doors
are closed and all the hot pipes working properly.
With every care, however, it is sometimes impossible
in cold and windy weather to prevent the tempera-
ture of the ward from falling, especially if it is heated
by fires alone. It is a little difficult to say at what
point a nurse should begin to close the windows,
supposing that she has first used every other means
of maldng the ward warm — certainly not until the
temperature has fallen below 56°, and then only after
asking the doctor or the sister of the ward. Let her
begin by closing one or two vnndows on that side
of the ward on which the wind is blowing.

When the Temperature of the Ward has risen
arjain to 60°, the Nurse must gradually reopen any
Windows that she has previously closed. This she
very frequently forgets to do.

PRACTICAL NURSING.

Nurses must remember that the temperature of a
ward is no guide to the purity of its atmosphere,
A ward may be very cold and yet insufficiently
ventilated.

The Temperature of the Sick-room. — In a hos-
pital ward the temperature must be kept as nearly
as possible at 60°, without regard to indi^ddual cases
that might be benefited by more warmth. The tem-
perature of the whole ward cannot be altered to suit
them. In private it is otherwise. The nurse has now
only one joatient to think about, and she can therefore
regulate the temperature of the room according to his
needs ; for there is no doubt that babies, old people,
cases of measles, and those sufi'ering from bronchitis,
require more warmth than other patients. For them
a temperature of 65° is more suitable than one of 60°;
at the same time, extra care must be taken in guard-
ing them against draughts. While using these pre-
cautions, the nurse must not forget the importance
of efiicient ventilation. Generally speaking, however,
the temperattire of the private sick-room, wliile the
patient is in bed, need not be quite so high as that of
a hospital ward. Except for special cases, 55° is
quite warm enough.

Lig"hting of the Ward. — The more sunshine and
light that a nurse can uitroduce into her ward the
better for her patients. There are, of course, certain
cases for which light is harmfid, while no patient
likes to have the sun glaring in his eyes. If it is
doing so, the niu-se must pull do^^^l a blind, not
forgetting to draw it up again when the sun has
passed. With these exceptions, sunlight does noth-
ing but good : it is good both for mind and body.

THE HYCxlENE OF THE WARD.

Moreover, it helps to purify tlie atmosphere of the
ward, since it is inimical to the growth of germs.

Finally, if a nurse wishes to do her best for the
hygiene of her ward, she must see that excreta, soiled
linen, and dirty dressings are at once removed ; that
bed-pans are always carried through the ward with a
cover or a cloth on them ; that the closets and various
sinks are kept quite clean, and constantly flushed ;
that the water-closets are thoroughly ventilated, and
the doors between them and the Avard closed. She
must have all her senses constantly on the alert.
Each time that she enters her ward she should at
once criticise the atmosphere and consider if it is in
the least close or stuffy. While doing so she should
glance round the ward and see that all the windows
are open at the top, that the blinds are evenly drawn
up, that the sun, if it be out, is not shinmg too brightly
on any patient's face, and that the fires are burning
properly, after which the thermometer will tell her
whether the temperature of the ward is what it ought
to be. Such a nurse has the hygiene of her ward at
heart, and is therefore in one way doing her best to
promote the wellbeing of her patients, and expedite
their recovery.

CHAPTEK IIL

WORK IN THE WARD AND PRIVATE SICK-ROOM.

It is now a recognised axiom that a patient's recovery-
is best promoted by cleanliness both of himself and his
surroundings. His body, his linen, the room in which
he lives, and, above all, the air which he breathes,
must be clean in the truest sense of the word. Surgery,
medicine, and nursing all owe the immense advances
which they have made in recent years to the recog-
nition of this truth. The great aim of hospital con-
struction and hospital work is the promotion of this
general cleanliness. A nurse should, therefore, during
her period of training, seize every opportunity of
making herself thoroughly acquainted with the prin-
ciples and practice of hospital work ; so that she may
know exactly what she ought to do when in private
she finds a patient whose surroundings do not conform
to that high standard of cleanliness to which she has
been accustomed during her hospital career.

Furniture of a Ward. — This shotdd consist only of
what is absolutely necessary. There will thus be less
chance of dust accumulating, and more chance of air
circulating. Iron bedsteads with a ware s])ring and

WORK IN WARD AND PRIVATE SICK-ROOM, 31

a horse-hair mattress, a locker beside each bed, which
miirht be constructed so as to form a bed-table, the
necessary number of tables, one of which would be
used by the sister as a -writing-table, some comfortable
chairs for convalescents and plain ones for the patients'
friends, a couch, and the necessary number of screens,
are all that is required. Poisons and stimulants should
be kept in a cupboard outside the ward ; or, if this is
not possible, be locked up in a cupboard inside the
ward, the key of which should be always in the pos-
session of the sister, or, in her absence, of the head
nurse. The ward may be rendered bright and cheerful
by the addition of plants and cut flowers. The latter
should not have too powerful an odour, and should be
removed at once when theu' freshness has gone.

Linen. — The amount of linen in a ward should be
in the following proportion : For each bed there should
be three pairs of large sheets and three draw-sheets,
three blankets and three pillow-cases, and in a ward
of thirty beds fifty counterpanes. The number of
towels, night-dresses, and other small articles will
depend on whether they are supplied by the institu-
tion, or, as is usual in general hospitals in London, as
far as possible by the patients. The sheets should be
about six feet wide and nine feet long, and should be
guarded by some distinguishing mark, such as a red
or blue stripe, as well as the name of the ward and
hospital, since this is easily cut out. The width is
useful in turning the sides into the middle, which pro-
longs the life of a sheet. The blankets should be single,
large, and of good quality. The counterpanes ought
to be light and not closely woven, since they should
be used merely for the sake of keeping the blankets

PRACTICAL NURSING.

clean and giving a smart appearance to the ward, not
with the idea of providing warmth.

The Staff of a Ward, — To keep a ward in a state
of real cleanliness, without overworldng any one, an
adequate number of staff is required. In a ward con-
taining thirty beds there should be a "sister," or head
nurse, who would be at all times responsible for the
management of the ward and condition of the patients.
Under her authority, on day duty, one certificated
nurse of three years' training, who would take her
place in her absence ; one stafip probationer, in her
second or third year of training, and two probationers
in their first year. On night duty, one certificated
nurse and one probationer. The two certificated
nurses would take alternate day and night duty,
three months at a time. There should also be
oae ward -maid to wash dishes, do the grates, and
other rough work. The floors, whether scrubbed or
pohshed, woidd be cleaned by outside help. Such a
staff should amply suffice for the thorough carrying
out of every detail of the ward work.

(a) The Sister should be a woman who has not only
had a full training as a nurse, but has shown qualifi-
cations suiting her for a post of responsibihty. She
should be a methodical and capable manager, econ-
omical and just. She should see that the hoiu-s of
coming on and going off duty are strictly observed by
her staff. The tone of the ward is in her hands, and
it should be her constant endeavour to render it as
high as possible. She should discoiu-age anything like
familiarity between the nurses and adult patients,
otherwise the discipline of the ward must suffer. She
should herself be most fastidiously clean and neat, both

WORK IN WARD AND PRIVATE SICK-ROOM. 33

personally and in her work, and punctual to the second.
She thus sets her subordinates a good example, giving
her the right to expect as much from them. She
should do all that lies in her power to help the nurses
to learn their work, and in all her dealings with them
observe a strict impartiality.

(6) The Certificated Nurse is responsible for the work
of the ward in the absence of the sister. She must
therefore make herself thoroughly acquainted with
every detail of its management, so that the work may
not suffer during the temporary absence of its head.
In all her work she must ever regard the sister's
wishes, and not her own views. She should always
be ready to help and to teach the probationers, and in
every way encourage their interest in the work and
their loyalty to the sister. At the same time, she
should remember her position in the ward, and exact
a proper respect from them, never tolerating anything
in the nature of familiarity, while careful not to make
too constant a display of her authority.

(c) The Probationers. — The probationer, too, has her
responsibilities, though they are less heavy than those
of the sister and head nurse. She must perform her
allotted duties conscientiously and to the best of her
abUity, never failing to report to the head nurse any
fresh symptom which she may observe in a patient, or
any complaint that one of them may make. Above
all, from the very commencement of her training she
must cultivate the habit of tidiness and her powers of
observation. She should be constantly on the watch
to see that everything is in its proper place, and, if it
is not, should at once put it there, without waiting
to be told to do so. She must remember that she is

VOL. I. C

PRACTICAL NURSING.

working in a charitable institution that has almost
certainly considerable difficulty in making both ends
meet, so that rigid economy is absolutely essential.
If she has omitted any portion of her duty, let her
report it at once, and not wait for it to be dis-
covered ; for her neglect, if it have anything to do
with the treatment of a patient, may entail serious
consequences if left unremedied. She should never
discuss either the medical officers or their treatment
with the patients ; and, while being kind and sym-
pathetic to the latter, should remember her position,
and always conduct herself with a proper decorum.
A probationer should never be afraid to ask the
head nurse to exjDlain to her anything which she
does not understand.

(d) The Night Nurse. — The responsibility resting
upon the night nurse is necessarily heavier than that
of the day nurse. She has of course the night super-
intendent to whom she can refer, who will decide
whether it is necessary to call up the medical officer
in the event of any patient showing a change for the
worse. At the same time, for a good part of the
night she is left entirely to herself, and may have to
settle many little points^ which on day duty would
be referred to the sister of the ward. It is essential,
therefore, that she should be both careful and re-
sourceful, and able to tell at once if a change for the
worse takes place in any patient. She must also
be conscientious, otherwise, when tu'ed, she may be
tempted to an imperfect performance of her duties.

The Work of the Ward. — There is no need to
speak of the work of a ward in detail. Each hos-
pital has its own method of arrangement, and even

WORK IN WARD AND PRIVATE SICK-ROOM. 35

each sister has her own routine and plan for the
proper carrying out of standing orders. There are,
at the same time, one or two general points which
it is as well to emphasise.

The nursing staff should go on duty at the precise
moment laid down in the regulations, and at once get
to work. Valuable time is often lost at the beginning
of the day by gossiping, instead of getting steadily
to work and leaving talk for the latter part of the
day, when there is less to do. Work should not
only be begun at the proper hour, but, with rare
exceptions, it should be finished at the proper time.
Except in urgent cases, for which no rule can be laid
down, nurses should endeavour to do their work in the
same routine, and at the same time each day. This is
what we mean by method, the possession of which
enables one nurse to do so much more work than the
best-intentioned woman without it. Nurses will find
that the best method includes the habit of cleaning up
as they go, putting away everything when they have
done with it, clean, neat, and in its proper place.

Pimctuality and orderliness are not of themselves
sufficient to ensure that the work of a ward shall be
performed in a perfectly satisfactory manner. These
quaUties by themselves would not produce the best
work. Coupled with, them must be a feeling of good
fellowship between the nurses, so that they are willing
to help one another ; and also a certain pride in the
ward, leading each nxirse to be anxious for its good
name. Under these conditions the work becomes a
pleasure, and is, moreover, the best that each member
of the staff can give.

Courtesy and kindness will always help to smootli

PRACTICAL NURSING.

away difficulties. Nurses have many opportunities of
helping one another, and should always be ready to
do so. They should strive to be courteous to every
one. A nurse, for instance, ought never to remain
seated when the sister or head nurse who is speaking
to her is standing. She ought always to rise when
one of the medical officers enters the ward, and not
sit down again until he has left. When a patient
asks for anything she should fetch it at once, and
not wait until it suits her convenience to do so. She
should always be ready to show some little attention
to a new patient, so that he may the more quickly feel
himself at home. With the friends of those who are
sick she should always be patient, and never let them
think that she in any way considers them a nuisance.

Convalescent patients are usually anxious and wil-
ling to help in the work of the ward, and there are
many light tasks that can be safely given them to
do. Such help must, however, always be voluntary
on their part.

Bed-making". — A nurse should of course be quite
familiar with the making of a bed and the changing
of sheets, and as this can only be taught in a ward
it need not be described here. The mattress must
be protected by a long macintosh, should the nature
of the case make its being stained even remotely
possible. The bottom sheet should be put on evenly,
and tucked under the mattress so tightly as to
present the appearance of a drmn - head : this is
essential to a well-made bed. The draw-sheet, which
may also have a macmtosh imder it, should be laid
carefully and neatly across the bed and firmly tucked
in ; no wrinldes should appear on either of these

WORK IN WARD AND PRIVATE SICK-ROOM. 37

sheets. The macintoshes are only used as a pro-
tection to the mattress, and should be withdrawn
as soon as they are felt to be unnecessary. The
upper bedclothes should be light and warm. The
sheet should be turned up at the bottom to pre-
serve a clean end, and over the blankets at the top.
The upper corners of the blankets may be folded
over to keep the bed tidy, and the counterpane
should be put on evenly and neatly. The upper
clothes should not be tucked in so tightly as to pre-
vent the patient moving his feet freely, while the
pillows should be arranged to suit the ease of the
patient and not the eye of the nurse. Only the upper
half of the pillow should rest on the bolster. The
lower half should he below the bolster, so that it may
support the patient's neck and shoulders. He would
then be much less likely to slip down into the bed.
The test of a well-made bed is that it should be
both neat and comfortable, and retain these qualities
throughout the day or night.

After each meal the draw-sheet should be drawn,
so that the patient lies in a cool spot. The mattress
shoiild, when possible, be turned once a-day, and the
bed thorouglaly made twice a-day. Well-made neat
beds, each exactly hke the others, standing quite
straight, with all the counterpanes arranged the same
length and in the same way, give a smart appear-
ance to a ward, and nurses are at times apt to sacri-
fice their patients to this appearance. The condition
of the bed must to some extent dejDend on the severity
of the case ; and, though patients may be encouraged
to keep their beds tidy, this must never amoimt to
tyranny. Nurses are apt to forget that at night

PRACTICAL NUfiSlNG.

the appearance of the beds is a matter of no con-
sequence whatever. There should be no hesitation
in turning back the counterpane, and loosening the
blankets, when a patient is hot and restless.

Aip- and Water -Beds. — These are most useful
when a patient has a bed-sore, or if from the nature
of his illness there is a possibility of his having one.

The best and handiest is the- tubular air-bed, con-
sisting of a number of stout rubber tubes which
should be arranged crossways. Each of these has to
be inflated separately, the whole being connected to-
gether by a strong light framework. It has the
advantage that an injmy to the bed, such as a pin-
prick, is limited to the one tube in which it occiirs,
which can easily be taken out and repau-ed. It is
useful, too, to be able to let the air out of one tube at
a time, and thus take all pressure off a part. The
same device makes the use of the bed-pan much
easier.

A water-bed is necessarily much heavier than an
air-bed. After being placed in position on the bed,
it is filled with water at a temperature of 90°. Some
jiidgment must be used with regard to the amount
of water put into it. If the bed is made too tense,
the patient will tend to roll off it. If it is not full
enough, his weight will displace the fluid, with the
result that he will rest, not on water, but on the bed
beneath it. A blanket should be placed on the water-
or air-bed, and on that the ordinary bedclothes.
When necessary, some of the water must be period-
ically removed and replaced by hot. These beds
must be thoroughly cleaned after use, and great
care taken to avoid damaging them with pins.

WORK IN WAllD AND rRIVATE SICK-ROOM. 39

Bed-pans are usually made of glazed earthenware,
as this is very easily kept clean. The commonest
and most useful shapes are the circular and the
sUpper. The round pa-n is generally used in hos-
pitals, as there is less likelihood of the contents
being spilled than is the case with the slipper ; and,
as the patient must be lifted up to have it adjusted,
it is less likely to nip the back.

If the patient is not absolutely helpless, one nurse
can give it. She should place her hand almost imder
the buttocks, and help the patient to raise himself,
the bed-pan being then placed in position. Before
attempting to remove it, the patient should be
lifted right oflp it. When giving the pan, some dis-
infectant, such as carbohc acid (1 in 20), or per-
chloride of mercury (1 in 1000), should be put into it,
unless the urine or stool is to be kept for examination,
and the handle plugged with an india-rubber cork, or,
failing that, with carboHsed tow.

After use it should at once be covered with a china
Hd, over which is thrown a cloth wrimg out of some
disinfectant. It is then straightway removed from
the ward, and, unless needed for inspection, at once
emptied, the pan bemg thoroughly flushed with cold
water. At least once a - day it shovdd be washed
with soap and water. The pan ought always to be
warmed before use.

If there is any cause to fear a bed-sore, or if the
patient is much emaciated, the rim of the bed-pan
should be oiled, or protected by a circular air-cushion,
one having been invented for that purpose.

Male patients only use the bed-pan when the bowels
are going to act ; for urine they use either a small

PEACTICAL NURSING.

chamber or a bottle, the former bemg preferable, as
it is the more easUy kept clean. It should be re-
moved from the ward as soon as it has been used, and
washed once a-day with soap and water. The urine
bottle is difficult to keep clean, being apt to become
furred and offensive.

Dusting. — This, as usually done, means that differ-
ent parts of an apartment exchange dust. Practically
none of it is removed. To avoid this, two dusters
should be used, one damp and the other dry. The
damp one takes up the dust, while the dry one after-
wards renews the poHsh. Dusting should be done
thoroughly and systematically every morning, and no
temptation should lead a nurse to overlook any corner
of the ward.

The ward floor, which should be of hard poHshed
wood, should be carefully swept every morning by the
ward-maid, as little dust as possible being raised in the
process.

The Lavatory and Bath-room should be attended
to each morning. The wash-basins, bed-pans, urinals,
and china bowls should be washed with soap-and-
water, such parts as the handles and rovmd the insides
of bed-pans and virinals being carefully looked to. The
sinks and water-closets must also be washed with soap-
and- water and thoroughly flushed. No amount of
other work excuses the neglect of this.

Weekly Cleaning". — Besides the daily cleaning,
there are various matters which need only be at-
tended to once or twice a-week. The window-ledges
should be pohshed twice a week with bee's-wax and
turpentine, and rubbed over daily with a clean cloth.
Once a-week the cupboards, cupboai-d-tops, shelves.

WORK IN WARD AND PRIVATE SICK-ROOM. 41

and jjiilley - handles should be scrubbed and cleaned.
Every corner of the ward should be inspected by
the sister, to see that it is, like Caesar's wife, " above
suspicion." Every corner and cupboard should be
found absolutely clean.

The Private Sick-room. — The ideal sick-room is a
large, bright apartment with a south or south-west
asjDect, big windows with a clieerfiil outlook, and a
good-sized dressing-room opening out of the bedroom.
Both should possess a fireplace. The walls should be
thick, and the doors and windows well hung. The
floor should be of pohshed hard wood, with rugs, and
the fmrdture comfortable if scanty. The walls should
be of restful green, the pictures cheerful, the ornaments
few but well chosen ; the bed single, iron, with a good
spring and a well-made hair mattress.

It rarely falls to the lot of the nurse whose work
lies among the middle classes to have her patients in
such quarters as these. More frequently she has to
make the best of a room possessing but few of the
above good points. In surgical cases, where a room
has to be prepared for an operation, her opinion may
be asked, and she should be prepared to give an
efficient one. The apartment chosen should be as far
as possible from the scene of daily domestic duties
and from outside noise.

Having secured the best room possible, the nurse
should satisfy herself that its fittings are in good
working order; that the windows open and shut
easily — if not, how to open and shut them with, the
least noise ; that the blinds fit properly ; that the
chimney does not smoke ; that the door closes noise-
lessly, and the handle turns gently ; if the floor is

PRACTICAL NURSING.

covered with carpet, that it is well laid and clean —
if poHshed, that the rugs or central square of carpet
are secured, so as to alford her firm foothold. Cur-
tains are best dispensed with, as they tend to keep
out both air and light, but, if necessary, are best
made of dimity or other easily washed material.

The floor should be polished, and covered with a
central square of carpet or rugs firmly seciu-ed by
carpet-pins. It should be thoroughly cleaned each
morning. If polished, it should be wiped first with
a damp duster and afterwards rubbed well with a
dry woollen cloth. If the illness is a long one, the
floor can be rubbed over with polish once a-fortnight.
If there is a carpet in the room, it should be swept
each day, having first been covered with tea-leaves
or damp sawdust, a disinfectant being used when
thought necessary. If, however, the sound of sweep-
ing annoys the patient, the floor should be rubbed
over first with a wet cloth, and afterwards with a
dry one, and thoroughly swept once a- week.

The Furniture of the Sick-room should consist of
nothing more than is necessary for the comfort of
the patient and cheerful appearance of the room.
Besides the bed, which should be placed so that the
nurse can get at her patient from either side, a bed-
chair, a table, and a bed-table, one or at most two
comfortable chairs, a good light screen, and, if there
is no dressing-room, a roomy cupboard where medi-
cines and other sick-room paraphernalia may be kept.
The room should be cheerful, and as Little suggestive
of a sick-room as possible. A few plants, and cut
flowers of not too strong a scent, are permissible.
The latter must be thrown away on the fii^st sign

WORK IN WARD AND PRIVATE SICK-ROOM. 43

of fading, aini the water in which they are placed
changed every day.

When worldng in private a nurse should always
endeavour to be quiet, but at the same time her
quietness must not be of the painfully obtrusive type.
Her shoes must not creak or her voice be loud ;
while, if the patient is annoyed or disturbed by the
slightest noise, she should put on coal with her hands,
protecting them with an old pair of gloves, and use
a wooden poker to stir the fire. On the other hand,
she should never creep about the room on tiptoe, or
whisper, imless the patient is asleep, otherwise she
will almost certainly irritate him.

CHAPTEE IV.

PEESONAL CARE OP THE SICK.

The admission of a new patient to the ward is at
once reported to the sister in charge, who in many
hospitals decides whether he is to have a bath, or,
being too ill, must be washed in bed. The former is
naturally preferable. In either case the pulse and
temperature would be first taken, and any special
symptoms noted.

Bathing a New Patient. — In the male wards this
is always done by a male attendant, in the female
wards by one of the nurses. The head nurse should
afterwards examine such parts as the naUs, knees,
and elbows, to assure herself that the cleansing has
been efficiently done. The bath shoidd be given
methodically and quickly, so that the patient may
be exposed as httle as possible. If the patient is
very dirty, the water should be changed more than
once, a few drops of ammonia or a Httle powdered
borax being added to it.

It is best to begin with the feet and legs, hands and
arms ; then change the water, and wash them again
together with the body. The head should always be

PERSONAL CARE OP THE SICK.

taken last. Soap should not be rubbed on it, but on
the flannel, the hair being afterwards thoroughly
rinsed. If the Imees, elbows, heels, and hands are
very dirty, and cannot be cleaned by the application
of soap-and-water, they may be rubbed with turpen-
tine, which must afterwards be carefully washed off,
or a plain hot-water fomentation may be applied for
a few hours. The bath should be given at a temper-
ature of 100°, the patient being afterwards thoroughly
and quickly dried with a warm towel, and at once
put to bed. If a female, a bath-towel or blanket is
laid on the pillow and the hair combed out on it, after
which the towel or blanket is folded over, and pressed
down on the hair, which wUl thus quicldy dry without
giving the patient cold.

Bathing a Patient in Bed.^ — If the patient is too
ill to be bathed, he or she may be washed in bed.

Having turned back the bed-clothes, a long mac-
intosh covered with a blanket is laid on the under
sheet. The edges of the blanket should overlap down
the middle of the patient when he is laid on it. His
clothes are now removed, care being taken to keep
him covered.

For washing, two basms are necessary — one large
and one small, two flannels, a piece of soap, and two
towels. The small basin is used for soapy water,
which must afterwards be thoroughly washed off
with the water in the larger basin. The temperature
of the water should be between lOS'' and 108°, as it
cools quickly.

The face is washed first, the body being taken
afterwards in small sections, each being carefully
dried and covered with the blanket before the next

PRACTICAL NURSING.

is begun. In this way the front and sides of the
body, shoulders, arms, and hands, are washed. The
water is now changed, and, when possible, the patient
turned on his side, and the back, from the nape of the
neck to below the buttocks, thoroughly cleansed and
dried ; after which the legs and feet are washed, and
the water agaia changed for the head. If the Ivuees,
elbows, or heels are very dirty, they may be treated
as previously recommended, care being taken after-
wards to completely remove the turpentine.

When washing the head, the basin should be brought
close to the bed, and as much on a level with the
patient as possible. The hair is then well rubbed
with soapy water, and afterwards thoroughly rinsed in
clean water in the large basin. If the head is pedicul-
ous, it should be combed with a small-tooth comb,
which is dipped into 1 in 20 carbolic every time it is
passed through the hair. When the hair is very dirty,
it is best to cut it off close to the scalp ; but this can
only be done with the patient's consent, or with a
written order from the physician. If permission
cannot be obtained to cut long hair which contains
a large number of pediculi, it is best treated in the
following manner : Thoroughly saturate it with car-
bolic oil, rubbing this well into the roots of the
hair, and afterwards cover it entirely with a pad
of absorbent wool soaked in the same. Over this
place a large square of lint, or oiled pajier, outside
that more wool, especially at the nape of the neck,
and bandage the whole firmly in position. At the end
of twenty-four hours it should be removed, the head
thoroughly washed with soap and soda, and the dead
lice combed out. It is a good plan, if a head is teem-

PERSONAL CARE OF THE SICK.

ing with lice, to put on the carbolic dressing at once,
and wash the patient afterwards. This will prevent
the lice escaping from the head. For the removal of
nits each nurse has her own pet remedy, which she
thinks the only one that is really efficacious. Turpen-
tine, vinegar, methylated spirit, mercurial lotions, and
other preparations are all said to bring about tliis
highly desirable result. It is very doubtful if one
has more power to do so than any of the others.

In washing a patient, the nurse should pay particu-
lar attention to such parts as the ears, eyes, nostrils,
axillae, umbilicus, the part between the buttocks, the
groins, knees, heels, and in stout women under the
breasts. In fat people the skin under the breast,
and also that between the buttocks, should be powdered
twice a-day.

While giving a bath, the nurse should note any
lumps, scars, or sores there may be on the body, and
subsequently report the same to the sister. She must
also carefully look for and report any scaly patches
on the scalp that might be ringworm, as it is most
important that this should be detected at once, and
not allowed to spread in the ward.

Directly the bathing is finished, the patient is put
comfortably to bed, a hot-water bottle being given him
if necessary. An hour later, when he has quite settled
down, his pulse and temperatiire are again taken.

The patient's clothes should be carefully examined,
those that are dirty or contain parasites being sent to
the laimdry and disinfecting chamber respectively,
the others being tied in a neat bundle and disposed
of according to the arrangements of each particular
hospital.

PRACTICAL NUESING.

Daily Wash. — Each morning, the upper bed-clothes
and sheet having been folded back, and the nightdress
removed, the patient should be washed to the waist,
back and front, lying the while between two blankets,
or between a blanket and a warm bath towel, the
latter being placed between him and the under sheet.
It is best done with two basins, that no soap may be
left on the skin. This thorough washing should be
done every morning ; the hands should be washed in
the middle of the day, and the hands and face again
washed at night before the bed is made.

The hair is then brushed and combed. In the case
of women it is best to divide it down the middle of
the back of the head, and plait in two tails behind
the ears, taking care to begin the plait rather low
down, so that the patient will not have it between her
head and the pillow. It should be well brushed each
day. The brushes and combs must be kept clean by
being washed at least once a-week. When a patient
who has had ringworm of the scalp leaves the hospital,
his brush and comb ought always to be burnt.

Heads that were pediculous on admission, or con-
tained nits, must be carefully examined and combed
every day, so as to ensure the prompt destruction of
any lice that may be hatched.

In private work a nurse should always endeavour to
make her patients look as nice as possible, and not be
above devoting some pains and attention to the doing
of women's hair.

The Teeth. — If the patient is too ill to attend
to his teeth himself, the nurse must do so for liim.
She should provide herself ynth. several small j^ieces
of stick about the size and thickness of a pen-holder.

PERSONAL CARE OF THE SICK.

Kound one end of each is to be wrapped a thin shred
of absorbent wool or a narrow strip of lint. This
must be done firmly enough to prevent either coming
ofi' in the mouth, but not so tightly as to interfere
with their easy removal from the piece of stick.
More commonly the lint or wool is wrapped roimd
the forefinger or a pair of dressing forceps. The
lint or wool should then be dipped in a solution
of boracic acid, lemon- juice water and glycerine, or
dilute Condy, and the gums, tongue, roof of the
mouth, and both sides of the teeth thoroughly
rubbed, each piece of lint or wool being used once
and only dipped into the mouth-wash when clean.
Of these mouth-washes Condy is the least pleasant
to the patient, but is useful when the breath is
fouL When the teeth are very dirty, dipping the
wet wool or Hnt into prepared chalk before rubbing
them will materially hasten the cleansing process. .
Convalescents should be made to use a tooth-brush,
small children having their teeth brushed for them
by a nurse, who must do so very gently to avoid
injuring the gums.

In specific fevers, or any disease which causes a
high temperature, the teeth demand most careful
attention, as they become covered with sordes, which
gives them a very dirty appearance.

Sordes are the secretions of the mouth which have
collected upon the teeth and dried there. In health
they are removed, or rather prevented from coUectuig,
by the process of mastication and by the continual
movements of the cheeks and tongue, which aid in
keeping the teeth and tongue clean. In acute ill-
nesses the mouth ought to be cleaned as often as

VOL. I. D

PRACTICAL NURSING.

every four hours, in less severe eases once or twice
a-day may be frequent enough.

The Eyes. — When suffering from extreme exhaus-
tion, patients frequently sleep with the eyes half
open, in consequence of which the conjunctivae be-
come irritated by dust. In such cases the eyes
should be carefully bathed with boracic lotion.

Bed-SOPes. — In a small minority of cases a bed-sore
is pardonable. As a rule it is the result of imperfect
care on the part of the nurse. To prevent, as far as
possible, the occurrence of this highly vmdesirable com-
pHcation, every nurse should make herself thoroughly
acquainted with the causes of bed-sores, their earliest
symptoms and usual situation, and their treatment.
While doing so, she will also learn how she may best
guard her patients against them.

Bed-sores have a great tendency to form on those
parts in which the circulation is feeble, so that the
blood stagnates in the tissues, which therefore do
not receive a sufficient supply of food ; consequently
their vitality is lowered, so that they readily respond
to slight injuries.
Causes —

(a) Pressure — e.g., when occurring over the lower
part of the back, and on the heels, hips, and shotdders.
Fat people are especially liable to this form of bed-
sore, since their great weight, continually pressing
the skin of the back into the bed, so interferes with
its circulation that it finally sloughs or dies. Going
to the other extreme, thin people are also very liable,
because there is no fat to protect their skin from
pressure by the bones.

(&) Irritation. — Constant friction so irritates the

PERSONAL CARE OF THE SICK.

skin that at last it becomes inflamed, a raw surface
is formed, and a bed-sore is the result. This kind of
bed-sore occurs on the elbows, back of the head, and
inner sides of the knees and ankles, owing to their
rubbing against one another.

Patients with incontinence of urine are prone to
bed-sores, the skin of the part that is wet becoming
sodden, and so readily yielding to pressure. Constant
irritation by the urine also causes it to inflame.

Creases in the under-sheet and crumbs in the bed
may cause sufiicient irritation to produce a bed-sore.

(c) Impaired Nutntion from Disease. — All bed-sores
result from impaired nutrition of the part, due to a
weakening of the circulation in it, the result of the
patient's illness and consequent confinement to bed.
Under this heading is included that special impair-
ment which goes with disease of the spinal marrow,
and which is due to an interference with the nerve-
supply of the part. This is the most difficult form
of bed-sore to prevent ; indeed, it is frequently quite
impossible to do so.

We may say, then, that bed-sores are caused either
by pressTu-e, or irritation due to friction, predisposing
factors being extreme emaciation, great weight, in-
continence of urine and faeces, and the want of proper
attention on the part of the attendant.

Prevention of Bed-sores. — "When a patient who is
stout sufi'ers from paralysis, with incontinence of
urine and sometimes of faeces, it requires unremitting
care on the part of the nurse to prevent the forma-
tion of a bed-sore. No method of prevention is better
than the frequent application of soap and water. A
nurse should never wait for the patient to complain

PRACTICAL NURSING.

of his back before beginning its use. Once a-day, at
least, all patients who are confined to bed should have
their backs and hips washed. The soap should be
thoroughly washed oif, and the skin well dried and
powdered, particular attention being paid to the fold
between the buttocks.

The skin may be treated after washing in one of
the following ways : —

(a) Spirit in some form may be apphed — methy-
lated spirit, brandy, or eau de Cologne being used.
Whichever is used must be thoroughly rubbed in.
This will increase the flow of blood through the skin
and so improve its nutrition.

(6) A solution of formalin, 1 in 100, quickly hardens
the skin, but is rarely suitable.

(c) The part may be painted with flexible coUodion.
This is also used later, when the first signs of a bed-
sore show themselves.

(d) Some emollient ointment may be well rubbed in.
By the first two methods the skin is hardened, and

in illnesses which are not likely to last long it is a
good enough plan. By the last method the skin is
softened and rendered pliable, and the massage that
is necessary to rub the ointment into it is good for the
vitality of the part by improving the circulation in it.
If, however, the nurse simply rubs the ointment on the
skin, it is the less useful treatment, as it is very soon
wiped off by the sheet, which it consequently renders
greasy. In all cases where the sphincters ai-e relaxed,
the sldn should be treated wdth ointment. This will
protect it from the irritatuig effects of the discharges,
the patient being always washed and rubbed when he
requires cleaning.

PEKSONAL CARE OF THE SICK.

Those parts which have been mentioned as liable to
break down with pressure should be examined daily
and regularly washed. The heels, which after the
back and hips are the most likely to become sore,
must be carefully attended to, pressure being taken
off them by ring cushions made of wool and covered
with a bandage, or the heels and ankles may have
wool bandaged round them. Ring cushions made of
wool are often recommended for the purpose of reliev-
ing pressure on the back, but are of very little use ;
indeed, with a restless patient they become a positive
danger. Water- and air-beds, by eqiialising the pres-
sure, are of the greatest possible value. In their
absence, ring cushions constructed on the same prin-
ciple are sometimes very useful. The knees, ankles,
and elbows may be protected by firmly bandaging
a thick layer of cotton-wool round them.

Second only to washing as a preventive measm^e is
a change of posture. This not only removes for a
time all irritation from the part, but is of the great-
est possible value in preventing stagnation of blood in
it. Pressure being taken off the vessels, blood is able
to pass more freely through them, and thus bring
more nourishment to the tissues. When possible, such
a patient should never be allowed to lie more than
two hours in one position, but be turned first on to
one side and then on to the other, and kept there by
the skilful arrangement of cushions.

Symptoms. — It is important that a nurse should be
acquainted with the first indications of the on-coming
bed-sore. The first obvious symptom is a reddening
of the skin, but even before this appears the patient
may complain of a burning or pricking sensation.

PKACTICAL NUKSING.

This should at once put the nurse on the alert.
The patient may, however, be too ill to feel any
discomfort; or, owing to paralysis, there may be no
sensation in the part.

The sore, when formed, may consist of nothing more
than an abrasion of the skin ; or a large slough may
gradually separate, leaving behind a deep ca\'ity,
frequently with bone exposed at the bottom of it.

Treatment. — The prevention of bed-sores is the duty
of the nurse ; but the first sign of one should be at
once reported to the physician or surgeon in charge
of the case. He may, if it results in nothing more
than an abrasion of the skin, leave the further treat-
ment in the hands of the nurse. In such
pad of lint dipped in friar's balsam may be apphed,
covered with three thicknesses of gauze cut a little
larger and dipped in collodion. This seals the part,
and prevents the sore being rubbed by bedclothes
or irritated by extraneous matter. By every possible
means the nurse must strive to keep all pressure
off the bed-sore.

When a slough has formed, its separation should be
hastened by the use of antiseptic fomentations. These
are usually discontinued after it has come away, the
cavity, if it be a large one, being sprinkled with iodo-
form, and carefully packed with gauze stri23s. Especial
attention should be paid to the tmdermined edges. A
shallow bed-sore might, when clean, be dressed with
eucalyptus and vaseline, or iodoform ointment, or
balsam of Peru may be applied. A bed-sore of any
size, or one that is progressing, will require dressing
at least twice a-day.

To sum up, the prevention of bed-soi'es in many

PERSONAL CAKE OF THE SICK.

uases requires a care as unremitting as it is faithful.
A day's neglect may undo the work of weeks, and
add a very umiecessary burden of discomfort to the
patient. The bed must be kept smooth, and no
crumbs allowed to remain in it ; the application of
soap and water must be regular and efficient ; if
ointment is beiag used, it must be rubbed into, and
not on to the skin ; and the patient must not be
allowed to remain too long in one position. In a
word, the most unceasing care and attention must
be exercised.

