LECTURES ON MEDICINE LECTURES ON MEDICINE 
A HANDBOOK FOR NURSES 
\/ BY 
CHALMERS WATSON, M.D., F.R.C.P.E. 
LECTURER ON CLINICAL MEDICINE, EDINBURGH UNIVERSITY 
SENIOR ASSISTANT PHYSICIAN, ROYAL INFIRMARY, EDINBURGH 
AUTHOR OF 
"FOOD AND FEEDING IN HEALTH AND DISEASE" 
"THE BOOK OF diet" 
Etc. 
NEW YORK: 
WILLIAM WOOD AND COMPANY 
MDCCCCXVIII PREFACE 
The curriculum for a nurse's training includes a series 
of lectures in medicine. On several occasions in the 
past few years it has fallen to me to give the lectures, 
ten in number, which comprises the theoretical part 
of the training in medicine given to the nurses in the 
Royal Infirmary, Edinburgh. On each occasion I 
have been impressed by the difficulty of presenting 
in ten lectures a satisfactory epitome of the principles 
and practice of medicine, in a form appropriate to 
nurses. The efficiency of a nurse bears a direct ratio 
to the knowledge she possesses of the nature of the 
disease in her patient, and to the principles guiding 
the physician in its treatment. In practice I have 
frequently found that the interest of nurses in their 
cases, and their ability to help the patient and the 
doctor, were in some measure prejudiced by defects 
in this direction-defects for which the nurse is hardly 
responsible. In my experience nurses as a class are 
extremely keen to make themselves more efficient, 
and they appreciate highly the instruction gained 
in their contact with the doctor. 
The lectures now published have been given at various 
times in the Royal Infirmary, either in the form of 
set lectures made as practical as possible, or in the 
form of bedside clinics to the nurses in my own wards, 
and the extent to which they have been appreciated 
has led me to issue them in their present form. 
V VI 
PREFACE 
Some readers may consider that the subject-matter 
of these lectures goes to some extent outside the re- 
quirements of a nurse, and is better adapted for the 
student or practitioner. I do not share this view. 
A nurse's training includes lectures on anatomy, physi- 
ology, materia medica, bacteriology, etc., all of which 
form the ground-work for her practical training. It 
has always seemed to me advantageous, alike from 
the patient's point of view and the doctor's, that the 
nurse should have a more thorough training in medicine 
than is possible in a short course of lectures, and my 
experience has shown me that the more completely 
nurses are equipped in this direction, the less likely are 
they to exceed their legitimate sphere of work. 
No attempt is here made to cover the whole ground 
of medical nursing. My aim has rather been to ex- 
tend the knowledge of the nurse in such a way as to 
secure in the highest degree her intelligent and effective 
co-operation in the management of her patients, and 
to be of as much assistance as possible to the physician 
in the investigation of the numerous diseases which 
through lack of knowledge are at present treated em- 
pirically. The intelligent co-operation of the nurse 
is of much value to the physician in any investigation 
he may undertake with the object of increasing our 
knowledge of the causation of disease, and so increasing 
our power of treating it. CONTENTS 
CHAP. PAGE 
I. Disorders of the Digestive System. 
Indigestion - Constipation - Gastric Ulcer- 
Duodenal Ulcer - Chronic Appendicitis - 
Colitis-Jaundice-Cirrhosis of the Liver . 1 
II. Disorders of the Blood and Ductless Glands. 
Anaemia - Addison's Disease - Exophthalmic 
Goitre ....... 45 
III. Disorders of the Heart and Circulation. 
The Pulse-Arterio-Sclerosis-Heart Disease- 
Aneurysm - Cerebral Haemorrhage, Throm- 
bosis and Embolism ..... 57 
IV. Disorders of Respiration. 
Bronchitis-Pneumonia-Asthma-Pulmonary 
Tuberculosis ...... 83 
V. Disorders of the Kidneys. 
The Urine-Acute Nephritis-Chronic Neph- 
ritis-Uraemia . . . . . .106 
VI. Disorders of the Nervous System. 
Neurasthenia - Unconsciousness - Peripheral 
Neuritis-Diseases of the Spinal Cord-General 
Paralysis of the Insane-Tumour of the Brain 
-Mental Derangement .... 127 
VII VIII 
CONTENTS 
CHAP. PAGE 
VII. Fevers. 
Measles-Scarlet Fever-Diphtheria-Cerebro- 
spinal Fever-Typhoid Fever . . .167 
VIII. General Conditions. 
Rheumatism and Rheumatoid Arthritis- 
Glycosuria and Diabetes-Poisons-Acute 
Alcoholism . . . . . . .198 
IX. Diet.' 
Dietary in Fevers - in Convalescence - in 
Auto-intoxication-in Chronic Heart Disease 
-Hospital Di> taries . . . . .231 
ILLUSTRATIONS. 
Radiograms of Bismuth Test Meals in the 
Stomach ...... . To facep. 7 
Radiograms of Heart Disease . . . „ „ 65 
Pulse Tracing Page 82 
Temperature Charts .... Tofacep. 105 CLINICAL LECTURES 
FOR NURSES 
CHAPTER I. 
DISORDERS OF THE DIGESTIVE SYSTEM 
INDIGESTION. 
(Syn. Dyspepsia.) 
Indigestion should never be regarded as a disease 
but as a symptom, and careful investigation is at all 
times desirable to ascertain the cause of the " indi- 
gestion." Many people suffer needlessly from prolonged 
symptoms of indigestion, and are treated empirically by 
various " stomach " medicines without benefit, when an 
adequate investigation would prove that the symptoms 
of indigestion are not dependent upon any primary 
derangement of the stomach, but are due to disease 
in another part of the digestive tract, or even to some 
general constitutional condition such as tuberculosis. 
Indigestion manifests itself in many ways. There 
may be loss of appetite and disinclination for food, 
or, more rarely, the appetite may be abnormally good, 
not being satisfied even by a large meal. A sense 
of weight and discomfort even amounting to pain after 
food are common symptoms ; this may occur immediately 
after food or from one to two hours after the meal. 
Eructations of gas and fluid of an unpleasant sour 2 
character (water brash) and vomiting are met with 
in varying degrees. Distension of the abdomen and 
flatulence may be the chief complaint. A varying 
degree of general asthenia, often pronounced, possibly 
with some loss of weight may complete the picture. 
On what do these symptoms usually depend ? Un- 
doubtedly in their simpler forms symptoms of indi- 
gestion are dependent on a slight degree of gastric 
catarrh, associated with injudicious feeding, irregularity 
in meals and hurried eating, often combined with con- 
stipation. The recognition of these causes and their 
correction will speedily effect a cure, little being necessary 
in the way of special medical treatment. It is, however, 
specially important to bear in mind that symptoms of 
chronic indigestion are very commonly due, on the 
one hand to disorders of the digestive tract below the 
stomach, and on the other to certain constitutional 
conditions ; and under modern conditions adequate 
investigation, including careful examination of the 
stools, and the use of bismuth test-meals, may be neces- 
sary to establish an accurate diagnosis. The more 
important of these conditions are as follows :- 
A. Focal Disease. 
1. Disease in the appendix region is a frequent 
cause of what is commonly called chronic indi- 
gestion. This takes the form of some chronic 
focus of mischief in the appendix, often associated 
with adhesions, which interfere with the free passage 
of the food, inducing marked stasis in the ileum 
with resulting fermentation and absorption of 
toxins. This condition has been termed appen- 
dicular dyspepsia. 
CLINICAL LECTURES FOR NURSES 3 
2. A gastric or duodenal ulcer is a frequent 
cause of chronic indigestion. The symptoms and 
physical signs present in cases of ulcer vary widely, 
and unless a thorough investigation is made, the 
real nature of the condition is overlooked, the 
condition being regarded merely as a case of " indi- 
gestion." Such cases are often associated with 
marked dental sepsis and pyorrhoea, and not in- 
frequently with an excessive secretion of acid in 
the stomach (hyperchlorhydria). 
3. Severe chronic constipation, unattended by any 
disease in the appendix region, is also a frequent 
cause of symptoms of chronic indigestion, the 
symptoms being due in great part to a dragging on 
the stomach and small bowel, from a chronically 
overloaded and displaced large intestine. The 
X-rays have special value in the diagnosis of this 
condition. 
4. Gall-stones are a not infrequent cause of 
chronic indigestion; the attacks of pain are, how- 
ever, less severe than those usually present in 
pronounced cases of gall-stones. 
5. Some local affection of the uterus or ovaries 
is sometimes the origin of the indigestion, and in 
all cases careful attention must be directed to the 
condition of the pelvic organs. 
B. Constitutional Conditions. 
Of constitutional conditions the more important 
are tuberculosis, ansemia, cancer, chronic Bright's 
disease, and diabetes. A troublesome indigestion, more 
DISORDERS OF THE DIGESTIVE SYSTEM 4 
CLINICAL LECTURES FOR NURSES 
especially in young subjects, who are pale and out of 
condition, is very often due to incipient tuberculosis, the 
symptoms being really due to a tuberculous toxaemia. 
It will be seen from the above that strictly speaking 
there is no such thing as the treatment of indigestion. 