The Moving" of Helpless Patients. — Every nurse
should know how to properly move a patient, who
is very weak or unconscious, from one part of his
bed to another, otherwise she will drag instead of
Ufting him, which is much more tiring for her, and
unpleasant for the patient. She should never try to
lift by herself a patient who is obviously too heavy
for her, or she will run the risk of hurting him, and
perhaps seriously straining herself.

If a nurse wishes to raise in bed a patient who
has sunk down off his pillow, she should place her
right hand and arm well behind his back, and the left
below the hips, and gradually move him up the bed.
He should help himself with the pulley, if there is
one, and he is not too weak. If he is too heavy
or cannot assist her himself, another nurse, standing
on the opposite side of the bed, will help, placing
her arms in a corresponding position. As a rule, a
nurse will need assistance when moving a helpless
adult.

When a patient has to be moved across the bed, the
nurse places her right arm in a slanting direction

PEACTICAL NUESING.

behind the patient's back, so that his left shoulder
presses against her right clavicle, while her fingers
come round on to the right side of his chest. The
left hand is placed across the front of the chest,
beneath the right shoulder. The upper half of the
patient is now slightly raised, and steadily moved
across the bed. The two hands are now sHpped
downward, so that one Hes in front and the other
behind the hips, and the lower half lifted over.

To move a patient from one bed to another the
two beds must be placed side by side, so that the
mattresses are in contact ; or one can be pulled a
Httle way over, so as to bridge the interval between
the beds. The patient is now slowly drawn across
by the sheet on which he is lying, this being after-
wards slipped away from under him ; or, if there are
enough assistants, he can be lifted, one taking each
corner of the sheet.

Passing the Catheter. — Patients sometimes at
first find a difficulty in passing water into a bed-paru
The position is novel and awkward, especially if the
pillows are low, so that the bed-pan raises the pelvis,
and with it the bladder, almost to the level of the shoul-
ders. The nurse must exercise the utmost patience,
not allowing her to remain too long on the pan at
a time, but removing it and giving it again a little
later. Especially to be deprecated is the custom some
nurses have of leaving very small childi'en on the
bed-pan for several minutes by themselves, so that
frequently they go to sleep in that position. In these
cases one sometimes finds bruises over the vertebral
column, owing to the child sHpping down on to the
bed-pan as it falls asleep.

PERSONAL CARE OF THE SIUK.

When a male patient is unable to pass water, a
fomentation applied to the lower part of the abdomen
is frequently efficacious. In the case of women, a
Uttle hot water may be put into the bed-pan, or a hot
sponge, quickly replaced by a cold one, held to the
meatus. If this has no effect, it may become necessary
to pass a catheter, but this would only be done by the
physician's orders, and the patient may wait some
hours before it is necessary.

When there is any risk of the urine shooting over
the pan into the bed, it is a good plan to give the
patient a piece of brown wool to hold in front, so that
she may direct the flow of urine into the bed-pan.

The Catheter is a hollow tube 8 to 12 inches long,
made of either gum. elastic, indiarubber, glass, or
silver. For women glass is the best, as it can be
kept absolutely clean. When used, it should be in
a state of surgical cleanliness — i.e., aseptic. To
render it so, it must be boiled for five minutes, and
then kept till wanted in a 1 in 2000 solution of per-
chloride of mercury, or 1 in 20 carbolic acid. Before
use, it should be dipped in sterihsed water.

Being quite sure that the catheter is fit for use, the
nurse should get ready a vessel in which to catch the
urine, a basin of boracic lotion, some wool sponges,
and some sterilised oil; after which she washes her
hands, and soaks them in an approved disinfectant.

The patient is placed on her back, the knees slightly
separated, and a blanket thrown over each. This
keeps her warm, and prevents undue exposure. The
nurse now separates the labia, and carefully cleanses
the parts roimd the meatus with the wocl sponges
and boracic lotion. The catheter is then dipjjed in

PKACTIOAL NUKSING.

the oil and introduced, care being taken by the nurse
to touch only the part which will be left outside.
The instrument should not be passed any further
when the urine has begun to flow, as the nurse must
be careful not to touch the wall of the bladder with
it. If the urine ceases to flow before the bladder is
empty, the catheter should not be pushed farther in,
but slightly withdrawn and again replaced. If the
bladder is very full, a small catheter must be used,
as it should be emptied very slowly, or it may not
be emptied entirely the first time the catheter is
passed. As the catheter is withdrawn, the finger
should be placed over the end of it to prevent urine
escaping from it into the bed. The parts are then
bathed and again dried. A strong stream of water
should be run through the catheter from the eye. It
is afterwards boiled, and then kept in a disinfectant
solution.

When, for some reason, the knees may not be sep-
arated, the nm-se in passing the catheter must trust
to her sense of touch. The urinary meatus is situated
just above the vagina, and can easily be seen or felt.
It has a slightly thickened, rounded edge, and the
nurse, by placing the first finger on it, can easily
pass the catheter into it. Care must be taken not
to pass it into the vagina. If this is done, the
catheter must be boiled again, or another used.

It is highly essential that niu-ses should recognise
the extreme importance of absolute cleanliness when
passing the catheter. The careless use of an unclean
instrument may introduce germs into the bladder,
which ^vill grow there and cause it to become in-
flamed— a most serious and painful condition, the

PERSONAL CARE OF THE SICK. 59
I

setting up of wliioli every nurse should do her utmost
to avoid.

Care of the Dead. — Soon after death the condition
called rigor mortis begins to set in, as a result of
which all the muscles of the body become stiff and
rigid. In anticij^ation of this, the nurse, as soon as
the friends have withdrawn, closes the eyes, when
necessary retainmg the hds in position with pads of
wet hnt, straightens the hmbs, and closes the mouth.
The lower jaw is supported either by means of a roller
bandage placed under it, or by passing a couple of
turns of bandage round the point of the chin and over
the head. To prevent it slipping, the bandage should
be spht in the centre where the chin i-ests on it.
When the muscles have firmly set, the support is
removed.

About an hour after death the nurse should proceed
to "lay out" the dead body. It is first washed all
over with soap and water, and the rectum and vagina
packed with absorbent wool to prevent the escape
of discharges. The ankles are tied together with a
broad strip of bandage, fresh dressings placed on any
woimd, the hair brushed and neatly done, and a night-
gown put on. Before washing a patient in a hospital,
any rmgs or earrings should be removed from the
body and given to the steward of the hospital. In no
case should the body be removed to the mortuary
with any ornaments on it, nor should the nurse her-
self deliver them to the patient's friends, otherwise
they may pass into the possession of the wrong indi-
vidual. If the death has occurred in a hospital, the
patient's name, and also that of the ward, together
■^vitli the hour at which death occurred, are written

PRACTICAL NURSING.

on a slip of paper, which is then pinned on the front of
the nightgown. Over all a clean sheet is thrown.
The body is now ready for removal to the mortuary.

In a private house the nurse should not hurry away
directly she has finished laying out the body, but
should wait to see if she can be of any further help
to the friends. Before leaving the room, she should
see that everything is in order.

CHAPTER V.

OBSERVATION OF THE PATIENT.

" The most important practical lesson that can be
given to nurses is to teach them what to observe, how
fco observe ; what symptoms indicate improvement,
what the reverse ; which are of importance, which are
of none." Further, a nurse must know how to rejDort
correctly and concisely what she has observed ; other-
wise, she will afflict the doctor with a wearisome re-
dundancy of detail, in which the most important points
in the case are either slurred over or left out.

When maldng a report a nurse should always strive
to be exact and give facts. She should never talk
vaguely about the patient "having slept badly," or
"not taken so well," but should be able to say how
many hours' sleep, or how many ounces of food, he
has had. Again, she must strictly confine herself to
those facts, and never, unless asked to, give her opin-
ion on the case. A nurse who volunteers suggestions
as to treatment or diagnosis does not know her place,
and hence lays herself open to rebuke. A clear and
brief reply in answer to each question is all that the
doctor wants.

PRACTICAL NURSING,

A niirse who can observe and report in this way
is one who has had a thoroughly efficient training
under skilled supervision, and profited thereby. She
is a great help to the physician, since she is not in-
frequently able to supply him with missing links in
the chain of evidence necessary for the completion of
his diagnosis, besides informing him of the progress
of the case during his absence. The following are
points to which a nurse should direct her attention,
both when she first sees her patient and while he re-
mains in her charge. Those points which are more
especially connected with the disease from which the
patient is sufifering will claim the larger share of her
attention. At the same time, she should be acquainted
with the explanation of any other symptoms that may
arise in the course of the illness, and it is of great
importance that she should learn to distinguish symp-
toms which are dangerous from those which are not ;
for at any time she may have to decide on her own
responsibility whether the change in her patient is
sufiiciently serious to warrant her in sending for the
doctor, or whether she would be justified in waiting
till the time of his usual visit. Let her never forget
that it is only by constant and careful observation of
her patients, together with ability to interpret what
she observes, that she can ever become a thoroughly
trustworthy and comjDetent nurse.

Appearance of the Patient. — Does the patient look
ill or in pain ? Has he the heavy, listless expression
of enteric fever, or the wide-awake, anxious look of
pneumonia and pericarditis? Has he the shrimken,
hollow-eyed, anxious face which accompanies acute
peritonitis ? Is he pale or flushed ? — sudden pallor

OBSEEVATION OF THE PATIENT.

coming on in a case of enteric fever or gastric vilcer is
usually due to severe internal li£emorrhage. Is there
a bluish tinge about the lips, cheeks, and edges of the
ears, due to imperfect oxygenation of the blood, the
result of either heart or lung disease? Does the
patient look well- or ill -nourished? Does he look
older or younger than he says he is? Is there any
obvious deformity or weakness of any part of the
body?

Position in Bed often gives most useful information.
A patient naturally hes in the position which gives
him most ease. If he has peritonitis, he will lie quite
still on his back, with the knees drawn up to relax
the abdominal muscles, and so take off all pressure
from the inflamed and tender parts within. Colic, on
the other hand, while it makes him draw up his legs,
tends to produce restlessness, and, contrary to periton-
itis, is relieved by pressure, so that the patient forces
his hands into his abdomen, or even Hes on his face.
Difficulty of breathing, whether due to heart or lungs,
makes him want to sit up. If he has pneumonia or
pleurisy on one side of the chest, he will lie on that
side, as by doing so he lessens its movement and thus
diminishes pain, while at the same time it gives the
unaffected lung a better chance of working. A
patient with heart disease often prefers to lie on his
right side, as this takes the weight of the liver off the
heart. In the advanced stages of enteric fever he Hes
helplessly on his back, never movuig of his own ac-
cord. When, after lying in such a position, he first
begins to move on to his side, we may be siu-e that
improvement has set in. Extreme restlessness, coupled
with sighing, is a symptom of severe haemorrhage, or

PRACTICAL NUESING.

of heart failure such as is seen in the final stage of
bad diphtheria.

Pain. — A nurse should always most carefully in-
quire into the character and duration of any pain of
which the patient may complain. In endeavouring to
estimate the severity of the pain, she must be on her
guard against exaggeration by the patient, for to some
people any pain is a bad pain. If there is really much
suffering, the patient's face will show it, while the
frequency of the pulse-beats will be increased. If the
pain is very severe, the patient may Ue still, being
afraid to move. Severe pain in the prgecordial region,
spreading thence down both arms, indicates a most
dangerous form of heart disease, which may straight-
way prove fatal unless relieved. Acute abdominal
pain and tenderness, arising in the course of enteric
fever, is in the great majority of cases due to that very
fatal complication, perforation of the intestine. Both
of these are cases in which the doctor should be sent
for at once. In neither is the patient restless : he
remains quite stiU, with anxious face, hardly daring to
breathe.

When describing a pain to the doctor, a nurse
should always endeavour to quote the patient's words,

The Skin. — The points to notice about the skin are
scars, ulcers, abrasions, bruises, or discoloration ; any
swelling, oedema, or jaundice ; the comparative mois-
ture or dryness of the skin, and its temperature.
Anything like profuse perspiration, occiu-ring dm'ing
the course of the illness, should always be reported, as
it is sometimes a symptom of weakness ; or it may be
an indication that pus is forming in some part of the
body.

OBSERVATION OF THE PATIENT.

Any scaly patches on the scalp should be reported,
as they may be due to ringworm.

The Eyes. — Any irregularity in the size of the
pupils, or tendency to squint, should be carefully
taken note of, as it may point to grave complica-
tions, especially in a case where there is any sus-
picion of meningitis. In the very serious condition
called " coma vigil " the patient lies unconscious
with the eyes widely open. In cases of extreme ex-
haustion the eyes are sometimes incompletely closed
during sleep, and hence are liable to irritation from
dust or flies.

The Ears. — Pain in the ear, or discharge from
that organ, should always be looked for in cases
of diphtheria, measles, and scarlet fever, where the
throat is inflamed. When the ear is discharging,
any swelling or tenderness of the bone immediately
behind it should be taken note of, as it is evidence
of commencing inflammation in the bone, which, if
not promptly and efficiently treated, may lead to
serious complications. Singing in the ears and deaf-
ness, following upon the administration of quinine
or saUcylate of soda, should always be reported. A
varying degree of deafness is almost always present
in enteric fever. In all cases where there is a pos-
sibihty of head injury, the nurse should watch for
the escape of blood or clear fluid (cerebro-sjainal) from
the ears.

The Alimentary System—

The Mouth. — The presence of " sordes " upon the lips,
teeth, and tongue should be noted. They are brown
or black crusts, made up of dead epithelium, the
remains of food, and various fungi, which form in con-

VOL. I. B

PRACTICAL NURSING.

sequence of the absence of the usual movements of
mastication, by means of which the mouth in health is
kept clean. Sponginess of the gums, and any tender-
ness or looseness of the teeth, should be carefuUy
"watched for when the patient is taking mercury, as
they point strongly to the necessity of stopping the
drug. Excessive secretion of saliva also goes to show
that the patient is fully imder its influence. Ulcera-
tion of the gums is an occasional complication of
scarlet fever

The Tongue. — The nurse should notice, when a
patient puts out his tongue, whether it is protruded in
a straight line ; if not, to which side it is inclined ;
also, whether it is tremulous. She should also note
whether it is clean or furred, dry or moist, and
whether any ulcers are present on it. The dry furred
tongue is most often seen in enteric fever ; but it may
also be produced by sleeping with the mouth open, the
tongue being dried by the air continually passing over
it. About the end of the fourth day of scarlet fever
we get what is called the " strawberry " tongue, which
is produced by a peeling of the tongue. That organ is
then left red and raw, with large prominent papiUge,
which resemble somewhat the seeds of a ripe straw-
berry.

Stomach. — Careful note should be taken of the
patient's appetite, and of the exact amount of food
he consumes in the twenty-four hours. Any difficulty
in swallowing, or symptoms of indigestion such as
flatulence, tightness of the chest, pain at the pit of
the stomach or between the shoulders, or nausea
after eating, should be reported, together with theu'
exact relation to food. If the jDatient vomits, the

OBSERVATION OF THE PATIENT.

quantity brought up should be measured, so that a
true estimate may be formed of the amount of food
thus lost. The first vomit should be covered over
and kept for the doctor's inspection, as should also
any subsequent matters that are rejected, if they seem
to the niu-se unusual in a^ipearance. Vomited blood
may have come from the throat after removal of the
tonsils, or from the nose, as the result of epistaxis ;
or it may have come from the stomach, being due to
the biirstmg of a blood-vessel within that organ, as
the residt of chronic liver disease in a drunkard, or
to the eating through of an artery by a gastric ulcer.
In this latter case it is imperative that the stomach
be kept empty. When blood has been retained for
some time in the cavity of the stomach, it becomes
partially digested, and then resembles coflFee-grounds
in appearance.

Intestines. —Marked abdominal distension, especially
when occurring in enteric fever or suspected intestinal
obstruction, is a grave and important symptom. Care-
ful note should be made of any pain in the abdomen,
its character and duration, together with its effect
upon the general condition of the patient.

Stools. — The points to be noticed are their shape,
colour, consistency, and amount; whether they con-
tain blood, mucus, pus, or undigested food ; the fre-
quency of the motions, and whether there is any pain
in passing them. Blood in the stools may be the
result of piles, or of ulceration in some part of the
large or small intestine. A "tarry" stool is one
which contains blood that has been acted upon by
the gastric juice. That blood has, therefore, been in
the stomach, or has come from the uppermost part

PRACTICAL NURSTNG.

of the small intestine. Iron and bismuth, when taken
internally, blacken the stools. Anything unusual
should be preserved and shown to the physician.
This should always be done with the first stool of
an enteric fever patient. Clay-colom-ed motions are
passed when, owing to some obstruction, bile is wa-
able to get from the liver into the intestine. Wlien
the cahbre of the rectum is much narrowed by a
cancerous growth or a simple stricture, the stools
are necessarily smaller, and in shape like a ribbon
or a pipe-stem.

Circulatory System. — A nurse should note any
comjDlaint of palpitation or of pain in the region of
the heart. The former is frequently a symjDtom of
no importance, being readily caused by antemia, ex-
citement, dyspepsia, and hysteria. The latter, if as-
sociated with heart disease, is of very grave import.
Any tendency to faintness should be noticed. Like
palpitation, it is much more common in people
with healthy hearts than with diseased. It should,
however, always be reported, as it may indicate a
dangerous degree of prostration. Pulsating tumom-s
should be noticed, and any swelling of the feet from
dropsy. The pulse will be described in the next
chapter.

Respiratory System. — The pomts to be observed
are the frequency of the respirations, whether they
are noisy or quiet, shallow or deep, difficult or easy,
regular or irregular in time and force. Irregular
respiration is one of the first symptoms of tubercular
meningitis, and therefore of much importance when
the presence of that disease is susjjected.

A nurse should never let the patient know when

OBSERVATION OF THE PATIENT.

she is coimtiug his respirations, otherwise he will
uiiiutentionally alter theu- frequency. After count-
ing the pulse she should, without moving her fingers
from the wrist, quietly observe and take note of the
movements of the chest.

Dyspnoea, or difficulty in breathing, is a symptom
that may be present in several diseases. It varies
very much in character, as well as in severity and
diu-ation. A nurse, when reporting an attack of
dyspnoea, should be able to describe its mode of
onset, how long it lasted, and the patient's behaviour
during its presence. The two great causes of dysj^noea
are heart disease and obstruction in some part of the
air-passages.

In bad cases of heart disease, where that organ is
much dilated, and hence too weak to do its work,
dyspnoea is often continuous and very distressing.
Such patients will sit bolt upright ui bed for many
horn's at a stretch, with blue Hps and heaving chests,
vainly trying to get enough air into their hmgs, and
slowly dying one of the most painful of deaths. They
cannot bear to be spoken to or to have any one near
them : their one desire is air. As a rule, they are
more comfortable sitting up in a chair, or if they are
strong enough, kneeling in an arm-chair with their
arms hanging over the back of it. This posture
brings them most relief, because it allows the abdom-
inal viscera to sink downwards, and thus gives freer
play to the heart and lungs.

In inflammation of the larynx, such as is met with
in diphtheria, inspiration is long and whistling or
crowing in character ; and, if the obstruction is
severe, there is, at the same time, a sinldng in of

PEACTICAL NURSING.

certain parts of the chest wall. It is a symptom
that should be at once reported.

In acute bronchitis respiration is laboured, aud
accompanied by wheezing and cooing sounds, the
patient having to be propped up in bed.

In acute pneumonia, unless the accompanying
pleurisy makes breathing painful, there is no
dyspnoea. The respirations are much increased in
frequency, but there is no obstruction to the en-
trance of air into the worldng part of the lungs.

In asthma the dyspncea is most intense and alarm-
ing, though a fatal termination is very rare. An attack
usually comes on at night, and lasts a variable time.
While it is present the patient sits upright in a chair,
gripping some support firmly with both hands, so that
he may throw more power into the muscles of inspira-
tion. Expiration is very prolonged and wheezing.

In inflammation of the kidneys dyspnoea sometimes
appears. It is an extremely grave symptom ; cases
which show it ahnost always terminate fatally.

Sighmg respiration, in which long deep breaths are
taken without dyspnoea or panting, appears in some
cases of diabetes a short time before death. In that
disease it has received the name of "air hunger."
Sighing respiration also accompanies the heart par-
alysis of diphtheria, and is a symptom of severe
haemorrhage. If, therefore, the nurse is in charge of
a case of enteric fever, or of a surgical case that has
been recently operated upon, she should, on hearing
this form of breathing, pay most caref id attention to
the pulse and general condition of the patient, "with
a view to determining the presence or absence of
other symptoms of heemorrhage.

OBSERVATION OF THE PATIENT.

Stertorous breathing is cliaraoterised by a loud
suoi'ing insjoiration. It is commonly present in
patients who are comatose.

Cheyue-Stokes breathing is a very extraordinary
form of respiration, which sometimes shows itself in
patients who are unconscious as the result of brain
disease. As a rule, it appears shortly before death,
though very occasionally recovery takes place. Very
rarely it is present in other diseases, and has not then
quite the fatal significance that it has in cerebral cases. L
It is characterised by a gradual deepening and quick-
ening of the respirations ; after reaching a certain
pitch of intensity they gradually subside, until at last
respu'ation ceases altogether. After a pause, lasting
several seconds, breathing recommences, and again
goes through the same gradual rise and fall.

Cough. — The points which a nurse should notice
about a cough are its frequency, duration, whether it
exhausts the patient, whether it is more marked dur-
ing one period of the twenty-four hoiu"S than another,
and its character. This latter feature varies very
much in different diseases.

In pneumonia and pleurisy the cough is short and
restrained, because it hin-ts the patient to cough; in
laryngeal obstruction it may be hoarse, or loud and
ringmg ; in hysteria it is barking ; in whoopmg-cough
a series of rapid short coughs is followed in most cases
by the whoop, though this is not always present ; in
early phthisis we hear a slight hacking cough. A
cough is characterised as "tight" or "loose" accord-
ing to the absence or presence of expectoration.

Expectoration varies in character in different dis-
eases, and also at different times in the same disease.

PRACTICAL NUESING.

If there is lung disease of an acute nature, a specimen
of expectoration should be kept each day for the
physician, and, if it seems to be excessive, the quantity
in each twenty -fom* hom-s should be measured. Its
appearance should be carefully observed by the nurse.
In acute bronchitis it is at fii'st white, frothy, and
stringy ; later on it becomes yellow and opaque. In
acute pneumonia it is very tenacious and of a rusty
or plum colom", owing to the presence of blood-colour-
ing matter in it. If there is gangrene of the lung, the
sputum is abundant, purulent, and very offensive. In
phthisis it is purulent. Children, as a rule, do not
expectorate, but swallow the sputum. This the nurse
should endeavour to prevent.

Hoimoptysis, or the spitting of blood, when occurring
in any quantity, is almost always due to phthisis.
In this disease the lung is gradually eaten away into
cavities. During this process an artery may be
opened before it is plugged with clot, and commence
to bleed. The blood gets into the trachea and is
coughed Vi^.^^^,^

Nervous System. — Under this heading come
several points to which a nurse should pay careful
attention.

Convulsions. — A nurse should always endeavour to
find out whether convulsions begin in one part — e.g.,
the side of the face or the hand — and spread from
thence to the rest of the body. The duration and
severity of the attack should also be taken note of.
They are liable to occur in brain and kidney disease,
ejDilepsy, and at the moment of death in almost any
ailment.

Coma is a condition of complete unconsciousness.

OBSERVATION OF THE PATIENT,

Should it attack a patient while under the nurse's
observation, she shovdd note whether the onset is
sudden or gradual, and if the latter, the length
of time that elapses before complete unconsciousness
supervenes.

Delirium. — Is it of the low muttering type, as
in advanced enteric, or active and noisy, as in the
early stage of acute pneumonia? Is it more pro-
no imced at one part of the twenty-four hoiirs than
another ?

Paralysis. — A nurse should note at once the exact
degree and extent of the paralysis, so that she may be
able to report any subsequent increase or decrease to
the medical attendant. If it comes on while she has the
patient under observation, she should note the manner
of onset — i.e., whether the paralysis is suddenly or
gradually established. Also she should notice whether
it varies at any time in the twenty-four hom^s — e.g.,
whether a patient who could not move the legs at all
when the doctor was present in the morning draws
them up slightly in the afternoon.

Loss of Speech. — Is there absolute loss of speech ; is
speech limited to "yes" and "no," or has the patient
a limited command of speech, but uses the wrong
words? Any of these conditions may accompany
paralysis of the right half of the body.

Sleeplessness may be caused by a variety of con-
ditions. A nurse should take care that it is not due
to cold feet, too few or too many bedclothes, the want
of a warm drink, or to a light shining in the patient's
face. It may also be due to pain or mental worry,
both of which the nurse should do her best to reheve.
A nurse should always note the exact number of hours

PRACTICAL NQKSING.

that her patient sleeps, whether his rest is disturbed
by dreams, and whether his mind wanders.

Tremor of the hands and tongue, apart from disease
of the nervous system, is a symptom of prostration, and
is common in the later stages of enteric fever.

Rigor is an important symptom of which the nurse
shotild take careful note and never fail to report.
Rigors vary much in intensity and duration. There
may be only a slight attack of shivering which quickly
passes away, or there may be most severe and gen-
eral shaldng, vsdth chattering of the teeth, lasting for
several minutes. "While the patient is in a rigor, the
face and tips of the fingers are blue, the pidse small
and hard, and the expression one of great discomfort.
The temperature is raised, and the patient may vomit.
Rigors are very important, suice they may either mark
the commencement of an illness such as acute pneu-
monia, or they may be the first indication of a serious
complication, such as perforation of the intestine in
enteric fever. A nurse should note the duration and
severity of the rigor, the condition of the patient while
in it, and his temperature both during and after the
attack.

Genito - Urinary System. — In female patients a
nurse should make herself acquainted with the regu-
larity or irregularity of the menstrual function, pres-
ence or absence of any discharge, and whether the
patient is pregnant.

Any pain or difficulty in passing urine, suppression,
or incontinence, must be noted and reported.

Examination of the urine will be considered in the
following chapter".

CHAPTER VI.

OBSERVATION OF THE PATIENT — continued.

The Pulse,

The pulse is one o£ our most important guides witii
regard to the patient's condition. Often it is the only
indication we have of improvement or the reverse. It
is therefore highly essential that a nurse should, to a
certain extent, be able to correctly interpret such ui-
formation as is afforded by the pulse, otherwise she
may, especially at night-time, overlook a change for
the worse in a patient. This is a most difficult task,
which can only be satisfactorily accomplished after
long and painstaking practice. There are, of course,
many points in connection with pulses which it is
quite unnecessary for a nurse to attempt to learn.
Practically, all that she needs is a sufficient know-
ledge of the pulse to be able to tell by it whether her
patient is gaining or losing strength. She must, in
other words, be acquainted with the meaning of
certain changes which may take place in a pulse. To
do this, she must constantly and carefully feel her
patients' pulses, and when she hears one of them

PHACTICAL NUKSINQ.

described as having a particular form of pulse, she
should repeatedly examine it until she feels satisfied
that she recognises its peculiar featiires. Frequent
comparison with a normal pulse is the surest way to
accomplish this. A nurse must always carefully
watch the effect of stimulants upon the pulse.

Before it is possible for her to understand the pulse
in disease, a nurse must have a thorough knowledge
of its characters in health ; its rate, varying from 72
per minute in the adult male to about 120 per minute
in very young children ; its size, and the ease with
which it may be stopped by pressure. When examin-
ing a pulse the nurse should place two, or better still,
three fingers upon the artery, the radial at the vrrist
being the one generally chosen. This refers to
adults ; in children one often has to be satisfied with
one finger. The pulse should be counted for half a
minute. If, owing to its extreme irregularity or
smallness, a nurse is unable to coimt the pulse at the
wrist, she should place her hand on the chest a little
below and internal to the left nipple and count the
beats of the heart. She should always endeavour to
take the piilse of a sleeping patient without waking
him. This may often be done by placing the finger
upon the temporal artery just in front of the ear.
Care should be taken, when feeling the pulse, that
the elbow is not bent, since that hinders the flow
of blood through the brachial artery, and so makes
the pulse at the wrist appear smaller than it
really is.

In examining the pulse a nurse should take note
of its frequency, size, compressibility, and regularity.
She must remember that it is slightly quicker by day

OBSERVATION OF THE PATIENT.

than by night, and decidedly more in the sitting up
than in the lying down position,

(1) Frequency. — Is it a quick or a slow pulse ? To
be strictly accurate, one should say, Is it a "frequent"
or an "infrequent" pulse? "Quick" and "slow"
are, however, the terms that are still in common use,
and therefore Hkely to be heard by nurses.

A quick pulse occurs with a high temperature, in
conditions of great weakness, &c. Its rapidity varies
greatly in different fevers. It is much quicker, for
instance, in scarlet fever than in typhoid. A pulse
that, with a stationary or falling temperature, gets
quicker day by day is the surest indication of a failing
heart.

A slow jJulse is most often fomid when a poison,
such as bile, is circulating in the blood. It is
sometimes the first symptom of commencing heart
paralysis in diphtheria, and is not uncommon in old
people with feeble hearts.

A running 2'>ulse is one that is so frequent, and at
the same time so small, that it cannot be counted.
The beats follow one another so quickly that there is
no appreciable interval between them : all that the
finger seems to feel is a kind of tremor in the artery.
It occurs, for the most part, in those who are
moribund.

(2) Size. — Under this heading we have to consider
the size of the vessel as well as the size of its beats.

A large pulse is one that feels larger than normal to
the finger, and is the usual accompaniment of febrile
conditions.

A small pulse is one that feels smaller than normal
to the finger. It is a sign of heart wealcness, since it

PRACTICAL NURSING.

shows that that organ is not keeping the arteries as
full of blood as it should. It must not be forgotten
that some people in good health have small pulses,
and that the small pulse of kidney disease is due to
quite a different cause.

A thready pulse is an extreme form of the small
pulse, and a sign of great and dangerous prostration.

(3) Compressibility. — Is it a hard or a soft pulse?
that is to say, does one have to press firmly or Hghtly
on it to stop its beating ?

A hard pulse is caused by inflammation of the
kidneys, and, to a less extent, by gout. When it is
present, there is said to be a condition of "high
arterial tension " or tightness, since the arteries are
tightly distended with blood. For this reason the
size of the beats is small. Firm pressure with the
fingers is required to stop its beating.

A soft pidse is also called the " compressible " pulse,
since its pulsation is too easily stopped by fight pres-
sure with the fingers. It is a sign of heart weakness,
since it shows that the heart is not sufficiently dis-
tending the arteries with blood.

A dicrotic pulse is a variety of the soft pulse, and
occurs most frequently in the late stages of enteric
fever. Each beat is followed by a smaller secondary
beat, hence the name, since " dicrotic " signifies " two
strokes." For every beat of the heart one feels a
large and a small beat at the wrist. Tliese two beats
of course only count as one, but sometimes they are so
nearly equal in size that nm^ses have been known in
counting such pulses to put them down at double
their real freqxiency. Should there be any doubt,
the point can easily be settled by counting the beats

OBSERVATION OF THE PATIENT.

of the heart. The dicrotic, like the soft pulse, is due
to imperfect filling of the arteries with blood. It is
not necessarily a dangerous symptom.

An Irregular Pulse. — A pulse may be irregular
in —

(a) Force. — The beats vary in strength, strong beats
being followed by weak beats, and vice versd.

(h) Rhythm. — There is not always the same interval
between the beats. The pulse goes quickly, then
slowly, and then quickly again.

This is a serious condition, which is most often
found in disease of the mitral valves of the heart ;
also in severe diphtheria. It is, with irregular respi-
ration, one of the earliest symptoms of tubercular
meningitis.

An Intermittent Pulse is one which occasionally
drops a beat. It is not necessarily a dangerous symp-
tom, being not infrequently due to dyspepsia or ex-
cessive smoking. It must not be confounded with
the irregular pulse, which is a much more serious
condition. The two are, however, often combined.

In conclusion, what nurses have especially to note
is the rate of the pulse and its size, remembering that
the quicker, the smaller, and the softer the pulse, the
greater the cardiac weakness, and, consequently, the
more dangerous the condition of the patient.

Temperature.

1. In Health. — The temperature of an adult in
good health should be about 98-4° F. Tliis is called the
" normal " temperature of the human body. It does
not, however, remain at that pomt throughout the

PRACTICAL NURSING.

twenty-four hours, but rises slightly towards evening,
reaching its highest point (99°) between 4 and 6 P.M.
Duruig the night it slowly falls, until between 2 and
4 A.M. it has reached its lowest point, viz., 97 '5°.
There is, therefore, each day a steady and regular
fluctuation between 97 "5° and 99°. These two points
are taken as the limits for health, i.e., a temperature
above 99° or below 97*5° is usually indicative of some
disturbance of the system. This daily rise and fall
are also present in disease. In enteric fever, for
instance, the temperature at 2 A.M. is always lower
than that taken at 6 P.M., there being often as much
as 2° or 3° difference between the two readings. This
is merely an exaggeration of the normal rise and fall
which in health takes place at these hours. In rare
cases we have what is called the " inverse " type of
temperature, i.e., it is highest at 2 A.M. and lowest
at 6 P.M. This is very unconxmon.

Further, not only does the temperature vary with
the time of day, but it also varies sHghtly with the
part of the body where it is taken. The surface of
the body is naturally cooler than the interior, since
heat is constantly escaping from it. The tempera-
ture, therefore, of the armpit and groin is lower than
that of the mouth, which, again, is lower than that of
the rectum. The difference is not great, the bowel
being barely 1° hotter than the skin.

2. In Disease.— In disease the temperature of the
body may be above or below normal, the former being
much the more common.

(a) Elevation of Temperature. — Anybody whose
temperature is higher than the normal is said to be
suffering from pyrexia. Fever is by many people

OBSERVATION OF THE PATIENT.

used in the same sense, though othei-s mean by it
both the pyrexia and the accompanying constitutional
distm'bance. If the temperature does not rise above
102°, the patient is said to be suffering from moderate
pyrexia ; if it reaches 104° or 105°, there is said to be
severe pyrexia ; while if it reaches 106°, the condition
is designated as hyperpyrexia, or excessive pyrexia,
and is one of great danger. By some 105° is con-

Name. /^B Age J7 Xi\^. Enteric Fever

106° J.

Fig. I. — Temperature Chart.

sidered hyperpyrexial. To put it ia other vp-ords, 102°
is a moderate degree of fever, 104° a high tempera-
ture, and 106° hyperpyrexia.

Pyrexia varies in character ; it may be either con-
tinuous, remittent, or intermittent.

A continuous fever is one in which the temperature
keeps constantly at about the same level — e.g., acute
pneumonia.

A remittent fever is one in which there is a marked
VOL. I.

PRACTICAL NURSING.

difference in height between the evening and morning
temperatures, the latter falling 2°, 3°, or 4°, but not
reaching normal — e.g., enteric fever.

An intermittent fever is one in which the morning
faU reaches or passes below the normal line, i.e., at
some part of the day there is a complete absence of
fever — e.g., malaria — and during the last three or four
days of the acute stage of enteric fever.

Fever terminates either by cnsis or by lysis. If
the former, the temperatm'e falls abruptly, reaching
normal in twelve to twenty-four hours, as in acute
pneumonia. If the latter, the descent is more gradual,
three or four days elapsing before the temperature
reaches normal and remains there. A crisis may be
accompanied by profuse sweating or diarrhoea, and
sometimes by marked symptoms of collapse, against
which a nurse shovdd always be on her guard, or the
patient may slip through her fingers xmawares.

Durmg convalescence a nurse must be prepared for
sudden and often inexplicable outbursts of pyrexia ;
for during that period the temperatvire is very im-
stable, trifling causes, such as worry or excitement,
being often sufiicient to make it rise 2° or 3° above the
normal. This is especially frequent in enteric, though
a careful watch must of course be kept for any com-
plication. Such pyrexias are usually of short dura-
tion, and imaccompanied by any symptoms of ill-being.
They should always be reported.

(6) Depression of Temperature. — A temperature that
is below 97-5° is called sub-normal. Wlien it reaches
95° there is a risk of collapse, though this is by no
means a necessary accompaniment, as such a tempera-
ture is occasionally seen -without any symptoms of

OBSERVATION OF THE PATIENT.

prostration. Sub-normal temperatures are most com-
monly seen in those who are convalescuig from one
of the specific fevers, such as diphtheria or typhoid.
They are partly due to the fact that the temperature,
having fallen below normal as the pyrexia subsided,
does not at once recover itself ; and partly to the
insufficient quantity of heat-producing food that has
been taken duruig the illness.

A sub-normal temperature may also be produced by
shock or haemorrhage. It is then a much more serious
condition, and if one as low as 95° be registered, a
fatal residt will probably ensue.