What we must attend to is the treatment of the condi- 
tion which is causing the indigestion. This necessitates 
a thorough investigation, in the course of which much 
assistance of value may be obtained from the careful 
observation and assistance of a skilled nurse. 
The following case may be taken as a typical and 
instructive example of " indigestion," of appendicular 
origin :- 
This young married woman suffered from indigestion 
for the past four years, during which various treatments 
had been tried without lasting benefit. Her chief symp- 
toms were vague abdominal discomfort, with occasional 
attacks of pain which bore no distinct relation to food, 
want of appetite, flatulence, and a marked general weak- 
ness. For the past two years she had felt quite unfit for 
ordinary domestic duties, making her life a rather trying 
one both for herself and her husband. At times she looked 
in fairly good health, which suggested to her doctor and 
her friends that she was " neurotic." On admission she 
was pale, thin, and of rather unsatisfactory colour. The 
abdomen was a little full, and occasionally some tender- 
ness on pressure was observed in the epigastric and ileo- 
caecal regions. The bowels were constipated and the 
stools were markedly offensive. X-ray examination re- 
vealed marked stasis in the ileum and colon. The case 
was clearly one of appendicular indigestion with a resulting 
condition of neurasthenia, this diagnosis being confirmed 
by operation. There is good reason for thinking that the 
complete freedom of symptoms afterwards established by 
the operation will be permanent; special attention to the 
action of the bowels was essential to complete success. 5 
DISORDERS OF THE DIGESTIVE SYSTEM 
CONSTIPATION. 
(Syn. Intestinal Stasis.) 
Constipation is one of the commonest and most 
important disorders occurring in every-day practice. 
It implies defective action of the neuro-muscular mech- 
anism of the bowel, as a result of which the contents 
of the large intestine are retained too long, thus allowing 
of the absorption of toxic products into the system, 
and inducing the phenomena of auto-intoxication. 
We will refer, firstly, to the general conditions which 
result from constipation, and, secondly, to the local 
conditions in the digestive tract which predispose 
to it, or which are brought about by its presence. 
(a) General symptoms of ill-health arising from 
chronic constipation. 
These are of the most varied kind. A remarkable 
degree of tolerance is exhibited by some people to 
constipation. Occasionally we meet with cases of 
fairly aggravated constipation where the patient feels 
and looks in good average health. This is explained 
in two ways. In the first place these patients have 
a high degree of resistance against the poisons, no bad 
effects being revealed until that resistance is overcome, 
as it will be sooner or later ; in the second place im- 
munity to symptoms in certain cases of constipation 
is probably due to the fact that the lining membrane 
of the bowel is still intact and is free from catarrh. 
Sooner or later, however, a certain degree of catarrh 
is induced, which allows of the much more ready ab- 
sorption of poison, the symptoms of auto-intoxication 
becoming thereby very evident. As a general rule, 6 
however, constipation involves ill-health and is very 
often of a serious kind. The more common clinical 
conditions arising from chronic constipation include 
the following :-Chlorosis or simple anaemia in young 
subjects, anaemia of so-called pernicious type occurring 
in adults, rheumatism and rheumatoid arthritis, neur- 
asthenia, and chronic indigestion. All of these symp- 
toms arise primarily in most cases from chronic con- 
stipation. Intestinal stasis undoubtedly also plays a 
part in inducing other common diseases, such as arterio- 
sclerosis and chronic renal disease. 
(6) The local conditions in the digestive tract asso- 
ciated with chronic constipation. 
It is important to realise that the underlying fault 
in chronic constipation may lie in the terminal part 
of the ileum, the ascending colon, the rectum, or in the 
intermediate transverse or descending colon. In many 
cases the defect is general, involving the whole bowel. 
Probably the most common part first to be affected 
is the caecum and ascending colon, the stagnation or 
stasis in this portion of the bowel being very often associ- 
ated with stasis in the terminal portion of the ileum. 
This ileal stasis, according to some authorities, is the 
most important and primary disorder. X-ray examina- 
tion, after a bismuth test-meal, is invaluable for giving 
precision in diagnosis, both with regard to the part of 
the bowel first affected and as to the exact cause or 
causes. 
When a case of chronic constipation of moderate 
severity is examined with the X-rays, it will be found 
that there is a remarkable degree of slowing of move- 
ment of the bismuth contents through the bowel. In 
CLINICAL LECTURES FOR NURSES 1. Stomach after ingestion of bismuth 
meal. Note the shape and size of 
the organ, which is here somewhat 
enlarged and atomic. 
2. Stomach one hour after ingestion 
of bismuth meal-hour-glass con- 
traction of stomach. Note the 
narrow constriction between the 
two parts of the stomach, due to 
cicatrisation from old ulcer. 
3. The caecal region six hours after 
bismuth meal. Showing retention 
of food in stomach (gastric stasis), 
and also undue delay in ileum (ileal 
stasis). Note that the stomach is 
displaced downwards. None of the 
bismuth has yet passed into the 
large bowel. 
4. Large intestine forty-eight hours 
after bismuth meal. Shows marked 
delay (stasis) in transverse colon 
which is also elongated and mark- 
edly displaced downwards. 
To face /. 7. 7 
health, when a bismuth meal is given at ten o'clock 
in the morning, two-thirds of that meal should be in 
the caecum and ascending colon in six hours. In twenty- 
four hours the bismuth should have largely disappeared, 
or a little only left in the rectum or descending colon. 
In cases of chronic constipation, on the other hand, 
at the end of six hours a marked degree of ileal stasis 
is frequently present, little or none being beyond that 
point (Fig. 3). After twenty-four or forty-eight hours 
the caecum or transverse colon may still be full, some 
of the bismuth having now reached the descending 
colon and rectum (Fig. 4). A similar condition may 
be present after seventy-two hours or longer. 
Much depends, as I have indicated, on the severity 
of the condition, and on which part of the colon is 
primarily affected. In all long-standing cases there 
is usually associated a dilatation of the affected part 
of the colon, and also a displacement of the bowel. 
Thus it is common to find the transverse colon very 
much proptosed, the middle part of the transverse 
colon may even lie in the pelvis (Fig. 4). This dis- 
placement of the colon is in turn a complicating factor 
as it further increases the difficulty. Not infrequently 
there are also adhesions extending from the colon to 
the abdominal wall or from one part of the bowel to 
another, and the effect of these adhesions is to still 
further increase the stasis. 
Before discussing treatment reference may be made 
to one or two further points of importance. It should 
be kept in mind that marked constipation may be 
present, even when the bowels move regularly-but 
inefficiently-every day. Intercurrent attacks of slight 
diarrhoea are not infrequently met with in cases of 
DISORDERS OF THE DIGESTIVE SYSTEM 8 
CLINICAL LECTURES FOR NURSES 
aggravated constipation, and may indeed be almost 
symptomatic of the condition. A distinct sluggish- 
ness of action is often present in women for a day or 
two prior to menstruation, and is still more pronounced 
as a rule in pregnancy. 
General Treatment. 
Before the treatment of any given case can be laid 
down, it is essential that an accurate diagnosis be made 
as to the part of the bowel chiefly affected, and as to 
whether there are any local contributory causes, such 
as adhesions, which might possibly prejudice the suc- 
cess of purely medical measures. The use of charcoal to 
colour the stools is a simple means of testing the rate 
of intestinal movement; if it remains in the stools 
beyond forty hours a corresponding degree of stasis 
is present. It is by no means uncommon to find sub- 
jects of constipation who have the greatest reluctance 
to taking any drugs, for fear of permanent harm to the 
bowel being induced. This idea is ill-founded, and 
much greater harm to the system results from the 
neglect of the bowel, than from attention to its function 
by the judicious use of aperients. At the same time 
we must remember that purgative remedies are palli- 
ative and not curative in their action, and it is always 
advisable to attempt the cure of the condition. This 
is readily effected even in obstinate cases if time and 
trouble are taken, and massage and physical exercises 
are applied under skilled direction. At the outset 
it is frequently necessary to have recourse to soap and 
water enemas, often combined with the judicious use 
of olive oil. The introduction of 8 to 10 ozs. of olive oil, 
followed in half-an-hour by an enema of soapy water -2 to 21 pints-may suffice to clear out the bowel. 
Frequently, however, the enema has to be repeated 
for days before the bowel is effectually cleared. There 
are many points of detail in the subsequent manage- 
ment of these cases which must be attended to if a cure 
is to be obtained. These are here summarised as 
follows :- 
1. It is advisable to cultivate regularly daily 
evacuation by morning visits. This is of the first 
importance. Neglect of this salutary habit plays 
an important part in the development of the trouble. 
2. A tumbler of hot water sipped slowly in the 
morning during dressing is useful in exciting the 
reflexes which regulate intestinal movement. 
3. Meals should be taken at regular intervals 
and masticated thoroughly. Special care should 
be directed to seeing that the condition of the teeth 
is thoroughly satisfactory. 
4. Many patients find that certain articles of 
diet have a useful laxative effect, more especially 
when taken in the morning, such as fruit, marma- 
lade, or other preserves. Oatmeal, brown bread, and 
green vegetables have a useful effect, on account 
of the relatively large amount of " ballast " formed 
from them. It is desirable to keep in view the 
importance of taking an ample supply of fluids, 
especially between meals. 