Taking" the Temperature. — This is done by means
of an instrument called a clinical thermometer. Those
used in this coimtry register the temperature accord-
ing to the Fahrenheit scale. It follows from what
has been said that the temperature should always be
taken at the same time each day, and in the same
place. If the axilla is used one day and the mouth
the next, misleading results are likely to be obtamed.
Having seen that the thermometer is clean, and
having carefully shaken the column of mercxu-y doAvn
to at least 2° below normal, the nurse may proceed to
take the patient's temperature in the axilla, groin,
mouth, or rectum.

1. In the Axilla or Groin. — "When either of these
parts is used, it must not have been exposed for
washing or dressing for at least half an hour previous
to the temperature being taken. Any perspiration
having been wiped away, the bulb of the thermometer
is carefully placed in position, and the arm brought
across the chest and kept there, the patient sup-
porting the elbow with his other hand, If he is too

PEACTICAL NURSING.

weak, the nurse must support the arm. If the groin
is used, the legs should be crossed at the knees.

Five minutes is long enough to register the tem-
peratiu"e, though a very slight rise may be noticed
if the thermometer is left for another five nunutes.
Instruments are also sold which are said to take the
temperature correctly in one minute, and others in
half a minute. To be quite safe, they should be left
in for at least double those times.

2. In the Mouth. — The bulb of the thermometer
must be placed under the tongue, and the patient told
to keep his lips closed untU it is taken out again,
which should be in three minutes' time. If the hps
are not kept closed, cold air will enter, and a too
low temperature be the result ; this method must
therefore be used only in the case of patients who
can breathe comfortably through the nose. For the
same reason, neither ice nor cold drinks should be
given for ten minutes before the thermometer is used.
If the lips are dry, they must be moistened, or the
patient will not be able to keep them properly closed.
This method must never be used with children or
delirious patients, as they may possibly bite the
thermometer in half; nor is it rehable with those
suffering from great prostration, as they are too
weak to keep the mouth closed for three minutes.

In the Rectum. — This is the most reliable method.
The rectimi must be empty of faeces, the instrument
oiled, introduced for inches, and left in position for
three minutes.

A nurse should not allow the patient to place the
thermometer in position, nor to remove it, else she
cannot be sure that the temperature has been properly

OBSERVATION OF THE PATIENT.

taken. The thermometer should be dipped in a cold
autise^jtic solution, and lightly dried before beiug used
for another patient. This is especially necessary when
taking tempera tm-es in the mouth. If the bulb of
the instrument is rubbed roughly when drying it, the
mei'cmy will begin to rise.

The temperatm'e should always at once be taken a
second time when an imexpectedly high or low record
is obtained, in case a faulty instrument has been used.
Also, it shoidd be taken again in half an hour, to see if
it is still rising or falUng. Not to do so, shows either
a lack of interest in the case, or a want of the true
mu'sing instinct.

Hysterical patients and mahngerers sometimes pro-
duce extraordinarily high temperatures by rubbing the
bulb of the thermometer. If the nurse has any reason
to suspect that such a thing is being done, she should
hold the instrument in position herself. In that way
alone can she be certain that fraud is not being
practised.

The Urine.

A healthy adult will pass on an average about 2|
pints of urine in tlie twenty-four hours. The amoimt
varies with the temperature of the surrounding air,
and consequent increased or diminished activity of
the skin. There is a certain quantity of water to
be removed from the system each day. If the skin
uses much of it in the making of sweat, there will
be less for the kidneys. When much fluid is taken,
more urine will be passed.

Urine is an excretion of great importance, since
dissolved in the water are certain poisonous sub-

PK ACTIO AL NURSING.

stances produced by the working of the different
organs, which, if left in the system, would quickly
kill the patient. In health, urine is clear when passed,
of a light amber colour, slightly acid, which may
change to faintly alkaline after a meal, with a
specific gravity varying between 1015 and 1020.
(The specific gravity of a fluid is its weight as com-
pared with that of water. When we say that urine
has a specific gravity of 1015, we mean that whereas
a certain quantity of water weighs 1000 grains, an
equal quantity of urine would weigh 1015 grains.)

In disease, there may be great changes in the
character of the urine. The quantity passed may
rise to 20 pints per day, or be only a few drachms ;
the colour may be almost quite black, or it may look
like water ; the specific gravity may be as low as
1002 or as high as 1060, and the reaction may be
strongly and persistently alkaline.

Suppression of Urine is a most serious and fre-
quently fatal symptom. It results from a comjjlete
failure on the part of the kidneys to do their work.
The patient passes no in-ine at all, the bladder being
quite empty. The poisonous waste substances which
should have been removed by the renal organs ac-
cumulate in the system, and quickly produce a most
dangerous form of blood-poisoning called urcemia.
Suppression of urine is most common in acute in-
flammation of the kidneys. It is also seen dm'ing
the last hours of life in severe diphtheria and cholera.

More often there is a partial suppression, a few
drachms or an ounce or two of hiffh-coloured m'ine
being passed in the twenty-fom^ hours.

Suppression may also result from blocldug of the

OBSERVATION OF THE PATIENT.

ureters by stones, so that no urine can pass from the
kidneys to the bladder. Such cases do not present
the symptoms of ursemia, which so frequently appear
when suppression is caused by inflammation of the
kidneys.

Retention of Urine is much less serious than sup-
pression. Urine is being secreted by the kidneys, but,
owing to the patient's inabihty to void it, is accumu-
latmg in the bladder, which may in consequence be
greatly distended.

Retention may be due to paralysis of the bladder,
or it may be caused by a diilHng of the senses, so that
the patient does not feel the desire to pass water.
This is seen in cases of typhoid, and as a result of
shock after severe accidents ; or it may be merely
the result of nervousness in a new patient. It is
a condition for which nurses should always watch,
especially in fever patients, and at once report.

Incontinence of Urine. — In this condition there
is inability to retain the in-ine within the bladder.
There may be complete incontinence, as is seen in
cases of disease of the spinal cord ; or there may be
incontinence with retention, the bladder being ex-
tremely distended with an occasional escape of urine;
or there may be the incontinence of childhood, due
to irritability of the bladder, worms, or faulty educa-
tion of the child.

Measuring" Urine. — In certain conditions, such as
inflammation of the Iddneys, or when less urine
than normal is being passed, as may happen in
diphtheria, the nurse is required to measure the total
amount voided during the twenty-four hours, and
record the same. To ensure obtaining all that is

PP.ACTICAL NUESING.

excreted during that time and no more, she should
make the patient empty his bladder immediately
before she starts measuring, because the urine that
is then in the bladder belongs to the preceding
twenty-four hours. For the same reason, when the
twenty-four hours come to an end she should again
make him empty his bladder, and add the urine then
passed to what she has collected. If during the day
any is lost through the patient passing it into the bed,
the niirse should put the sign -|- after the ntunber
of ounces she records, as indicating that the patient
has passed more than that amount.

Both the vessels into which urine is passed, and
also those in which specimens are put up for ex-
amination by testing, must be kept scrujaulously clean,
and absolutely free from any trace of stale urine ;
otherwise, the next specimens they contain may be
spoilt by contamination.

If soda is used to cleanse the vessels, they must be
thoroughly rinsed with water afterwards, or the next
urine that is placed in them will be rendered alkaline.

Examination of the Urine. — Anything like a
complete examination of the urine could never form
part of nurses' work, but they are often asked to test
it for albumen or sugar. They should therefore have
some slight knowledge of this subject. Such know-
ledge can only be gained by practical demonstration.

Colour varies to a certain extent with the quantity
passed : the more concentrated the urine, the higher
its colour. Smoky urine indicates the presence of
blood, which is also shown by the chocolate-coloured
deposit which settles on standing. It is present in
acute inflammation of the kidneys.

OBSERVATION OF THE PATIENT.

Dark olive-green urine is caused by the absorption
of carbolic acid. It is not infrequently caused by
the use of carbolic acid fomentations in young chil-
dren, and should be at once reported. It must not be
confounded with smoky urine, which at first sight it
closely resembles.

Porter-coloured urine is due to the presence in it of
a large quantity of the colouring matter of the blood.
It occurs in " bleeders," a rare and peculiar class of
individuals who, as the result of the smallest scratch,
suffer from severe and sometimes fatal haemorrhage.

Bile gives to lu-ine a deep yellow -ochre tinge, a
somewhat similar colour being produced by the in-
ternal administration of rhubarb.

Deposit. — A nm-se shoidd always notice whether
the urine is clear when passed, and only becomes
turbid on standuig. A light-pink or salmon-coloured
deposit has no evil significance. It consists of urates,
is the usual accompaniment of a high temperatiu-e,
and is of frequent occurrence in people who are
in perfect health. It appears when the urine has
become cold, and disappears if it is heated.

Blood gives rise to the chocolate-colom-ed sediment
already mentioned.

Pus produces a milk-white def)osit at the bottom of
the specimen-glass.

Mucus produces a light flocculent deposit or cloud.
It is frequently present in health.

Reaction of Upine. — In health, urine is acid for the
greater part of the twenty-four hours — i.e., it turns
blue litmus-paper red. For a short time after meals
it may be slightly alkaliue, the change being due to
certain elements in the food. Urine may change

PRACTICAL NUKSING.

slightly the colour of both red and blue litmus, or it
may be neutral in reaction and hence affect neither.

In some fevers urine is rather more strongly acid
than usual, but the only important change in disease
is a marked alkaline reaction, accompanied by an
offensive ammoniacal odoiu". This indicates decom-
jDosition of the urme in the bladder. It is most
common in paralysis of that organ from spinal dis-
ease, and is not infrequently due to the use of an
imperfectly cleansed catheter. If not quickly checked,
it will set up cystitis — i.e., inflammation of the bladder.

Albumen is what a nurse is most often asked to
test for. It is very frequently a symj^tom of inflam-
mation of the kidneys, but is also present in the urine
in various other conditions, such as heart disease and
extreme anaemia, also when the working of the kidneys
is disturbed by a high temperatiu^e. Various tests are
used for albumen, but they all depend upon the fact
that that substance is coagulated by heat or strong
acids, and then appears as a cloud in the fluid which
contains it. An example of this is seen in the case
of white of egg, which consists of pure albimien.
Boiling coagulates it, converting it from a transparent
liquid into an opaque white soHd.

In examining a urine for albumen, the nm'se should
proceed as follows : —

If it is expected of her, she first determines the
specific gravity of the specimen by means of a urin-
ometer. She next tests it with litmus-paper to see
whether it is acid or alkaline.

In order that one may see clearly any cloud that
forms in the process of testing for albumen, it is essen-
tial that the mnne should, to start wth, be quite clear.
In maiay cases it is so ; in others the cloudiness is due

OBSERVATION OF THE PATIENT.

to lU'ates, wliich disappear entirely when the fluid is
gently warmed. Sometimes, however, the urine is
opaque, owing to the presence of mucus. The only
way to get rid of this is to strain the urine through a
filter-pajDer fitted into a small glass funnel. The fluid
wliich passes through wiU be quite clear. Having
now obtained a perfectly clear ui'ine, the niirse pro-
ceeds to test it for albumen. This she is usually
expected to do in one of the three following ways : —

1. Heat and Acetic Acid. — A perfectly clean test-
tube is filled three parts full of urine. If the fluid is
alkahne or neutral, two drops of dilute acetic acid are
added to it. Occasionally a faint cloud will now
aj^pear, which the nurse should always look for and
report, as it persists on boiling and is not due to
albumen, which might therefore be wrongly reported
as present. To avoid this difiiculty, acetic acid should
not be added before boiling if the urine is already acid
— that is, if it turns blue htmus-paper red. The
uppermost part of the column of urine is then held in
the flame of a spirit-lamp till it boils. "While doing
this, the test-tube is held by the lower end in a slant-
ing direction over the flame, with the other end
pointing away from the nurse, so that if the urine
should spiu-t out of the tube when it boils, she may not
be scalded. While heating it, she should move the
test-tube romid and rotmd, so that the sides may be
kept wet, or they will be cracked by the heat.

If a cloud appears on boiling, a few drops of acetic
acid are added. Should the cloud persist, it is formed
by albimien ; if the acid causes it to disappear, it con-
sists of salts called phosphates.

By only boiling the upper part of the fluid, one is
able to compare the cloudy i^ortion with the clear un-

PRACTICAL NURSING.

boiled part below. This is often of great use in
deter miniug whether a small quantity of albumen is
present or not.

2. Nitric Acid. — A small quantity of strong nitric
acid is placed in a test-tube, which is then held slant-
wise while the urine is allowed to trickle slowly down
the side. Being lighter than the acid, it floats on it.
If albimien is present in the urine, a white ring ^vill
appear at the point where the two fluids meet.

3. Picric Acid. — The test-tube is filled one-third full
of urine and as much picric acid added. If albumen
is present, a cloud forms which persists after heating
with a spirit-lamp. This should always be done, as
with picric acid a cloud is sometimes obtained, disap-
pearing on heating, which is therefore not albimxeru
The picric acid may also be floated on the urine just
as the latter was on the nitric acid. In albuminuria
a ring appears at the junction of the two fluids. This
is a most useful method of detectmg a very faint
trace of albumen, the ring so formed being much more
obvious than a very slight general opacity. Picric
acid, however, like acetic acid, forms with some
urines a cloud which is not due to albumen, and
which persists on boiling.

Sugar is present in the disease known as diabetes
mellitus. The easiest and most rehable test for its
presence in uruae is to take about a teaspoonful of
Fehling's solution (which contains sidphate of copper,
caustic soda, and tartrate of potash), boil it in a test-
tube, and then add very gradually an equal bulk of
urine. An orange-red deposit, which persists on boil-
ing, indicates the presence of sugar.

CHAPTER VII.

DIET IN DISEASE.

In this chapter we shall consider first the general
principles which guide the physician in dieting his
patients, and afterwards the administration of the
diet by the nurse. This is such a very important
part of her duty that every nurse ought to have a
clear idea of those principles, and of the best way in
which t]iey may be carried out. Witliin the limits
of one chapter it would obviously be impossible
to consider in detail the appropriate diets of the
various diseases. "What follows will refer generally
to the feeding of patients who are, or have been,
acutely ill.

Diet in Acute Disease. — In acute disease (by
which is meant an acute febrile illness, such as
enteric fever, pneumonia, &c.) there are two urgent
reasons for giving the patient as nourishing a diet as
possible —

1. To keep up his strength.

2. To hinder wasting.

It is in these very cases, however, that we have
to be most careful and circumspect in what we give

PRACTICAL NURSING.

our patients ; for one result of acute disease is
a general derangement of the organs of digestion.
They become weak and disinclined to work; hence
the patient is liable to dyspepsia, and suffers from loss
of appetite. This weakness is most marked in the
case of the stomach, which after a time becomes so
helpless that it practically does no digesting at all :
it merely serves as a reservoir in which the food
collects before it passes on into the small intestine.
It is well, therefore, to remember that extreme mus-
cular prostration in fever connotes a similar condition
of the stomach. Under these circumstances that
organ must be tenderly dealt with, and its work
made as light as possible. "While using every endeav-
our to keep up the patient's strength, we must not
overtax his feeble digestion, otherwise it will be upset,
and we shall then have done a positive harm to
the invalid. This weakness of the organs of diges-
tion varies very much in different patients. Some
show no sign of it throughout their illness, while in
others it is one of the most troublesome and worrying
symptoms.

In feeding our patients we must, therefore, keep the
following objects in view : —

1. To check wasting, by giving as much food as is
safe and possible.

2. To give nothing that cannot be easily digested
and absorbed.

Milk. — There is no doubt that, as a rule, fluid food
is more easily digested than solid, and consequently
more quicldy absorbed. Our staple article of diet
in all cases of acute illness is therefore milk. It is
what is known as a perfect food, since it contains

DIET IN DISEASE.

all the elements required for the feeding and build-
ing up of the tissues. Admirable food though
milk is, it sometiraas_causes severe indigestion ; for
the acid gastric juice coagulates it, so that it
forms small solid particles called curds. These tend
to stick together, and in this way frequently form
large hard masses, which the patient's feeble
stomach is quite incapable of digesting. As a re-
sult, he has pain at the pit of the stomach, and
perhaps vomits the offending masses of curd. If
he does not, they pass into the bowel, where they
tend to set up coHc and diarrhoea. Ultimately, they
may appear, still undigested, in the stools, so that
the patient has had all his pain and trouble for
nothing.

When a patient suffers from dyspepsia, or j^asses
undigested milk in his motions, we must do what we
can to aid digestion. We must prevent, as far as
possible, the formation of these hard lumps of curd.
The most certain method of achieving this is by
partly digesting the milk before it is given to the
patient. That part of it which forms curd is by this
means so altered, that, when taken into the stomach,
it is unable to give rise to the hard masses it pre-
viously did. Milk which has been completely digested
has, however, such a bitter taste that few people
would care to druik it. By allowing the peptonising
agent to act upon the milk for not more than half an^
hour, the bitterness is avoided, wliile the process oi
digestion is sufficiently advanced for the patient to
complete it without the pain or trouble caused by
ordinary milk.

Benger's and Mellin's foods, when added to milk.

PRACTICAL NQESING.

also diminish the tendency to curd formation, while
at the same time they add to it a certain amount
of nourishment.

Diluting milk with barley- or lime-water, one-third
of either to two-thirds of milk, helps in some degree
to jarevent the small atoms of curd sticking to one
another, as does also the addition of ten grains of
bicarbonate of soda or potash to each pint of milk.
Mixing milk with plain water tends to produce the
same efiPect, and thus renders it easier of digestion.
For this reason, all patients suffering from a high
temperature ought to have their milk diluted. The
thirst which naturally accompanies that tempera-
ture will lead them to drink qtdte enough of this
diluted milk in the twenty-four hours.

Whey. — When a patient cannot digest milk in. any
form, whey is sometimes tried for a time. It may be
prepared by boiling a pint of milk with two teaspoons-
ful of lemon-juice, and then straining through muslm,
the curd being at the same time broken up with a fork
and squeezed, to express all the fluid from it. Whey
is more frequently made by bringing a pint of milk to
a temperature of 100°, adding to it two teaspoonsful
of essence of rennet, and then letting it stand in
a warm place till the curd has set. ^Hiey is very
easy of digestion, but naturally does not contain much
nourishment, since almost all the fat and proteid are
left behind in the curd. Whey may be used for the
purpose of diluting milk.

Beef-Tea is another fluid that is usually included in
the fever patient's dietary. By this time, probably,
most nurses are aware that it is not, strictly spealdng,
a food. It contains practically no noimshment, and

DIET IN DISEASE.

therefore cannot assist in promoting the growth of
the tissues. It is, however, most useful for its
stimulating properties, as well as for the salts
which it contains. Moreover, it is said by some
authorities to assist in checking tissue waste.

Peptonised beef- tea, solidified with isinglass and
iced, makes a pleasant change.

Egg's are, like .milk, a perfect food, though they do
not contain anything like the amount of nourishment
with which they are popularly credited. Still they
are a useful adjunct to the fever patient's diet, and,
as such, are frequently ordered. They are always
given in the uncooked state, and may be mixed with
broth, tea, or milk ; or the white of egg alone may
be added to the milk. This is very easy of digestion,
and, when well mixed with milk, by shaking the two
together in a clean bottle, woiild be taken imnoticed
by the patient. If the whites of four to six eggs
are given in the twenty -four hours, an appreciable
quantity of nourishment is added to the diet. The
eggs must, of course, be perfectly fresh.

Meat Juices and Essences. — Various patent pre-
parations of this character are largely used, especially
in private practice. The great majority are quite
lacldng in nourishment. They act in the same way
as beef -tea. The nicest way to give a meat essence is
to place it on ice and freeze it. After this treatment
it is sometimes readily taken by people whom it
woukl otherwise nauseate. The most reliable member
of this class is raw meat-juice freshly prepared each
day by the nurse herself.

According to Dr Cheadle, this should be made as
foil ows : Finely mince fresh rump-steak (which should

VOL. I. G

PRACTICAL NURSING.

• be quite free from fat), add 1 ounce of cold water for
' every 4 ounces of meat, and, after mixing, let it stand

. ,r- for half an hour. The juice is then expressed, prefer-
ably by means of mushn. The resulting fluid is highly
nourishing and easy of digestion. It does not keep
well, and should therefore be made t^vice a - day.
When given to an adult, this should be either hot or
ice-cold, never lukewarm. Meat that is dry should
be scraped instead of minced, and the water then
added.

Jellies as ordinarily made are in no sense of the
word a food. They are, however, pleasant to the
palate, and for that reason, if patients hke them, are
commonly given.

Bread-jelly, though seldom used, is, on the contrary,
both digestible and nourishing. It is made as follows :
s A thick slice of stale bread is soaked in cold water for

\ six'liours, to~remove any acid or irritating matter.
The water is then squeezed out of it, and the pulp
gently boiled for . twojiours. The resulting mixture
is then strained, and rubbed through a fine hair-sieve
or muslin. The fluid and solid material which passes
through sets into a jelly as it becomes cold. A couple
of table-spoonsful of this jeUy, mixed with milk and
sUghtly sweetened, is usually readily taken and much
enjoyed by enteric fever patients. Flavouring the
jelly with lemon makes it more palatable, as does
also the addition of a little cream to the milk and
sugar. It needs making twice daily, as it does not
keep long. ""^ "

Custards, corn-flour, and light mflk-puddings are
also sometimes allowed to patients sufi^ex'ing from
fever.

DIET IN DISEASE,

Alcohol may be given to a fever patient for one
of two reasons.

1. To Assist Digestion. — When well diluted {e.g.,
1 ounce of alcohol to 6 ounces of water), tliis drug
mildly stimulates the mucous membrane of the
stomach, and, by increasing the flow of gastric juice,
aids digestion. At the same time it cleanses the
palate and improves the appetite. To produce these
good efiects, a small quantity of the diluted alcohol
(about an ounce) should be sipped a few minutes before
the meal, while the rest should be taken with the
food.

2. To Stimulate the Heart. — Alcohol eflPects this by
stimulating or irritating the mucous membrane of the
stomach, which passes on the stimulation or irritation
through the central nervous system to the heart.
Ammonia stimulates the heart in a similar maimer
by irritating the mucous membrane of the nose. It is
obvious that the more alcohol is diluted, the less will
it stimulate the stomach, and consequently the less
will it stimulate the heart.

When, therefore, we wish to stimulate the heart,
alcohol should be administered in a much more con-
centrated form than when it is given to aid digestion.
Not more than two parts of water should be added
to one of alcohol, and this mixture should be slowly
drunk. At the same time, it must be given often, so
as to keep up the stimulating effect. If given often,
it must be used in small doses, otherwise the patient
will be injuriously affected by the quantity. Brandy
should not be given in milk, but in water, as it will\
then have a more decidedly freshening effect upon the
palate.

100

PRACTICAL NURSING.

Tea. — If the doctor has no objection, and it does
not cause indigestion, a good cup of tea twice in
the twenty-four hours will be much appreciated by
every fever patient. It is very refreshing, and helps
the patient to take his milk. 4 A.M. and 4 P.M. are
about the best times to give it.

Water. — Provided it does not interfere with the
taking of milk, a patient should be allowed to drink
plenty of cold water. ISTot only is it grateful on ac-
coimt of thirst, but it is needed to replace the loss of
water from the system ; also to flush the tissues, and
thus cleanse them from the waste products which are
produced in excessive quantity dm^ing a febrile attack.

IC6 broken into small pieces is frequently given for
the reUef of thirst and extreme dryness of the mouth
and tongue. It should be used in moderation. "When
given for nausea or vomiting, it should be swallowed
whole, and not allowed to melt in the mouth. To
drain away the water, ice should be kept on a piece of
flannel tied across the top of a basin. Under these
conditions it will last longer.

The Average Fever Diet. — Having passed in re-
view the various articles that may form part of a
fever dietary, we must now consider the amount of
food that is usually given to one of these jDatients
in the twenty-four hours. Every one is agreed that
he must be fed frequently and in small quantities.
Not too much must be given at a time, or the weak
stomach will be overtaxed ; while if Httle is given,
that little must be often, or the patient will fail from
want of nourishment. Fortunately, a patient with a
high temperature suffers from a chronic thirst, and
is therefore always ready for a drhik.

DIET IN DISEASE.

101

For an adult patient a very common allowance is
3 pints of milk in the twenty-four hours. As he will
need a drink at least every two hours, this should be
divided into twelve feeds of 5 ounces. Each 5 ounces
of milk should have about 3 of barley- or lime-water
added to it, thus giving the patient a drink of 8 ounces
every two hours. If he is ordered to be fed every hour,
he would get half this quantity in each feed. When
beef-tea forms part of the diet, it should be given in
feeds of 5 ounces at a time. The milk should be cold,
the beef -tea is usually warm ; though, if the patient
prefers it cold, there is no objection to it being so
given. The above quantities represent a fan' average
allowance for an adult. Some fever patients will take
more, others less. Some will be unable to digest the
milk, unless it is still further diluted ; others will re-
quire it to be partly digested. If they vomit, it must
be peptonised, and at first given in smaller quantities.
Sometimes even this is rejected, in which case we
have to fall back upon whey and veal broth, or even
resort to rectal feeding. Home - made koumiss is
sometimes very useful in these cases.

The Feeding- of the Patient by the Nurse. — The

first and most important duty of a nurse is to see
that her patients take a sufficient quantity of food in
the twenty-four hours. With the majority there is no
trouble ; but occasionally they are very tiresome, and
tax both the nurse's patience and her ingenuity in
overcoming their objections to the constantly appear-
ing milk. A nurse must never give in to these objec-
tions ; but with quiet and gentle persistence must let
sixch patients see that she is determined to have her
own way. With the permission of the medical attend-

102

PRACTICAL NURSING.

ant, a little variety may be introduced by occasionally
flavouring the milk vv^ith tea or coffee, or giving it
sometimes in the form of a jelly or as junket. This
latter dish, iced, w^ith a little whij)ped cream spread
over it, wHl usually form a most acceptable change of
cHet. If the patient's obstinacy proves unsurmount-
able, the nurse must never fail to acquaint the medical
attendant with this state of afiFairs. Some nurses do
not like to do this, thinking such an admission a
reflection upon themselves. Did they recognise how-
serious a matter the loss of food is to their patients,
they would not allow themselves to be influenced by
such a small consideration.

In connection with this may be mentioned a 'doubt
which sometimes rises in a nurse's mind as to what is
the right thing to do. Ought she to wake a patient,
who has previously been sleeping badly, in order that
he may take his food at the usual time ? In such a
case the nurse should, if possible, have previously
obtained instructions from the doctor as to whether
he would like the patient roused for every feed diu-ing
the night in the event of liis sleeping soimdly. In the
absence of such instruction, a nurse must use her judg-
ment in deciding whether sleep or food is most needed
by the patient. If he is being fed hourly, she might
certainly give him a double quantity, and thus only
wake him every two horn's. If he is being fed two
hourly, she ought certainly not to allow hmi to miss
more than one feed. A good nurse ^dll often be able to
give her patients a drink of milk without fully waldng
them, so that they drop off to sleep again at once.

A nurse should observe strict punctuality in giving
her patients their milk. This is almost always done

DIET IN DISEASE.

103

out of a feeder holding about 10 ounces, partially-
covered over at the top, and fitted with a curved spout.
Placing a folded towel under the patient's chin, the
nurse passes her left arm behind his neck, or, better
still, beliind the pillow, and thus raises his head a few
inches ofiF the bed. Placing the spout between his
Hps, she gently tilts the feeder up, and allows about
half an ounce to run into his mouth. She then with-
draws the spout, while the patient swallows the milk.
After a few mouthfuls, the niu-se removes her arm,
and the patient is allowed to rest for a minute or
two, since anything like hurry should be carefully
avoided. The feeding is then resumed and finished,
after which the nurse wipes the patient's mouth, ar-
ranges his pillow, and leaves him to sleep. The degree
of prostration determines very largely the speed with
which a patient is able to drink his milk.

A better method of feeding, both for the patient
and the nurse, is to allow the former to suck the milk
out of a feeder or a cup by means of a bent glass
tube. He can then drink it as slowly as he likes,
without being raised from the bed, the mu-se merely
supporting the feeder. In default of the glass tube, a
piece of moderately fine rubber drainage tubing might
be used, but the former is in every way preferable.
Both tubes would need careful cleansing after use, and
the rubber one should be kept in clean water.

For patients who are very weak and helpless, a use-
fid plan is to put a small piece of drainage tubing on
to the nozzle of a glass syringe, fill the latter with
milk, place the end of the tubing between the patient's
hps, and very slowly empty the syringe, giving the
patient plenty of time to swallow.

104

PRACTICAL NURSING.

When feeding a patient who is partially unconscious,
great care must be taken, otherwise the food may get
into the lungs and set up a fatal pneumonia. In
such a case, rubbing the spoon or spout of the feeder
against the patient's lips wiU often cause him instinc-
tively to open them, when a small quantity of milk
may be safely poured into the mouth. In the same
way, a patient who is sleeping soundly can often be
roused sufficiently to take a drink without being com-
pletely awakened.

MUk should not be left uncovered beside the patient's
bed, otherwise it collects dust and germs from the
surrounding atmosphere.

N'o milk that is in the least sour should be used. If
it is suspected — and a nurse should always smell and
taste it before use- — some should be boiled, when the
formation of curds will indicate the unwholesome con-
dition of incipient sourness, and lead to its condemna-
tion ; for no amount of boiling will render such a milk
fit for food.

Alcohol. — The best method of administering this
drug as a stimulant has already been described (p. 99).
The doctor will say how much is to be given, and will
also probably indicate how often. If he does not, the
nurse should ask him. Every two hours is a very
common time ; though, if the patient is very weak,
some may be needed every hour. For instance, if
§ iii of brandy are ordered to be given in the twenty-
four hours, it may be administered in doses oi ^ii
every two hours, or 5 i hourly. It should be di'imk
slowly, and, for the reason stated on p. 99, not mixed
with more than two parts of water. Putting a tea-
spoonful or two of brandy into a feeder of milk renders

DIET IN DISEASE.

105

it quite useless as a stimulant. A uurse should, there-
fore, not give brandy directly after a feed of milk;
otherwise the stimulant will be rendered inert by ex-
cessive dilution in the stomach.

Diet in Convalescence. — Wlien the fever has
come to an end, a gradual return is made to soHd
food. The speed with which that return is made
will depend, in the first place, upon the nature of the
patient's illness, and, secondly, upon the condition of
his digestive apparatus. One who has had enteric
fever will be longer in reaching his minced fowl and
mutton chop than one who has had pneumonia.
Similarly, a more gradual return will be necessary
for the patient who has had dyspepsia than for one
who has throughout shown no sign of that comj)laiiit.

In feeding a convalescent patient, a nurse may have
one of two difficulties to contend with.

(a) To get him to take enough.

(6) To prevent him taking too much.

The second of these two difficulties most often occurs
with the convalescent enteric-fever patient. After a
jarolonged course of milk, he is naturally afflicted with
a ravenous appetite, which he thinks it hard he can-
not gratify. In such a case, the nurse must foUow
strictly the doctor's instructions with regard to the
patient's diet, taldng care that the latter eats nothing
but what has been ordered for him, explaining to him
the risks he runs if he disobeys those orders. It is
especially on visiting days that a nurse should keep a
careful eye on such patients, since they sometimes per-
suade their friends to bring them food, which, if taken,
may be the means of causing a relapse.

To persuade the convalescent to eat, when lie does

106

PEAOTICAL NURSING.

not want to, is a much more difficult matter. This
can best be achieved by making each meal as tempt-
ing as possible. With that end in view, the plate
should contain only a small quantity of food. A
heaped-up mass of meat and vegetables would only
create loathmg in one of delicate appetite. Let the
plate and its contents be hot, and let everything
that the patient can want during his meal be got
ready before he is invited to commence it.

When the patient has finished, what is left should
at once be taken away, even though it be the greater
part of the meal. To leave the food beside the
patient's bed, with the idea that by-and-by he will
perhaps feel incHned to eat a httle, is the surest way
of preventing him so domg. If he could not eat it
when it was fresh and hot, he certainly will not
do so when it has become cold and is iminviting to
look at.

Alcohol, when given to a convalescent, is used for
the purpose of stimulating appetite and aiding diges-
tion. It is therefore best given as recommended ear-
her in this chapter.

The Private Patient's Diet. — It is when attending
upon a fever patient in private that a nurse realises
what an immense aid a knowledge of cookery is to
the successful practice of her profession. This is
especially true of the convalescing stage, when the
patient is sufficiently recovered to take an interest in
liis food, and to object to a sameness of diet. Having
obtained the doctor's permission as to the extent to
which she may vary the food that is ordered, she
should endeavour to present it to her patient in as
many different forms as possible, so as to provide a

DIET IN DISEASE.

107

little variation at each meal. He will then take it
more readily and with greater relish.

A patient, for instance, whose principal article of
diet is milk might have it varied for him in the
following ways. It can be made into a jelly with
isinglass, alone, or flavoured with cocoa ; or it can be
given as junket. A little whipped cream should be
spread over each. It can be given with bread jelly,
which is very digestible, slightly flavoured with lemon
in the making, a little cream and powdered sugar
being added to the mixture ; or a powdered rusk
could be used instead of the bread jelly. It can be
flavoured with tea or cofifee, made into koumiss, and
given at night or in the early morning as wine-whey.
A hght, well-made custard is usually admissible, and
thin milk gruel, peptonised, and sweetened or salted
according to the patient's taste, could do no harm.
"Well-made ice-cream, flavoured with cofl'ee or choco-
late, is sometimes very useful. Other methods of pre-
paring milk will occur to most practical nurses. A
nurse would, of covirse, not treat her patient to all of
these variations directly he was put on hquid diet,
but would wait imtil he began to tire of his milk,
and then begin to gradually introduce them. At the
same time he would almost certainly be allowed light
broths, such as those made of chicken and veal.

When he has reached the convalescent stage, the
nurse must still consult his tastes as much as possible,
both with regard to his diet and the hours at which
he takes it. She must also be constantly on her
guard against doing anything which might set him
against his food. Scrupulous cleanliness, and extreme
nicety in serving each meal are essential, care being

108

PRACTICAL NUESING.

taken that the patient is not kept waiting, nor dis-
gusted by the sight of a large quantity of food. It is
always better to aUow him to help himself from a
covered dish, when he can take as much or as little
as he likes. The nurse should exercise her ingenuity
in the production of dainty httle dishes that may pos-
sibly tempt his appetite. She must never feel discour-
aged by his rejection of them, but must promptly set
her wits to work to think of something else, remember-
ing that it by no means follows because two patients
have the same kind of illness they will both like and
be suited by the same kind of food. Nothing that
the patient is going to eat should be prepared in his
apartment. He must know nothing about his next
meal, before it is placed in front of him by the nurse.
Similarly, if food or stimulant must be kept in the
room, they should not be placed beside the patient's
bed, but where he can neither see nor smell them.
The nurse ought never to talk to her patient while he
is eating, nor should she, if it can be helped, be in the
room while he is doing so. The remains of the meal
must, of course, be taken away at once.

If possible, the nurse should always have her own
meals in another room, for watching somebody else
eat is apt to engender a loathing for food in one who
is troubled with a delicate stomach.

A nurse must never taste the patient's food in his
presence — e.g., to see whether the broth or beef-tea is
too hot. This should always be done outside, and
with a different spoon to that which the patient is
going to use. Most people would strongly object to
eating with a spoon which had recently been in an-
other person's mouth.

DIET IN DISEASE.

109

Filially, when reporting to the doctor, whether in
hospital or in private, upon the amount of food which
the patient has consumed, a nurse must always en-
deavour to be exact, and give quantities. She should
never talk vaguely about the patient having "taken
well," because opinions frequently differ as to what
constitutes "taking well." In such a matter the
doctor does not want to know what the nurse thinks,
but what the patient has done.

110

CHAPTER VTIL

COLD BATHS AND PACKS.

In this and the following chapter it is proposed to
deal with the various forms of baths and packs as
used in the treatment of disease. Their influence
primarily falls upon the skin. A brief consideration of
its functions is therefore necessary, before attempting
to explain the object and effects of baths and packs.

The Functions of the Skin —

1. It is the Principal Channel by which Heat
escapes from the Body. — In health the human £odj
remains constantly at about the same temperature.
Yet heat is contuiually being produced by the difier-
ent muscles and organs of the body. Of these, the
muscles are the most important. They sujDjsly four-
fifths of the total heat of the body. Even when they
are at rest this supply does not cease, though it is
naturally much augmented when they are actively
contracting. To compensate for this continual pro-
duction of heat in the interior, there must be a corre-
spondingly constant loss at the surface ; otherwise the
temjDerature of the body would rise above wliat is
called the " normal " limit for healtli.

COLD BATHS AND PACKS.