5. Drugs.-Drugs are useful for the relief, rather 
than for the cure of the condition. For habitual 
use, the best remedies include figs, e.g., syrup of figs ; 
prunes, e.g., in the form of a prune paste (prunes, 
DISORDERS OF THE DIGESTIVE SYSTEM 
9 10 
CLINICAL LECTURES FOR NURSES 
senna, and ginger), senna, e.g., senna pods. These 
are simple vegetable tonics or mild laxatives. As 
useful lubricants, special value attaches in many 
cases to the use of paraffin or petroleum and agar- 
agar, of which there are many preparations on 
the market. Drugs which excite peristalsis in- 
clude cascara, nux vomica, aloin, and these are 
given in tonic doses twice or thrice daily. Calomel 
and euonymin are useful as combined hepatic and 
intestinal stimulants. Any tendency to undue 
griping is relieved by the use of small doses of 
belladonna. In certain cases a morning saline is 
the best remedy, more especially in adult and 
later life. 
6. Some simple muscular exercises, and more 
especially exercises adapted to strengthen the 
abdominal muscles and promote a free natural 
movement of the diaphragm, are of the very first 
importance. Five or seven minutes' devotion to 
this once a day is an excellent investment for 
health. 
7. Massage applied to the spine and to the 
abdominal muscles, especially combined with a 
course of active and passive exercises to restore 
the tone of the abdominal muscles, vessels, and 
nerves, is the most important remedial measure 
in our possession. This involves at least half- 
an-hour's treatment daily, and requires to be 
continued for a few weeks if the constipation is 
to be cured. DISORDERS OF THE DIGESTIVE SYSTEM 
11 
GASTRIC ULCER. 
Epigastric pain aggravated by food, vomiting, and 
haematemesis, occurring in a young person, especially 
a female, constitute the leading features upon which 
the diagnosis of gastric ulcer is made. The condition 
is usually associated with pronounced constipation 
and anaemia, the former being the most important 
factor in the development of ulcer. There are great 
variations in regard to the incidence of the various 
symptoms ; occasionally there may be no symptoms, 
the first indication of an ulcer being a perforation, 
but the diagnosis of the condition is as a rule an easy 
matter. A simple erosion of the stomach, however, 
may give rise to all the symptoms of gastric ulcer with- 
out the antecedent history. The symptoms of duodenal 
ulcer are referred to in a separate lecture. 
The following two cases may be cited here, which 
illustrate well the different stages of gastric ulcer. 
One patient was admitted extremely ill and pulseless 
after a very severe haemorrhage from gastric ulcer; 
the other one, now convalescent, with a typical history 
as follows :- 
Girl, aged nineteen, began to complain about two years 
ago of symptoms of indigestion, and more especially pain 
in the epigastric region coming on soon after food, the 
pain being of a burning character and passing through 
to the back. These symptoms lasted for three weeks 
and were followed by the vomiting of blood. After a few 
weeks' rest and treatment the patient recovered, and 
remained well until a few days before admission, when 
she suddenly felt sick, complained of pain in the stomach, 
and vomited two large basinsful of blood. The bowels 12 
CLINICAL LECTURES FOR NURSES 
have been constipated. On admission the patient was 
blanched, the pulse was quick and weak in character, and 
the stools contained blood in large quantities. The patient 
was ultimately discharged feeling and looking very well, 
with no symptoms or physical signs of digestive or other 
disorder. This patient illustrates the liability of the con- 
dition to recur. 
Course and Termination. 
(a) Recovery.-By far the greater number of 
cases recover. 
(6) Perforation.-About eight to ten per cent, 
of cases perforate. This more frequently occurs 
in cases in which the symptoms are latent, the 
onset being characterised by acute agonising pain 
in the abdomen, collapse, fall of temperature, ex- 
tremities cold and bathed in sweat, with a weak 
thready pulse and shallow breathing. 
(c) Cicatricisation.-In a few cases the subse- 
quent contraction of the scar of the ulcer with, 
it may be, adhesions which have developed in 
association with it, produces chronic trouble, some- 
times associated with hour-glass contraction of 
the stomach (see Fig. 2). 
(d) Chronic progressive ulceration.-In some 
cases, owing to an excessive amount of inflammation 
round the seat of the ulcer, considerable chronic 
inflammation takes place, which may produce 
symptoms and physical signs suggestive of a tumour. 
There is further a risk of this condition becoming 
malignant. 13 
Treatment. 
The leading indications are to heal the ulcer, relieve 
the symptoms associated with its presence, and treat 
the conditions consequent on it, such as constipation, 
anaemia, and hyperchlorhydria. Complete rest in, bed 
for several weeks is usually essential, giving the stomach 
complete rest for a few days, the patient being fed by 
the rectum. The details of treatment may be con- 
sidered from, (1), the immediate, and, (2), the later 
points of view. 
The Immediate Treatment. 
1. Absolute rest in bed for two or three weeks 
or more, in proportion to the severity of the 
haemorrhage. 
2. For two or three days or thereby the stomach 
should be given complete rest, nourishment being 
given by the bowel. 
3. At the outset, sedatives are valuable for 
arresting the haemorrhage and diminishing the 
restlessness and pain, and so ensuring complete 
rest to the patient,-e.g., | gr. extract of opium, 
| gr. of morphia, or | gr. of heroin. This may be 
repeated two or three times within the first twenty- 
four hours. 
4. Diet.-For forty-eight hours or thereby the 
patient should be fed exclusively per rectum, the 
nourishment consisting in 10 ozs. of normal saline 
every four hours. If ordered, a little stimulant 
can be given with the saline. Subsequently nutrient 
DISORDERS OF THE DIGESTIVE SYSTEM 14 
enemata may be given which may alternate with 
the saline ; glucose, white of egg, milk and brandy, 
are the most valuable ingredients. 
Forty-eight hours a^ter the bleeding has stopped 
there are two systems of feeding available, firstly, the 
system of beginning with extremely light feeding with 
teaspoonful doses of nourishment, e.g., milk, increasing 
in amount daily, until at the end of the fourth or fifth 
week a full light diet might be in use. The second system 
is that of feeding more liberally from the outset, be- 
ginning on the third day with a little milk, white of egg, 
chicken tea, and increasing in amount and strength of 
nourishment rapidly, until at the end of ten or fourteen 
days the patient might be taking a diet including beef- 
tea, milk, chicken, fish, and bread, with light puddings. 
The latter method of feeding when practicable is ad- 
visable, as it keeps up the strength of the patient and 
shortens the period of convalescence. The test of the 
diet is the patient's toleration for it, and freedom from 
symptoms. 
5. The bowels must be carefully regulated by 
suitable aperients. 
6. Tonics are of value, more especially iron, 
arsenic, and occasionally strychnine. 
The Later Treatment. 
The important points in the later treatment are to 
regulate the patient's feeding, both as regards frequency 
of, and the nature of the meals-excessive tea drinking, 
too frequent meals, hurried eating, are common faults. 
Further steps must be taken to correct the constipation 
CLINICAL LECTUTR.ES FOK NURSES DISORDERS OF THE DIGESTIVE SYSTEM 
15 
permanently. When practicable this can best be done 
by a course of massage and exercises of a curative kind 
carried out daily for four to six weeks. Keep in view 
the general correctness of the axiom that the most 
frequent site of gastric ulcer is in the appendix region ; 
this axiom implies that stasis or stagnation in the ileum 
or colon, often combined with some old standing disease 
in the appendix region, is the original exciting cause 
of the gastric ulcer. The liability to recurrence of the 
ulcer is illustrated in one of the cases referred to, and is 
due to the fact that the primary disorder in the bowel 
lower down had not been effectively corrected. 
In a previous lecture I described the clinical features 
and management of gastric ulcer, and to-day we are 
considering the closely allied subject of duodenal ulcer. 
There are certain points of contrast in these two con- 
ditions : gastric ulcer is essentially a disease of the 
female sex, and is most commonly met with in young 
women between the ages of eighteen and twenty-five ; 
duodenal ulcer on the other hand is essentially a disease 
which affects men, and more especially between the 
agee of twenty-five and forty. To this general rule 
there are of course exceptions. 
Symptomatology. 
In a typical case of duodenal ulcer, the clinical features 
are characteristic. The patient complains of pain 
in the epigastric region, frequently severe, and coming 
on about two hours after food. This pain is relieved 
by the taking of food, hence the term " hunger pain " 
DUODENAL ULCER. 16 
which has been applied to it. A further notable feature 
of the pain is its liability to occur during night, the 
patient being wakened in the early hours of the morn- 
ing by a vague discomfort or severe pain. The attack 
of pain may last for a few minutes or half an hour, 
and may recur each night. More frequently there are 
long intervals of complete freedom from pain, the 
attacks lasting for a week or two and tending to recur 
every few months or at longer intervals. Other symp- 
toms of gastro-intestinal derangement may be present, 
such as flatulence, irregular action of the bowels- 
which may be sometimes constipated and sometimes 
loose-with acid eructations, and not infrequently 
the passage of blood in the stools, known as melaena. 
This haemorrhage from the bowel is a very characteristic 
physical sign. Many cases of duodenal ulcer, however, 
run their course without the occurrence of any haemorr- 
hage. 
Symptoms. 
There is a great variation in the symptoms of duodenal 
ulcer. On the one hand it is by no means very un- 
common to find that the ulcer is first revealed by a 
perforation, there having been no previous symptoms 
of digestive disorder, or only symptoms of the most 
trivial kind. On the other hand, many cases are met 
with in which the symptoms above described are present 
in their classical form. In a proportion of cases the 
symptoms may be less clearly defined, and the patient 
is for months or years erroneously labelled and treated 
as a case of chronic " indigestion." It cannot be too 
strongly emphasised that the term indigestion is a 
symptom and not a disease, and the application of 
CLINICAL LECTURES FOR NURSES 17 
modern methods of examination can in nearly every 
instance lead to accurate diagnosis of the condition. 
The symptoms of the disease tend, as has been already 
indicated, to recur, and cases are known where the disease 
has existed for twenty years or more. 
On physical examination the general appearance of 
the patient varies according to the stage of the disease. 
If the patient is seen during an attack, he looks ill, and 
the examination of the abdomen usually reveals pain 
on pressure, localised mainly to the epigastric region, 
but often associated with some pain on pressure in the 
iliac region. If the patient is seen during the interval, 
his general condition may appear quite satisfactory. 
This fact often leads to the medical man overlooking 
the true significance of the history. In cases of long- 
standing, the patient may show a moderate degree 
of emaciation and ansemia, and in some cases physical 
examination may reveal a small hard swelling in the 
region of the duodenum, the condition at this time 
closely simulating malignant disease. The presence 
of blood in the stools has been already referred to. 
Examination with the X-rays frequently gives informa- 
tion of the greatest value. Sometimes the nature of 
the disease can be determined with certainty by the 
presence of bismuth adhering to the base of the ulcer. 
More commonly the examination of the screen shows 
irregular action of the duodenum in the passage of the 
bismuth contents through it. In some cases the duo- 
denum is shown to be dilated. A common accompani- 
ment is marked stasis in the terminal part of the ileum. 
According to many authorities, the great majority 
of cases of duodenal ulcer are secondary to the existence 
of disease involving the appendix or the terminal portion 
DISORDERS OF THE DIGESTIVE SYSTEM 18 
of the ileum. It is therefore essential that in all doubtful 
cases attention be specially directed to the investigation 
of this region. 
Treatment. 
The treatment of duodenal ulcer may be medical 
or surgical. In cases of long standing which have 
proved resistant to medical treatment, and in cases 
associated with recurring haemorrhage, surgical treat- 
ment is indicated, the operation usually performed 
being gastro-enterostomy. In favourable cases the re- 
moval of the ulcer may be carried out, and in cases 
where there is evidence of disease of the appendix, that 
requires to be dealt with. 
The principles of medical treatment can be shortly 
summarised. A period of complete rest in bed is essen- 
tial to establish the most favourable conditions for the 
healing of the ulcer. Tire chief symptom-abdominal 
pain-is relieved by the administration of large doses 
of alkalies-carbonate of soda or carbonate of magnesia 
-which as a rule give immediate relief, probably by 
neutralising the excessive secretion of acid-hyper- 
chlorhydria-which is frequently present in these cases. 
In exceptional cases a dose of morphia or heroin, prefer- 
ably given hypodermically, may be necessary for the 
relief of the severe pain. 
The diet should be largely protein in character, 
including a liberal supply of milk, fish, chicken, and 
white of egg. The albumin of these foods is of special 
value in neutralising the hyperacidity. The bowels 
must be carefully regulated by the judicious use of 
aperients-the prevention of ileal stasis and of colon 
stasis or constipation being one of the most important 
CLINICAL LECTURES FOR NURSES 19 
factors in the successful medical treatment of these 
cases. 
After the acute symptoms have passed off, various 
tonic remedies, notably arsenic, iron, and strychnine, 
are indicated. 
The success of medical treatment can not as a rule 
be determined from hospital observation. The test 
of the efficiency of the treatment lies in the patient's 
power to resume his ordinary work and to remain 
permanently free from symptoms, and if the patient 
cannot stand that test, there should be no delay in 
having recourse to operation. 
DISORDERS OF THE DIGESTIVE SYSTEM 
CHRONIC APPENDICITIS. 
A word of explanation is necessary as to the inclusion 
of a lecture on chronic appendicitis in a course of lectures 
on Medical Nursing. 
Chronic disease of the appendix is essentially a surgical 
condition, and can only be adequately dealt with by 
removal of the appendix. The frequency, however, 
with which chronic appendicular mischief is over- 
looked in practice, the affected subject remaining in 
permanent poor health and treated as a case of 
indigestion, neurasthenia, chronic constipation, or as 
" neurotic," makes it desirable to draw special atten- 
tion to the medical aspects of the condition. Errors 
in diagnosis arise from failure to recognise that chronic 
focal mischief in the appendix is a frequent cause of 
conditions such as indigestion, neurasthenia, rheumatism, 
and chronic constipation with colitis. 
Any latent septic mischief in the appendix sooner 20 
CLINICAL LECTURES FOR NURSES 
or later involves in a more or less marked degree the 
large and small intestines and stomach. It is now 
recognised that a large proportion of cases of stomach 
derangement and of duodenal ulcer occur as secondary 
results of disease in the ileo-caecal region. We also know 
that ileal stasis on the one hand, and general colon 
stasis on the other, with resulting dilatation and dis- 
placement of the bowel, are frequently present in asso- 
ciation with disease in the appendix region. We have 
in the ward at present two typical cases of chronic 
appendicitis. In both instances the patients have 
been the victims of prolonged ill-health for many years, 
and had undergone different forms of medical treat- 
ment without benefit Their cases have been variously 
diagnosed as due to indigestion, neurasthenia, or of 
neurotic origin. The following are typical cases in which 
the symptoms are those of neurasthenia or indigestion. 
In other cases the symptoms may be referred to the 
joints or the muscles, the case clinically coming more 
under the category of rheumatism. I cannot do better 
than submit a full summary of the history of these 
two interesting cases prior to their discharge from the 
ward. 
Neurasthenia and Indigestion due to Chronic 
Disease of the Appendix with Adhesions. 
1. David 8., aged forty-three years, a clerk, was admitted 
to my ward complaining of slight pain in the epigastric 
region, usually commencing in the evening, with increasing 
asthenia of about ten years' duration. His illness started 
acutely about ten years previously with severe abdominal 
pain and vomiting ; he was in bed for two months at that 
time, and he had had recurring attacks of pain with obvious 
gastric disturbances since. The pain usually came on DISORDERS OF THE DIGESTIVE SYSTEM 
21 
about eight o'clock in the evening, shortly after supper, 
always localised to the epigastric region, and keeping him 
awake part of the night. It was relieved by hot appli- 
cations. He used to vomit about twice a week, usually 
about 11.30 p.m., but the vomiting has been less frequent of 
late. His appetite has been fair, but he was much troubled 
with flatulence and water-brash. During the last few 
years he has frequently been in bed for a week or two at 
a time. His weight is about a stone below his normal. 
He has suffered from constipation since the onset of his 
illness ten years ago, and has been much troubled with 
headache. There is nothing to note with regard to pre- 
vious illness, personal habits, or heredity. 
The general condition of the patient is very unsatis- 
factory. His face is thin and drawn, his nutrition very 
poor, and his complexion pale and sallow. On objective 
examination his tongue is flabby and dirty, his breath is 
slightly offensive, and there is a considerable degree of 
pyorrhoea. On examination of the abdomen there is 
distinct pain on pressure in the right iliac region, also 
tenderness on pressure immediately to the left of the 
umbilicus and over the upper part of the right rectus 
muscle, which shows a distinct degree of rigidity. There 
is marked gurgling in the ileo-caecal region. On examina- 
tion by a test-meal the acidity of the gastric contents was 
found to be normal. On examination after a bismuth 
test-meal the stomach was found normal in position and 
action. After six hours there was an abnormal retention 
of the bismuth meal in the terminal coils of the ileum 
(ileal stasis), and after forty-eight hours a moderate degree 
of colon stasis, commencing at the hepatic flexure. The 
motions were constipated and offensive. The pulse was 
weak, and the heart-sounds feeble. This combination of 
symptoms and physical signs point clearly to a primary 
lesion in the ileo-csecal region, interfering with the free 
passage of the ileal contents into the caecum, probably 
due to adhesions, which may be secondary to old-standing 
appendix mischief. In view of the chronic history and 
the local condition it is inadvisable to waste time over a 
prolonged course of medical treatment, and it has been 
arranged, therefore, that an operation be performed. 22 
At the operation the correctness of the diagnosis was 
established. The patient already feels and looks much 
better, and there is little doubt that a satisfactory return 
to permanent good health will be attained, and that this 
will be maintained, especially if steps are now taken, by 
suitable exercises and massage, to improve the weakened 
tone of the intestinal and abdominal musculature. 
2. The second case is that of Mary R., aged twenty-eight, 
single. She was admitted complaining of pain in the 
stomach, vomiting, and general weakness of ten years' 
duration. The illness began with pain in the region of 
the stomach, this being at first of an intermittent kind ; 
it might last for a few hours or a whole day. At first 
there would be intervals of freedom for a month or two, 
but these intervals gradually diminished in length until 
in the last year there was seldom more than a day or two's 
freedom from pain. Her illness has been accompanied 
by increasing disability for house work. There was no 
history of hsematemesis, or melama, and she is not much 
troubled with wind or water-brash. The patient thought 
she was rather better on a full diet than on a restricted one. 