Ill

The skin^j!Jid.4ungs are the two channels through
which this loss takes place. Of these two, the skin is
the more important, since about four-fifths of the total
loss of heat from the body takes place through it.
Heat escapes from the skin —

(a) By Radiation and Conduction. — When two bodies
of unequal temperature are brought in contact with
one another, that which is hotter gives up some of its
heat to the cooler. The latter conducts heat away
from the former. Thus the water of a cold bath con- '
ducts heat from the skin. Except in the middle of
summer, the surroxmding atmosphere is of a lower
temperature than our bodies ; consequently heat radi-
ates from us into it by way of the skin, in the sanie
way as it does from a fire.

(6) By the Evaporation of Sweat. — During the eva-
poration of a fluid, heat is abstracted from the body
upon which that fluid is situated, and its temperature
is therefore lowered. The more quickly the fluid
evaporates, the more quickly is heat abstracted. Thus,
ether, which evaporates with extreme rapidity, pro-
duces, for that reason, a feeling of intense cold when
placed upon the skin.

Embedded in the skin are immense numbers of little
glands, caUed sweat-glands, which open on the surface
of the skin by very minute apertures called " pores."
From these pores the perspiration is continually es-
caping. Under ordinary circumstances the quantity
escaping at one time is so small that it evaporates
before it has time to collect upon the skin in distinct
drops. This is called "insensible" perspiration, be-
cause it is not evident to the senses. When more
sweat is secreted than can be at once evaporated, it

112

PRACTICAL NURSING.

appears on the skin as drops of moisture, and is then
called " sensible " perspiration. The quantity secreted
in the twenty-four hours varies very much, being de-
pendent upon such external conditions as the temper-
ature of the atmosphere and the amount of exercise
taken. Muscular action gives rise to an increased
production of heat, yet during and after severe mus-
cular exertion the temperature of the body does not
rise. This is accounted for by the fact that the sweat-
glands are at the same time excited to increased ac-
tivity, so that there is a corresponding increase in
the loss of heat, owing to the evaporation of sweat.
The same thing happens when the temperature of the
surrounding atmosphere is higher than that of the
body, as is the case, for instance, when a patient is
having a hot-air bath. The sweat-glands at once
begin to secrete more sweat, and thus prevent the tem-
perature of the body rising.

Thus, by means of evaporation and radiatioUj^ a
large quantity of heat is abstracted from the blood
in the skin, and so the production of heat, which is
constantly proceeding in the interior of the body, is
coimterbalanced.

Dogs have practically no sweat-glands, and their
skin, covered as it is with hair, can lose but very little
heat by means of radiation. Consequently their siu-plus
heat can only escape in one way — viz., by the lungs.
Hence their very rapid respiration in hot weather or
after a sharp run, since the more quickly they bi-eathe
the more heat they lose.

2. It is at times one of the Organs of Excretion. —
The kidneys and the limgs are the organs which re-
move from the system tlie poisonous waste products

COLD BATHS AND PACKS.

113

formed during the working of the various parts of the
body. Of these two, the kidneys are by far the more
important. "When, however, they are diseased, the
skin, by means of its sweat-glands, becomes for the
time an organ of excretion ; and, by reheving the
kidneys of a portion of their work, plays a most
useful part in the removal of waste material from
the body. Otherwise, it does practically nothing to-
wards cleansing the system, it being now recognised
that the function of the sweat-glands is to promote
the escape of heat from the body, and thus to regulate
its temperature.

The skin is also shghtly absorbent, and is the chief
seat of the sense of touch.

Cold Baths, etc.

Until quite recently it was thought that the bene-
ficial effects, which followed upon the use of cold baths
in the treatment of fever, were due to the lowering of
the temperature. This view is still true for cases of
hyperpyrexia, in which the thermometer registers 107°,
108°, or higher. These are medical emergencies, where
the temperature must be lowered as speedily as pos-
sible, since its continuance at such a height will almost
certainly kill the patient. The use of baths, however,
in a disease such as typhoid fever, is now believed
to do good principally by increasing the destruction
and removal from the system of the j^oison of th/a
disease, and only secondarily by the lowering of the
temperature.

Cold water, when applied to the skin, stimulates the
internal organs, as is shown by its eHect upon the
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114

PRACTICAL NURSING.

heart in cases of fainting. - Similarly, iri typhoid it
increases the activity of those^^lands which are en-
gaged in destroymg'~^BhB^o]m)n^ojE the^di^^g^se, thus
leading to a more rapid removal of it from the system.
It has been shown that, imder the influence of cold
baths, the urine of typhoid-fever patients has contained
three times as much of the " toxin " or poison of the
disease as it did when the baths were not beuig used.
That is to say, the poison was being three times as
rapidly removed from the system, which is a matter
of great importance when we remember that the
patient's illness, v^dth all its symptoms, is entirely due
to the presence of this toxin in the circulation.

Another advantage of this method of treatment is
that it acts as a sedative to the nervous sygtem. It
lessens delirium an^Tnduces sleep.' Further, it is a
stimulant to the heart, and braces up the circulation.
At the same time, by lowering the temiDerature, it
tends to diminish wasting.

We may say, then, that cold water, when used
externally in the treatment of fever, pi-oduces the
following beneficial effects : —

(a) The removal of toxins from the system is
hastened.

(6) Pyrexia is diminished.

(d) The circulation is improved.

(e) "Wasting is lessened, and nutrition improved.
Antipyretic drugs — such as antifebrin, antipj-i'iu,

&c. — are objected to on the score that, although they
lower the temperature, they depress the activity of the
different excretory glands, and hence hinder the removal
of toxins from the system. Statistics show that cases

COLD BATHS AND PACKS.

115

treated with baths have -a much lower mortality than
those treated with antipyretic drugs, which goes far
to prove that the former method does something more
than merely lower the temperature. We still, how-
ever, take the temperature as ovir chief guide in order-
ing baths for fever patients. Being caused by the
poison of the disease, its height is an indication of the
amount of that poison circulating in the system, and
therefore of the necessity for batliing.

The systematic use of cold water in the treatment
of disease is usually reserved for cases of enteric fever.
In other illnesses, as a rule, it is only appUed when the
temperature is sufficiently high to have an injm-ious
effect upon the patient.

Before giving any sort of hath, a nurse should
obtain exact instructions as to the temperature of the
bath, and the length of time the patient is to be kept
in it. To follow out the former of these two instruc-
tions to the letter, she must never be without her
bath thermometer.

Cold water may be used in the treatment of fever
in one of the following ways : —

1. Cold Bath. — This is undoubtedly the most effica-
cious. At the same time, it is more or less of a shock
to the patient, and for that reason is seldom used in
this country, except when the immediate lowering of
a dangerously high temperature is desired.

A long bath, half full of water at a temperature of
about 65°, is placed transversely at the foot of the
bed. This position is recommended by Dr Hare as
preferable to having the bed and the bath in the same
straight line. A small towel is fastened round the
patient's hips with a safety-pin, and his night-shirt

116

PRACTICAL NURSING.

taken off. His head and neck are then sponged with
cold water, and the bed-clothes afterwards removed.
He is now carefuUy lowered into the bath on a sheet.
For systematic bathing, Dr Hare's perforated canvas
stretcher on Hght wooden poles would be much better
than a sheet. It fits loosely into the bottom of the
bath, the patient being again Hfted out on it, and
laid on a macintosh. When first placed in the
water, the patient gasps for breath, but this gradually
passes off. Owing to the contracting effect of the
cold water upon the superficial blood-vessels, his ptilse
becomes smaller. To the uninitiated this might appear
a dangerous symptom, wliereas it is merely a normal
resiilt of the bath. With the gasping resj^iration there
is usually a slight degree of shivering, which soon stops.
Later on in the bath shivering may again commence.
This must not be taken as an indication for stopping
the bath, unless it becomes violent. While in the
water, the patient's skin should be subjected to firm
yet gentle friction by the nurse's hands.

At the expiration of ten minutes a blanket is thrown
across the top of the bath, and the towel removed from
the hips. The patient is then lifted out by placing the
hands behind him, and leaving the wet sheet in the
bath. Still covered by the blanket, he is laid upon
another which the nurse has warmed and placed upon
his bed. He is now rapidly and gently dried with a
warm towel, the two blankets slipped away, a sheet
and one blanket thrown over him, and his night-shirt
put on. There is no need to heap blankets uiDon him,
or put hot bottles to liis feet, imless he remains very
cold, or continues to shiver after removal from the
bath, in which case a hot drink should first be eiven

COLD BATHS AND PACKS.

117

to liijji. At the same time, a mirse must have these
things ready, as weU as some brandy and a hypodermic
syringe, in case symptoms of coUapse should appear.
In this country, at any rate, a medical man is usually
present when a cold bath is given.

In a private house, where there is no portable bath,
the following method may be used : —

The head of the patient's bed is raised about a
foot from the groimd. A long macintosh, that has
been warmed, is spread imder him, a sheet thrown
over him, and his night-shirt removed. Pillows are
placed beneath the macintosh on each side of the
patient, and a hip- or foot-bath stood at the bottom
of the bed. "Water is then poured over the patient
at the head of the bed, whence it rims over him
down the macintosh trough into the receptacle at
the foot,

2. Tepid Bath gradually cooled. — This is more

pleasant than the cold bath, and, being less of a
shock, can be used in cases where the other might
prove dangerous. It is always used for children in
preference to the cold bath.

The patient is prepared exactly as for the cold bath.
The temperature of the water to begin with shoidd
be about 90° F, From this point, by the gradual
addition of cold water, it is slowly reduced to 70°.
While the patient is in the bath, one nurse shSul3
be continually adding a Httle cold, and, when neces-
sary, removing some of the warm water, the while
keej)ing a careful watch on the thermometer. The
other nurse should devote her entire attention to
the patient. If ice is also being used, it must be
broken up into small pieces before the bath is com-

118

PKACTIUAL NUKSING.

menced, otherwise it will take too long to ^melt.
While the bath is being given, the water must be
frequently moved about by the nurse's hand, so as to
keep the temperatiire of the whole as even as pos-
sible. The bath thermometer must remain all the
time in the water, so that the descent of the mercury
may be constantly watched. The patient's body must
be rubbed by the nurse while he is in the bath. He
' should be taken out as soon as his temperature has
i fallen to 100°. It is seldom necessary or desirable
to keep hirfrin. longer than twenty to twenty-five
minutes, as his temperatiu"e will continue to fall for
a short time after removal from the bath. It is best
taken in the mouth. If, however, the patient is
delirious, or if a child and very restless, the ther-
mometer should be placed in the rectum. While in
the bath, the patient should be carefully watched for
the first symptoms of collapse, and, if these appear, at
once removed.

This form of bath is naturally both slower to act
and much more trouble to give than the cold bath.
It takes a large quantity of ice to produce much efi'ect
upon the temperature of a long bath half full of
water at 90°. Crushed ice sufficient to fill sis pint
measures, when added to such a bath and dissolved
in it, only reduces the temperature about 4°. With a
feverish patient immersed in the water, the efi'ect
would be still less. If, on the other hand, cold water
is added, before 70° is reached the bath would be
much too full. Some of the water must therefore
be removed. When the bath is fitted with a tap, its
contents are easily drawn off into buckets. If it has
no tap, the warm water should be siphoned ofi" into

COLD BATHS AND PACKS.

119

pails by means of a long piece of drainage tube, while
cold water is added to take its place. This is a neater
and more rapid method of removing the surplus water
than baUng it out with jugs or basins.

If the patient is a child, it can be carried to the
bathroom, where giving a graduated bath becomes a
very simple matter. Very young children should not
be kept in the bath longer than ten minutes, nor
should the temperature of the water be reduced for
them below 80°.

It is of great importance that the chest should not
be submerged when cases of inflammation of the lungs
are bathed, otherwise the act of respiration is rendered
more difficult by the weight of the water. This pre-
caution is especially necessary in the case of young
children, because of their more flexible chest-walls.
The nurse should support the back of the patient with
one hand and sponge the chest with the other.

3. Cold Pack. — The bed-clothes are first taken ofiF
the patient, and a blanket thrown over him. A large
macintosh covered by a blanket is then shpped under
him, a small towel fastened round his hips, and his
night-sliirt removed. Two large sheets are taken, and
each folded once lengthways and once crossways, thus
making four thicknesses, and then wrung out of cold
water (65° F.) One of these is placed under the pa-
tient, and the two sides of it brought up to the front
of the body between the arms and ribs, and also tucked
round the thighs and legs. The other sheet is then
laid on the front of the body, tucked round the neck
and also beneath the body on each side, passing on the
outer side of the arms. It is important that the pack
should be closely adapted to the whole of the trunk.

120

PRACTICAL NURSING.

and not separated from it by the arms. This is much
easier of attainment with two sheets than with one.
The feet are usually left uncovered. If the patient
shivers much, a hot bottle may be appHed to them.
The patient, covered with one blanket, is left in the
pack for ten minutes. At the end of that time the
sheets are separately removed, again wrung out of
cold water, and reapplied. This process is usually
repeated at least four times.

Another plan is to combine the cold pack and the
cold affusion. The sheets, having been once appHed,
are kept cold by sprinkhng the patient with water
from a small watering-pot, or rubbing him with ice.
This can be done every three or four minutes, front
and back, untU the temperature, as taken in the
mouth, has fallen to the required point ; or the upper
sheet can be removed, and, the patient being turned
slightly on one side, the inner surface of the under
sheet be sprinkled with cold water. This method
involves less disturbance of the patient than does
the changing of both sheets ; at the same time it
is less pleasant, since the wetter the sheets are, the
greater the discomfort caused by their appHcation.

A partial cold pack can be given by means of
towels. The patient having been prepared as before,
three towels are wrung out of cold water and applied
lengthways, one to the trunk and one to each of the
lower extremities. They will, of course, need frequent
changing. About every three minutes they should,
one at a time, be taken oS, wrung out of cold water,
and reapplied. This is, naturally, a less efficient method
of reducing pyrexia than either of the others. It may,
however, be the only one possible in private nursing.

COLD BATHS AND PACKS.

121

When taken out of a cold pack, the patient is treated
in the same way as after a cold bath. Hot bottles
and warm drinks are only given if he continues to
shiver or remains very cold.

4. Cold Sponging". — For performing this small
operation a nurse needs — a bath thermometer, a basin
of water at a temperature of 65° F., another contain-
ing small pieces of ice, a small sponge (one about the
size of a large orange is quite big enough), a blanket,
and two bath towels or draw- sheets. The blanket is
sHpped under the patient, his night-dress removed,
and the bed-clothes taken off, with the exception of
one blanlcet, which is turned down as far as the
hips. The towels or draw-sheets are then tucked
closely against each side of him, passing to the neck
behind the shoulders, so as to catch the water which
runs off him in the process of sponging. The blanket
will protect the bed against any which escapes the
towels.

The nurse takes her sponge, dips it in the water,
squeezes sufficient out of it to prevent it drippmg as
she moves it from the basin to the patient, and then
lightly dabs the body of the latter with it. The sponge
should be so wet that each time it touches the patient
a few drops of water escape from it. These, as they
run off the chest, will be caught in the towels, leaving
the bed quite dry at the end of the operation. This
is a much more efficacious method than placing the
patient under a blanket, and stroking him in sections
with an almost dry sponge. The chest and abdomen
must be freely_^exposed during tlfe' whole ^oT'Jthe
sponging, and, by a series of Light dabs or tajos,
kept constantly wet. The operation should last for

122

PRACTICAL NURSING.

at least_ten_miimteSj^and, if the jDatient is standing
it well, may, in the absence of directions, be advan-
tageously prolonged to fifteen. It is hardly worth
while sponging the Umbs ; but the back can easUy
be done, by turning the patient on to his side and
re-arranging the towels. If ten minutes have been
devoted to the front of the trunk, five will be enough
for the back. Sponging the back with cold water
stimulates the cu-culation in the skin, and helps to
prevent bed-sores. When the sponging is finished,
the patient will be dried by lightly dabbing him with
a warm towel. The" towels and blanket are then
removed, and his night-dress put on. Before the
back is sponged, the front of the chest should be
dried. Dm-ing the operation the temperature of the
water will be kept at, or a little below, 65° by the
addition of ice. Sponging a patient by this method
produces the minimum of disturbance with the maxi-
mum of efiect. That effect, however, is at the best
poor compared with the result of the cold or tepid
bath, and is much more transitory. It is but seldom
that one is able to effect a greater reduction of tem-
peratm-e by sponging than 2^°. Such a reduction is,
however, ample, if the cold-water treatment is being
regulai'ly used in a case of enteric. The patient's
temperature should be taken thirty minutes after the
completion of the spongingT'as' that is the time when
it is likely to be at its lowest as the result of this
treatment. If taken within ten or fifteen minutes,
the thermometer should be placed in the mouth or
the rectum.

Instead of using cold water, some physicians order
patients who are suiferuig from high fever to be

COLD BATHS AND PACKS.

123

sponged with water at a temperature of 110° F.
The object of this method is to dilate the vessels
in. the skin, and so bring a large quantity of blood
to the surface of the body, where it will be exposed
to the cooling influence of the air.

Sepid sponging is frequently used for checking the
profuse night-sweats of early phthisis.

5. Cradling". — This is the least efficacious method
of reducing a liigh temperature. It has, however,
one great advantage — viz., that it can be used with
practically no distiu-bance of the patient ; hence it
can be apphed in cases where there might be an
objection to the employment of any of the methods
previously described.

The bed-clothes are taken ofi", and a blanket folded
over the feet and legs as high as the knees. Two large
body-cradles are then placed over the patient. These
are covered by a sheet which is tucked in at the
sides of the bed, but folded back at the foot and top,
so that, though the patient is in no way exposed,
a free current of air may pass through beneath the
cradles. The night-dress is now drawn up. The
patient may be left for some hours in this position,
till the temperature, which should be taken every
hour, has fallen sufficiently. If the temperature shows
no signs of coming down, three or four ice-bags may
be hung inside the cradles. These must not touch
the patient, and should be wrapped in Hnt to prevent
any dripping of water. If the feet become cold, a
hot bottle may be apphed. If the weather is at all
chilly, this form of treatment is attended with con-
siderable discomfort.

The foregoing five methods of reducing pyrexia

124

PRACTICAL NURSING.

have been taken in their order of efl&ciency. The
cold bath is by far the most certain and rapid method
of lowering a high temperature, while sponging and
cradling take a much lower place. They can, how-
ever, be used in cases where, owing to the condition
of the patient, the more potent methods are inad-
missible. Hence the necessity for their inclusion in
this chapter.

125

CHAPTER IX.

HOT BATHS AND PACKS.

The application of lieat to the surface of the body
produces dilatation in the vessels of the skin, and
therefore increases largely the quantity of blood
which they contain. This extra supply has been
drawn from the muscles and internal organs, which
consequently contain less blood than they did before
heat was applied to the skin. Now, in health, the
more blood there is passing through any part of the
body, the more food does that part obtain, and there-
fore the greater is its activity or power of work.
Conversely, a diminished supply of blood to a part
means less work for that part to do. Hot baths and
packs, by drawing blood from the deeper structures
to the surface of the body, are therefore useful in
the following conditions : —

(a) Inflammation of the Kidneys. — By diminish-
ing the amount of blood that is passing through the
kidneys, hot baths lessen the work of those organs,
and therefore give them a better chance of recovery.
At the same time, by increasing the blood suj^ply
of the skin, they throw more work upon the sweat-

126

PRACTICAL NURSING.

glands — i.e., they increase the flow of perspiration.
When the kidneys are inflamed the sweat-glands
reUeve them of a portion of their work, and remove
from the blood certain of those poisonous waste sub-
stances which in health should appear in the urine.

(6) Muscular Spasm. — When the blood supply of
a muscle is diminished, its functional activity is at the
same time depressed. Hence, if it has previously been
contracting so energetically as to cause pain, a hot
bath, by withdravdng blood from it, and so causing
it to become relaxed, will help to stop such painful
contractions. Thus is explained the beneficial effect
of a hot bath in those forms of (^lic which are caused
by contractions of the circular muscle in the wall of
the intestine. Infantile convulsions are relieved in a
similar way. "

(c) Insomnia, apart from such a cause as pain, is
due to a too persistent activity of the brain. It will
not stop working, and hence the individual to whom
it belongs is imable to sleep. A hot bath, by drawing
blood from the brain to the surface of the body,
lowers the activity of that organ, and conduces to
sleep.

(cZ) Pain. — Hot baths exert a soothing influence
upon the nervous system, and thus diminish pain.
They are useful in chronic painful affections of joints,
nerves, and muscles, and also in some forms of abdo-
minal pain.

Before giving any of these baths, a nurse should
get everything ready that she is likely to want, in-
cluding brandy and a hypodermic syringe.

1. Hot Bath. — The temperature of a hot bath may
vary from 100° to 110° F., or even higher. To begui

HOT BATHS AND PACKS.

127

^vith, it should not exceed 100°. After the patient
has been Hfted in, its temperature should be raised
very gradually, by the addition of hot water, to the
degree ordered. The hot water should be added very
slowly at the foot of the bath, and while this is being
done the nurse must move the water about with her
hand, so as to ensure its bemg thoroughly mixed ;
otherwise there is a certain amount of risk that the
patient may be scalded, since hot water, being lighter
than cold, rises to the top. The temperature of the
bath should always be tested by a thermometer, but
if, by chance, the nurse is unable to procure one, she
had better test the heat of the water with her elbow,
as that part is more sensitive than the hand. The
body should be entirely immersed, except in cases of
heart or lung disease, when the chest must be left
imcovered.

WJien used for the relief ofjjKan, it is best to give
the bath at the bedsIcTa^After remaining in for
about ten minutes, the patient is taken out, quickly
and Ughtly dried, and put to bed in a warm blanket.
An hour should elapse before the blanket is removed.

When the hot bath is given to iwomote sleep, the
patient is taken out at the end of five minutes,
thoroughly and quickly dried witlTa couplei~of warm
towels, and put comfortably to bed in a warm night-
dress.

If the case is one of kidney disease, the patient should
remain in the water from five to ten mmutes after the
thermometer has registered 1 1 0° F. He is then quickly
removed to his T)ed, and, without being dried, rolled
up in a hot blanket which has been previously laid
there. Another warm blanket is then wrapped closely

128

PRACTICAL NURSING.

round him, especially about the neck, hot bottles put
in the bed, and the bed-clothes replaced. If the
patient is a male, a small towel should be pinned
round the loins before he is put into the bath. When
he is ready for removal, a hot blanket is laid across
the top of the bath and the towel unpinned. As he
rises, or is hfted out, the blanket is wrapped round
him. The patient must be kept as warm as possible,
since the only object of the bath in kidney disease
is the production of profuse perspiration. The skin
must therefore be carefully guarded from the least
semblance of a chill. But Httle good can result from
the hot bath if the patient is dried, put into a cotton
night-gown, and placed between sheets. Perspiration
will then be very sHght. Cold water should be given
the patient to drink after removal from the bath, as
this encourages in a marked degree the secretion of
sweat. After remaining in the blankets for about
an hour, the patient is gradually uncovered, sponged
with tepid water, dried with warm towels, taken out
of the wet blankets, and put to bed. As this is a
very exhausting method of treatment, the patient
must be carefully watched for any sign of faintness
or prostration.

When the hath is given to produce muscular relax-
ation, the patients are generally children suffering
from convulsions or spasmodic crouja. If the latter,
they are often frightened by the sight of the steaming
water. It is therefore a good plan to place a towel
or blanket across the top of the bath, and lower the
child on it. In both cases the child should be im-
mersed to the neck, while cold water is squeezed out
of a sponge over the head. Hot water should be

HOT BATHS AND PACKS.

129

added to the bath very carefully, as a child's skin
is much more tender than an adult's, and will not
stand a higher temperature than 103° to 105° F.

During the time that a patient is in the hot bath, a
cloth rung out of cold water may advantageously be
kept on the forehead. At the same time the nurse
must carefully watch the patient, removing him at
once on the least indication of faintness.

Fiy. 2. — Allen's Hot-air Balh.

2. Hot-air Bath. — For giving this, Allen's appar-
atus, miims the boiler, is the most convenient.

A blanket is first placed beneath the patient and
his night-dress taken off. A small blanket folded
double is next laid over him, the bed-clothes are re-
moved, and two body-cradles of wickerwork arranged
so as to cover the whole body from the shoulders
down to the feet. The cradles are covered with a
blanket, that with a macintosh, and that again with

VOL. I. I

130

PEACTICAL NURSING.

a second blanket. The object of the macintosh is to
prevent the escape of hot air. A bath thermometer is
placed just within the cradles at the head of the bed,
and the blankets are then well tucked in, especially
about the neck and shoulders, the handle of the
bath thermometer, however, being left outside. Then
from the foot of the bed is drawn away the blanket
that was folded over the patient, and the spout of
the kettle placed just within the lowermost cradle.
If the kettle is placed upon the box from which it
has been taken, it will be raised to exactly the right
height for an ordinary hospital bed. It is as well
to wrap a piece of flannel bandage round the spout,
otherwise the blankets, which are to be tightly pinned
round it, may be scorched. The cradles, if of iron,
must be similarly protected. The kettle may be
heated either by spirit-lamps or by gas. A cloth
wrung out of iced water should be laid on the
patient's foreheadT'anBT&equently changed while the
bath lasts. At the same time, cold water should be
given him to sip, as this encourages the fl.ow of per-
spiration. Tliis form of bath lasts, as a rule, for
about half an hour, the temperatme, which should
be raised very gradually, ranging from 110° to 160° F.
The maximum both of time and temperature -will only
be endured after the patient has been subjected to this
form of treatment for some time. If the patient is
perspiring freely, or the heat of the bath is sufficient,
one or more of the lamps may be put out, or the gas,
if being used, may be partially turned olf. While in
the bath, the patient should never be left, but should
be most carefully watched. At the first sign of ex-
haustion or faintness, the lamps must be put out and
the cradles removed.

HOT BATHS AND PACKS.

131

When the bath is finished, the kettle and ther-
mometer are first removed. Then the small folded
blanket, which should be very warm, is put iinder the
cradles from the top, and pushed as far down as
possible. Then, going to the foot of the bed, the nurse
passes her hand beneath the cradles, and draws the
blanket down, so that it completely covers the patient.
This is to prevent any risk of burning the patient,
when the heated blankets fall on him as the cradles
are removed. With a dropsical patient and very hot
blankets this accident might otherwise happen. With
as little disturbance as possible the cradles and mac-
intosh are then withdrawn, and the bed - clothes
allowed to fall quietly upon the patient. These
coverings should be allowed to remain some time, the
blankets both below and over the patient, as they get
wet with perspiration, being from time to time re-
placed by warm dry ones. When the skin has ceased
to act, the patient should be sponged with tejoid
water, and a warm night-dress put on.

3. Vapour Bath. — A macintosh is placed beneath
the blanket upon which the patient lies, and Allen's
apparatus with the boiler, or an ordinary bronchitis-
or croup-kettle, used for producuig the steam ; other-
wise the arrangements are the same as for the hot-air
bath. Care must be taken that hot water does not
drip from the nozzle of the bronchitis-kettle on to the
patient. This is prevented by hanging a small tin on
to it, or by the use of absorbent wool. Allen's appar-
atus has a special shield for the steam to strike
against. This is hung on the outside of the lower-
most cradle. The same precautions must be used to
guard the patient against the least breath of cold air,
and also to anticipate the occurrence of fainting, that

132

PRACTICAL NURSING.

were mentioned in the description of the preceding
bath. A vapour bath, when given to an adult, usually
lasts about thirty minutes, the temperature ranging
from 105° to 120" F. This is natm-ally much lower
than that of the hot-air bath, since dry heat, as is
well known, can be borne of a much higher temper-
ature than moist heat. Wlaen the bath is finished,
the patient is treated in the same way as after a
hot-air bath.

Some medical men prefer to have their patients
wrapped in a blanket during a vapour bath. Under
these conditions the character of the bath is altered,
the skin not being exposed to the action of the vapour.
Unless Allen's apparatus is used, it woidd be safer to
treat yoimg children in this way.

Either a vapour or a hot-air bath can be given to a
patient sitting in a chair beside his bed. A chair
with a wooden bottom, the seat and back of which
should be covered with a blanket, is taken, and the
kettle arranged so that the spout projects beneath the
chair. It should be placed at one side of the chair, so
that the steam does not play on the patient's legs.
The patient, whose night-dress has been removed, is
then, from the chin downwards, closely enveloped in
blankets, which pass from the front of him rormd
to the back of the chair. They are carefully pinned
round the nozzle of the kettle, so as to exclude cold
air and prevent the escape of warm. The after-
treatment has been already described. If a hot-air
bath is to be given, the funnel and boiler are removed,
and the rest of the bath with the lighted lamp inside
placed underneath the chair.

4. Hot Wet Pack. — The patient is prepared in the

HOT BATHS AND PACKS.

133

same way as for a cold pack. The sheets in which he
is wrapped are wrung out of water at a temperature
of 110°. After they have been put on, two or three
hot blankets are rolled tightly round the patient,
especially about the neck, and the bed-clothes re-
placed. In a short time profuse perspiration ensues.
At the end of half an h^Hf ^ jvhich is the time usually
ordered, the patient is rapidly sponged with tepid
water, dried, and put into a warm bed. While doing
this, great care must be taken by the nurse in guard-
ing him against a chill.

5. Dpy Pack. — ISTo sheet is used in this form of
pack. The patient is closely wrapped up in__several
hot blankets, and left for as long as the physician
has" ordered. The dry pack is another very eificient
promoter of profuse perspiration. After the pack
the patient is sponged, dried, and put to bed.

This form of pack is always used when a hypoder-
mic injection of pilocarpine is given, a drug which
quickly causes copious sweating.

Before leaving the subject of hot baths it will be,
perhaps, as well briefly to enumerate the principal
points which a nurse should bear in mmd when giving
one of them : —

(a) The temperature of the bath must be gradually
raised, and constantly watched.

(b) The patient must be neither scalded nor biu-nt.

(cZ) The patient must be carefully guarded from
cold air, both during and after the bath.

(e) He must not be left alone while in the bath.

134

PRACTICAL NURSING.

Miscellaneous Baths.

Under this heading will be mentioned various baths
which are used in the treatment of disease, which
diiFer both in their mode of apphcation and object
from those previously described.

1. Continuous Bath. — This bath is used for ex-
tensive burns, certain forms of skin disease, and
large wounds with much sloughing and offensive
discharge. It acts by keeping the injured surface
constantly clean, thus putting it in the best possible
condition for repair. It is also now being used by
some physicians in the treatment of enteric fever.
The bath, which may last for some days, should be
kept as nearly as possible at about the normal body
temperature. If the patient complains of feeling
cold, it might be raised to 100° F., but should not
imder ordinary circumstances go above this point,
nor fall below 96° F. A water-cushion is placed
at the bottom of the bath for the patient to rest
on. A support for the head is made by arranging
some pieces of webbing or bandage across the upper
end of the bath, and on that laj^ing an air-cuslaion.
To retard the escape of heat, the bath should be
covered with a long macintosh sheet and a blanket.
It must be kept at an even temperature by the ab-
straction and addition of an equal quantity of water
at least every hour. Three times a-day, or more often
if necessary, the^atient must be lifted out, ^Tapped
in a warm blanket, and placed on lier bed that she
may use the bed-pan ; twice dm"ing that time the
water should be entirely changed. A thermometer
must be kept constantly in the bath. It should be

HOT BATHS AND PACKS.

135

susiJended from the side, so that it hangs in the
water.

The patient, particularly if a' child, should never be
left alone while in the bath.

2. Local Baths. — These are hot baths, acting upon
a limited area of the body.

(a) Ai-m and Leg Baths. — These are given in special
trough-shaped baths, and are generally used for foul
wounds. The bath should be half filled with water
at 100°, and, after adding to it the lotion which is
ordered, carefully arranged on the bed with sand-bags
or pillows, so that it is comfortable, and caimot easily
be overtm^ned. The arm, or leg, as the case may be,
is then laid in it, and the bath covered with a small
blanket to hinder cooling. The water shoidd be
changed every hour. If the limb is very painful, the
water can be siphoned off ; by doing this, all dis-
turbance of the patient will be avoided.

(6) Hip Bath, or sitz bath, as it is sometimes called.
It is most useful in cases where there is disease of the
pelvic organs. It acts upon them in the same way as
a poultice or fomentation does when applied to the
chest in cases of limg disease.

The bath must not be filled too full. The tem-
perature of the water ought to be about 105°. A
blanket should be arranged round the patient and
bath, so that the upper part of the former may not
be chilled, nor the temjoerature of the latter too
quickly lowered.

(c) Foot Bath. — This is sometimes used for sprains,
but more frequently in the hope of checking a com-
mencing catarrh. In such a case an ounce of jaustai'd-
is often added to the bath. The telmperature of the

136

PRACTICAL NURSING.

water should be about 110° F., and the feet be kept in
it for ten minutes.

3. Mustard Bath. — This is sometimes used m cases
of convulsions, spasmodic crouj), or measles when the
rash has not developed properly ; also for yoimg
children when collapsed after severe diarrhoea.

An ounce of mustard should be added for every.five
^galloiis of water. Some physicians prefer to have it
double this strength. The mustard may be put into
a muslin bag, from which it is squeezed out when put
into the water, or it may first be mixed with a httle
warm water and afterwards added to the bath : it
should never be sprinkled on the surface of the water.
As this form of bath is generally used for children,
the temperature, starting at 100°, should not rise
above 105° F. The nurse will suj^port the child in
the bath, and remove it when her own arms begin
to tingle.

4. Mercurial Vapour Bath. — To give this, a patient
must have a vapour bath when sitting upright in a
chair. A small dish containing the amount of calomel
prescribed is placed over a spirit-lamp imder the chair.
The calomel is converted by the heat of the lamp into
vapour, which is carried upwards by the steam, and
deposited upon the patient's body. When aU the
calomel has disappeared, the bath is stopped, a warm
flannel nightgown put on, and the patient placed in
bed. The calomel must not be wiped off, otherwise no
benefit would follow upon its use.

5. Sulphur Bath. — For every gallon of water
which is going to be put mto the bath, take a
quarter of an ounce of sulphuretoLpotassium. Dis-
sofveTIns amounTin two galTous of boilmg water.

HOT BATHS AND PACKS.

137

and add to the batli, the temperature of which
should rise froni 100° to 110° F.

6. Iodine Bath. — This is used to stimulate slow-
healiug ulcers, and may be given as a partial or local
bath. To every gallon of hot water one-sixth of an
ounce of tincture of iodine is added.

7. Bran Bath is prepared by boUing 4 lb. of^bran
in a gallon of water, straining, and adcTmg^he in-
fusioir~to~an~ordinary hot bath. While in the bath
the patient should not be rubbed. If it is neces-
sary to moisten the face, it should be dabbed with
a very wet sponge.

8. Alkaline Bath is prepared by adding 6 ounces of
carbonate of soda or potash to a hot bath. This bath
is usually given for ilieuinati.sm. The patient must be
very gently handled, and not hurried or chilled.

9. Electric Bath. — This is given as a stimulant
to the nervous and muscular systems. The patient
having been put into a hot bath, the two poles of
the battery are placed in the water. The current
should be mild at first, and then gradually increased
in strength. The bath should last for about fifteen
minutes.

10. Brine Bath is prepared by adding about 6 lb.
of common salt to an ordinary hot bath. It acts"as^
sliglfT^timulant to the sldn.

11. Starch Bath. — Dissolve 2 lb. of starch in cold
water. Add enough boilmg water to form a thick
mucilage. This will be sufficient for a long bath half
full of water.

12. Acid Bath. — Add 1 ounce of strong hydro-
chloric acid to every 10 gallons of water.

138

CHAPTER X.

HOT AND COLD APPLICATIONS.

One of the commonest of a nurse's duties is tlie appli-
cation to an inflamed or painful part of a fomentation
or an evaporating lotion. Both of these remedies have
for their object the hastening of repau* in the inflamed
part, as well as the rehef of pain. A clear under-
standing of their method of action will not only render
their use more interesting, but will prevent the mis-
take nm^ses occasionally fall into of supposing that, if
in a particular case a hot application does good, it
necessarily follows that a cold one will do harm.

Inflammation. — "When from any cause a part of
the body becomes inflamed, the following changes
successively take place in its tissues : —

To begin with, the blood-vessels dilate and become
more and more full of blood-cells, the current at the
same time getting slower and slower, until at last
it ceases altogether. There is now a complete block
in the over-distended vessels, which are closely packed
with red and white blood -cells. This accumulation
of cells is due to the fact that the vessel -wall has
been damaged by the irritant which is causing inflam-

HOT AND COLD APPLICATIONS. 139

mation, hence the blood-corpuscles have a tendency to
stick to it and so block the way.

Following upon this, the contents of the smallest,
and therefore most thin-walled, vessels begin to escape
into the surrounding tissues, so that the part becomes
swollen. It is also tender, because the blood -cells
(which are almost all white corpuscles) and fluid
that have escaped from the vessels are pressing upon
the deHcate nerve filaments of the part, and so are
giving rise to sensations of pain.

After a time, if the cause of the inflammation be
not too severe and have ceased to act, the contents
of the vessels begin to move onward, the ceUs which
have produced the block detaching themselves one by
one and passing away, until at last the current of
blood rrms through the vessel as freely as it did
before inflammation commenced. At the same time
the ceUs and fluid which are in the tissues outside
the vessels are carried away by the veins and lym-
phatics, and the parts which they had invaded resume
their normal condition.

If, however, the irritant be suificiently intense, or
long continued in its action, the block in the vessels
continues, more and more of the white cells escaping,
until at last an abscess is formed.

To recapitulate. When any part of the body be-
comes inflamed, the following changes successively
occur in its blood-vessels : —

(a) They become more full of blood. This is the
stage of "congestion."

(6) They become blocked with blood-colls, so that
the current ceases to run. This is the stage of
"stasis" or standstill.

140

PRACTICAL NURSING.

This inflammatory process may terminate in one
of two ways —

(a) Resolution. The block in the vessels is re-
moved, the cells in the tissues pass away, and the
inflammation is at an end.

(&) Suppuration. Inflammation persists, until at
length pus is formed.

Treatment of Inflammation by Heat and Cold.
— Heat, when applied to the skin, causes redness,
because it dilates the vessels, and so increases the
quantity of blood in the part. Cold produces the
opposite efliect, causing the skin to become white by
contracting the vessels, and so diminishmg the blood
supply.

For the purpose of treatment, the process of
inflammation may be roughly divided into three
stages.

In the earliest stage, viz., that of congestion, om^
object is, if possible, to avert the inflammatory process
— i.e., to prevent the escape of cells and fluid from
the blood-vessels. This we are more likely to accom-
plish by means of cold than heat, owing to the efifect
which the former has in diminishing the blood supjDly
of a part. Hence, the usefulness of iced compresses
and evaporating lotions in the early treatment of
a sprain.

In the next stage inflammation has become estab-
lished. Our object now is to brmg it to an end
as quickly as we can ; and, if possible, to prevent
the onset of suiDpurati#n. This is the stage in which
either hot or cold apphcations may be used. For

HOT AND COLD APPLICATIONS.

141

while the latter diminish the blood supply, and with
it the amount of fluid and cells which are escaping
from the vessels, the former, by dilating the vessels,
bring more blood to the part, which may possibly
clear the way, by washing on the cells which are
blocking the vessels.

In the last stage suppuration is inevitable, and here
hot moist applications are the only treatment that is
admissible ; for they relieve pain, hasten the forma-
tion of pus, and render its passage to the surface
easier.

The Reflex Action of Heat and Cold on the
Internal Organs. — -It is not difficult to understand
the effect of hot and cold appKcations upon the super-
ficial structures — i.e., the parts lying immediately be-
neath the skin. It is less easy to explain the action
of these agents upon the internal organs. A fomen-
tation applied to the abdomen will relieve the pain
of intestinal colic ; while an ice-bag will check diar-
rhoea, and a linseed poultice on the chest will remove
the unpleasant sensation of tightness and stuffiness
which is associated with the commencement of acute
bronchitis. It is impossible to suppose that the cold
of an ice-bag, or the heat of a poultice, extends from
the skin through the chest or abdominal wall to the
organs beneath. That is quite out of the question.
In such cases heat and cold transmit their influence
in a roundabout way by means of the central nervous
.system. When, for instance, an ice - bag is placed
upon the cliest or abdomen, an impulse passes along
the nerves rimning from the skin to the spinal mar-
row. From the spinal marrow tlio impulse returns
along the nerves wliich run to the arteries supplymg

142

PRACTICAL NURSING.

the organ above which the ice-bag is placed. As a
result, those arteries contract, so that a smaller quan-
tity of blood passes through the organ than did before
the ice-bag was applied. In this case the ice-bag is
said to have produced a "reflex" or indii^ect contrac-
tion of the internal vessels, since its influence passed
to them indirectly through the central nervous system.
At the same time it would be causing a dn-ect con-
traction of the vessels in the skin upon which it was
lying. In the same way, a key apphed to the nape
of the neck will often check bleeding from the nose,
by causing a reflex contraction of the blood-vessels in
the interior of that organ.

Hot Applications.

When applying heat of any kind, a nurse must
take particular care in the case of patients who are
completely or partially unconscious, or are suffering
great pain, or have dropsy, or are paralysed in any
way, or subject to fits. Any of these conditions may
lessen the patient's sense of external discomfort ; and
an exhausting and slow-healing wound may be jDro-
duced by the incautious application of too great heat.

Hot a]3plications may be either moist or dry. The
former are the more efficacious, their influence pene-
trating farther and lasting longer; while the latter
can~be borne at a higher temperature.

1. Poultices are of various kinds, and may be made
of almost any sort of meal that will retain heat and
moisture.

(a) Limeed Poultice. — Crushed linseed is most com-
monly used for a poultice. The oil which it contains

HOT AND COLD APPLICATIONS. 143

is useful both as an emollient and as a retainer of
lieat. To make the poultice, a nurse requires a povl-
tice-boarcl, a suitable bowl, a strapping-can, a spatula
or a long, fiat, pliable knife, together with the tow or
Hnen on which the poultice is to be spread. If tow
is used, it should be pulled out so as to lie flat and
even.

Half fill the basin with boiling water, then fill the
strapping-can and put the spatula in it. When the
basin is quite hot, empty it, and putting in a sufficient
quantity of water, add the linseed quicldy, sprinkling
it with one hand while stirring with the spatula.
When it is sufficiently firm and free from lumps,
and comes clean away from the edge of the dish,
turn it out on the linen or tow, and spread evenly
and quickly with the spatula, dipping the latter in
the strapping - tin between each stroke. The layer
of linseed-meal shotdd be a quarter of an inch deep,
and it should be spread to within 1 inch of the edge
of the Hnen or tow, when the former should be folded
and the latter rolled in all round. It should be car-
ried to the patient doubled on itself, and rolled in
hot wool or between two hot plates. Care should
be taken that it is not apphed too hot. To assm-e
herself that it is of the right temperature, the nurse
should apply the back of her hand to it. If any of
the linseed adheres to her hand, the poultice has been
badly made, and should be discarded. When the
poultice has been placed in position, it is covered
with a thick layer of cotton wool, extending an inch
beyond it in every direction, and secured by a band-
age. When changing a poultice, the nurse should
undo the bandage, but not remove the old poultice

144

PRACTICAL NURSING.

till the hot one is ready to replace it. At least once
in twenty-four hours the part should be washed. A
linseed poultice is usually changed every four hours.
Sometimes a piece of muslin is laid over it, or the
surface is rubbed with warm olive-oil, to prevent it
adliering to the skin. If the poultice has been well
made, neither of these precautions is necessary.

When poultices are used to relieve internal pain in
any part, and when lightness is not essential, they
may be applied in a flannel bag, m shape like an old-
fashioned postman's bag.

The boiled Hnseed or oatmeal, which may here be
used, is put into the bag with a spoon, pressed out
flat, covered with wool, and secured in position with a
bandage, the flap of the bag being fastened down by
a few stitches. The advantage of this poultice is that
it may be applied hotter, and retains its heat longer,
than one made on tow or linen. The ntirse should see
that she is supplied with at least three bags, as they
must be washed and dried before being used again.

Linseed poultices are sometimes applied to wounds
to promote the separation of sloughs. The boiling
water in such cases usually contains an antisej)tic
such as carboHc acid or chlorinated soda.

A jacket poultice should be made on linen, and in two
halves, one for the front, the other for the back of the
chest. After being covered with wool, it is secui'ed in
place by a many-tailed bandage with shoulder-straps.
The linseed should never be more than a quarter of an
inch thick, otherwise its weight increases the already
existing difficulty of respiration.

(b) Charcoal Poultice. — This is sometimes used for
offensive sloughy wounds, charcoal being an excellent

HOT AND COLD APPLICATIONS. 145

deodorant. It is, however, a dirty apj)lication, and
has now been almost superseded by hot wet antiseptic
dressings. One part of charcoal is mixed with four
of hnseed-meal or bread crumbs, and sufficient boiUng
water added to make it of the right consistency.
The wound needs careful cleansing each time the
poidtice is changed.

(c) Bread Poultice. — This is not very often used, as
it does not retain the heat for any length of time. A
sufficient quantity of stale bread-crumbs is mixed
with boiling water, and allowed to stand for ten
minutes in a vessel which is placed in boiling water.
It is then well stirred up with a fork, the water
poured ofF, and more boiling water added. This is
left for about a minute and then drained ofiF, the
poultice being now spread and applied. It should be
changed very frequently, as it quickly cools and cakes.
To prevent the bread-crumbs adhering to the skin, the
latter should be rubbed with some simple ointment, or
warm oil spread over tloB jaouTtice.

(df'~StarcR Poultice. — This is sometimes used in
irritable affections of the skin, as it forms a very
bland and soothing apphcation. A little cold water
is first added, and then sufficient boihng water to
make it into a thick paste. It should be spread on
muslin or soft linen, and applied like a hnseed
poultice,

(e) Yeaat Poultice is sometimes used as a gentle
stimulant to a slow-healing ulcer. Three ounces of
yeast are mixed with half a pound of linseed-meal or
wheaten flour, three ounces of water at 100° F. are
added, and the poultice put into a mushn bag large
enough to permit the dough to rise. It is now placed

VOL. L K

146

PRACTICAL NURSING.

near a fii'e, and when the dough has risen appUed to
the wound.

(/) Mustard Poultice. — This is a very conunon and
most useful form of poidtice. The proportion of mus-
tard to linseed varies with the age of the patient and
the object of the poultice. If it is being used for the
reUef of pain in an adult, equal parts of mustard and
linseed may be used, the application being removed
at the end of fifteen or twenty minutes. If the poul-
tice is being applied to the chest for bronchitis, one
part of mustard to two of Imseed should be used for
an adult, and one to five for a child. The mustard
is made into a paste with lukewarm water, and the
Hnseed mto a poultice with boiling water ; the two
are then thoroughly mixed and at once apjDlied.

When equal parts of mustard and hnseed are used,
which should be done if no directions as to strength
are given, the sm-face of the poultice should be covered
with fine muslin. This poultice is intended to redden
the skin, not to bhster it, and the niu-se must be very
careful that the latter elFect is not produced. After
removing it, the part should be dried, and the skin
carefully examined to see that no particles of mustard
are adhering to it. It is then dusted with powder and
covered with cotton wool, or a jalain linseed poultice
applied, according as the niu-se has been directed.
This should be done quickly and thoroughly, as ex-
posure to the air intensifies the irritating and stinging
eiTect of the mustai-d.

The efficacy of a poultice as a means of applying
moist heat to any part of the body dei^ends upon the
nurse, who should see that it is made of water that is
quite boihng, and that the tow or linen, basin, and

HOT AND COLD APPLICATIONS. 147

spatula are properly warmed. It is only by taldng
these precautions that a poultice can be applied at a
suitable heat. When a poultice is finally omitted, the
part should be covered for two or three days with a
thin layer of cotton wool.

2. Fomentations or Stupes.— This is the cleanest
and most convenient form of locally applying moist
heat. If used for the relief of urgent pain, a fomenta-
tion should be changed every twenty minutes. They
are frequently left on for two hours at a time, but
unless they are very carefully covered in by wool and
bandaged closely to the skin, they become chilly and
uncomfortable long before that period has elapsed.
The best material for a stupe is soft old flannel,
though hnt and absorbent wool are often used. Two
thicknesses of the material, if it be flannel or lint,
are required. A stupe-wringer is advisable, though
a towel is sometimes used instead. The wringer is
made of ticking or stout towelling, 18 inches long
and 10 wide, with a broad hem at each end, through
which is passed a stout piece of wood the shape of a
ruler. The wringer is laid in a warmed basin, and
the two thicknesses of flannel or lint spread out on it.
Boiling water is then poured over it, after which, by
twisting the two pieces of wood in opposite directions,
the fomentation is wrung out quite dry. If any super-
fluous moisture is left in it, it cannot be borne so hot
by the patient, and is more likely to scald him. The
fomentation is carried to the bedside in the wringer.
It is there taken out, shaken to admit air between its
folds, and put on as hot as the patient can bear. It is
then covered over with another piece of flannel or
jaconet, which must be an inch longer in every

148

PRACTICAL NURSING.

direction than the fomentation. Over this a thick
layer of wool is placed, and the whole bandaged
firmly in position. The wool is used to keep the
heat in the fomentation, not to prevent the escape
of fluid, since this in a properly made fomentation
practically does not exist.

Turpentine Fomentation. — This is prepared as fol-
lows : After pouring the boihng water over the
flannel and wringer, add 2 ounces of turpentiue ; this
will float on the surface of the water. Lift the
wringer out as straight as possible, so that the tur-
pentine may be spread evenly over the surface of the
fomentation, and wring quite dry. A more even dis-
tribution of the turpentine is possible by this method
than by sprinlding the drug on the fomentation after
the latter has been wrung out. This fomentation is
not, as a rule, repeated, but is followed by a simple
stupe or warm cotton wool. After removing it, the
nurse should look carefully for any spot that is especi-
ally red, or is blistered, and should cover such spots
with small pieces of hnt spread with simple or other
ointment ; or, if the skin is very red, dust it with zinc
and starch powder.

Opium and belladonna are sometimes applied on
stupes, half a teaspoonful of the tinctm^e being
sprinkled on the flannel after it has been wrung
out. As some people are peculiarly susceptible to
the influence of belladonna, the nurse should carefully
note and report any dilatation of the pui^ils or com-
plaint of dryness of the throat, both of which symptoms
point to a shght degree of belladonna-poisoning.

Spongiopiline is a thick, felt-like, absorbent material,
one side of which is covered with waterproof to pre-

HOT AND COLD APPLICATIONS.

149

veut evaporation. It may be used in the applioatiou
ot" auy of the fomentations mentioned. It is some-
what difficult to wring sufficiently dry, and is also
expensive, so that it must not be rejected after being
once used.

Hot Sponges may be used to foment the face or
throat. They should be wrung dry, apphed as hot
as possible, and changed continually. Such a fomen-
tation can only be used for a short time.

The nurse must exert some ingenuity in cutting the
fomentation, so that it may accurately fit the part to
which it is to be apphed. In fomenting the breast,
the flannel should be roimd, with a hole in the centre
for the nipple, and slit out one side so as to fit com-
fortably without rucking. When a Hmb is to be fo-
mented, it should be done in sections, as it would be
difficult to apply one large piece of flannel sirfficiently
hot.

3. Hot dry Applications —

(a) Hot Bottles may be made of tin, earthenware,
or indiarubber. For the feet either of the first two
materials would do ; when the bottle is to be appHed
to any other part of the body, an indiarubber bag is
more comfortable and efficacious. A hot bottle should
always be entirely encased in a thick flannel bag,
which must have no holes in it. Care must be taken
that the bottle does not leak, and that, when it is put
into the bed, it does not rest against the patient.
Nothing reflects greater discredit on a nm^se, or is
more annoying to her, than to have to report a burn
produced by a hot bottle. Particular care should be
taken in the case of children, and patients who are
unconscious. These should be kept under frequent

150

PRACTICAL NURSING.

observation by the nurse. The bottles should be
changed at frequent intervals, and, if possible, with-
out disturbing the patient.

A hot brick wrapped in flannel is sometimes used
instead of a bottle.

(b) Hot Wool or flannel is often used for inflamed
joints, or for abdominal discomfort or pain. A thick
piece of brown cotton wool or flannel is toasted in
front of the fire, or heated in the oven between two
plates. It must be changed frequently, and, if
the patient is restless, lightly secured in place by a
bandage.

(c) Hot-bran Bag. — Two soft muslin bags are half
filled with bran. One is put in the oven between two
plates, and, when sufliciently warm, applied, being
afterwards covered with hot wool. The second is got
ready against the time that the first is removed. Bran
bags are Hght and comfortable when heat is required
for a limited period ; but, as they do not long remain
warm, they become troublesome.

Salt- or hop-bags are made and heated in the same
way.

(d) Pneumonia Jacket is used for children with
bronchitis or broncho - pneumonia, when a Hnseed
poultice is unnecessary, and it is merely desired to
keep the chest warm ; or it may be used after a poul-
tice has been taken ofi'. It is cut out in soft muslin,
or Hnen, which is double, and between the two layers
is laid a single sheet of brown wool. The edges are
lightly quilted and tacked down. The back and front
are fastened together down one side and across one
shoulder, the other side and shoulder being secured by
tapes.

HOT AND COLD APPLICATIONS.

151

Cold Applications

Are most useful during the early stages of an inflam-
mation, since tliey tend to check the process by then-
contracting influence upon the blood-vessels, and
consequent diminution in the escape of then" contents.
Great care, however, is necessary to see that they are
cold ; and that an iced compress does not, by neglect
on the part of the nurse, become converted into a
lukewarm fomentation. When this happens, more
harm than good has been done by the use of cold ; for
during the reaction which necessarily follows, there is
a great increase in the quantity of blood flowing to
the part, and as a result a further advance in the pro-
cess of inflammation.

1. Ice-bag's are made of various shapes and bizes
to suit the part to which they are to be applied.
The most useful is the cap -shaped ice-bag. This
should be half filled
with small pieces of
ice, with which may
be mixed a Uttle com-
mon salt to intensify
the cold ; or sawdust
may be added, since
this, by soaking up
the water, makes the

ice last longer. Care should be taken to see that
the plug which closes the opening fits accurately,
or water may escape from it into the bed. A
single fold of lint should always be placed be-
tween the patient's skin and the ice-bag. The bag
must be refilled before all the ice is melted, otlier-

^k- Ice-bag.

152

PRACTICAL NUHSING.

wise it merely becomes a receptacle for lukewarm
water.

2. Ice Poultice. — This may be made in the following
way : Take a double thickness of gutta-jDercha tissue a
little larger than the area to be covered. SiDriukle on
the lower leaf of the tissue a thin layer of linseed-meal,
and upon it place ice, crushed small, to the depth of
half an inch. Sj)rinlde the ice with common salt, and
on the top of it add another layer of linseed-meal.
Ttirn the upper leaf over the lower, and then seal
the edges with chloroform or turpentine. Put the
poultice into a flannel bag, and place imder it a fold
of lint.

3. Iced Compress.— Three thicknesses of lint are
cut to a suitable size and shape, and squeezed out of
the iced lotion between two flat wooden discs connected
by a hinge, or they may be wrung dry in the same
way as a fomentation. This is done to avoid the
heat of the hand. If a bandage is required to keep
them in position, as when the eye is being treated, a
single turn is all that is required. A block of ice
should stand in a bowl beside the bed, with another
compress ready to replace the one in use. They
shoiild be frequently changed, and require um^emitting
attention to be effective.

4. Evaporating" Lotions. — A single fold of lint is
used, and the part to which it is applied left exposed,
so that evaporation may be accelerated. To put
on jaconet and a bandage is a great blunder, since
the apphcation straightway becomes converted into a
fomentation, producing exactly the opposite efiect
to that which was intended. Fi"equent changing is
necessary to ensvu'e that the lint remains moist, or if

HOT AND COLD APPLICATIONS.

153

it is on a part like the knee, it is better to drop lotion
on the lint. To keep the bed clean, a draw-sheet and
a macintosh should be placed under the part that is
being treated.

5. Leiter's Tubing- is soft metal tubing, the coils of
which are arranged in the shape of a cap, so that it
can be easily applied to the head, that being the part
of the body for which it is generally used. From the
upper end of it a rubber tube leads into a can of iced
water. From the other end similar tubing runs to a
receptacle on the floor. By means of a clip on the

Fig. 4. — Leiter's Tubing.

upper piece of rubber tubing, the speed A'vith which
the water passes through the coil can be exactly regu-
lated. To start the water runnmg, the nurse holds
the upper end of the topmost piece of rubber tubing
firmly in her left hand, while she passes the thumb
and first finger of her right hand down the whole
length of it, squeezing it firmly as she does so. This
will expel the air, so that when the left hand relaxes
its hold water will rush into the tube, and the right
hand now releasing the lower end, the apparatus be-
gins to work.

154

CHAPTER XL

C0UNTER-IRRITA2JTS —SYRINGING THE THROAT,
NOSE, AND EAUS.

Counter-irritants are local applications used for the
relief of pain or the checking of inflammation. By-
drawing blood to that part of the skin to which they
are apphed, they diminish the supply to the deeper
structures, such as the muscles and the internal organs
which lie beneath their pomt of application. Tliis
latter effect is probably produced by reflex action, as
was explained in the previous chapter, when the influ-
ence of heat and cold on the various parts of the body
was discussed. The action of the difierent members
of this group varies in intensity from a mere blush up
to actual inflammation, as evidenced by the presence
on the slvin of vesicles or even pustides.

1. Mustard Plaster is much stronger than a
mustard poultice. To two parts of fresh mustard
add one of flour, and make into a paste with tepid
water. Spread evenly on a piece of linen cut to a
suitable shape and size, and cover with a single
layer of washed muslin and apply. It should be left
long enough (about twenty minutes) to thoroughly

COUNTEK-IREITANTS.

155

reddeu, but never to blister, the skin. If necessary,
it may be secured in place with a bandage. Less
mustard and more flour may be used ; this would be
advisable in the case of a child. If the patient is
unconscious, or in great pain, the nurse must carefully
watch the efi'ect of the plaster, or a troublesome sore
may result. After the plaster has been taken ofi',
the niu"se should carefully wipe the sldn, to remove
any particles of mustard that may be adhering to it,
dust with starch powder, and cover with wool and a
bandage.

2. Mustard Leaves may be used instead of the
plaster. They are more convenient, being always pre-
pared and ready to hand at any chemist's ; but they
are somewhat uncertain in their action, and are Hable
to produce such an extreme degree of discomfort as to
necessitate their removal before any good efifect has
had time to follow their application. The part should
first be washed, the mustard leaf moistened in warm
water, and kept in place by wool and a bandage. In
the case of children, or people with sensitive skins, the
surface of the leaf should be covered with a layer of
washed muslin, to diminish the irritation. For such
patients a moderately weak mustard plaster is prefer-
able. When the mustard leaf is removed, the part
should be dusted with starch or other powder, and
covered with wool.

3. Iodine. — Before applying tinctiu-e of iodine, the
part should be well washed with soap and water. The
iodine is then painted on with a camel's hair brush.
After the first coat has dialed, a second should be ap-
plied. In the case of children one is enough. Lini-
ment of iodine, which is four times as strong as the

156

PRACTICAL NURSING.

tincture, is sometimes ordered, either alone or diluted
with the latter preparation.

4. Liniments are very mild counter-irritants which
are rubbed in by hand after the part has been washed.
Rubbing should be continued until the part is fairly
dry and the skin red and glowing. More rarely, a
piece of lint is soaked in the liniment and bandaged
on the part. In such a case the nurse must take
care that the effect is not more severe than is
required.

5. Blister. — This is a much more severe form of
counter-irritation, since actual inflammation in the
shape of a blister is set up. Cantharides, the Spanish
blistering fly, is the agent used. It may be appHed as
a plaster or painted on the part.

When the plaster is used, the part should be well
washed with soap and water, and sponged with ether
to remove grease from the skin. The jalaster ha^ing
been cut to the size and shape required, is moistened
with warm water, placed in position, covered with
wool, and secured with a bandage. This is fastened
loosely, so that there may be no pressure on the bleb
when it rises. For children a layer of fine washed
muslin should be placed between the plaster and skin,
to lessen the severity of its action.

When bhstering fluid is used, the part to be painted
should be outlined with oil, to keep the counter-irritant
within bounds. Two or three coats are then painted
on, each one drying before the next is applied, and the
part covered with wool and a loose bandage.

The plaster should be left on for about ten hours,
or in the case of a child half that time. It is then
very carefully removed, and, if vesication is slight

COUNTER-IRRITANTS.

157

or absent, a poultice or fomentation applied. The
bleb which has been produced is snipped at its
lowest point with a pair of sharp clean scissors, and
the fluid gently pressed out with absorbent wool. It
is then dusted with powder and some cotton wool
bandaged on it. Sometimes the fluid is allowed to be
reabsorbed, the bleb being left unopened and merely
protected with wool and a bandage. A nurse should
always obtain clear instructions from the medical
attendant as to the size of the bHster, and the exact
locality where he wishes it applied.

6. Croton-oil is a very powerful counter-irritant
wliich is but rarely used. A few drops are placed on
flannel and rubbed in. It produces a pustular rush,
which generally leads to permanent scarring of the
skin at that part.

7. The Actual Cautery. — The instrument usually
employed is that invented by a French surgeon
named Paquelin. As a counter-irritant it may be
used —

(a) For the relief of pain, in which case the heated
point is not brought into contact with the skin, but is
moved to and fro in close proximity to it, so as to
produce a reddening of the surface.

(6) For the treatment of chronic joint inflammation.
— Here the point of the instrument, being hept at a
dull red, is Ughtly drawn across the part to be treated,
so as to produce a superficial burn, which is dressed in
the ordinary way.

8. Leeches. — Nowadays leeches are not often used
merely for the purjaose of bloodletting, that being much
more easily and expeditiously accomplished by means
of the knife. The relief of pain and the cliecking of

158

PRACTICAL NURSING.

inflammation are the proper uses for leeches — i.e., they
are to be regarded rather as coxmter-irritants. Each
leech withdraws from one to three drachms of blood.
The smaller, pomted, end is the head of the anunal.

Before applying a leech, the part should be washed,
the soap being carefully removed with clean warm
water. The skin is afterwards thoroughly dried and
well rubbed with a towel, so that the blood may be
brought to the surface. It is of great importance
that the leech should be handled as little as possible,
otherwise it will take much longer to bite. It should
be allowed to crawl out of the box on to a clean folded
towel, and from thence be directed on to the skin,
care being taken not to apply it over any large vessel.
If the leech refuses to bite, placing a drop of milk
on the skin, or scratching the skin so as to draw
blood, will often prove efficacious. If it seems to be
working sluggishly, it may be stimulated by geutly
stroking its back with a piece of lint.

When a leech is ordered to be applied in the
neighbourhood of the eye, it is placed in a test-tube
half full of cotton wool, which should be held over
it until it has commenced to suck, and then gently
shpped away. This same method of apphcation
would be used, if it were desired that the leech should
attach itself to one particular spot. When applied to
the interior of the nose, mouth, or vagina, a tliread
should be passed through the tail by means of a
needle. This controls its movements, and does not
interfere with its worldng.

A leech will continue sucking for about three-
quarters of an hour. It should be allowed to suck for
as long as it likes, and never be forcibly removed,

COUNTER-IRR ITANTS.

159

otherwise its teeth may be left in the skin, when a
troublesome and slow-healing wound is produced. A
pinch of salt on the head will always make a leech
relax its hold. If bleeding is to be encouraged, a
fomentation should be applied to the bites, otherwise
a pad of absorbent wool should be bandaged on the
part. The patient should not be left for any length
of time imtil the bleeding has ceased, as occasionally
this is very troublesome, needing the use of styptics or
even a red-hot needle to arrest it.

After removal, a leech should be destroyed, as it
will be a long time before it is fit for work again.
If it is desired to keep it, it should be placed in a
plate of salt to make it vomit the blood it has taken,
and afterwards put into a jar of water with sand
or fine gravel at the bottom, and a perforated lid, the
water being changed daily at first, and subsequently
once a-week. A leech -bite always leaves a small
triangular scar.

9. Cupping" may be performed in two ways — viz.,
the dry and the wet. Both operations have for their
object the drawing of blood from the deeper parts to
the skin ; but while the dry method leaves the blood
in the skin, the wet allows it to escape into a cup
by means of small incisions.

(a) For dry cvipping five or six cujoping-glasses, or,
failing them, an eqiial nvmaber of port-wine-glasses
are necessary, some methylated spmt, and a box of
matches. A little spirit is poured into a cup, which
is moved about so that the fluid is spread evenly over
its surface ; the excess is allowed to escape by turning
the cup completely over. A small piece of paper is
lighted and dropped into the cup ; the spirit flares

160

PRACTICAL NURSING.

up and the cup is at once applied, the flame being
immediately extinguished. The heated air in the
cup, as it cools, contracts and draws upon the skin,
which is sucked up into the cup so as to make a dis-
tinct swelling. If the alcohol is allowed to burn out
before the cup is applied, the edges of the latter may-
become so hot as to inflict pain upon the patient.
The cups are generally left on for about three or fovir
minutes, and should always be taken ofi' before any-
thing like bruising has been produced. When re-
moving them, the nurse should press the skin down
at the edge of the cup with the tip of her tinger,
so as to let air enter the cup, when it will easily
come off.

(b) In wet cupping several small incisions are made
in the skin with a scalpel, or a special instrimient
called a scarificator, before the cup is appHed. This
is then done in exactly the same Avay as for dry
cuppmg. Blood is sucked out of the small cuts into
the glass. After the operation is over, an ordinary
dry dressing is apphed, or the surgeon may order
a fomentation to keep up the effect of the counter-
irritation. This is also sometimes used after dry
cupping. This method of treatment is most com-
monly used in inflammation of the kidneys, the cups
being applied to the loins.

Ointments may be applied either spread with a
spatula on the smooth side of a piece of lint, or they
may be rubbed in by hand — that is to say, by in-
imction. This latter process is especially used ia the
treatment of scabies and of syphilis. Before rubbing
in an ointment the part should be washed with soap
and hot water, the ointment is then well rubbed in

SYRINGING THE THROAT.

161

with the pahn of the hand, and a layer of flannel
afterwards applied. Mercurial ointments should never
be rubbed into the same part on two successive days.
The inner side of the thigh and the armpit are parts
that are generally used for this purpose. A nurse
should always be on the look-out for any symptoms
of mercurial poisoning, either in the patient or herself,
for she must naturally, during the process of rubbing
it in, absorb a certain amount of the drug. To
avoid this risk, the patient may be taught to rub
in the ointment for himself, or the nurse may do so
with a piece of lint. The usual symptoms of mer-
curial poisoning are tenderness on biting, a feeling
of soreness about the gums, together with an excessive
flow of saHva. Their appearance in the case of the
patient is an indication for omitting any further in-
imction until the medical attendant's wishes are
known. If the nurse herself is the sufferer, she
should give up rubbing in the ointment and ask
somebody else to do it.

Lotions. — It has already been pointed out that
evaporating lotions must be applied on a single thick-
ness of lint, wliich is to be left uncovered. Lotions,
other than evaporating, are used by soaking a double
thickness of lint in them, squeezing out the excess
of moisture, but by no means wruiging them dry,
and, after placing the lint in position, coveruig it
with a piece of jaconet or oiled silk to prevent
evaporation, and lightly bandaging it on.

Syring-ing" the Throat. — This is very necessary in
severe cases of scarlet fever and diphtheria, where the
pharynx becomes full of thick muco-pus. Removing
this makes both breathing and swallowing easier for

VOL. I. L

162

PRACTICAL NURSING.

the child, while at the same time it tends to promote
healing of the inflamed fauces.

The best form of syringe to use is the 4-ounce india-
rubber ball syringe. The nozzle should be only 1^
inch long. If a long 3-inch nozzle is used, there is
more risk of damaging the back of a child's throat
with it, should the patient be restless. With the
short nozzle this is almost impossible. It is as well
to use two syringes, so that one may be filling itself
in the porringer of lotion while the other is being
used.

If it is hkely to struggle, a sheet is wrapped closely
round the child, so that it cannot move its arms. It
is then sat up in bed. The nurse seats herself on its
right hand, and, placing her left arm round its neck,
keeps its head firmly pressed against her left side, while
at the same time she bends it forward over the basin in
front of her. She then takes one of the full syringes
from the porringer of lotion, passes the nozzle between
the child's hack teeth into the mouth, and forcibly
compresses the ball. Having given the chUd time to
regain its breath, she empties the syrmge, and re-
places it in the porringer to fill again. She must be
careful not to inject the lotion while the child is
drawing in its breath, otherwise it may suck some of
the fluid into its larynx. By passing the nozzle be-
tween or behind the back teeth, there is less risk of
the tongue intercepting the lotion on its way to the
inflamed throat ; by bending the child's head over the
basin, the chance of fluid getting into the air passages
is very considerablj'' diminished.

Syringing" the Nose. — This is usually done when
the throat has been finished, a weaker lotion and

SYRINGING THE NOSE.

163

the same syringe being used. A nurse should al-
ways be very gentle when syringing out a child's
nose, as it is by no means pleasant ; nor, if force is
used, is it devoid of risk. For at the back of the
nasal cavities on each side is the opening of the
Eustachian tube, which leads into the middle ear.
If the nose is forcibly syringed out, some of the dis-
charge may be cMven up these tubes into the ears,
and there set up inflammation. There is no doubt
that some cases of ear discharge originate in this
way. A nurse ought never to attempt to force
lotion into the nose when it is blocked by inflamma-
tory swelling. She should place the nozzle of the
syringe just outside the nostril, and gently play on
the opening with a stream of lotion. No patient
who is seriously ill ought to be made to sit up for the
purpose of having his throat or nose syringed, if he is
sensible enough to submit to the operation without
struggling. It can be done equally easily in the
recumbent posture, the head bemg brought to the
edge of the pillow, so that the mouth hangs down
over the basin.

Nasal Douche. — This is another method of cleans-
ing the nasal cavities. It is preferable to syringing,
inasmuch as there is no risk of undue force being used ;
at the same time, it means more apparatus, which is
undoubtedly a drawback. Above the level of the
patient's head is placed a glass vessel containing the
warm lotion. In it is placed the weighted end of a
piece of fine drainage tubing about 4 feet long. To
the other end of the tubing is attached a small glass
or bone nozzle. If there are two nurses, nothing in
the way of special apparatus is needed, since one of

164

PRACTICAL NURSING.

them can hold a porringer of lotion, with the upper
end of the drainage tube in it, above the patient's
head. Lotion is started running through the tube by
the method described in the last chapter in the use of
Leiter's tubing. The tube is then placed just within
the patient's nostril, while he bends over the basin,
breathing quietly with his mouth open. The lotion
will, if the nasal passages are free, make its exit by
the other nostril.

"When the nurse has finished syringing a patient's
nose and throat, she should take the bone nozzle out
of the syringe and put it in a porringer to be boiled
before being used again. It is as well to have several
spare nozzles in a ward, so that each patient can have
a clean one ; those that have been once used being
collected in a porringer and boiled at the end of the
day. The same applies to the nozzle of a nasal
douche.

Syring-ing- the Ears. — Various forms of syringe
are used for cleansing the ears. The brass one is
about the best, though there is a very convenient
httle 2 -ounce rubber -ball syringe. If the child is
restless, it is as well to protect the nozzle with, a
small piece of drainage tubing. This is more esjjeci;
ally necessary in the case of the brass syringe.

Seating herself opposite the afifected ear, tlie mu-se
takes hold of it with her left hand, and draws it
gently backwards and upwards. By doing this she
tends to straighten the passage of the external ear,
thus maldng it easier for the lotion to enter. The
nozzle of the syringe is then placed just "odthin the
upper part of the opening of the ear, the handle of the

SYRINGING THE EARS.

165

mstrumeiit being slightly depressed, so that the point
of the nozzle is directed towards and touches the roof
of the ear. The syringe is then gently emptied. As
the lotion escapes from the ear it is caught in a kidney-
shaped tray, which is pressed closely against the neck.
Or a sjaecial trough can be hung over the ear, down
which the lotion will run into a basin.

There are two reasons for holding the syringe in
the way just mentioned, so that it may empty itself
on to the roof of the external meatus.

1. It is easier to cleanse the Ear. — By syringing
straight into the ear, any pus or wax that the ex-
ternal meatus may contain is driven inwards on to
the drum, on which some of it will probably be left
when the lotion flows back again. If, on the other
hand, the syringe is pointed slightly upwards, it is
emptied on to the roof of the meatus, along which
the lotion runs till it meets the drum, when it
ttu-ns down and runs out, washing everything in
front of it. By no other method of syringing could
a foreign body which had become firmly fixed in
the ear be removed.

2. It is more pleasant for the patient. — If the syringe
is emptied straight into the ear, the lotion falls directly
on the drum. This is frequently both painful and
startling to the patient. By syringing so that the
lotion runs along the roof of the canal the drum
receives no shock, and the operation becomes less
unpleasant.

If the child is at all inclined to struggle, a second
nurse should be present to hold it, otherwise it is
imijossible to properly cleanse the ear.

166

■PRACTICAL NURSING.

After aa ear has been syringed, the meatus should
be dried with absorbent wool, and its external opening
carefully packed with the same. Should the child
have a tendency to jsick the wool out of its ears, a
strip of bandage might be passed over them, and
fastened on the top of the head, or paper splints be
put round the elbows.

167

CHAPTER XII.

ENEMATA, ETC.

An enema is a liquid preparation which is injected
into the rectiun.