She had been in bed for weeks at a time on account of her 
stomach trouble. She has had no previous illnesses of 
any consequence, but has never been robust. Her personal 
habits have been satisfactory ; her mother was a martyr 
to indigestion. 
The general condition of the patient is poor. She 
is anaemic, thin, with a soft and flabby muscular system. 
With regard to her digestive system, the patient com- 
plains of pain in the umbilical region, passing through to 
the back, and sometimes to the left side, usually fairly 
severe, and lasting many days, which is relieved by vomit- 
ing, the vomited matter being usually sour fluid, and 
occasionally bile. The pain is not notably influenced 
by the ingestion of food. The bowels are stated to be 
regular. Objectively, the tongue is flabby and furred, 
the teeth are all artificial, having been in an unsatis- 
factory state for a long time prior to their removal a few 
years ago. The abdomen is exceedingly soft and flabby, 
with marked splashing in the ileo-csecal region, and also 
CLINICAL LECTURES FOR NURSES 23 
to a much less extent in the epigastric and left lumbar 
region. On X-ray examination very marked ileal stasis 
was present, with a nearly equally-pronounced general 
colon stasis, the whole colon containing bismuth after 
forty-eight hours. There is no evidence of disease of the 
gall-bladder. Other systems are apparently normal, with 
the exception of-(1) a weak condition of the circulation 
generally ; (2) numerous catarrhal cells in the urine ; 
and (3) slight excess of indican. The combination of the 
history with the clinical conditions described point clearly 
to the ileo-caecal region being the primary source of the 
mischief, the ileal stasis being, in all probability, the primary 
factor associated with a septic focus in the appendix. At 
the operation the correctness of this opinion was confirmed. 
It is now a month since the operation, and appearances 
promise well for a completely successful result. 
Diagnosis. 
The diagnosis of these cases is easy if the frequency 
of disease of the appendix be kept in view and adequate 
investigation made to determine its presence. The 
application of X-rays after a bismuth meal is specially 
valuable. Special attention should be directed to the 
adequate study of the stools and urine in these cases. 
The stools are almost always profoundly deranged, 
being offensive, constipated, or sometimes unduly loose. 
The urine may be slightly turbid, due to the presence 
of catarrhal cells or bacteria. 
The Treatment is in the first instance surgical, and 
consists in the removal of the appendix and relieving 
any adhesions which are present. In doubtful cases 
a thorough examination should be made, not only of 
the ileo-csecal region, but of the duodenum and stomach. 
Special precautions are necessary at the operation to 
avoid sepsis even in its minor forms, as that predisposes 
DISORDERS OF THE DIGESTIVE SYSTEM 24 
CLINICAL LECTURES FOR NURSES 
is to the formation of new adhesions. Convalescence 
in many cases tardy on account of the long duration 
of the previous toxaemia. An important part of the 
after-treatment in many cases is the application of 
massage and remedial exercises to strengthen the 
muscles of the abdomen and bowel, in order to re- 
move as far as possible the atony and displacement 
or prolapse of the bowel which are prominent features 
in cases of long standing. 
COLITIS. 
(Syn. Mucous colitis.) 
Colitis is an inflammation or catarrh of the colon. 
It is a condition of great clinical importance on account 
of its frequency, the severity of the symptoms which 
may be present, and the fact that the symptoms are 
in many cases not directly related to the bowel, with 
the result that the true nature of the disease is often 
overlooked. 
There are two main types of the disease : one the 
common variety, known as mucous colitis ; the other 
rarer and more acute, and associated with haemorrhage, 
known as ulcerative colitis. The two diseases are 
clinically distinct. We will now consider the symptoms 
and treatment of mucous colitis. 
COLITIS. (Syn. Mucous colitis.) 
The symptoms complained of by a patient suffering 
from mucous colitis are of the most varied nature. 
They may be those of simple indigestion, characterised 
by a varying degree of abdominal discomfort and some- DISORDERS OF THE DIGESTIVE SYSTEM 
25 
times pain, with a general want of vigour, associated 
with diarrhoea or constipation, or diarrhoea alternating 
with constipation; the stools being either loose or 
constipated, and containing a large amount of mucus. 
In other cases the symptoms may be mainly those of 
neurasthenia, characterised by great diminution of 
physical and mental vigour, irritability, or depression, 
and associated usually with constipation, want of appe- 
tite, flatulence and abdominal discomfort. In not 
a few cases of this group there may be no symptoms 
referred to disorder of the digestive tract, and the 
evidence of any local derangement in the bowel is only 
forthcoming if a very careful inquiry is made into the 
symptoms and a careful examination of the stools. 
Diagnosis. 
The diagnosis of a case of colitis can only be con- 
clusively established by the careful examination of 
the stools ; the essential feature being the passage of 
a large amount of mucus. This may take the form 
of numerous large shreds of mucus, often described 
by the patient as a jelly-like material, or it may form 
the coating of a mass of faeces. If the bowel be cleared 
out either by means of a suitable aperient or by an 
enema, and subsequently washed out by a couple of 
pints of plain water, the returned fluid will contain 
a large amount of mucus-this mucus being character- 
istic of the disease. 
The disease is often complicated and aggravated 
by other disorders, notably severe constipation (colon 
stasis), stasis of the last part of the ileum (ileal stasis), 
and focal mischief in or around the appendix. In cases 26 
CLINICAL LECTURES FOR NURSES 
associated with abdominal discomfort and pain as a 
prominent feature, the pain is due to spasmodic con- 
traction of one or other part of the colon. On exa- 
mination of the digestive tract with the X-rays, it 
may be found that the contents pass through the colon 
with undue rapidity, there being frequently, however, 
some delay in the terminal part of the ileum. In other 
cases there is very marked colon stasis, the delay being 
pronounced in the caecum, ascending colon, the trans- 
verse colon, or in the descending colon. As already 
mentioned, the distinctive feature of the disease is 
only determined by the careful examination of the 
stools. 
In the differential diagnosis special attention has 
to be directed to excluding disease of the appendix, 
the early stages of malignant disease, and in some 
cases melancholia of primary origin. A septic con- 
dition of the teeth and gums (pyorrhoea) is frequently 
present, and is sometimes the starting point of the 
disease. There is one peculiarity about the disease 
which must always be kept in view, and that is the 
tendency for those affected with it to become unduly 
self-centred with regard to their health, and to greatly 
magnify the symptoms. It is of the utmost importance 
that this fact be sufficiently recognised by the doctor 
and by the nurse in charge. 
Prognosis. 
A guarded prognosis, more especially as to the dura- 
tion of treatment, is essential. Cases of colitis are 
frequently tedious and often intractable, and care 
and treatment may be necessary for many weeks and 
even months. Success in treatment largely depends DISORDERS OF THE DIGESTIVE SYSTEM 
27 
upon the accuracy in diagnosis as to the severity of the 
lesion, and on the skill of the doctor and nurse in hand- 
ling the patient. If the catarrh of the colon is very 
advanced, and is shown by the X-rays to be associated 
with pronounced dilatation and stasis of the colon, 
and if medical treatment carried out for a short time 
fails to give the promise of a successful result, the ques- 
tion of skilled surgical treatment should be early con- 
sidered. 
Treatment. 
Few conditions call for greater skill and tact in treat- 
ment. In no condition is it more essential to recognise 
the importance of treating the patient more than the 
disease. The first difficulty that presents itself is the 
question of the advisability of putting the patient 
to bed. In many cases this is essential, more especially 
in cases associated with marked neurasthenic symptoms 
with ansemia. In other cases where the symptoms are 
slight, it is disadvantageous to put the patient to bed, 
as the mental effect of enforced rest is frequently pre- 
judicial and tends to his over-concentration on the 
symptoms. The first essential therefore is accurate 
diagnosis as to the degree of severity of the condition, 
and this diagnosis can only be made after a careful 
survey of the nature and duration of the symptoms, 
a study of the temperament of the patient, the general 
appearance of the subject, and the condition of the 
stools as determined by medical examination. 
The principles of treatment are (1) to give the bowels 
as much rest as possible, by keeping the patient in bed 
and by making the diet light and nutritious ; (2) to 
clear out the bowel thoroughly by means of lavage. 28 
CLINICAL LECTURES FOR NURSES 
care being taken not to overdo this treatment by carry- 
ing it out too long, and so further aggravating the 
atonic condition of the muscles of the colon ; (3) to 
tone up the muscle of the colon and the abdominal 
wall by means of skilled massage with exercises, and 
in some cases, judicious application of the faradic 
current; (4) in cases which prove resistant to treat- 
ment, the use of an autogenous vaccine prepared from 
the bacteria in the stools is sometimes of great value ; 
(5) the administration of a mental tonic is of the utmost 
importance, encouraging the patient, and getting his 
mind directed away from his bowel and his symptoms 
generally ; (6) in aggravated cases of long standing 
which prove resistant to medical treatment, the question 
of operative treatment-appendicostomy followed by 
irrigation of the colon, or a partial or complete colectomy 
-has to be considered. 