It may be given with one of the following objects
in view : To reheve pain, to diminish spasm, to stimu-
late, to kill worms, to produce an action of the bowels,
to feed the patient. Its composition and size will vary
with the purpose for which it is used.

The apparatus required will be described with each
form of enema. The fluid to be injected must be pre-
pared in a suitable vessel, and at the time of admin-
istration must be of the right temperature. When a
large quantity is to be used with a Higginson's syringe,
it is best prepared in a deep basin, and since it is
always a matter of some difficulty to keep the end of
the syringe under the fluid, a larger quantity than is
actually required should be prepared.

After use, the apparatus should be most carefully
cleaned. When a catheter is used, a copious stream
of water should be allowed to run througli it from the
eye downwards. It should then be laid in some dis-
hifectant, and again before use have a stream of water

168

PRACTICAL NURSING,

rim through it from the eye. Indiarubber tubing
shovild be treated in the same way. Glass fimnels,
glass syringes, and pipettes should be washed in soapy
water and rinsed in clean water, or they may be boiled
in water containing some soap and a little soda, and
kept in a clean place till required. If oil has been
used, the whole apparatus should be boiled in water
containing soap and soda, and afterwards rinsed with
plenty of clean warm water.

When a Higginson's syringe has been used to give
a soap-and-water enema, the nurse should fii'st see
that the nozzle is clean, and then pump plenty of
warm water through it. If it has been used for oil,
or any other medicinal enema, the water pumped
through it should contain soap and a little soda.
This should be repeated once or twice, and when
the niu"se has satisfied herself that it is clean, it
should be rinsed with clean warm water and huns:
up with the nozzle downwards. These syringes should
always be susj)ended from the metal end ; for if folded
up, they crack at the folds, and soon become useless.
A rubber syrmge shrinks and becomes hard when
kept in a dry place, or when not in constant use. It
is, therefore, a good plan to soak it in warm water
before giving an injection.

Position of Patient during administration of
Enema. — The patient is usually placed in one of
two positions, on the left side or on the back.
Very occasionally, when the case is one of obstiuate
constipation, the patient is placed in the knee-chest
position. No doubt it is most convenient to have
the patient lying on his left side, since the large
intestine runs backward from the anal apertm'e in

ENEMATA, ETC.

1B9

the direction of the left hip ; but it sometimes hap-
pens that it is impossible to put him in that posi-
tion, as, for instance, after an abdominal operation,
or injiu-y to the spine or pelvis. In such a case the
enema must be given with the patient lying on his
back. This is more difficult, and nurses will find it
a good plan to accustom themselves to this position,
so that when necessary they may do it easily, and
not cause the patient discomfort.

Turn the patient on to his left side, bringuig him
as near as possible to the right-hand side of the bed,
so that the buttocks may almost jDroject over the
edge, incline the shoulders to the other side of the
bed, and flex the knees. Place under the patient a
warm macintosh covered with a towel or doubled
draw-sheet, and turn back all the bed-clothes with
the exception of one blanket. Having placed the
fluid to be injected in a convenient position, and oiled
the catheter or nozzle of the syringe, take it in the
right hand. Now pass the index finger of the left
hand between the buttocks, and lay it Hghtly on the
anus, and pass the tube below the finger into the
rectum, guiding it backwards and upwards. In doing
this, it will be found that as soon as the nozzle touches
the anus, the sphincter muscle contracts. ISTo force
must now be used, but the nurse should pause for a
second, keeping the tube in place. Almost immedi-
ately the muscle will relax and the tube slip in. The
nm-se must take care to pass the tube over the small
tongue of integument which is found at the anterior
angle of the anus, otherwise, by pinching or turning
it in, she may cause the patient considerable pain and
discomfort.

170

PEACTICAL NUESING.

If the patient may not be turned on to his side,
he should, lying on his back, be brought as near the
right-hand side of the bed as possible. The warmed
macintosh being in position, and the bed-clothes lim-
ited to one blanket, the nurse flexes the patient's right
knee, and placing the index finger of the left hand
upon the anus, presses back the small fold of integ-
Timent just mentioned. The tube is then gently passed
with the right hand, being directed backwards and
slightly downwards. Should the tube meet with
any obstruction, it must be withdrawn a short dis-
tance and again pressed inwards. The obstruction
may be caused by the end of the instrument coming
in contact with a solid lump of fajcal material, or
becoming entangled in a fold of the intestinal mucous
membrane.

When the injection has been given, the tube should
be gently and slowly removed from the rectum, and
firm pressure at once put on the anus and peringeum
with a folded towel, to assist the patient in retaining
the enema.

Purgative Enemata. — Purgative enemata are
given either with the object of assisting in an easy
action of the bowels, as before and after operations,
or for the relief of constipation. When the rectum
is distended by a quantity of fluid, not only is any
faecal material wliich it contains softened and rendered
easier of expidsion, but the whole of the large in-
testine from the caecum onwards is stimulated to
contract upon its contents, and thus force them
towards the anal opening. Purgative enemata are
best given in the early morning. The following are
the principal forms of this enema : —

ENEMATA, KTC.

171

1. Soap-and-Water Enema. — This is made by dis-
solving 1 oxmce of soft soap in a pint of warm watei'.
For adults 1 pint is usually sufficient, though some-
times more is required ; for children up to ten years
of age 1| ounce for each year is a very safe rule.

This form of injection is usually given with a
Higginson's syringe, to the nozzle of which should
be attached a No. 12 rubber catheter. The tem-
perature of the enema at the time of use should be
about 95°. If too hot or too cold, it is more hkely
to be speedily rejected, and hence less efficacious.
Having carefully filled the syringe, so as to expel
all air, the nurse oils the nozzle and introduces it
as far as the shield ; or, if a catheter is attached,
passes that for 6-8 inches, and then very slowly
and steadily pumps in the soap-and-water. There
should be no attempt at hurrying, otherwise the
enema may be instantly returned. Five minutes at
least should be occupied in injectmg 1 pint. If the
patient complains of pain while the enema is being
administered, the mrrse must wait till it has passed
off before she continues, which she should then do
in a very gradual manner. For giving small soap-
and - water enemata to yoimg children, a rubber
catheter and the barrel of a 2-ounce glass syringe
should be used. The enema should be retained from
ten to fifteen minutes, and the nurse can assist the
patient in doing this by pressure on the anus and
perinseum with a folded towel. When gi'sang any
sort of purgative enema, a warmed bed-pan should
be ready at hand to prevent accidents.

2. Glycerine Enema. — This is usually given by
means of a special vulcanite syringe holding Jialf

172

PRACTICAL NURSING.

an ounce. For an adult 1 to 2 drachms is sufficient,
and half a drachm for a cTiild. It should be given
without the addition of water, as it acts by h-ritating
the wall of the rectum, and thus causing the intestine
to contract, besides inducing a secretion of fluid from
it, which effects will naturally be much diminished
by dilution. The only reason for adding water woixld
be if the patient found pure glycerine too irritating.

3. Turpentine Enema. — When given as a purgative,
1 ounce of oil of turpentine is mixed with 15 ounces
or tnm starch.

""More frequently this form of enema is used for the
rehef of abdominal distension in cases of typhoid fever,
in which case half an ounce to 1 ounce of tm'pentine
may be given in 2 ounces of starch. This is very
efficacious in brmging about the expulsion of gas
from the bowel, and does not cause so much dis-
turbance of the patient as the larger enema. The
smaller injection should be given by means of the
apparatus described for the use of nutrient enemata,
the larger by the Higginson's syringe.

4. Olive-oil Enema. — An ordinary ohve-oil enema
consists of 4 ounces of oil mixed with 8 oimces of
starch mucilage ; or a very common method is to
warm 4 ounces of oil and run it into the bowel by
means of a soft catheter and glass fiumel, following
it up in half an hour's time with an ordinary soa^a-
and-water enema.

Olive-oU may also be given as a "gravitation"
enema. This is used in very obstinate cases of con-
stipation, such as are caused by lead colic and
chronic obstruction. A pint to a pint and a half
of warm oil is introduced iuto the bowel by means

ENEMATA, ETC.

173

of a soft rubber catheter, to which is attached a long
piece of tubing and a glass funnel, the latter being
held from 2 to 3 feet above the level of the patient,
so that considerable force is exerted by the oil upon
the interior of the bowel.

5. Castor-oil Enema. — This consists of 1 ounce of
castor-oil mixed with 10 ounces of tliin starch, or 1
ounce of castor-oil mixe3"with 3 ounces of olive-oil may
be warmed and injected, and followed in half an hour
by a soap-and-water enema.

Nutrient Enema. — This is given when a patient is
taking insufficient food by the mouth, or when, from
some cause or other, it is considered desirable to give
the stomach a complete rest. Under such circum-
stances food is injected into the rectum.

The powers of digestion possessed by the rectum are
naturally not very marked, since under normal condi-
tions this is no part of its work, though it freely
absorbs flviid. Any food, therefore, that forms part of
a nutrient enema must be thoroughly digested before
use. Milk should be peptonised or pancreatised for at
least an hour at a temperatiu-e of 130" to 140° F.
before it is injected into the bowel. At the end of
that time, if it is not going to be at once used, it
should not be boiled, but should be placed on ice till
required. By doing this the peptonising process,
which is temporarily stopped by the ice, will begin
again when the enema is introduced into the rectum,
whereas, if the milk is boiled, the peptonising sub-
stance is completely destroyed.

Further, in health the lower part of tlie rectum is
empty, fsecal material collecting in the portion of bowel
immediately above it, and only passing into it during

174

PRACTICAL NUKSING.

the act of defsecation. It follows, therefore, that we
must be careful not to inject more than a small
quantity into the bowel, otherwise we shall irritate it
by distension, and so cause it to reject the fluid.

The size of the enema, together with the frequency
of injection, will be determined by the medical ofiicer
in charge of the case. Four ounces every foiu" hours
is a usual quantity for an adult, half that quantity
being used for children of five years. Peptonised mUk
is usually the chief constituent of these enemata.

The apparatus to
be used should con-
sist of a« rubber
catheter (Ro. 8), to
which is attached a
foot of rubber drain-
age tubing, into the
other end of which
is fixed a small glass
funnel, or, better
stm, the barrel of a
2-ounce glass syringe,
or the catheter and
drainage tube may
be joined by a couple
of inches of fine glass
tubing, such as is
used for pipettes.
The barrel of a glass
syringe is preferable
to a glass funnel, as
being more easily fitted to the drainage tubing, and
less likely to allow of the fluid being spilled during use.

Fig. ^.—Apparatus J or giving a
Nutrient Enema.

EN EM ATA, ETC.

175

This form of apparatus might very well be used for
the giving of every sort of enema except the glycerine.
Nutrient enemata should never be givefi loitli a A-ounce
i-ubhei' ball syringe. It is almost impossible to inject
the fluid sufficiently slowly by this instrument, the
hand becoming tired by the prolonged strain, or to
avoid injectiug air if less than 4 oimces is used.
Besides, it is a difficult instrument to clean thoroughly.
Indeed, it ought never to be used for any form of
rectal injection.

Owing to the limited power of digestion possessed
by the rectum, the whole of each enema is never
absorbed ; a certain amount of soHd material is always
left on the wall of the bowel. It is very essential that
this shoidd be removed, since, if left, it will hinder the
absorption of the next enema ; and, by undergoing
decomposition, set up an irritable condition of the
rectum. Patients who are being systematically fed
by the bowel should therefore have a plain water
enema once in each twenty-four hours. This alone,
however, is not enough. Before each enema is given,
the rectum should be gently washed out in the manner
described below. This not only removes the remains
of the previous injection, but freshens up the mucous
membrane of the gut, and so predisposes it to absorb
the food which immediately follows.

The patient being in the position already described,
the nurse pours a small quantity of warm water or
boracic lotion (temperature 95°) into the glass funnel
till it appears at the eye of the catheter, thus expel-
ling all air. She then nips the catheter between the
thumb and forefinger of her right hand, so as to pre-
vent any more fluid escaping, and having oiled it,

176

PRACTICAL NURSING.

passes it carefully into the bowel for about 6 inches in
a backward and upward direction. She then slowly
runs in 6 to 8 ounces of the fluid (if the patient be an
adult). Depressing the funnel below the level of the
bed, before it is quite empty, just as in washing out a
stomach, she lets the fluid run out again into a vessel
which she has ready for it. This process she repeats
three or four times, till the lotion comes back quite
clear. She now withdraws the catheter about 4
inches, so as to be sure that no lotion has collected in
the bowel below the eye of the instrument. Having
made certain that the rectum is both clean and empty,
she carefully passes the catheter in again tiU about 6
inches of it lie in the interior of the bowel, and then
very slowly runs in the nutrient enema. This should
be about 95° in temperature, and it should take at
least 5 minutes to give 4 oimces. To ensure the fluid
entering very gradually, the funnel should be raised
but a very short distance off the bed.

Having completed the operation, the nurse slowly
withdraws the tube, and, if the patient is a child,
keeps a folded towel pressed against the anus and
perinaeum for a few minutes. This will help to coun-
teract any tendency to reject the enema. In fm-ther-
ance of this object, the patient should lie quietly on
his left side for at least an hour after the injection.
In cases where the bowel is irritable and tends to
reject the enema, the lower end of the bed or cot
should be well raised from the ground. Lifting it 2
or 3 inches by means of blocks is of very little use.
It should be raised at least 1 foot, and can often be
kept for many days in that position witliout any
expression of discomfort on the part of the patient.

ENEMATA, ETC.

177

In very young children the same result may be
accompUshed by placing a pillow beneath the
hips. By raising the lower end of the body in
this way, the fluid is made to run higher up the
bowel, and thus prevented from pressing upon the
anal aperture. The addition of a small quantity
of opium to an enema promotes its retention, but
hinders absorption.

Sometimes large nutrient enemata, containing as
much as a pint, are ordered. By giving three of
these in the twenty -four hours the patient is afi'orded
a much larger quantity of nourishment than by the
method just described. They are, however, very sel-
dom used, being difiicult, and sometimes impossible,
of administration, while the smaller enemata are quite
efiicient as a temporary resource, and much less likely
to be rejected. Naturally, such a large quantity of
fluid could not be accommodated within the rectum ;
if left there, it would be at once returned.

A stout rubber tube, such as is used for washing
out the stomach, should be carefully passed for at
least 10 inches into the rectum in a backward and
upward direction. The great difiiculty is to be sure
that it is not curling upon itself within the bowel, in-
stead of moving upwards. To obviate this as much as
possible, the thick tube is used ; otherwise, the enema
is given as previously described, half an hour at least
being expended on the operation. Before giving one
of these large nutrient enemata, the end of the bed
should be well raised, so that the fluid may find it
less difficult to run up the bowel, or the buttocks
may be supported on pillows. These large enemata
may also be given as follows : An irrigator, sus-

VOL. I. M

178

PRACTICAL NURSING.

pended above the bed, is connected by means of
rubber tubing with a small catheter in the rectum.
The tubing is compressed by a clip, so that fluid
from the irrigator can only pass through it very
slowly, and thus enter the rectum drop by drop,
where it is absorbed before any quantity can
accumulate.

Starch-and-Opium Enema. — This is given for the
relief of pain, or to check excessive diarrhoea such
as is sometimes present in enteric fever. For an
adult 2 ounces, for a child 1 ounce, of thin starch,
mixed with the prescribed amoimt of laudanum, is
heated to a temperature of 95°, and slowly injected
into the bowel by means of a glass syringe and some
drainage tube, or it may be run in through the ap-
paratus used for nutrient enemata.

Besides those which have been described, various
other forms of enema are sometimes ordered to stimu-
late the patient, destroy worms, or check diarrhoea.
These need no special description, since the constituents
and exact quantities to be used would always be
ordered by the medical attendant. They should all
be given by the nutrient-enema apparatus.

Washing out the Bowel in Children for Diarrhoea.

— This is a most useful, and frequently very efficacious,
method of treating acute diarrhoea in yoimg children.
A nurse may be told to perform this operation, and
she would be supposed to know how it was done.
Plain water at a temperature of 95° is often used, or
it may have a teaspoonful of common salt, or some
emolhent such as starch, added to it. In chronic
diarrhoea, astringents, such as taurun and sulphate
of zinc, are sometimes used.

ENEMATA, ETC.

179

To do any good the large intestine above the rec-
tum must be washed out, so that a much larger
quantity of fluid will be used than when giving a
soap-and-water enema to a child of this age. For
a child of two years at least a pint should be run
in by means of the nutrient-enema ajaparatus. One
nurse should inject the water, while a second passes
her left hand under the child's legs and raises its
buttocks well ofi" the bed, while with her right hand
she kneads the left-hand side of the abdomen in an
upivard direction, so as to heljj the fluid up the bowel.
The catheter should be passed for at least 4 inches
into the rectum, and the fluid run in very slowly to
avoid giving pain.

Passing" the Long Rectal Tube. — This is used

simply for the reHef of abdominal distension. This
condition being due to an accumulation of gas in the
intestine which the bowel is too weak to expel, a tube is
passed in through which it can escape. A stout rubber
tube, such as is used for the giving of large nutrient
enemata, is passed into the rectimi for about 10
inches, or until gas escapes freely. This method of
reUeving abdominal distension is by no means in-
variably successful.

Suppositories are solid preparations of a conical
shape, and of varying size, according to their con-
tents. They are usually made of cacao butter, with
which is incorporated the drug desired to be used.
This is most commonly mor23hia. Others contam
digested meat, and are called " zyminised " sup-
positories. The cacao butter melts readily in the
rectum, and then the drug which it contains is
absorbed.

180

PRACTICAL NUESTNG.

Having placed the patient on his left side, the nurse
oils the suppository, and then slowly passes it into
the rectum. It is important that it should really
enter the cavity of the bovs^el, and not remain gripped
by the anal sphincter. A towel pressed against the
anus and periuEeum for two or three minutes will
obviate any tendency to ejection.

181

CHAPTEE XIII.

MEDICINES AND THEIR ADMINISTRATION.

Drugs may be introduced into the system in five
different ways. They may be swallowed, inhaled,
injected under the skin, rubbed into the skin, or
injected into the rectum. Whichever way is chosen,
the drug is, as a rule, first taken into the blood, and
by it carried to the organ which it is intended to
affect. Some purgatives, for mstance, are absorbed
either from the stomach or intestiae into the blood,
by which they are carried to the muscle in the
wall of the large intestine, which they stimulate to
contract more forcibly and so move the contents
of the bowel onwards. Other drugs, however, act
directly upon the mucous membrane of the intestinal
canal.

1. By the Mouth. — The great majority of medicines
are given by the mouth, and hence are absorbed into
the blood from the stomach or intestines. Drugs
given in this way may be administered in the form o£
liquids, pills, powders, or in capsules.

(a) Ldquids. — Except in the case of certain oils, Hquid
preparations of drugs — i.e., solutions of them or then'

182

PRACTICAL NUESING.

active principles — are combined to fomi mixtures,
which may contain one drug or half-a-dozen.

Before giving a dose of a mixture, the nurse should
never omit to read the label, however confident she
may be that she has got the right bottle. Even if
there is only that one bottle in the room, she should
still do so, that there may be no risk of the habit
being broken. Nurses when they first begin to ad-
minister medicines are most anxiously careful ; but,
as time goes on, famiharity breeds contempt in some,
and the fear of making a mistake gradually loses its
hold on them. They become too confident, and then a
little careless, until one day they do make a mistake,
the consequences of which may be very serious.

Having read the label and shaken the bottle, the
exact dose is poured into a graduated medicine-glass.
It must never be guessed, and spoons are not reliable
measures. When a certain number of drops are to be
given, a minim measure should, if possible, always be
used, since drops vary very much in size with the
character of the fluid and the shape of the bottle —
e.g., a drop of glycerine is much larger than a drop of
water. If one or two drops of a medicine are ordered,
a safe plan is to measure out ten drops, and then add
enough water to bring it up to five di^achms. Each
drachm of this mixture will contain two drops of the
medicine. While pouring out the medicine, the bottle
should be held Avith the label uppermost, that this
may not be soiled if any drops should run down
the side.

If the medicine is very unpalatable, sucking a piece
of ice or a peppermint drop beforehand will partially
get over the difl&culty, since they -numb the nerves of

MEDICINES AND THEIR ADMINISTRATION. 183

taste in the mouth ; or the nose may be pinched while
the dose is being swallowed.

Castor and cod-liver oils may be given to adults
in the following way, if they are private patients,
and their medicines have to be made as nice as
possible for them. A teaspoonful of sherry, or a
small quantity of lemon-juice, is poured into a wine-
glass, which is then tilted, so that the wme or
lemon-juice runs all round it and hence prevents the
oU sticking to the glass. The oU is then poured in
carefully, so that the edges of the glass are not
touched by it, and on it is placed another teaspoonful
of sherry or more lemon-juice. For children the oil
should be placed in a bottle with an ounce of milk
and a pinch of sugar, the mixtiire being heated and
then well shaken. As a result, the oil mixes intimately
with the milk, and is taken without difficulty.

(6) Pills contain drugs in a solid form. When they
reach the stomach, they break up and are absorbed.
Sometimes it is desired that they should not break up
until they reach the intestine, and they are therefore
coated with a special material which the gastric juice
is not able to dissolve.

There are two objections to the use of pills. In
the first place, unless they have been recently made
they become so hard and dry that sometimes they
pass entire through the stomach and intestines, and
appear in the stools. For this a nurse should always
be on the watch, and never forget to report the
occurrence to the medical attendant. Secondly, some
people cannot swallow a pill, and the smaller it is
the less likely are they to be able to do so. Even
after a tumbler of water has been drunk, it still

184

PRACTICAL NUESING.

remains at the back of the throat. This difficulty is
frequently overcome by eating a mouthful of bread,
which sweeps the pill down with it.

As a last resort, the pill may be crushed or cut into
small pieces. By doing this it is converted into a
coarse powder, which any one can swallow with the
aid of a little water.

(c) Powders. — These should be shaken on to the back
of the tongue, and then washed down with a drink of
some fluid. If the powder has a very disagreeable
taste, it may be given in a capsule, or wrapped up in
a rice-paper wafer. This is first moistened and then
folded over the powder, which is dropped on it. This
rather tmcomfortable-looking bolus, with the assist-
ance of a driuk of water, is easily swallowed.

(d) Capsules are small jDcar - shaped recejDtacles
made of gelatine, which are sealed up after having a
dose of the drug placed in them. They are easily
swallowed, and the gelatine, like the rice-paper wafer,
is at once dissolved by the gastric juice.

In addition to the above, drugs are compressed
into "tabloids," and can also be taken in the form of
" palatinoids," a recent and very handy invention for
those who cannot swallow pills. They are larger and
flatter than pills, and are said to at once open when
they reach the stomach.

When to give Medicines. — This is a matter which
is, of course, hardly ever left to the discretion of the
nurse, full directions being usually given as to the
time of administration of each dose. From this time
a nurse should never vary, but always be punctual
to the minute. If a medicine is ordered for 8 P.M. it
is intended to be given at that hoiu', and not at ten

MEDICINES AND THEIR ADMINISTRATION. 185

minutes to, or a quarter-past. Under this heading
it is proposed to explain why particular medicines
should be given at a particular time — i.e., the reason
for the doctor's directions.

Drugs, such as cod-hver oil, which might possibly
cause nausea are given shortly after a meal, as the
stomach, being busy with the food, is then less likely
to take olfence at them.

Alkaline mixtures are usually given a quarter of an
hour before food. If taken soon after a meal, they
neutralise some of the acid gastric juice, and so tend
to interfere with the process of digestion. Taken on
an empty stomach, they are very quickly absorbed
into the circulation. Acid mixtures are best taken
shortly after a meal.

Purgatives are given so that they may stimulate
the bowel about the time when an action should
normally take place — viz., after breakfast. Thus pills,
which are slow to act, are administered at bed- time;
while a seidlitz powder, or mineral water, is best
taken half an hour before breakfast, as the stomach
and intestine being empty at that time, it is quickly
absorbed, and rapidly produces an action of the
bowels.

Drugs which have for their object the kilhng of
intestinal worms should always be given when the
digestive tract is as free as possible from food, so that
the parasites may not be protected by it against the
action of the medicine. They are, therefore, usuaUy
administered late at night or early in the morning,
food being withheld for a few hours previous to the
draught, and also subsequently.

A medicine that is ordered to be taken before meals

186

PRACTICAL NUESING.

should be given a quarter of an hour before food ; one
that is ordered after meals, immediately the food is
finished.

A nurse ought never to give a double dose of medi-
cine at one hour, because she had forgotten the
previous dose when the time for it came roimd.
After each dose of medicine the measure should al-
ways be washed.

2. By the Lungs. — Given in this way drugs are
inhaled — i.e., drawn with the air at each inspiration
into the lungs, where they settle upon the lining
membrane of the air sacs and bronchial tubes, from
which they are absorbed by the blood-vessels. Medi-
cines which are inhaled are usually intended to act
only upon the lungs, and are, therefore, almost entirely
reserved for cases in which these organs are diseased.
Inhalations are also used for sore throat, and when
the larynx is inflamed. They are given in one of the
following ways : —

(a) The drug is dropjjed ujjon a piece of sjaonge,
wool, or lint, which is placed in a wire respirator to be
worn by the patient over his mouth.

(&) The drug is placed in an earthenware inhaler,
together with a pint of water at a temperature of
150° F. The patient places his hps to the glass mouth-
piece, and, breathing only through the mouth, draws
into his lungs at each inspiration the vapour, and with
it the essence of the drug.

Or the hot water and drug may be placed in a
vessel with a wider opening, such as a basin or jug, so
that the patient may inhale through the nose as well
as the mouth. This is a very useful method in the
treatment of an ordinary cold in the head.

MEDICINES AND THEIR ADMINISTRATION. 187

(c) The drug may be administered by means of
a Siegel's spray, which throws a fine cloud of steam
and the medicated sohition upon the patient's mouth,
which he consequently breathes in at each inspiration.
Care must be taken that the apparatus is working
proi^erly, or a jet of boiling water may spout on to the
patient's face and scald him.

Lastly, certain drugs, such as chloroform, ether, &c.,
are inhaled for the purpose of producing ansesthesia.

3. Hypodepmie Injections. — By this method the
drug to be administered is injected under the skin.
" Under the skin " is the meaning of both " hypo-
dermic" and "subcutaneous." Absorption into the
circidation is very much more rapid by this way than
by either of the others ; the drug, if it is going to
produce any etFect, doing so within from one to five
minutes of the time of injection. It is also a much
more certain method than any of the others, since
we know that the whole of the dose will be absorbed,
which we cannot be sure is the case when it is
swallowed and mixed in the stomach with the con-
tents of that organ. Being such a potent method, it
is, as a rule, used only in cases of emergency, when
we wish at once to relieve pain, induce vomiting or
sweating, or stimulate the heart.

All nurses should learn the proper use of the hypo-
dermic syringe, since at any time they may be called
upon to give an injection ; though this is seldom done
unless the medical man is absolutely satisfied of their
ability to do so, for any mistake with such concen-
trated solutions as are used for this purpose might
have the most serious consequences.

Having first tried the syringe, to see that the needle

188

PRACTICAL NUESING.

is not blocked, and that the piston does not allow fluid
to escape behind it when the opening in the nozzle of
the instrument is plugged with the finger, the nurse
proceeds to fill it with the solution poured into a
minim measiu-e which has first been carefully cleansed.
The needle should not be on the syringe while this is
being done ; otherwise, if the piston works stiffly, it
may suddenly slip, and, taking the nurse unawares,
cause the point of the needle to be damaged against
the bottom of the glass. Now, placing the needle on
the nozzle of the instrument, it should be directed
upwards, and the piston slowly pressed home, until a

Fig. 6. — Hypodermic Syi-inge.

di"op of fluid escapes from the needle, which shows
that all air has been expelled from the syringe.

The next step is to mark off the dose to be given.
This is best and most safely done by means of a regu-
lator, which moves up and down the piston-rod, on
which are marked tiny divisions, each of which repre-
sents a minim. If five minims are to be given, the
regulator is screwed up until it is five of these divisions
distant from the barrel of the syringe, as shown in fig.
6. Now, when the piston is driven home, as soon as
those five minims have been injected, the regulator
comes to a stop against the barrel, and prevents any
more being given. In the absence of a regidator, the
syringe must be emptied until no more than the dose
ordered remains in it, which is then injected.

MEDICINES AND THEIR ADMINISTRATION. 189

In giving the injection, a fold of skin is raised be-
tween the thumb and forefinger of the left hand, and
the barrel of the syringe being grasped lightly by the
thumb and two first fingers of the right hand, the
point of the needle is quickly pushed in beneath the
sldn in a horizontal direction to a distance of half
an inch, and the injection given. As the needle is
withdrawn, the thumb and forefijiger of the left hand
should hghtly but fiirmly grasp the opening in the
skin, to prevent the possibility of fluid escaping.
When the needle has been vsdthdrawn, the little swell-
ing should be gently rubbed in the upward direction,
to promote rapidity of absorj)tion. Some physicians
prefer that the needle should be passed straight down-
wards into the limb, so that the injection is made,
not beneath the skin, but into a muscle. This is said
to be less painful, and also less hkely to produce an
abscess. If this is done, the skin is not raised, but
stretched taut by the left hand, so that the needle
may more easily enter.

The needle should not be pushed in with a sudden
stab, as that may startle the patient, and lead to its
being broken. It should be passed in quickly but
quietly, for if it has a sharp point, there is practically
no pain caused by this part of the operation. If the
patient is a child, an assistant should hold the limb.

Injections are usually made into the outside of the
arm or thigh, the latter being chosen if the patient is
a woman, in case any scarring should result. Great
care must be taken tliat the point of the needle does
not enter a vein, as if that happened, the drug, being
carried straight to the heart, might produce A^ery
alarming symptoms.

190

PRACTICAL NURSING.

After use, the syringe sliould be thoroughly cleansed
by filling and emptying it several times with cold
water. It is important that no water should be
left in the needle, otherwise the mside of it becomes
rusty, and, finally, blocked. It is no use blowing
through the needle with the mouth, as nurses so
often do, as that is quite inefficient, besides being a
by no means cleanly proceedmg. The only certain
method is to fill the syringe three or four times with
air, and force that through the needle, and afterwards
to draw a little absolute alcohol through it by means
of the syringe. After this, the wire must always be
replaced in the needle.

If considered desirable, the needle can be easily
sterilised before each injection, by boiling it over a
spirit-lamp in a table-spoon or test-tube.

4. Inunction, which means the rubbing of an oint-
ment into the skin. The portion of skin to be treated
should first be washed with soap and warm water,
and carefully dried. This is done with a ^dew to
stimulating the circulation in the skin, so that it may
the more quickly absorb the medicament. This method
of introducing drugs into the system is practically
reserved for the administration of mercury in cases
of syphilis, though sometimes cod-liver oil is given
in this way to very emaciated patients.

Nurses must remember, when practising inunction,
that the ointment is to be rubbed into the skin, and
not left on it, the part being thoroughly massaged
by means of the palm and finger-tips. It should take
from twenty minutes to half an hour to rub in the
usual dose of mercmnal ointment. The insides of the
arms and thighs, and the sides of the chest and abdo-

MEDICINES AND THEIR ADMINISTEATION. 191

men, are the best sites for inunction. The same place
should not be used on successive days, otherwise there
is a risk of the skin becoming inflamed. Inunction is
usually performed at bedtime. The patient should
wear a flannel night-gown, and take a warm bath in
the morning.

5. Rectal Medication. — Drugs may be introduced
into the rectmn in either the liquid or the sohd form.
They are given in this way when the patient is un-
conscious, or vomiting, or for the relief of diarrhoea
or rectal pain, or for the piu-pose of stimulating a
patient who is collapsed after operation. Liquid
preparations should be run in by means of the appa-
ratus recommended for the administration of nutrient
enemata. Opium is the drug that is most commonly
administered in this way in combination with starch.
Suppositories are small cone-shaped bodies which
contain drugs in a soHd form. They are usually made
of cacao butter, which melts at once from the heat of
the rectum. Their method of administration has been
already described.

Drug's which may produce Symptoms of Poison-
ing".— Nurses should know something about the action
of the more important drugs, since certain of them at
times produce symptoms showing that the patient is
being injuriously aifected by their admmistration,
which should therefore be discontinued. A nurse
should be able to recognise these symptoms, so thai
she may at once report them to the medical attendant.
She should always be on the look-out for them, since
it by no means follows that they will not aj)pear
because small doses are being taken. Some peojole,
owuig to their extreme susceptibility to a drug, are

192

PRACTICAL NURSING.

at once poisoned by it in a way that could not possibly
have been anticipated.

Again, certain drugs, of which digitalis is the best
example, after being taken for some time, aU at once
produce symptoms of poisoning. They are said to
have a "cumulative" action — ^. e., they gradually
accumulate in the system until one day a certain
hmit is reached, and symptoms are suddenly produced.
On the other hand, some drugs, of which opium is the
best example, after a time gradually lose their effect,
so that the dose has to be correspondingly increased,
till at last the patient tolerates doses which it would
have been highly dangerous to give him when he first
began to take the drug.

In the following hst the symptoms given are not
those which would follow a jaoisonous overdose of each
drug, but only such as might arise diu"ing its medicinal
administration : —

Alcohol. — Reference is here made only to the use of
alcohol as a stimulant in cases of illness, such as enteric
fever. It is especially given in cases of low muttering
dehrium, with a dry tongue and I'apid feeble pulse ;
though very frequently it is administered for the last-
named condition only, that being the chief sign of a
failing heart. If restlessness and delirium become
more marked, the tongue more dry, and the pulse
more rapid in a jaatient Avho is not used to alcohol,
such as a woman or a chUd, there is a possibility that
the drug is to a certain extent responsible for these
symptoms. A nurse should therefore carefully note
its effect upon them.

Antifebrin and Antipyrin, when given even in small
doses, produce in some people symptoms of collapse, as

MEDICINES AND THEIR ADMINISTRATION. 193

shown by palpitation and faintness. Such symptoms
should always be reported by the nurse to the medical
attendant before giving another dose of the drug.

Arsenic. — Danger from the use of arsenic most often
arises in cases of St Yitus's dance, for which it is
sometimes given in much larger doses than for any
other disease. Under these circumstances arsenic may
injm-iously affect the nerves of the arms and legs,
causing those members to become paralysed. Any
obvious increase in weakness of the limbs should be
carefully looked for and reported. Arsenic may also
produce vomiting and pain in the epigastrium.

Bromide of Potassium, when given for a lengthened
period, as is usually done in cases of epilepsy, tends to
produce muscular weakness and nervous depression,
while sometimes a pustular rash appears on the face
and trunk.

Belladonna and Atropine, which is its active prin-
ciple, produce in people who are very susceptible to
their influence a dry throat, dilation of the pupils,
and sometimes a red rash like that of scarlet fever.
In more severe cases delirium and convulsions super-
vene. This indicates an extremely dangerous state of
affairs.

Carbolic Acid. — The first symptom of poisoning by
this drug is a dark ohve-green colour of the urine.

Chloral in some people dangerously depresses the
action of the heart, and slows the respiration. When
the drug is being continuously given, as is sometimes
done in chorea and tetanus, the nurse should most
carefully watch the pulse and breathing.

Digitalis, after being administered for some time,
occasionally produces sudden symptoms of depression

VOL. I. N

194

PRACTICAL NURSING.

and faintness, accompanied by vomiting and slow-
ing of tlie pulse. This condition is more likely to
come on when the patient is sitting up. Any one
who is taking large doses of digitahs should there-
fore be kept in the recumbent or semi -recumbent
position.

Iodide of Potassium in some people very readily pro-
duces running from the eyes and nose, and less often a
rash on the face, trunk, and limbs.

Mercury after a time tends to produce swelling and
inflammation of the gums, with loosening of the
teeth and foetor of the breath. "With this there is a
metallic taste in the mouth and an increased flow of
saliva. A nurse should most carefully watch for these
symptoms, and without fail report any of them,
whenever this drug is being continuously used.

iVkr Vomica and Strychnine. — Strychnine is the
active principle or essence of nux vomica, just as mor-
phia is of opium. After being taken for some time,
these drugs in some patients produce muscular twitch-
ing, which is an indication for discontinuing the
medicine.

Opium and Morphia. — Very young children are
most easily poisoned by even a very small dose of
these drugs. Minute contraction of the pupils, and
great difficulty in rousing the child, show that it is
being dangerously affected by the opium. The same
symptoms may occur in adults whose kidneys are
diseased, or who are in the later stages of acute
pneumonia.

Quinine in some people readily produces headache,
deafness, and singing in the ears, while more rarely a
very irritable rash follows its administration.

MEDICINES AND THEIR ADMINISTRATION. 195

Sodium Salicylate frequently produces transient deaf-
ness and singing in the ears. These symptoms, though
trying to the patient, are not necessarily an indication
that the drug should be discontinued.