It will be convenient to describe the treatment of 
a case of average severity. 
A.B., clerk, age thirty-five, admitted complaining of 
indigestion, abdominal discomfort, and constipation, al- 
ternating with diarrhoea, accompanied by slight loss of 
flesh, and great want of vigour : sleeplessness was a promi- 
nent symptom, this being often induced by an ache or 
pain in the back. Physical examination revealed a very 
flabby condition of the muscles of the abdominal wall, 
and also of the intestinal muscle, associated with some 
splashing over the caecum and colon. Frequent examina- 
tion of the stools revealed the presence of a large quantity 
of mucus, the stools being markedly offensive. After the 
bowel had been thoroughly cleared, examination by the 
X-rays showed distinct ileal stasis, a moderate degree of 
colon stasis, and a spasmodic condition of the descending 
colon. DISORDERS OF THE DIGESTIVE SYSTEM 
29 
The details of treatment as carried out in the above 
case were as follows :- 
1. Complete rest in bed : this was maintained 
for a little over three weeks. 
2. After a preliminary dose of calomel followed 
by a morning saline, the bowel was washed out 
each day by an enema consisting of two pints of 
water containing a very little soap, and fifteen 
minutes afterwards, when the enema returned, 
the bowel was irrigated by a couple of pints of 
plain water administered at blood-heat. This was 
continued daily for a fortnight, by which time 
the irrigating fluid was returned perfectly clear, 
the amount of mucus being now very considerably 
reduced. 
3. The diet was restricted to milk foods, and 
fish or chicken; no red meats being allowed. 
Little fluid was given with meals and no soups. 
4. Ten oz. of hot water were given on an empty 
stomach three times a day 
5. After a fortnight, massage was commenced 
-ten to twelve minutes' abdominal massage 
being given daily, accompanied by digital manipula- 
tion of the spine, some general massage, and a few 
trunk exercises, these being gradually increased. 
6. A simple tonic was administered containing 
strychnine and arsenic ; the chief value of this 
being in all probability its mental effect. 
7. The importance of the application of mental 
tonic treatment both on the part|of the doctor 
and the nurse was kept in view. 30 
CLINICAL LECTURES FOR NURSES 
ULCERATIVE COLITIS. 
Ulcerative colitis is a rarer, more acute and more 
severe type of inflammation. It is most frequently 
seen in subjects who have previously suffered from 
catarrh of the colon and more especially dysentery. 
It is not infrequently fatal. It is characterised by 
severe diarrhoea and the frequent passage of stools 
containing a mixture of blood and mucus often in 
large amount. It is usually associated with abdominal 
discomfort or pain, great physical weakness, aneemia, 
deranged digestion, and irregular temperature. 
Diagnosis. 
The diagnosis is usually easy, the distinctive feature 
of the disease being diarrhoea associated with stools 
containing mucus and blood. Tuberculous disease 
of the bowel and early malignant disease may closely 
simulate this disease. 
Treatment. 
Treatment has to be conducted on the same general 
lines as those laid down for simple or chronic colitis. 
The internal administration of quinine is often bene- 
ficial. The external application of heat to the abdomen, 
and an occasional dose of a sedative, e.g., Dover's powder, 
are sometimes useful in relieving this diarrhoea without 
in any way aggravating the inflammation. Washing 
out the bowel from below is sometimes useful, but is 
often impracticable on account of the pain. The 
results of bacteriological examination of the stools 
may suggest the advisability of the use of an auto- 31 
genous vaccine. In severe cases the question of per- 
forming an appendicostomy, and washing out the bowel 
from above with a weak solution of eusol or other anti- 
septic, has to be considered. 
DISORDERS OF THE DIGESTIVE SYSTEM 
JAUNDICE. 
Jaundice is a symptom, not a disease. It varies 
in severity from a slight yellowish tinge of the con- 
junctivae, with lack of clearness of the skin, to a con- 
dition in which the whole skin is of a dark yellow or 
saffron colour, and the conjunctivae a deep yellow 
tint. It is due to the presence of bile in the blood. 
Its presence is always an indication that there is some 
obstruction to the free passage of the bile between its 
site of production in the liver and the opening of the 
common bile duct in the duodenum. 
The following three cases may be given here which 
illustrate very well the three most common clinical 
conditions associated with jaundice. These are- 
1. Simple Catarrhal Jaundice. 
2. Gall-Stones. 
3. Malignant Disease. 
We shall discuss these seriatim. 
1. SIMPLE CATARRHAL JAUNDICE. 
This is a disease most commonly seen in young adult 
subjects ; it may arise after a chill, or more often without 
apparent cause. The clinical features are well brought 
out in a typical case. 32 
CLINICAL LECTURES FOR NURSES 
History.-Man, aged twenty-two, was admitted to the 
wards three weeks ago, complaining of jaundice, which 
had developed three days before admission. With the 
exception that he felt out of sorts, and disinclined for 
food on the first day, he complained of no symptoms 
except discoloration of his skin and eyes. He had also 
observed that his stools were pale in colour and the urine 
unusually dark. 
On examination, the patient was found to be a well- 
nourished man ; skin markedly jaundiced ; conjunctivae 
very yellow; tongue dry and coated with a yellowish- 
grey fur ; abdomen was slightly full ; the liver was a little 
enlarged, some tenderness being complained of on pressure 
over it; the motions were quite white, due to the absence 
of bile and to the presence of undigested fat; the urine 
was dark-green in colour, with characteristic froth on 
the surface, due to the presence of bile pigment in large 
amount; the temperature was subnormal, the pulse 
rather reduced in rate, 70 per minute. 
These, then, are the typical features of a case of 
simple catarrhal jaundice. The condition is the result 
of a catarrhal or infective process, originating as a 
rule in the duodenum, spreading up into the bile duct, 
obstructing the passages, and thus leading to the absorp- 
tion of the bile into the system. In some cases there 
may be a slight rise of temperature at the outset, with 
increased pulse rate; more commonly the pulse is 
rather diminished in rate, due to the effect of the bile 
on the circulation. 
In most cases, the pathogenic organism is the bacillus 
coli communis. The disease occurs most commonly in 
subjects who suffer from constipation, or otherwise have 
weak digestion. 
Prognosis. 
Is invariably good-complete recovery being the 
rule in from four to six weeks or thereby. DISORDERS OF THE DIGESTIVE SYSTEM 
33 
Treatment. 
Keeping in view the cause of the condition, the prin- 
ciples of treatment can be readily understood. Complete 
rest in bed is advisable; judicious clearing out of 
the bowel by suitable aperients, the administration 
of a simple light diet and appropriate liver stimu- 
lants, form the chief points in treatment. You can 
judge of the rate of recovery in an average case from 
the condition of the case above cited. He is now, 
three weeks after admission, nearly recovered. His 
skin and conjunctivae are nearly normal in colour. 
The patient feels well, but is slightly pale and still 
somewhat sallow in colour. The urine is clear; the 
stools are normal in colour. His pulse, temperature, 
and respirations are normal. 
The details of the treatment applied in the above 
case were as follows :- 
(a) Complete rest in bed for fully a fortnight. 
(&) The administration of 1 grain of calomel 
each night for three nights, followed by 1 oz. of 
Henry's solution in the morning. 
(c) Diet restricted during the first four days 
to milk, water, and chicken tea-3 pints of milk 
in twenty-four hours being given ; later, bread, 
toast, and milk puddings were added. The patient 
is now on the light diet of the hospital. 
(d) The local application of liver packs each 
day, the pack being renewed every half-hour for 
two hours. 34 
CLINICAL LECTURES FOR NURSES 
(e) The administration of a general tonic con- 
taining strychnine and nitro-hydrochloric acid as 
a liver stimulant. 
(/) We prescribed some physical exercises for 
him afterwards, adapted to increase the action 
of his diaphragm, and strengthen the action of the 
abdominal and intestinal muscles generally : these 
exercises are a most useful part of the treatment. 
The most important essentials in the after treatment 
are, the correction of constipation, careful feeding, 
and attentions to the functions of the kidneys and skin. 
2. JAUNDICE DUE TO GALL-STONES 
(Cholelithiasis). 
The presence of gall-stones in the gall-bladder is a 
very common occurrence, although it is only in the 
minority of cases that they give rise to any definite 
symptoms. In number and size the gall-stones vary 
very greatly : there may be a single stone of large 
size, or many hundreds of small calculi. In some 
cases there may be no actual calculi, but merely a 
deposit of a very fine nature, spoken of as " gravel." 
They are mainly composed of cholesterin, derived from 
the bile, and arise from a bacterial infection of the bile 
ducts, the infection spreading upwards from the in- 
testine. Normally, bile is sterile, but in practically 
all cases of cholelithiasis micro-organisms are obtained 
if carefully searched for. As a rule, the bacillus coli 
communis is the microbe found, but the typhoid bacillus, 
staphylococci, and streptococci have also been found, 
and it is probable that other bacteria may be responsible DISORDERS OF THE DIGESTIVE SYSTEM 
35 
for the catarrh of the main duct and of the gall-bladder 
(cholangitis) which induces the condition. 