Weig-hts and Measures. — A nurse should know
the tables of weights and measures ordinarily in use.

Weiglits-

20 grains (gr. xx)
437| grains
16 ounces

= 1 scruple (9i)

= 1 ounce

= 1 pound (Ibi)

Fluid Measures

60 minims (mix)

8 drachms
20 ounces

8 pints

= 1 fluid draclim (3!)
= 1 ounce (gi)
= 1 pint (01)
= 1 gallon (Ci)

Approximate Measures —

A teaspoon holds aboiit 1 fluid drachm

A dessertspoon
A tablespoon
A wine-glass
A teacup
A breakfast-cup

2 fluid drachms

4 „ or ^-ounce

1^ to 2 ounces

Some nurses have great difficulty in working out
the dose of a drug which is contained in solution, when
so many grains of the drug are ordered instead of so
much of the solution.

A mixture, for instance, contains 30 grains of chloral
in each ounce, and the patient is ordered to have 10
grains given him, if he does not sleep. How much of
the solution ought she to give him? N'ow, 10 is the

196

PflACTICAL NUESING.

third part of 30 ; to get 10 grains he must, therefore,
have the third part of an ounce of the mixture — i.e.,
the third part of 8 drachms — viz., 2| drachms, or 2
drachms and 40 minims.

Again, the mixture is said to contain one grain of
chloral in each 8 minims — i.e., the patient must take
8 minims to get one grain. If he is ordered 15 grains,
the nurse must give him 8 times 15 — i.e., 120 minims
of the mixture ; if he is ordered 10 grains, 8 times 10
— i.e., 80 minims; in other words, she must multiply
the number of grains ordered by the number of minims
in which each grain is dissolved.

A 5 per cent (5%) solution is one that contains
5 grains of the drug in every 100 minims of the solu-
tion, a 10 per cent one that contains 10 grains in 100.
20 per cent is therefore twice as strong as a 10 per
cent, and 10 per cent twice as strong as a 5 per cent.
To convert a 10 per cent solution into a 5 per cent it
must, therefore, be mixed with an equal quantity of
water or other diluent.

Explaining such simple calculations may seem ab-
surd to some people, but everyday experience shows
that it is by no means uncalled for.

All medicines should be kept in a cupboard, the key
of which is in the possession of the sister or head nurse
of the ward. All poisons should be carefuUy labelled.
The liniments and lotions should stand on a shelf by
themselves, poisons like morphia and strychnine on
another shelf, while a third is occupied by the ordinary
everyday medicines. If this rule is always observed,
and the cupboard kept constantly locked, there is no
excuse for administering a poison by mistake.

In conclusion, we would most strongly urge nurses

MEDICINES AND THEIR ADMINISTRATION. 197

never to forget the limits of theii' profession, when
asked, as occasionally they are sure to be asked, what
medicine they would advise. In such a case they
should always refer the questioner to the medical
attendant. Let them never forget that, except in an
extreme emergency, no nurse should ever take upon
herself to make a diagnosis or to prescribe.

198

CHAPTER XIV.

THE NTJRSING AND FEEDING OF SICK CHILDREN.

Nursing of Sick Children. — This is in every way
more difficult than the nursing of adults. A young
child cannot tell its nurse what is the matter. She
must, by keen observation, be able to interpret the
meaning of its different symptoms, without having
them put into words, as would be done by an older
patient. Frequently, too, there is difficulty in getting
a child to do what its nurse wants, xmless she has
been successful in gaining its confidence, to accom-
plish which she will often require much tact and
patience. These difficulties are in a measure over-
come by that innate sympathy and liking wliich
almost all women feel towards children, which help
them to recognise a child's wants by its looks and
inarticulate mutterings far more quickly than a man
could.

Often a nurse's patience is strained almost to the
breaking pomt by a child's wilfidness, but she must
never give way. Reprove it in a kindly manner of
course she may, but she must never scold or threaten
a child ; while if she should so far forget herself as to

NURSING AND FEEDING OF SICK CHILDEEN. 199

raise her hand agamst it, she should certainly be asked
to leave.

One thing which a nurse should always bear in
mind is that a very trifling matter, such as a slight
chill or a little indigestion, may produce the most
alarming symptoms in a child, symptoms that the
same causes would be powerless to produce in an
adult. On the other hand, a child, if it is much ex-
hausted by disease or want of food, may present hardly
any symptoms at all, though suffering from an acute
illness such as pneumonia. In the first instance the
indications are more urgent than they would be in the
case of an adult ; in the second instance the opposite
holds good. This apparent contradiction is due to
the extremely sensitive and excitable character of a
healthy child's nervous system, in consequence of
which it is easily upset by trifling ailments, so that it
produces exaggerated symptoms ; while, on the other
hand, it is more quickly exhausted by illness and want
of food, so that it then responds only feebly to the
stimulus of disease. A nurse must therefore be on her
guard against underrating the importance of an illness
occurring in one of these weakened children, because
the symptoms are not so in-gent as she has been accus-
tomed to see in adults. Rather, the danger is greater,
the lack of symptoms indicating a serious defect in
vitality. It is on this account most essential that a
nurse should exercise her powers of observation to
the utmost, so that she may gain all the informa-
tion possible from a child's expression, its cry and
posture.

Observation of Patient —

(a) Expression. — If a child is in pain, it will always

200

PRACTICAL NURSING.

show it in its face. Sometimes it is possible to tell
from the expression in which part of the body the
paia is situated. According to Dr Eustace Smith,
"pain m the head is indicated by a contraction of the
brows ; in the chest by a sharpness of the nostrils ;
and in the belly by a drawing up of the upper lip."
Exhaustion, which sometimes comes on very rapidly,
especially after acute diarrhoea, is shown by depres-
sion of the anterior f ontanelle in infants, by pallor of the
face with Uvidity of the lips, and by sinking in of the
eyes with incomplete closure of the Hds during sleep,
so that the white of the lower half of the eyeball is
seen. Exhaustion, when extreme, is a symptom of
great danger, and one that must be carefully watched
for by the nurse. Stimulants internally, and im-
mersion for three or four minutes in a hot mustard
bath, are the most efficient means of overcoming this
condition.

(6) Cry. — The character of a young child's cry often
gives as much information as the articulate speech of
an adult. A child that is himgry gives vent to a
prolonged passionate cry, after which it tries to extract
nourishment from its fingers or thumbs, and faUing
to do so, cries again. With pain in the abdomen, we
get a loud paroxysmal cry, accompanied by a dra-ndng
up of the legs ; with exhaustion a low whine. With
meningitis we get at intervals sharp pierciug screams,
the child between whiles lying quietly on its back.
When there is inflammation of the larynx, the cry is
hoarse and whispering. With inflammation of the
lungs a child as a rule cries but little, because of the
pain which a deep breath causes it.

NURSING AND FEEDING OF SICK CHILDREN. 201

nurse, as sometimes conveying a certain amount of
information. Healthy children, when sleeping, com-
monly lie on their sides ; when seriously ill or suffer-
ing from exhaustion, on the back with the face directed
upwards. Drawing of the head backwards may be
due to meningitis. Abdominal pain will cause a child
to draw its legs up. This postui-e soon after a meal
is a sure indication that food is the cause of the
trouble.

To see if a child is losing flesh the inner sides of
its thighs should be examined. Acute diarrhoea will
quickly make these parts soft and flabby to the touch,
with wrinkling of the skin.

Hygiene. — A nurse must never forget that cleanli-
ness, warmth, and fresh air are prime factors in the
successful nursing of sick children. Another factor of
great importance — viz., a suflicient supply of good food
— will be treated of shortly.

All soiled linen should be removed at once. In
an infants' ward, the sister or head nurse should
frequently go roimd the cots to see if any child
requires changing. A wet diaper not only chiUs an
infant and irritates the skin, but it also lessens the
purity of the air the patient is breathing. When
removing a stool, the nurse should carefully note any-
thing unusual about it, such as the undigested curd of
milk, mucus, or an abnormal colour, and report the
same to the medical attendant.

Every infant, unless too ill, should have a warm
bath (95° F.) each day. About two hours after break-
fast is the best time to give it. The child should be
kept in the water from three to five minutes, and
then be thoroughly dried with a soft towel, siaecial

202

PRACTICAL NURSING,

attention being paid to such parts as the groins,
armpits, and backs of the ears.

Warmth and fresh air are both mdispensable, yet by-
many nurses they are considered to be antagonistic, so
that one is provided at the expense of the other. To
keep a child warm, the windows are closed, that there
may be no risk of anything in the nature of a draught.
This is a great mistake. Young children, it is true,
need more warmth than adults ; but at the same time
they have a greater need of fresh air, both on account
of their age and also their habits. To keep a child
warm, the windows must not be closed, unless the
temperatin-e of the i-oom persists in falling below 60°
F., but warmth must be provided by means of flannel
night-gowns which completely cover the extremities, so
that if the child is restless and kicks off its bed-clothes
it will still be protected from cold. A child should not
be smothered in bed-clothes, otherwise it will get too
hot and throw them off, with the risk of a chill.

Cold hands and feet are harmful to a young child,
for they mean that blood which should be circulating
in the skin has been driven inwards, so that the
internal organs become congested or over-full of blood.
This causes them to work badly, and predisposes to
inflammation, so that with cold hands and feet you are
more likely to have pain after food, diarrhoea, and
bronchitis.

Sunlight should never be kept away from a child
unless it is shining in its face, in which case the blind
should be tem'porarily lowered. Children, like every-
thing else that is growing, are the better for sunlight.

Feeding". — When an infant is being bottle-fed, there
are several points to which a nurse must direct her

NURSING AND FEEDING OF SICK CHILDREN. 203

attention. In the first place, it is most essential that
the bottle should be quite clean and free from any trace
of decomposing curd. This can only be attained by
using at least two bottles ; seeing that directly the
child has fixdshed its meal the bottle is thoroughly
cleansed with soda and hot water, especial care being
paid to the teat, and that it is then put into a solution
of boracic acid or salicylate of soda until it is again
required. In addition to this, the bottles and teats
should be boiled at least once a-day. A nurse must
never give a child more than it is ordered, because she
thinks it unsatisfied and still himgry. A child that is
ill will often cry between its meals because it is thirsty.
This is easily remedied by a teaspoonful or two of cold
water. The milk, unless otherwise directed, should be
given at a temperature of about 95° F.

As regards the manner of feeding, the child must
not be left alone to bolt its food. One great advan-
tage of the boat -shaped feeding-bottle is that the
nurse is intended to hold it in her hand while the
child is feedmg, which, however, many fail to do. The
child should be shghtly propped up ; it is more likely
to vomit, if allowed to lie flat on its back when sucking.
The nurse should seat herself beside it, and hold the
bottle in her hand ; or, if the child is well, take it in
her lap, and support its head on her arm. By holding
the bottle, she is able to see that the child does not
take its meal too quickly ; while, as the bottle gradu-
ally becomes emptied, she is able to tUt it up, thus
keeping the end of the teat under the milk, so that the
child does not draw air into its stomach. It shows
bad management when an infant is left sucldng away
at a bottle which is lying in such a position that the

204

PIIACTICAL NURSING.

child cannot get at the milk, but is filling itself with
air. It is almost sure to have pain and possibly
vomiting as the result. After a child has finished its
meal, the nurse should note whether it suffers from
discomfort or flatulence ; whether its abdomen becomes
unduly distended, and whether it seems to be satisfied.
If it vomits, the quantity brought up should be noted,
together with the length of time after the meal.

A nurse should never, when feeding a young child,
try to make it eat by first putting the spoon into her
own mouth. She should never blow upon the food
to cool it ; the breath is often impure, and may make
the food injurious to the child.

As regards the feeding of sick children who have
passed the stage of infancy, there is little to be said.
The great thing is to get them to take their food
regularly and in proper quantities. This is often a
very difficult matter, since it is impossible to reason
with very young children, and at times they will
not be coaxed. A quiet insistence will often over-
come their obstinacy, but threats and anything in
the natiu-e of force, except by the doctor's orders,
must never be used. It is most wrong for a nurse
to hold a sick child's head down on the piUow, while
she tries to force the food into its mouth. More-
over, the child in its struggHng is liable to draw
the food through the larynx into its lungs, and so
set up a pneumonia which will in all probability
prove fatal. To avoid any such risk as this, to-
gether with the wasting of the child's strength that
results from its objection to being fed, the food is
introduced into the patient's stomach by means of
a tube.

NURSING AND FEEDING OF SICK CHILDREN. 205

Forced Feeding". — For the forced feeding of sick
children the apparatus most commonly used is an
ordinary soft rubber catheter (about No. 6 size), to
which is attached a piece of drainage tubing, a short
piece of glass tubing being often used to connect the
two. To the other end of the drainage tubing may
be fixed either a glass funnel or the barrel of a
glass syringe (see fig. 5, p. 174). The latter is de-
cidedly preferable, for the reason that fluid is much
less likely to be spilt than it is out of a funnel,
if the child struggles. Also, when the tube gets
blocked, as sometimes happens, you can introduce
the piston and force the fluid down the barrel.
Instead of the rubber catheter, one made of silk
web, or a special black tube with a funnel-shaped
expansion at one end, can be used. The latter
needs softening ia warm water before it is passed.
It is much more expensive, and easily spoilt, owing
to the readiness with which these tubes crack. They
can, however, owing to their comparative stifliiess,
sometimes be passed when the rubber tube persists
in forming coils at the back of the mouth instead
of travelling down the oesophagus. The milk should
be poiu-ed into the funnel-shaped expansion from a
feeder vidth a spout.

The following are the principal methods of forced
feeding : —

(a) The Food is injected into the Mouth. — This is
generally used for very young infants who refuse
the bottle because of the pain which sucldng causes
them. Thrush, or any form of stomatitis, might
produce this condition. It is also used after the
operation for harelip has been performed. A couple

206

PRACTICAL NURSING.

of inches of drainage tubing are fixed on to the nozzle
of a glass syringe, and the milk is slowly and inter-
mittently injected, the child, which is in the recum-
bent position, being given plenty of time to swallow.
The patient's head is held on one side, so that the fluid
may run round the side of the mouth, and thus have
a better chance of escaping the larynx. Children of
this age do not struggle, but lie with the mouth open,
trying to cry between each mouthful, so that the
operation is easy of performance.

(b) The Food is injected into the Nose. — This may
be used for the last class of cases, or for older cliildren
who would actively object to the tube in the mouth.
Food is sometimes administered in chis manner after
tracheotomy has been performed. The apparatus
described in the last paragraph is used, and the end
of the drainage tube being placed just within the
nostril, the syringe is slowly emptied. The milk
runs along the floor of the nose, and so into the
pharynx, when it is swallowed. For the carrying
out of this method of feeding, it is of course essen-
tial that the nasal passages should be clear, and not
plugged with thick mucus.

(c) A Tube is passed through the Nose into tJie
Stomach. — This is the most generally useful method
of forced feeding. It is frequently ordered in certain
forms of paralysis after diphtheria, when the muscles
of the pharynx are aflfected, so that the power of
swallowing is partially or entirely lost. The child
being ia the recumbent position, and, if there is only
one nurse to do the feeding, wapped up in a draw-
sheet, the end of the tube is vaselined, or dipped in
ohve-oil, and passed along the floor of the nose into

NURSING AND FEEDING OF SICK CHILDREN. 207

the pharynx, and on into the stomach. The nurse
must be careful, when introducing the tube into the
nostril, to point it straight backwards, and not direct
it upwards ; otherwise, it will at once catch against
the roof of the nose and come to a full stop. This
difficulty is much less hkely to happen with the rubber
catheter than with the stiffer black tube, for the for-
mer is so flexible that it easily glides off an obstruc-
tion and makes its way onwards. It finds its own
way through the nose, while the other is more capable
of direction, and hence also of misdirection. This
flexibility of the catheter leads it sometimes to coil up
at the back of the mouth, an occurrence for which a
nurse must always be on the look-out. The tube
ha\Tng gone down, the next question which the be-
ginner anxiously asks herself is, " Is it m the gullet or
the windpipe ? " The latter lying immediately in front
of the former (see fig. 7), it would at first sight appear
very easy for the tube to get into the wrong passage.
As a matter of fact this does not often happen,
though a nurse, when first performing the operation,
often thmks that this is the case, because she hears
air coming from the tube ; that she not unnaturaUy
thinks must be from the lungs, whereas it is only gas
escaping from the stomach. If air bubbles up in a
steady stream during both expiration and inspiration,
and if pressure with the hand on the epigastrium
forces out more air, the tube must be in the stomach.
If the tube had passed through the larynx, the child
would be in a condition of urgent dyspnoea. More-
over, the tube would very soon come to a stand-
still, since the windpipe is much shorter than the
gullet. If, therefore, 12 inches of tubing have passed

208

PRACTICAL NURSING.

througli tlie nose without meeting with any obstruc-
tion, and the child is breathing quietly, the end of
the catheter, provided it is not curled up in the

Palate

Vertebra{_
CoLuma

Fig. 7. — Section through head and neck, showing a black nasal tube
in position. More of the tube should be outside the nose.

mouth, is certainly in the stomach. If one of the
black tubes is being used, about one - third of it
should be left outside the nose.

NURSING AND FEEDING OF SICK CHILDREN. 209

Having passed the tube, it is well to wait for a few
seconds before pouring in any food, to allow the child
to quiet down, if it has been coaighing or struggling.
It happens not infrequently at some stage in the
feeding that the tube gets blocked, and the fluid con-
sequently ceases to rim down it. This little difiiculty
is easily surmounted by passing the thumb and fore-
finger down the drainage tubing, squeezing it firmly
while doing so, or if this fails, introducing the piston
into the barrel of the syringe and forcing it down-
wards. If a black tube is being used it is safer to
strain the food through muslin, and thus avoid the
risk of a block.

If the child coughs during the operation, the drain-
age tube should be nipped between two fingers, or
the thumb placed over the end of the black tube,
to prevent the food being forced out. The milk must
be poured in in a continuous and steady stream. One
lot should not be allowed to completely disappear from
sight before more is added, because each time that
is done air is forced into the child's stomach, which
may lead to pain or even produce vomiting.

At the end of the operation the tube should be
withdrawn steadily and not with a jerk, the thumb
being pressed over the opening of the black tube, or,
if a catheter is used, the drainage tube firmly caught
between the thumb and finger. The object of this
precaution is to prevent food escaping from the tube
as the end of it is withdrawn.

(<T) A Tube is passed through the Mouth into the
Stomach. — This is not so easy as passing a tube
through the nose ; it is more likely to provoke vomiting,
and it requires the help of an assistant to hold a cork

VOL. L 0

210

PRACTICAL NURSING.

or a gag between the child's teeth, to prevent it biting
the tube. As a rule, this method is used when the
nasal tube has failed to pass, owing to complete ob-
struction of the nasal passages, or when the catheter,
in exceptional cases, persists in entering the wind-
pipe instead of the gtdlet. This operation is usually
performed by a medical man, though nurses are some-
times called upon to carry it out.

The child having been wrapped in a sheet, the
assistant takes her place on the left side of the bed.
With her left hand she holds the gag in position, so
that the child's mouth is kept widely open, while with
the right she makes firm pressure on the forehead to
keep its head steady. The other nurse takes the tube
in her right hand, and dips the end of it in oHve-oil.
She then places the first two fingers of her left hand
well on to the back of the patient's tongue, pressing
that organ forwards, while at the same time she
rapidly passes the tube towards the back of the
throat along the groove between her two fingers.
Speed is very essential in these cases, as any fumbling
about with the tube at the back of the throat will
almost certainly result in -the patient retching. A
larger tube should be used than for nasal feeding, its
increased size making it stifi'er, and consequently easier
to pass.

211

CHAPTEE XY.

CONTAGION AND DISINFECTION.

In this chapter it is proposed to consider the general
principles imderlying the management of infectious
diseases. The individual fevers and their nursing will
be discussed in the next volume.

It is of great importance that a nurse should ap-
preciate the extent of her responsibilities, when she
undertakes the charge of a patient suffering from an
infectious fever. She must think of her patient, the
public, and herself.

While doing her utmost to help the patient safely-
through his illness, she must never forget that the
slightest carelessness on her part may residt in others
catching the disease. At the same time, it is clearly
her duty to guard herself by all reasonable precaiitions
against infection. She should keep her finger-nails
short, never omit to use the nail-brush before a meal,
and get all the fresh air she can. Not that she ought
ever to put herself first, and be careful to the verge of
fearfulness on her own behalf — that is a fault that can
very seldom be laid to the charge of nurses ; much
more often one has to blame them for not taking

212

PRACTICAL NURSING.

enough care of themselves, which is in itself a serious
fault. Moreover, those who are careless about them-
selves are apt to be the same about other people, and
hence are more likely to carry contagion away with
them from the sick-room.

Contag"ion. — The contagion of a disease is some-
thing which, leaving the patient's body in the breath,
excretions, or in flakes of dead skin, is able to start
the disease in another individual. We know what
the contagion or source of infection is in some of the
specific fevers — for example, diphtheria is known to
be caused by a very minute rod-shaped germ. On
the other hand, as yet we do not know the nature
of the contagion in scarlet fever, smallpox, &c., the
germs of those diseases so far not having been dis-
covered.

It is not always possible to say when an individual
contracted one of these specific fevers ; because for
some time after the contagion enters the system it
gives no sign of its presence, the affected person's
health continuing as good as it was before he became
infected. This period, which varies in length in differ-
ent diseases, is called the stage of incubation. Dm^ing
it the germs are busy multiplying in the system, and
producing their poison. After a time, when suffacient
of the latter has been made, the jjatient falls ill, and
symptoms of the disease for the first time manifest
themselves. This is called the period of invasion,
since it is the beginning of the illness. In some dis-
eases at a later period a rash appears, giving rise to
a third stage, the stage of eruption. All the symp-
toms of the disease — fever, wasting, rash, and delirium
— are due to the " toxine " or poison which is being

CONTAGION AND DISINFECTION.

213

manufactured by the germs, and carried all over the
system in the circulation.

The various fevers differ widely among themselves
as regards the period of illness when they are most
infectious, the ease with which the contagious element
is destroyed, the channel by which that contagion
enters, and also that by which it leaves the system.

Disinfection.^ — ^ Nurses should understand clearly
the difference between disinfectants and deodorants.

A disinfectant is something that "frees from in-
fection " — i.e., if used in sufficient strength it kills
the contagious element. A deodorant, on the other
hand, merely "frees from smell" — i.e., it hides the
odour, but does not necessarily destroy the cause of
it, though some deodorants are also disinfectants.
CarboHc acid is a disinfectant, eau-de-Cologne a de-
odorant. The risk attached to the use of deodorants
is that some people are qmte satisfied when they have
hidden a smell, instead of finding out and removing
the source of it. . A bad smell is Nature's danger-
signal, to hide which is equivalent to the removal of
the notice-board which tells you where the ice on a
frozen pond is dangerous.

No amount of sweet-smelling odours, or spraying
with carbolic lotion, could render the air of a room
healthy if a bed-pan with a stool in it were allowed to
remain under the bed. On the other hand, there is
no objection to the use of eau-de-Cologne in modera-
tion when the bed-pan has been removed, provided
that it is never used as a substitute for ventilation.

Disinfectants. — The only absolutely reliable disinfec-
tant is heat in the shape of boiling water, steam, or
hot air of a temperature of 250° Fahrenheit. Articles

214

PliAOTICAL NURSING.

tliat have been disinfected by heat are said to have
been steriHsed — i.e., they are by it rendered absolutely
free from every sort of germ. For things that cannot
very well be subjected to the action of heat we have
to use chemical disinfectants, called " germicides," or
germ-killers. These are very much less satisfactory
than heat.

Of chemical disinfectants the best are carbolic acid,
1 in 20, and perchloride of mercury, 1 in 1000, If
used in weaker solutions than these, they cannot be
reHed upon to kill germs. Another very ef&cient, but
more expensive, disinfectant is formalin, 1 in 100.
Milk of lime and chloride of hme are very useful for
disinfecting stools.

Disinfection of Patient and his Suppounding'S.
— We must now consider in detail the best method
of disinfecting the patient and his surroundings — i.e.,
of preventing the spread of infection. Some of the
precautions named refer more particularly to private
mirsing.

(a) Air of Room. — Constant and free ventilation is
absolutely the only method of purifying the air of the
apartment in which the patient is lying. This is most
important, as all manner of noxious emanations are
given off by the patient's body, which are hm'tful both
to himself and his attendants. The risk of the latter
catching the disease is much diminished by free venti-
lation. The window, unless the weatlier is very cold,
or the patient suffering from bronchitis, should be kept
constantly open from the top, a screen, if necessary,
being arranged to keep the draught oif the bed. In
mild weather the window should be opened top and
bottom twice a-day, and the room thoroughly flushed

CONTAGION AND DISINFECTION. 215

with fresh air, the patient meanwhile being carefully
covered up.

A small fire is an aid to ventilation, as has already-
been explained.

Attempting to disinfect the air of the sick-room by
means of carbolic sprays, or by standing dishes of the
same lotion about the apartment, is absolutely useless.
They act to a certain extent as deodorants, but noth-
ing more. A sheet kept constantly wet with 1 in 100
carboHc lotion is usually Inmg over the door of the
j^atient's room in private houses. As long as it is wet
it is imdoubtedly useful, since dust and germs, which
would tend to blow from the sick-room into the house
when the door is opened, will strike against the moist
surface and be retained by it. Moreover, the presence
of the sheet gives a feeling of security to the rest of
the household, which is of some importance when it
contains any nervous individuals.

(6) Ldnen of Patient. — Both the body and bed linen
after use should be at once placed in a disinfectant
solution. The strength of this will depend upon the
purpose for which it is used. If it consists of carbolic
acid, and is intended to disinfect the Unen (i.e., to Idll
the germs in it), nothing weaker than 1 in 20 will be
of any use. This is very trying for the hands. If,
however, the solution is intended to check the growth
and prevent the spreading of germs, 1 in 40 is quite
strong enough. Better than this would be a solution
of izal or lysol (1 in 100), as these preparations do
not roughen the skin of the hands in the same way
that carbolic acid does. Perchloride of mercury stains
linen, and formalin is expensive, besides being very t[
irritating to the eyes and lungs.

216

PRACTICAL NURSING.

A hip or foot bath would be a convenient receptacle,
as a large quantity of the disinfectant is needed when
articles like sheets have to be soaked in it. The bath
should stand in an adjacent apartment. Immersuig
them in a disinfectant solution renders them for the
time quite imable to give olf any infectious matter,
contrary to what would be the case were they dry.
'No dust can escape from them, and, therefore, vmless
they are handled, no germs.

As regards the final cleansing of these articles, they
should, i£ possible, fx^ washed ^t home, or, if that
is not practicable, they should be placed in boiling
water for ten minutes before being sent out of the
house. This can usually be managed by means of
a large stock-pot. If there is a steam disinfecting
station near, the patient's linen should pass through
that before going to the pubhc laundry.

If there is no convenience at home for washing or
boUing the linen, and no disinfecting station to send
it to, it should be allowed to soak for at least twelve
hours in the disinfecting solution before going to the
laundry. It should then be tied up in a clean sheet,
having been kept in the disinfectant till the tinie
comes for it to be fetched. This ensures its being
wet when it leaves the house, so that no dust can
escape from it when handled.

Especial care is needed in the treatment of soiled
linen from oases of enteric fever. If very dii'ty, it
should first be rinsed in plain water, being well pi'essed
and stirred about with a stout stick, to remove as
much of the excretal matter as possible before placing
it in the bath with the other articles.

CONTAGION AND DISINFECTION.

217

freshly prepared milk of lime, 1 in 20 carbolic acid,
or 1 in 1000 perchloride of mercury, may be used.
Before it is given to the patient a small quantity
should be put in the bed - pan, the handle of which
should have been previously firmly plugged with a
rubber cork or carbolised tow. ^f ter use, it is covered
up and at once removed from the room, and enough
disinfectant added to completely cover the stool. The
best method for finally disposing of an enteric stool
would be to mix it with sawdust and burn it, or with
lime and bury it. As a rule, neither is practicable,
and it has to be emptied down the w.c. Before doing
this, it should be allowed to stand for an hour, to give
the germicide a chance of acting upon the microbes
of the disease, which abound in the stools and urine of
enteric patients. At the best this is a very imperfect
method of disinfection. While the stool is standing,
the bed-pan should be covered with a cloth moistened
with 1 in 20 carboHc, which should be thickly sprinkled
with carbolic or sanitas powder. This will absorb any
noisome emanations. This should also be done when
a stool is being kept for the medical attendant's
inspection.

The urine should be mixed with an equal bulk of
a similar solution, and also allowed to stand for an
hour before being emptied away.

(cZ) Sputum. — Some 1 in 20 carbolic, or 1 in 1000
perchloride, should be placed in the cup before use,
more with a view to preventing the sputum adhering
to the sides and bottom of the vessel than with the
idea of disinfection, since germicidal solutions are quite
unable to penetrate a thick glairy sputum, and Idll
the germs which are buried m it.

218

PRACTICAL NURSING.

All discharges from the patient's nose and mouth
should be wiped away with wool or pieces of soft rag,
which should be placed in a porringer and subsequently
burnt. Handkerchiefs should never be used in diseases
like scarlet fever, measles, and diphtheria, where the
great source of infection lies in these discharges.

(e) Patient's Body. — In scarlet fever the flakes of
sldn which separate from the body during the process
of desquamation are infectious. Many physicians,
therefore, during the peeling stage, have their scarlet
fever patients anointed daily from head to foot ^nXh.
a germicide, usually carbolic acid dissolved in olive-
oil. This also is of advantage in preventing the
escape of dust and particles of skin from the patient.
In addition, warm baths are frequently given during
convalescence.

When discharged, the patient should have a final
bath in a difi'erent room to those in which he has
been living, washing himself thoroughly from head
to foot with soap and hot water. After drying him-
self, he should proceed, wrapped in a clean blanket, to
a fresh apartment, where he vnll find clean clothes
waiting for him.

After death the body is still infectious. It should
be washed aU over with soap and water, and as soon
as possible screwed down in the coffin.

(/) Patient's Room. — After a patient has finally left
his apartment, it, and all it contains, should be dis-
infected as thoroughly as possible before it is allowed
to be used again. Exactly the same precautions
should be taken with the rooms of those who have
been in attendance on him.

Everything that can be spared should be bm-nt,

CONTAGION AND DISINFECTION.

219

since tliat absolutely destroys all risk. This should
invariably be done in the case of the patient's brush
and comb, nail-brush, tooth-brush, and sponge, and
the broom which has been used to sweep the floor.
All the bedding, and any carpets or blinds there may
be in the room, should be sent to a disinfecting
station to be treated with steam. If that is not
possible, they must be disinfected at home with
formalin, and afterwards exposed for some days to
the action of sunlight and fresh air, both of which
help to destroy the vitality of germs. All small
articles — such as knives, spoons, and forks — should
be boiled, and all crockery-ware thoroughly cleansed
with boiling water, and immersed for some horn's in
1 in 20 carbolic acid.

As a preHminary to the final cleansing, the room
and its furnitxu'e is usually subjected to fumigation
by means of the vapour of burning sulphur. This
is a very unreliable method, and consequently ob-
jectionable, owing to the blind faith many people
have in it, which leads them to trust to it alone, and
neglect other and much more essential precautions.
Every orifice by which air can enter or escape from
the room — such as doors, windows, chimneys, and
ventilators — is first closed up by the help of paste
and paper. The room should then be filled with
steam by boiling a kettle over a spirit-lamp, as the
sulpliiu" fumes act better on a damp surface. The
fire-irons should be removed, otherwise they will be
discoloured by the sulphur.

A small room 11 feet square and 12 feet high
would require about 5 lb. of sulphur, one twice that
size 10 lb., and so on. The sulpluir is placed in

220

PEACTICAL NURSING.

common earthenware dishes, which stand in larger
ones containing water. A little methylated spirit
is poured over the sulphur to make certain of its
catching light. The door leading into the chamber
is afterwards pasted up on the outside, and the room
left for twenty-four hours.

In the place of sulphur formalin may be used. It is
much more efficacious and also much more expensive.
A special apparatus with directions for use is sold, by
which tabloids contauiing formalin are vaporised by
means of a lamp.

A simpler method is to hang one or more sheets in
the room, and by means of a watering-jDot -wdth a fine
rose, saturate them with formalin. At the same time,
articles, such as mattresses, which it has not been
possible to disinfect with steam, shoidd be freely
sprinkled on both sides and hung over the backs of
two chairs. All this will have to be done very quickly,
as the vapour of formalin is most irritating.

At the expiration of twenty-four houi's doors and
windows are thrown open. All the f urnitm'e in the
room, doors, floors, window - sills, &c., are to be
thoroughly scrubbed, the paper stripped ofi" the waUs,
the ceiHng whitewashed, and the woodwork repainted.
If possible, the room should then be left for a week,
with the doors and windows wide open, so that it may
be thoroughly aired.

221

CHAPTER XVI.

ON THE PRODTJCTION OP SURGICAL CLEANLINESS.

The success of the surgical nurse of the present day
depends entirely on her ability to understand and
appreciate the theory of "asepsis," or surgical cleanH-
ness, which underlies the practice of modern surgery,
and her capacity for intelligent attention to the minut-
est details. By absolute, or surgical, cleanliness is
meant, not merely a freedom from dirt, such as would
be obvious to the naked eye, but also a freedom from
germs. To properly understand the importance oi
this, it is necessary first to say a few words about

GePms, or microbes, as they are called, are ex-
tremely minute forms of vege-
table life belonging to the order ».*•;. "n'^^v.

Each one of us carries countless thousands on the

germs.

222

PEACTICAL NDRSING.

sldn, as well as in the nose, throat, stomach, and in-
testines. They are, therefore, naturally more numer-
ous where many human beings are congregated to-
gether— e.g., there are more of them in towns than
in the country.

Very many germs are quite harmless ; others set up
certain diseases such as diphtheria and typhoid fever;
while a third class, when introduced into wounds,
cause them to become inflamed and suppurate.

Germs multiply with the most extraordinary rapid-
ity. A single microbe is able to give rise to many
thousands of its kind in the course of a few hours. To
do this it must be living under favourable conditions ;
it must be supphed with both heat and moistiu^e. The
germs which are contained in a dry piece of dijahtherial
membrane, though alive, are not growing, because
they lack both warmth and moisture. If, however,
that dried membrane is placed in a flask of broth
which is kept at the temperature of the human body,
those germs will quicldy increase in number, because
now they have both warmth and food. The tempera-
ture of the human body is favourable to the existence
of most germs. These organisms gain admittance in
the food, or by way of the nose and lungs, or by
wounds.

When germs, which are poisonous to human beings,
have established themselves within the body, they
irritate the part in which they are located, and set up
inflammation — e.g., the germ of pneumonia causes
inflammation of the limgs, that of diphtheria inflam-
mation of the throat, while various others set up
inflammation and suppuration in wounds. At the
same time, while grooving in these various situations,

PRODUCTION OF SURGICAL CLEANLINESS. 223

they produce certain poisons or toxines, which are
absorbed into the circulation, and set up fever and
various other symptoms.

The Progress of Surg-ery. — Fifty years ago
surgeons knew practically nothing of the influence of
germs upon the healing of wounds. Suppuration after
operation was then the rule rather than the exception,
the death-rate in consequence being enormously high;
indeed, many surgeons refused to undertake ojaerations
which are now performed with impunity.

Then came M. Pasteur with his wonderful researches
hito the processes of fermentation and putrefaction,
both of which he proved conclusively to be the work
of germs. From the knowledge so gained Lemaire
argued that sujjpuration occurring in a wound was
due to the same cause, and instead of being essential
to the process of healing, as had hitherto been taught,
was inimical to that process, and should, if possible, be
stopped. This, he showed, might be done by means of
antiseptics, which would either kill the germs or at
least prevent them growing.

To Lord Lister belongs the credit of grasping the
enormous importance of Pasteur's and Lemaire's dis-
coveries upon the practice of surgery. He went a
step further, and devised a method whereby living
germs or bacteria, as they are called, might be pre-
vented entering an operation wound, and causing it to
become septic.

Antiseptic Surgery. — His method was called the
" antiseptic " method, and consisted in the constant
u.se of antiseptics, or, as they are more properly called,
germicides, so that all germs in the neighbourhood of
the wound might be killed. With this end in view

224

PRACTICAL NURSING.

a spray of carbolic acid and water played on the
wound during the time it was exposed to the air. It
was flushed with a strong germicidal solution before
the stitches were put in, and dressings impregnated
with some antiseptic were afterwards apphed. The
sponges, instruments, and hands of those who assisted
at the operation were treated with similar solutions.

These precautions were essentially " antiseptic " —
that is to say, they were imdertaken with a view to
killing any septic germ which might happen to gain
entrance to the wound, the original idea being that
microbes, being everywhere jDresent, must gain access
to the wound, and consequently such solutions must be
used as would kill them or hinder their development.