As already indicated, gall-stones are frequently 
present and produce no distinct clinical evidence of 
their presence, and when definite symptoms are pro- 
duced by gall-stones, jaundice is by no means invariably 
present. Jaundice is only present when the gall-stone 
in its passage obstructs the common bile duct, thus 
allowing the absorption of the obstructed bile into the 
system. 
There are several conditions which predispose to 
gall-stone formation. Gall-stones occur much more 
frequently in women than in men ; this is possibly 
associated with their taking less exercise and with the 
wearing of corsets, which may tend to impede the 
flow of bile through the liver and from the gall-bladder 
into the cystic duct and common bile ducts. Sedentary 
habits, from whatever cause arising, undoubtedly 
predispose to cholelithiasis. Injudicious eating and 
drinking is a very important factor ; long-continued 
ingestion of excess of starchy foods is a common pre- 
cursor of the development of gall-stones. This faulty 
feeding induces a tendency to catarrh of the stomach 
and duodenum, with abnormal fermentation brought 
about by bacterial action. If the faulty feeding is 
associated with the immoderate use of spirits, wine, 
or beer, the tendency to gall-stone formation is much 
increased. 
Symptoms. 
The symptoms induced by gall-stones vary greatly 
in different cases. The stones may be in the gall-bladder, 
cystic duct, or common bile duct. So long as thoy 36 
remain in the gall-bladder, there may be no symptoms 
of any kind, unless possibly some slight uneasiness 
and discomfort in the epigastric region with tenderness 
below the right costal margin. When a stone is dis- 
lodged and the calculus reaches the cystic duct, a typical 
attack of gall-stone colic is induced : this takes the form 
of very severe pain, beginning under the right costal 
margin and radiating thence towards the pit of the 
stomach and round the right side in the direction of 
the right shoulder. Not infrequently the pain ends 
with the onset of vomiting. In a severe seizure there 
may be great collapse, so that the condition may simulate 
angina pectoris, perforation of a gastric ulcer, or other 
grave abdominal disorder. Jaundice is not usually 
an accompaniment of gall-stone colic, when the colic 
is due to the presence of a stone in the cystic duct, 
but in some cases it may appear at the end of twenty- 
four hours and persist in a slight degree for a few days. 
In such cases it is due to catarrh spreading to the common 
bile duct and interfering with the flow of bile. These 
attacks may be repeated at intervals of a few days, 
weeks, or months, the patient being quite comfortable 
in the intervals between the attacks. 
Gall-stone in the Common Duct. 
The symptoms of gall-stone colic, wThen the stone is 
in the common duct, resemble closely those already 
described for a stone in the cystic duct, but differ in 
regard to the seat and distribution of the pain and in 
the occurrence of jaundice. The pain in such a case 
begins in the epigastrium and may radiate to the left 
side of the abdomen. The tenderness is usually most 
marked in the middle line about midway between 
CLINICAL LECTURES FOR NURSES 37 
the umbilicus and the ensiform cartilage. Should the 
stone quite fill the duct, or should it become impacted 
at the entrance of the bowel, the jaundice will be per- 
sistent, and may become extreme. In many cases 
there is an associated catarrh of the gall-bladder, an 
infective cholangitis, which may be a serious complica- 
tion. 
Diagnosis. 
In uncomplicated cases of gall-stones, the diagnosis 
does not, as a rule, present much difficulty. The 
situation, character, and distribution of the pain and 
tenderness, along with the accompanying symptoms, will 
usually suffice to render the case clear. The locality 
in which the stone is situated can frequently be de- 
termined by noting the point of greatest tenderness. 
If the common duct is blocked, and more especially 
if the obstruction is complete, the jaundice will become 
intense, and there may be great difficulty in eliminating 
malignant disease as a probable cause. A previous 
history of attacks or spasms, and particularly on 
account of severe pain at the onset of the illness, with 
local tenderness, point to gall-stones. In doubtful 
cases, an exploratory incision may be required to clear 
up the diagnosis. 
The history of the following case is very typical of 
jaundice due to obstruction in the common bile duct:- 
Woman, aged forty-five, was suddenly seized with severe 
pain in the pit of the stomach, which doubled her up, the 
pain radiating towards the left shoulder ; it was followed 
by vomiting. The pain was very severe, associated with 
some collapse, and was only relieved by hypodermic in- 
jection of morphia. It was followed in a few hours by 
DISORDERS OF THE DIGESTIVE SYSTEM 38 
CLINICAL LECTURES FOR NURSES 
development of marked jaundice, the stools becoming 
clay-coloured and the urine dark green from the presence 
of bile pigment. For many years previously she had 
suffered from indigestion, with occasional attacks of ab- 
dominal pain, not of a severe character. The patient 
fed well, took little exercise, and was fond of an occasional 
glass of beer. On admission she was markedly jaundiced. 
She was a rather fat and flabby subject; the abdomen 
was rigid, and marked pain was complained of on the 
slightest pressure in the epigastric region. The tempera- 
ture was slightly increased, 100.2 F. ; the pulse rate 90 ; 
/he tongue dry and coated with a yellowish-white fur. 
There was some tenderness over the gall-bladder, due 
to an associated infective cholangitis. 
These are the typical clinical features of a case of 
jaundice due to obstruction of the common bile duct, 
presumably by calculus, with an associated catarrh 
of the gall-bladder-the correctness of the diagnosis 
being established at the operation. 
Treatment. 
This may be conveniently considered under the 
following heads :- 
(a) The treatment of biliary colic, associated with 
jaundice. 
(6) Later treatment. 
(c) Prophylactic treatment. 
(a) Treatment of biliary colic. 
The main indication is to relieve the pain which is 
induced by the spasm. This is effected by the ad- 
ministration of morphia, usually subcutaneously, aided 
by external applications of warmth (hot bottle, or hot DISORDERS OF THE DIGESTIVE SYSTEM 
39 
fomentations). The stools should be carefully examined 
for the presence of the calculus, which in favourable 
cases is passed by the bowel. Where the stone is im- 
pacted and the obstruction is complete, operation is 
necessary. 
(6) Operative treatment. 
An operation is frequently necessary for the removal 
of the stone. The stone may be impacted at the ter- 
mination of the common bile duct in the duodenum, 
in the common bile duct, or in the cystic duct. If 
impacted in the cystic duct, jaundice is absent, or is 
only present in a slight degree due to an associated 
catarrh of the common bile duct. In addition to re- 
moving the calculus from the biliary channel, drainage 
of the gall-bladder is usually necessary. 
(c) Prophylactic treatment. 
As gall-stones are chiefly met with in subjects who 
lead a sedentary life, feed injudiciously, and are specially 
liable to suffer from constipation, prophylactic measures 
must be directed in these directions. Exercises in 
the open air should be cultivated, and physical exer- 
cises, often combined with massage, adapted to strengthen 
the diaphragm and the abdominal muscles and quicken 
the abdominal circulation generally, are of great value. 
With regard to diet, the main essentials are to avoid 
over-eating ; to restrict rich feeding of all kinds and 
condiments, taking special care to restrict the starches 
and sugars; to masticate the food thoroughly, and 
to drink two or three tumblerfuls of water, or alkaline 
water, three times a day on an empty stomach ; spirits, 40 
CLINICAL LECTURES FOR NURSES 
wine, and beer are better withheld. The bowels should 
be regulated by an occasional mercurial, followed 
by a morning saline : a teaspoonful of phosphate of 
soda, or sulphate of soda, taken in a tumblerful of 
hot water the first thing in the morning, is a useful 
measure. A properly defined course of massage and 
exercises for the permanent correction of the constipa- 
tion, for promoting a more free action of the diaphragm, 
and for correcting the stagnation of the whole venous 
system of the abdomen present in these cases, is a most 
valuable measure. 
3. JAUNDICE DUE TO MALIGNANT DISEASE. 
Not infrequently jaundice is one of the leading sym- 
toms present in malignant disease. It is due to the 
presence of a tumour, which may be small or large, 
situated in such a position as to obstruct the free flow 
of bile through its normal channel. The tumour may 
be in the head of the pancreas, or in the duodenum, 
its presence in either of these situations obstructing 
the termination of the common bile duct. In other in- 
stances the tumour involves the common bile duct in 
its course. A feature of these cases is not infrequently 
the comparative absence of symptoms; pain is fre- 
quently absent in the early stages of the disorder. 
The following case is fairly typical :- 
A man of forty-two was admitted to the hospital, com- 
plaining of jaundice of six weeks' duration. Ten years 
ago a tumour of a malignant nature was removed from 
the bowel, but since that time he had enjoyed good health 
till six months ago, when be began to lose weight and also 
appetite. Jaundice supervened six weeks before admis- 
sion, and speedily became intense, and in the last few DISORDERS OF THE DIGESTIVE SYSTEM 
41 
weeks has been associated with marked itchiness of the 
skin. On objective examination, the patient was deeply 
jaundiced ; he showed a moderate degree of cachexia; 
the stools were clay-coloured ; the urine contained much 
bile pigment; the liver was slightly enlarged ; but there 
was no other marked physical sign-no pain was com- 
plained of, nor was pain elicited on palpating the abdomen. 
This condition was clearly due to a deep-seated growth 
of a malignant nature, originating either in the head of 
the pancreas, or in the region of the duodenum : the jaundice 
being due to the obstruction at the termination of the 
common bile duct. 