Aseptic Surgery. — At the present day our object is
still to keep the woimd free from germs ; but it is now
recognised that the principal danger hes in its du-ect
contamination during the operation. Our efl^orts are
therefore now directed towards ensuring a complete
freedom from living germs of everything which may be
used during an operation. By doing this, we, as far
as possible, prevent germs entering the wound, which
is better than allowing them to get in, and then
endeavouring to kill them with antiseptics. At the
same time, we have by no means given up the use of
these drugs. They are most useful, and in many cases
indisi^ensable to the production of a state of sm'gical
cleanliness.

Antiseptics. — There are a great variety of drugs
which, when used in a sufficiently concentrated form,
possess the power of killing germs, while in weaker
solutions tliey are able to prevent their growth. Two
of the most reliable, but which at the same tune have

PRODUCTION OF SURGICAL CLEANLINESS. 225

the drawback of being two of the most poisonous, are
carboHc acid and perchloride of mercury.

Carbolic Acid, which is obtained from coal-tar, is
a crystalline substance soluble in alcohol, ether, or
glycerme. For lotions it is usually dissolved in
glycerine, to which is added distilled water sufficient
to bring it to a strength of 1 in 20. "When intended
to act as a germicide, it must not be used in a weaker
solution. This strength is useful for disinfecting
excreta, but is too strong for application to wounds.
For such it should be diluted to 1 in 40 or 1 in 60 ;
though occasionally the pure acid is rubbed into very
foul and sloughing wounds, since these do not possess
the same power of absorption that a clean raw sur-
face does. The first symptom of carboHc-acid poison-
ing is a dark oHve- green appearance of the urine,
which is readily produced by the application of car-
bolic compresses to the skin of yoimg children. The
drug should be at once discontinued. Carbolic gauze,
which is of a deep yellow colour and rather harsh
texture, contains 5 per cent of the acid, and forms
a very useful antiseptic dressing. A solution of car-
bolic acid, as strong as 1 in 20, blunts knives, if they
are left in it for any length of time, but otherwise
has no injurious efi'ect upon metal instruments.

Perchloride of Mercury acts as a germicide when
used as strong as 1 in 1000, though less eflicient than

1 in 20 carbolic acid. For washing out cavities, where
there would be a risk of absorption, 1 in 8000 is strong
enough. Sal alembroth gauze and wool, which are
dyed a bright blue colour, are said to contain 1 and

2 per cent of the drug respectively, combined with
chloride of ammonium. Perchloride of mercury is

VOL. I. p

226

PRACTICAL NURSING.

intensely poisonous, producing vomiting and diarrhoea,
and, if enough has been absorbed, collapse and death.
Metal instruments should never be placed in a solution
of it, otherwise they become black, owing to the mer-
cury being deposited on them.

Biniodide of Mercury is used in the same way, and
of the same strength as the perchloride. It is difficult
to obtain pure, and is very expensive. It is much less
irritating to the skin, and a 1 in 500 solution in spirit
is frequently used for disinfecting the hands before an
operation. It does not, like the perchloride, coagulate
blood, and sponges are therefore easily and quickly
cleansed in it during an operation. It is only used as
a lotion ; there is no corresponding gauze or wool.

Cyanide of Mercury and Zinc is, like the perchloride
and biniodide, intensely poisonous. It is only used to
impregnate gauze and wool, which contain 3 per cent
of the drug, and are dyed a pale lavender colour. It
is less irritating to the sldn than the perchloride.

Boracic Acid is a very feeble antiseptic, but pos-
sesses the advantage of being practically non-poisonous,
so that it can be used for washing out large wounds
and cavities where a more powerful germicide would
be inadmissible.

Iodoform is a yellow powder, Avith a chai'acteristic
and very powerful odour. It is dusted over wounds,
when the operation is comiDleted, and the dressings
about to be apphed. It is frequently diluted with
2 or 3 parts of powdered boracic acid, as a larger
quantity can then be used — e.g., in filling small cavi-
ties— with much less risk of poisoning the patient.

In addition to the above there are Izal and Lysol,
which, like carbolic acid, are prepared from coal-tar,

PRODUCTION OP SURGICAL CLEANLINESS. 227

and have the advantage of being non-poisonous ; lodol,
which is an inodorous powder possessing the same
qualities as iodoform ; Thymol, Salicylic Acid, Euca-
lyptus Oil, Pennanganate of Potash, and many others.

The production of Asepsis. — By " asepsis " is
meant the absence of septic germs — i.e., a condition of
surgical cleanliness. It is of the utmost importance
that a nurse should understand, and know how to
render aseptic, everything which is concerned ui the
treatment of an operation wound. Owing to the
universal prevalence of germs, it is by no means an
easy matter to protect the patient from them. This
can only be done by the most careful, intelhgent, and
unremitting attention to minute details of cleanliness,
assisted by the judicious use of antiseptics. The non-
success of many an operation has been due to some
slight carelessness on the part of a nurse who has
failed to recognise the importance of little things.
Want of attention at any point may admit of the
entrance of germs, and consequent suppm-ation of the
wound. The great truth that a nurse must always
keep before her is, that for the production of asepsis
cleanliness is all important, and that antiseptics play
but a very secondary part. She must never delude
herself with the idea that a dip into 1 in 20 carbolic
acid will make up for want of thoroughness in clean-
ing. Such a delusion, which even now is only too
common, is fraught with danger to the patient.

Everything likely to come within the field of an
operation will now be enumerated, and the best way
to render each as nearly as possible aseptic pointed
out.

1. The Operating Theatre. — The theatre, or, if in

228

PRACTICAL NUESING.

a private house, the room where an operation is going
to be performed, should be —

(a) Clean and free from dust. Where there is dust
there are germs. The less dust there is moving about
in the air at the time of operation, the fewer germs
there will be to settle with it on the wound. No
dusting or brushing should therefore be done in a
room for at least four hours before the operation is
performed, so that the germs in it may have plenty of
time to settle again on the walls and floor. Such
dusting, as is necessary, should be done with a damp
cloth. Modern theatres are built with glazed walls
and mosaic flooring, and are therefore easily kept
clean by flushing with a hose. In a private house
the curtains and carpet should be removed, and
the room scrubbed and dusted the day before the
operation.

(b) Of a proper temperature. It is very essential
that the room should be warm enough, otherwise the
patient will be more likely to suffer from shock after
the operation. The nurse should therefore be thor-
oughly acquainted with the method of warming the
theatre, and be able to regulate it accurately. A good
average temperature is 70°, which in severe abdom-
inal operations might with advantage be raised to
80°, but the. surgeon's wishes in this respect should
always be consulted, as some operators prefer a higher
temperature than others.

The nurse in charge of the theatre should always be
sure that the water supply is in good order, and that
plenty of both hot and cold is obtainable.

2. Tables. — Modern operating - tables are made of
brass, or enamelled iron, frames with plate-glass tops.

PRODUCTION OF SURGICAL CLEANLINESS. 229

An iron frame is preferable to one of brass, since the
former is easily cleaned with soap and water, while
the latter requires a lot of polishing. The table upon
which the operation is going to be performed is usually
kept warm by hot water or some other means. It
should be thoroughly cleaned before an operation, and
at once covered with a sterilised sheet. There are, in
addition, other smaller tables for the instruments,
dressings, and bowls of lotion, and one for the anass-
thetist's use.

In a private house the wooden table, which is prob-
ably the only one obtainable, should be scrubbed with
soap and hot water some hours before the time of
operation, and at once covered with a clean sheet.

The instruments should be laid on a clean towel
which has been vvTung out of 1 in 20 carbolic lotion.

3. Sponges are by no means easy to sterilise — i.e., to
render absolutely free from germs — since they are at
once spoiled by boiling. To see whether a sponge
is sterile, a small piece is snipped off vsdth surgically
clean scissors and dropped into specially prepared
broth, which is then placed in an incubator. If the
sponge contains germs, they wiU quickly grow in the
brotli, and be at once recognised when a drop of it is
examined next day under the microscope. In the
same way we can tell whether we have been suc-
cessful in rendering our hands, or the patient's skui,
absolutely clean.

The following is, according to Mr Lockwood, the
best method of cleaning sponges : —

New sea-sponges should first be well beaten and
shaken, and afterwards a good stream of water
allowed to run through them, to get rid of as

230

PRACTICAL NURSING.

much sand as possible. They are then squeezed
dry, and transferred to a solution of hydrocliloric acid
( 3 ii. to Oi. of water), where they are left for twenty-
four hours. This dissolves out any pieces of shell or
coral they may contain. They are next washed in
steriUsed water (i.e., water which has been boiled for
fifteen minutes and then cooled), and afterwards placed
in a hot solution of washing soda ( 5 i- to Oi. of water).
They are next thoroughly rinsed in hot sterilised
water, and then placed for twelve hours in a cold
solution of sulphurous acid and sterihsed water (1
in 3). This bleaches them and completes the cleans-
ing process. It is important that the sponges should
be completely covered with this solution, as any part
of them which is exposed to the air becomes dis-
coloured. Finally, the sulj^hurous acid is washed out
of them with sterihsed water, and they are then placed
in a glass jar containing a 1 in 20 solution of carbolic
acid, where they remain till wanted. Tliis solution
must be changed once a-week.

Before an operation, the sponges are removed from
the jar with a pair of sterihsed forceps, and placed in
basins containing the antiseptic solution which the
surgeon is going to use. They should be handed in
the basins, the operator or his assistant squeezing
them out as they require them. They are then more
hkely to be aseptic than if they are wrung out by
the nm-se, since the less they are handled the better.
During the operation the sponges should be washed
by some one with aseptic hands in lukewarm sterihsed
water, so that the blood may not coagulate in them
as it would if hot water were used, and again handed |
to the surgeon in a basin of antiseptic solution.

PEODUCTION OP SURGICAL CLEANLINESS, 231

One nurse should attend to the sponges and dress-
ings alone, and, having previously thoroughly cleansed
her hands, should touch nothing during the operation
which is not sterile. Any sponges that have been
used for a foul wound, or that may have come in
contact with pus, should be destroyed. Any that
might fall on the floor would be placed on one side,
and not used again diu-ing the operation. Some
operators, not feeling satisfied that sea-sponges, after
being once used, can be rendered surgically clean,
prefer to use pads of gauze, or balls of absorbent
wool wrapped in gauze and steriUsed.

After an operation, the sponges should be thoroughly
washed at once in the cold soda solution, to get rid of
all fat and blood, before placing them in sulphurous
acid and sterilised water.

4. Instruments. — All instruments can be rendered
absolutely sterile by means of boiling water. A clean
sauce-pan will do perfectly well, though a metal ster-
iliser containing a vsdre basket in which the instru-
ments are placed is more convenient. The water
should first be brought to the boiling-point, then, a
teaspoonful of washing soda being added to each pint
of it, the instruments are immersed, and the water
kept on the boil for another five minutes. The instru-
ments are now sterile, and should be removed with
a pair of sterilised forceps from the soda solution or
the wire basket, and placed in a sterile dish containmg
1 in 60 carbolic lotion.

The object of boiling the water before placing the
instruments in it is to expel any air that it may con-
tain, as there is then less likelihood of their becoming
rusty. This is further prevented by the addition of

232

PRACTICAL NURSING.

the soda. Knives should have their blades wrapped
in white wool or lint to protect the edges. With the
instruments will be boiled any rubber or glass drainage
tubes that are going to be used.

5. Dressings. — These are sterilised by means of steam
in a special apparatus. This, when ordered by the
surgeon, should be done after the dressings have been
cut. They should be placed in the steriliser folded up
in a towel, which should not be opened imtil they are
just about to be applied. If the surgeon thinks they
are sufficiently sterile in the packets in which they are
suj^plied, great care should be taken that no dust gets
to them in their preparation.

The nurse should undo the packet, and then wash
her hands before touching the contents, which should
be laid on a clean towel and cut with sterilised scissors.
Directly the dressings are cut, they should be wrapped
in a sterilised towel and kept in an air-tight box till
wanted. With the dressings can be sterilised such
towels as are going to be used in the field of operation.

Silk which is going to be used for either sutures or
Hgatures is usually sterilised by boiling.

6. The Patient's Skin. — The great difficulty in steril-
ising the skin is to get rid of the greasy secretion
with which it is covered, since the germs which are
on it, being coated by this grease, are thereby pro-
tected against the action of the various disinfectants,
which are quite unable to penetrate it. That is the
reason why merely dipjomg the hands into a solution
of carbolic acid or perchloride of mercury is so abso-
lutely inefficient as regards the production of sui'gical
cleanliness.

PRODUCTION OF SURGICAL CLEANLINESS. 233

To begin with, the part should be shaved, and then
thox'oughly scrubbed with soap and hot water to
which has been added a Httle washing-soda. The
nail-brush, when not in use, should be kept in a solu-
tion of jDcrchloride of mercury. Afterwards it is well
rubbed with turpentine or ether to remove all grease.
A dressing soaked in weak carbolic (1 in 50) or per-
chloride lotion (1 in 2000) is then applied, and left on
till the time of operation. For children the lotion used
would only be half the above strength. This prepara-
tion of the part should be done at least twelve hours
before the time of operation.

7. The Hands. — The hands of the operator and all
his assistants must be rendered as nearly absolutely
clean as possible. For this purpose the nails should
be cut quite close, and the hands given a thorough
scrubbing with soap and hot water and an aseptic
nail-brush, after which they should be soaked for a
couple of minutes in an apjjroved antiseptic. When
a nurse has cleaned her hands in this way, she should
be very careful to touch nothing that is not sterile
imtil the operation is completed.

We are able to tell if the skin is aseptic by employing
the same method that is used for sponges or dressings.
A small piece of skin is snipped off with sterilised
scissors and dropped into a tube of broth, where any
germs that may be present will quickly grow and
multiply.

All surgeons and their assistants wear clean linen
blouses, so that no portion of their ordinary clothes
can come in contact with anything in the field of
operation.

234

PRACTICAL NURSING.

The air of an operating-room we cannot sterilise.
To minimise as far as possible the number of germs in
it, all dust should be avoided ; while irrigation with
weak antiseptic lotions is used to render harmless any
microbes that may stray from the atmosphere into the
wound.

235

CHAPTER XVII.

STnRGICAI. NimSING.

In this chapter it is proposed briefly to consider
surgical nursing .from a general point of view. Indi-
vidual operations, together with the special treatment
of certain wounds and injuries, will form part of the
next volume.

Wounds. — Open wounds may be : —

(a) Incised — i.e., made with a sharp cutting instru-
ment, and therefore presenting clean-cut edges.

(6) Lacerated, in which case the edges are ragged.

(d) Punctured, in which the external openmg is
small as compared with the depth of the woimd.

Incised wounds are liable to bleed freely, but, other
things being equal, heal rapidly. Lacerated and con-
tused wounds, on the other hand, bleed less and heal
more slowly. Punctured wounds, owmg to the small
external opening, are difficult to drain, and hence liable
to become inflamed.

Healing of Wounds. — This takes place in one of
two ways : —

1. Without Liflammation — i.e., without more than

236

PRACTICAL NURSING.

the temporary inflammation caused by the infliction
of the wound. The edges straightway become glued
together, and remain so. There is at no time any
discharge beyond a small quantity of blood-stained
serum in the first few hours. At the end of ten days
or a fortnight the wound has completely healed, a thin
red scar being all that remains of it. This is called
"pi-imary union," or "union by first intention." Tliis
is the way in which incised wounds usually heal, and
such punctured wounds as have been made by a clean
cuttmg instriunent, and contain no foreign matter in
their depths.

2. With Inflammation. — Some source of h-ritation
is present in the wound, which prevents the sides of
it becoming glued together and healing by jDrimary
union. As a result of this, the inflammation, which in
a clean-cut wound does no more than glue the edges
together, persists, and leads to the formation of pus.

This irritation may be due to the nature of the
injury — e.g., if the edges of the wound are bruised or
lacerated, they must die and be separated from the
adjacent healthy tissues before healing can take place.
Or it may be caused by the presence of a foreign body
or some poison in the wound, want of proper di'ainage,
or lack of vitality in the j)atient. Owing to one of
these causes, persistent inflammation is set up in the
wound, leading to the formation of pus, and con-
sequent slow process of healing by " granulation " —
"union by second intention," as it is called.

In such a case, about the thu'-d or fourth day after
the injury small red elevations are seen at the bottom
of the wound. These are called " granulations " or
"granulation tissue." Day by day this tissue grows

SURGICAL NURSING.

237

upwards from the bottom of the wound. It is so
delicate and easily irritated that even the dressings
which rest on it cause the cells which line its surface
to perish and separate from it.

When the granulation tissue has filled the wound,
and risen on each side to the level of the skin, the
latter begins to grow over it, until at last the whole
of the wound is covered with skin, and heahng is
complete.

The scar formed when healing takes place by this
method is very different from that which follows
"primary union." In that case, owing to the sides
of the wound at once growing together, practically no
new tissue is formed, so that scarring is reduced to a
minimum. When much granulation tissue is formed,
a well-marked scar is the necessary result, since all
the new tissue eventually develops into fibrous or
scar tissue. This, as it forms, very slowly contracts,
so that if the original injury, such as a deep burn,
caused much loss of tissue, the ultimate deformity
from contraction of the scar may be very great.

Treatment of Wounds. — Speaking generally, the
following precautions are necessary to ensure the
healing of a wound : —

The wound itself must be absolutely clean, and free
from all foreign matter which might irritate it and
set up inflammation. If necessary, it must be well
drained, so that there may be no accumulation of
discharges in it. That part of the body which has
been wounded must be kept at perfect rest. This is
most essential. The general health of the patient
must be maintained, and his surroundings rendered
as hygienically sound as possible.

238

PRACTICAL NURSING.

In wounds that are healing by " second intention "
the granulation tissue sometimes grows so exuber-
antly that it projects above the level of the skin,
which is in consequence unable to grow over it and
complete the process of healing. To remedy this, the
surface of the granulation tissue is destroyed by the
application of an astringent, such as nitrate of silver,
so that it is reduced to the level of the sldn, which
is now able to spread over it. In other cases the
granulation tissue is pale, flabby, and unhealthy look-
ing. For this a stimulating lotion or ointment is
applied, causing it to grow with increased vigour.

Skin-grafting.- — This form of treatment is employed
when a large area of graniilation tissue has to be
covered with skin, as after extensive burns. By
means of a very sharp knife, which should only go
just deep enough to draw blood, pieces of skin are
pared off the arm or leg of the patient, and, with
as little handling as possible, laid on the granulating
surface. The "grafts" are then covered with a piece
of oiled silk to prevent them adhering to the dress-
ings, which, as a rule, are left undisturbed for about
four days. Those grafts which adhere, and finally
grow on to the granulating surface, become centres
from which skin spreads outwards over the sore to
meet that which is growing inwards from the edges.
The time taken in healing is thus materially shortened.

Shock. — Shock is a condition of intense depression
of the nervous system, due either to injury or fright.
Gunshot wounds, burns, and injuries received in rail-
way accidents are especially liable to produce shock,
the two last-named more especially, from the state
of terror which is induced by them. Severe opera-

SURGICAL NUKSING. 239

tions, such as those on the abdommal viscera or
amputation through the thigh, are liable to be fol-
lowed by shock. A nervous, excitable patient will
sulfer more from shock than one who is calm and
phlegmatic. The same may be said of one who has
great mental worries, bad health, or who has been
poorly and improperly fed. The severity of this
condition after operation has been much lessened
since the introduction of anaesthetics, and since more
care has been taken in keeping up the warmth of
the body during operation.

Symptoms. — ^The patient lies in a condition of pros-
tration or coUapse. The pulse is rapid and smaU,
the temperature sub-normal, respiration sighing, ex-
pression anxious, while the skin of the face and trunk
is palHd and perhaps covered with a cold sweat.
There may be nausea and vomiting, and in severe
cases relaxation of the sphincters, leading to incon-
tinence of iu"ine and fseces. If the patient fails to
rally from this condition, death ensues.

Treatment. — To remove the depression of the ner-
vovis system, and resuscitate the patient's vital powers,
we use warmth externally and stimulants internally.
Pillows should be taken away, and the foot of the bed
raised. Hot blankets are then vsrrapped round the
patient, and hot bottles placed near him, care being
taken that the latter are properly protected by flannel,
since shock is accompanied by a lessened sensibility to
pain, so that a burn might easily be produced with-
out the patient knowing it. A fomentation applied
to the region of the heart, or to the periuEeum, is a
very useful method of stimulation. While external
warmth is being applied, stimulants should be ad-

240

PRACTICAL NURSING.

ministered internally. Hot beef-tea, coffee, and tea
are all useful, if the patient is able to take them.
They should be drunk slowly, in small quantities at
a time. Should vomiting be troublesome, rectal in-
jections will have to be used. Hypodermic injections
of strychnia, ether, or brandy are most usefid, and
in many cases indispensable, in the treatment of
severe shock. Morphia or opium is used if much pain
is present as well as shock, so that it seems probable
that the latter may to a certain extent depend upon
and be due to the former. Warm sahne solutions are
sometimes injected into a vein ^vith the happiest
result.

In the treatment of shook care must be taken that
the stimulation does not go too far, or an injiu'ious re-
action may be produced. All that is wanted is to
restore the exhausted nervous system to its normal
condition. As soon as the pulse begins to improve,
and the patient to show signs of returning strength,
the stimulants should be gradually discontinued.

The Preparation of a Patient for Operation. — If
possible, a warm bath should be given the evening be-
fore. That part of the sldn which is to form the field
of operation is then jDrej^ared in the manner Avhich has
been already described (p. 232). A pui'gative is after-
wards administered. This may be any medicine the
patient has been accustomed to take, if it is known
to be effective. It shoidd be followed in the earl}^
morning by a soajj-and- water enema, and this, if
it brings away much fvGoal material, by one of plain
warm water. If the operation is abdominal, parti-
cularly if it is in any way connected with the bowel,
the nurse ought to obtain detailed directions as to

SURGICAL NUESING.

241

this i^art of tlie preparation, since the usual procedure
might do harm, "While preparing a patient for opera-
tion, the nurse should do what she can to keep his
spirits from failing, by taking a cheerful view of the
case, and sjjeaking of the good that will result from
the operation.

As a ride, no solid food is allowed to be taken
during the six hours immediately preceding the time
of operation ; otherwise the patient will probably
vomit while u.nder the ana3sthetic, in which case there
is a risk of food getting into his air-passages. There
is no objection, however, to a cup of hot beef-tea, or
some stimulant and water, being given a couple of
hours before the surgeon's arrival. These are both
very quickly absorbed, and hence stay but a short
time in the stomach. In the case of patients who are
very weak, and in constant need of nourishment, it is
as well to ask for instructions in this matter.

Before going to the theatre the hair should be
brushed, and in females plaited on either side and
arranged without hair-pins, so as to be out of the
way of the operator and his assistants. False teeth
shoidd be removed, and the patient attired in a
clean night-dress, stockings, and warm flannel opera-
tion-gown. Just before the operation the patient
should pass water ; in abdominal cases the catheter
should be used, to make certain that the bladder is
empty ; while if the operation is likely to involve that
organ, the nurse should ask for directions.

The Operation-Bed. — This is made in the ordinary
way, except for very special cases. It is as well, in
case of accident, to place a macintosh beneath the
under sheet, which, together with the draw-sheet,

VOL. I. Q

242

PRACTICAL NURSING.

must be tucked in tightly to prevent rucking. If
there are any symptoms of shock or collapse after
the operation, a blanket should be placed between
the patient and the upper sheet. The bed should
be thoroughly warmed by means of three hot-water
tins encased in flannel bags. Care must be taken
that the patient does not burn himself against the
tins. This is an accident which reflects great dis-
credit upon the nurse in charge of the case. It is
one that may easily happen to a patient who is still
under the influence of the ansesthetic or is sufi'ering
much pain. The upper bed-clothes should be laid
loosely on the bed, so that they may be quickly
thrown back the moment the patient arrives. The
pillow should be low and covered with a towel, or
taken away altogether, another towel being at hand
to tuck round the patient's neck and protect the
upper sheet. A vessel should be placed at the bed-
side in case of sickness. The patient should not be
left by himself xmtil he has completely recovered
from the auEesthetic. If he shows signs of vomiting,
his head should be turned on one side and the vessel
placed near his mouth.

Feeding- Patients after Operation. — As a rule, no

food is administered for three or four hours after an
operation, or imtil the nausea which follows the anes-
thetic has passed off. ISTot too much ice shoidd be given
the patient to suck if he complains of thu^st, as this
is only hkely to prolong the ^-omiting. If, however,
small pieces are swallowed whole instead of being al-
lowed to melt in the mouth, ice is really usefid for the
checking of nausea. Sips of hot water are preferable.
A tumbler of hot water is often a most usefid form of

SUEGIGAL NUESING.

243

treatment for persistent ether or chloroform sickness,
since, when returned, it practically washes out the
stomach. Iced compresses to the neck also help to
check vomiting. This they do by acting upon the
two great nerves which run from the brain to the
stomach, one lying in each side of the neck. If the
patient is very weak or collapsed, it may be necessary
to administer food or stimulant by the rectum almost
immediately after the operation. The urgent desire
for drink which follows upon great loss of blood is
sometimes rrlieved by slowly injecting into the bowel
half a pint to a pint of warm water with a pinch of
salt in it. The nurse should have the necessary ap-
paratus for rectal feeding ready, as weU as a syringe
for the subcutaneous injection of strychnia or ether.
As the effects of the ancesthetic pass off, food should
at first be given in very small quantities by the
mouth — half an ounce of milk at a time — the amount
and frequency of administration being gradually in-
creased. No rules can be laid down with regard to
the length of time that should elapse before the
patient reaches his ordinary diet, since surgeons differ
widely in their practice on this point. Should the
patient's temperature rise during convalescence, it is
always a safe plan to place him on milk until the sur-
geon's wishes are known.

The Dressing- of Wounds. — The first dressing after
an operation is usually done by the surgeon, or in a
hospital by the house surgeon. When preparing the
dressings, the nurse must pay the same attention to
detail that she did for the operation.

Everything that is likely to touch the wound, or be
required by the surgeon, should be sterile ; and the

244

PEACTICAL NURSING.

nurse should wash her hands in the same careful
manner, and touch nothing afterwards which is not
sterile without taldng this precaution again. The
scissors which will cut the sutures, and the forcejDS
which will remove them, should be i-endered sterile by
boiling.

The dressing of granulating wounds — such as burns,
scalds, &c. — is often left to the nurse. Before un-
covering the wound, she should see that she has
everything she is likely to want for the dressing. The
edges of the wound should be kept quite clean, the
adjacent skin being occasionally washed ^vith soap and
water, the wound itself meantime being covered with
a temporary shield of wet lint. Kubbing should
always be away from the wound, the sides of which
should at the same time be supported by the other
hand, so that no strain may be put on them, otherwise
healing will be retarded. Moist absorbent wool may
be used for sponging, or odds and ends of gauze left
over from dressings, and kept in a clean jar. After
once touching the wound, they should not again be
dipped in the lotion, but be placed in the receiver
for soiled dressings. When it is necessary to sponge
a wound, the sponge should be pressed firmly on the
surface of the wound and not drawn across it.

Should the old dressing adhere to the wound, it
should be thoroughly soaked with lotion before any
attempt is made to remove it. Strapping should be
first moistened, and then taken off by lifting the two
ends, and at the same time pulling them sharph^
towards the wound. This is much less disagreeable
than doing it slowly and gently. If the part has
much hair on it, it sliould be sliaved before the

SURGICAL NURSING.

245

strapjDing is applied, otherwise the process of removal
is very painful. Turpentine will remove any marks
left on the skin by strapping, care being taken that it
does not touch the wound, and that it is afterwards
washed off with soap and water. When the surface
of the wound is being cleansed by means of a glass
syringe, or an irrigator, the nurse should not allow
the nozzle of the instrument to become soiled by the
discharge. Soiled dressings should be handled as
little as possible. They should not be carried round
from bed to bed, but be removed from the ward as
soon as fresh ones have been put on.

It is not only m the operating-theatre that a nurse
must attend to small details of cleanliness ; all her
work should be done in the same thorough manner.
She should wash her hands before attending to each
patient, and when dressing wounds, making beds, or
doing ward work, she should remove her cuffs and
turn up her sleeves. Wounds should not be dressed in
a ward where beds are being made, or where dusting
and sweeping have but lately been finished.

The Importance of Rest in the Healing- of
Wounds. — This has already been mentioned earlier
in the chapter. It can do no harm to again call
the attention of nurses to the fact that if the edges
of a wound or a broken bone are not allowed to
remain in complete apposition (i.e., if they are in
the least degree separated by movement of the jDart),
liealing is prevented or much retarded. A patient
should therefore not be allowed to do anything for
himself, entailing movement of the injured part,
until the surgeon considers healing complete. It is
to ensure this most necessary rest that splints and

246

PRACTICAL NURSING.

bandages are applied ; and it is most important
that a surgical nurse should clearly understand why-
such things are used, their action, and method of
adjustment. Further, she must see that they do
not shift after they have been once put on. She
should also find out in what position the surgeon
wishes his patient to lie, since, after amputation of
the breast, some surgeons like their patients to lie
on their backs, others prefer to have them on their
sides. In whatever position the patient is placed,
he must be made as comfortable as possible, and
pillows arranged so as to lessen the aching weariness
of remaining long in one position. Finally, nm'ses
should remember that useful little saying, " Never
move a patient twice when once will serv^e."

The Preparation of Lotions. — All nm-ses should

understand how to prepare lotions from concentrated
solutions. Many do not ; wliile others, though work-
ing correctly, do so by rote. A few words in ex-
planation of this part of a surgical nurse's duty may
prove helpful.

If we take 1 pint of a lotion containing 1 ounce
of carbohc acid in each 20 ounces of the solution, and
add to it another 20 ounces of water, we get a lotion
containing 1 ounce of carbolic acid in each 40 ounces
of the solution, or, as we say, it is of the strength of
1 in 40 (i.e., 1 part of the acid in 40 parts of the
lotion), and is therefore half the strength of the 1
in 20. If we add 40 ounces of water, we make it
1 in 60, or one-third the strength of the 1 in 20.

To take a more difficult example. A nurse is given
a bottle containing a 1 in 50 solution of jDercliloride
of mercury (i.e., a solution containing 1 grain of per-

SUKGTCAL NURSING.

247

chloride of mercury in each 50 drops). She is told
to make a pint of 1 in 1000. Simple division tells
us that 50 goes into 1000 twenty times. A solution
containing a grain in every 50 drops is therefore
twenty times the strength of one containing a grain
in every 1000 drops. One part of the former must
therefore have 19 parts of water added to it to bring
it down to the required strength — i.e., 1 ounce of the
1 m 50 solution added to 19 ounces of water will make
a pint of 1 in 1000. Similarly 1 ounce of the 1 in 50
added to 39 ounces of water makes 1 in 2000, added
to 59 ounces of water makes 1 in 3000. Some nurses
have a difficulty in seeing this. They think that if
one solution is twenty times stronger than another,
the first ought to be diluted with 20 parts of water,
instead of 19, to bring it down to the strength of the
second. Let us take two solutions, one of the strength
of 1 in 1 (i.e., a grain in each drop), and the other
1 in 20 (i.e., a grain in each 20 drops). The first is
clearly twenty times stronger than the second ; but to
convert 1 in 1 into 1 in 20, we add 19 parts of water
to the one part of water in which the grain is already
dissolved. If we added 20 parts of water, our solution
would be of the strength of 1 in 21 instead of 1 in 20.

INDEX.

Air- and water-beds, 38.
Albumen, how to test for, in

urine, 90.
Alcohol, how to give, 99.
Alimentary system, observation

of, 65.

Antifebrin and antipyrin, 192.
Antipyretic drugs, objection to,
114.

Antiseptic surgery, 223.
Antiseptics, 224.
Applications, hot and cold, 138.
Arsenic, 193.

Asepsis, ]Droduction of, 227.
Aseptic surgery, 224.
Atropine, 193.

Bath, cold, 115.
hot, 126.
hot-air, 129.

tepid, gradually cooled,
117.

vapour, 131.
Bathiug a patient in bed, 45.
Baths and packs, cold, 110.

and packs, hot, 125.

hot, precautions when giv-
ing, 133.

miscellaneous, 134.
Bed-making, 36.
Bed-pans, 39.

Bed-sores, 50.
Belladonna, 193.
Blistering, 156.
Boracic acid, 226.
Bran-bag, hot, 150.
Bread-jelly, 98.
Bromide of potassium, 193.

Capsules, 184.

Carbolic acid, 193, 225.

Castor and cod-liver oils, how to

give, 183.
Catheter, passing the, 56.
Cheyne-Stokes breathing, 71.
Chloral, 193.

Circulatory system, observation

of, 68.
Cold applications, 151.
Coma, 72.

vigil, 65.
Compress, iced, 152.
Contagion and disinfection, 211.
Convulsions, 72.
Counter-irritants, 154.
Cradling, 123.

Cumulative action of drugs, 192.
Cupping, 159.

Dead, care of the, 59.
Diet in acute disease, 93.
in convalescence, 105.

INDEX.

249

Digitalis, 193.

Disinfectants and deodorants,
213.

Disinfection of patient and sur-
roundings, 214.

Dose of solution, how to deter-
mine, 195.

Douche, nasal, 163.

Dressings, sterilisation of, 232.

Dyspnoea, 69.

Ear, how to syringe the, 164.
Enema, gravitation, 172.
Enemata, various, 170.
Excreta, disinfection of, 216.
Expectoration, varieties of, 71.

Feeding of patient after opera-
tion, 242.

Feeding of patient by the nurse,
101.

Fever diet, 100.
Fever, forms of, 81.

modes of termination, 82.
Fomentations, 147.
Forced feeding, methods of, 205.

Germs, 221.

Hremoptysis, 72.
Hands, sterilisation of the, 233.
Hygiene of the ward, 16.
Hypodermic injections, 187.

Ice-bag, 151.
Inflammation, 138.
Inhaler, 186.

Instruments, sterilisation of, 231.

Inunction, 190.

Iodide of potassium, 194.

Iodine as a counter-irritant, 155.

Iodoform, 226.

Izal, 226.

Leaves, mustard, 155.
Leeches, 157.

Leiter's tubing, 153.

Linen of fever patient, treatment

of, 215.
Liniments, 156.
Long rectal tube, 178.
Lotions, evaporating, 152.

preparation of, 246.
Lysol, 226.

Medicines and their administra-
tion, 181.
Medicines, when to give, 184.
Mercury, 194.

and zinc, cyanide of,
226.

biniodide of, 226.

perchloride of, 225.
Milk, treatment of, when causing

indigestion, 95.
Morphia, 194.

Nervous system, observation of,
72.

Nose, how to syringe the, 162.
Nux vomica, 194.

Ointments, 160.
Operating theatre, 227.
Opium, 194.

Pack, cold, 119.
dry, 132.
hot wet, 132.
Palatinoids, 184.
Paralysis, 73.
Patient, daily wash of, 48.

moving a helpless, 55.
observation of the, 01.
preparation of, for oper-
ation, 240.
Patient's skin, sterilisation of,
232.

Pediculous head, treatment of, 46.
Personal care of the sick, 44.
Perspiration, sensible and in-
sensible, 111.

250

INDEX.

Pills, 183.

Plaster, mustard, 154.
Pneumonia }aoket, 150.
Poultice, ice, 152.
Poultices, various, 142.
Powders, 184.
Pulse, varieties of the, 77.

Quinine, 194.

Raw meat juice, 97.
Rectal feeding, 173.

medication, 191.
Respiration, changes produced in

air by, 17.
Respiratory system, observation

of, 68.
Rigor, 74.

Salicylate of soda, 195.
Shock, 238.

Sick children, nursing of, 198.
Sick-room, temperature of the,
28.

Siegel's spray, 187.

Skin, functions of the, 110.

Skin-grafting, 238.

Sleeplessness, 73.

Speech, loss of, 73.

Sponges, sterilisation of, 229.

Sponging, cold, 121.

hot, for pyrexia, 122.

Spongiopiline, 148.
Strychnine, 194.
Sugar, how to test for, in ui-ine,
92.

Suppositories, 179.
Surgical cleanliness, 221.
nursing, 235.

Teeth, cleaning of patient's, 48.
Temperature of body, taking the,
83.

Throat, how to syringe the, 161.

Urine, 85.

examination of the, 88.
incontinence of, 87.
measuring, 87.
retention of, 87.
suppression of, 86.

Vapour bath, 131.
Ventilation, nui-se's duty with
regard to, 21.
principles of, 18.

Ward, temperature of the, 25.

work in a, 30.
Washing out the bowel, 178.
Weights and measures, 195.
Whey, 96.

Wounds, dressing of, 243.

varieties of, 235.

THE END.

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