Prognosis. 
In such cases is very bad, patients usually dying in 
a few weeks or months. 
Treatment. 
Is mainly symptomatic : keeping the patient as 
comfortable as possible ; feeding very carefully so as 
to stave off as long as possible the advent of gastric 
catarrh with vomiting, and the administration of se- 
datives if required. These cases are very seldom amen- 
able to operative treatment. 
CIRRHOSIS OF THE LIVER. 
There are two main types of cirrhosis of the liver : 
*(1) associated with a liver which is reduced in size, 
so-called atrophic cirrhosis, or alcoholic cirrhosis ; and 
(2) associated with enlargement of the liver, so-called 
hypertrophic cirrhosis of the liver. The following case 
illustrates very well the history and clinical features 42 
CLINICAL LECTURES FOR NURSES 
of cirrhosis of the liver of the common type. The history 
of the patient is as follows :- 
A.B., cab-driver, has long been in the habit of 
taking alcohol to excess. A few months before admission 
he began to complain of symptoms of indigestion and 
constipation, with occasional attacks of looseness of the 
bowel. Some oedema of the feet developed later, with 
marked swelling of the abdomen and breathlessness on 
exertion, which led him to seek advice at the hospital. 
On physical examination the patient presents the general 
appearance of a man who has indulged too freely in alcohol; 
his complexion is dirty; there is no distinct jaundice. 
His general nutrition is impaired ; there is slight oedema 
of the feet and very marked swelling of the abdomen. 
The abdomen presents a characteristic rounded appearance, 
due to the presence of fluid. The umbilicus is flush with 
the surface of the skin ; the tongue is furred ; the stools 
are very offensive ; the pulse rate is markedly increased, 
and the heart sounds are weak. The increase in the pulse 
rate and weakening of the heart sounds being the result 
of the toxic effects of the alcohol on the heart muscle. 
The most characteristic symptom of cirrhosis of 
the liver is ascites or dropsy of the abdominal cavity. 
The presence of ascites can usually be determined 
by simple inspection combined with percussion, which 
reveals the presence of dulness in the flanks. In doubt- 
ful cases the diagnosis is verified by the use of the 
exploring needle. Occasionally the earliest symptom 
of the disease is haemorrhage from the stomach, this- 
being due to pronounced venous congestion of the 
blood-vessels of the stomach and the lower part of 
the oesophagus. The history of alcohol and the general 
features usually make the diagnosis quite clear. In 
exceptional cases a differential diagnosis has to be 
made from other conditions associated with ascites. DISORDERS OE THE DIGESTIVE SYSTEM 
43 
such as pressure on the portal system by enlarged 
glands of tuberculous or other nature, or by neoplasm, 
or the result of chronic peritonitis. In cases associated 
with hajmorrhage, a differential diagnosis has to be 
made from cases of gastric or duodenal ulcer, and the 
early stages of malignant disease. Ascites associated 
with heart disease is readily determined from the co- 
existence of general dropsy, and from the condition 
of the heart and circulation generally. 
Prognosis. 
The prognosis in cases of alcoholic cirrhosis of the liver 
is a guarded one. By the time that symptoms of this 
severe condition are established, the disease of the 
liver is fairly advanced, and such cases as a rule do 
not live more than a few years. In favourable cases, 
however, a satisfactory recovery is established, and 
provided the patient regains good habits, a fair standard 
of health may be maintained for many years. 
Treatment. 
1. Prolonged rest in bed is essential, usually 
from six to eight weeks. 
2. The removal of fluid from the abdomen has 
to be effected either by the judicious use of pur- 
gatives and diuretics, or by withdrawing the fluid 
from the abdominal cavity by means of Southey's 
tubes, the fluid being withdrawn very slowly. 
The repeated use of small doses of calomel followed 
by a morning saline of judicious strength ; the 
administration of a diuretic,-e.g., sodium theo- 
acetate, is valuable in removing the fluid. 44 
CLINICAL LECTURES FOR NURSES 
3. The diet should be light and dry, little fluid 
being taken with meals. All forms of alcoholic 
liquor should be withheld. 
4. At the outset, the administration of a bismuth, 
rhubarb, and soda powder may be useful for clearing 
the tongue. 
5. Of tonic measures, potassium iodide and 
arsenic are the most generally useful. 
HYPERTROPHIC CIRRHOSIS. 
Short reference only need be made to the rarer form 
of cirrhosis known as hypertrophic cirrhosis associated 
with enlargement of the liver. 
The most prominent symptom here is jaundice, 
which may be associated with digestive disturbance, 
the passage of pale stools, and a highly coloured urine 
containing bile. The liver is enlarged and may be 
tender. There is no ascites. 
The causes of this condition are obscure. Alcohol 
in various forms is one of the determining causes. 
Treatment is carried out on the same lines as those 
mentioned above. CHAPTER II. 
DISORDERS OF THE BLOOD AND 
DUCTLESS GLANDS. 
AN^M I A, 
INCLUDING 
Simple Anaemia (Chlorosis) and Pernicious Anaemia, 
There are three main clinical types of anaemia, cases 
of which are to be seen in every hospital. These are, 
simple anaemia or chlorosis, primary anaemia-so-called 
pernicious anaemia, and secondary anaemia. The last- 
named is, as its name indicates, a sequel to some obvious 
physical disorder, such as loss of blood from haemorrhage, 
or the cachexia of malignant disease. We are not 
further concerned with this variety, and the two con- 
ditions whose management we have to consider to-day 
are those of simple anaemia (chlorosis) and primary 
or pernicious anaemia. 
The Etiology of these Disorders. 
The exact causation of these diseases is unknown. 
There are several theories, but the final cause of either 
is not determined. With regard to simple anaemia or 
chlorosis, a condition most typically seen in young 
women, the view is generally held that the condition 
is the direct result of constipation, some poison being 
absorbed from the bowel, which interferes with the 
proper formation of the blood elements in the bone 
45 46 
CLINICAL LECTURES FOR NURSES 
marrow and the system generally. Pernicious anaemia, 
on the other hand, is essentially a disease of adult life, 
most commonly seen between the ages of thirty and 
forty-five, and is more common in men than in women. 
With regard to the cause of the disease, the toxaemia 
or infective theory is the view which is now most widely 
held. According to this view the disease is due to the 
toxins produced at a latent focus of sepsis in the system, 
this septic focus being most commonly seen in con- 
nection with the teeth, gums, digestive or utero- 
genital tract. Some physicians consider that these are 
the result of the anaemic condition rather than the cause. 
A careful examination into the history of these cases, 
however, lends ample support to the view, now held 
by practically all the authorities on the subject, that the 
condition is due definitely to a toxin or toxins produced 
at some septic focus, which disturbs the function of the 
bone marrow, and leads to the particular blood con- 
dition present in this disease. It will be convenient to 
discuss separately the two types of anaemia. 
SIMPLE ANEMIA OR CHLOROSIS. 
This is essentially a disease of young women between 
the ages of fifteen to twenty-five. It is characterised 
by general anaemia or bloodlessness, with lack of vigour, 
breathlessness on exertion, and in some cases slight 
oedema of the feet; varying symptoms of indigestion 
are present, and constipation is usually a most pro- 
nounced symptom. In many cases, however, the ex- 
istence of constipation is denied, this being so even in 
cases where a soap-and-water enema may be required 
for many days after admission to hospital to effect a 
preliminary clearing out of the bowel. (It cannot be DISORDERS OF THE BLOOD AND DUCTLESS GLANDS 
47 
too clearly emphasised that great caution is required 
in accepting the statement of any patient with regard 
to the presence or absence of constipation.) The pulse 
is increased in rate and weak in character, and the heart 
is dilated in proportion to the severity of the anaemia. 
The blood is found to be watery, the blood-cells con- 
taining too little haemoglobin. The red cells may be 
reduced from 5,000,000 per cubic millimetre, to 3,750,000, 
and the haemoglobin from 100 per cent down to 30 per 
cent. This relatively greater reduction in the amount 
of haemoglobin present is one of the special features 
of the blood in simple anaemia. Amenorrhoea is a 
common symptom, and is probably protective in nature. 
In many cases the teeth are defective, both in number 
and in quality, and the gums are frequently in an un- 
healthy septic condition. The possibility that the 
anaemia is secondary to a latent focus of tuberculous 
mischief should always be kept in view. 
The General Treatment. 
The condition is readily amenable to treatment if 
the necessity for rest is recognised, and the treatment 
persevered with until the condition of the blood is 
restored and the constipation corrected. The treatment 
may be shortly summarised as follows :-rest, aperients, 
and iron. 
The details of treatment required for the average 
case are as follows :- 
1. Complete rest in bed for three weeks, and 
subsequently a graduated amount of liberty and 
movement being allowed. 48 
CLINICAL LECTURES FOR NURSES 
2. The bowel cleared by the administration of 
a soap-and-water enema, which requires to be 
repeated for four days if necessary until all scybalous 
masses are removed. Thereafter one grain of 
calomel may be given, followed by 2 ozs. of Henry's 
solution, and the bowels kept judiciously active 
by half a teaspoonful of cascara, and half a tea- 
spoonful of glycerine given twice daily. 
3. Diet.-If there is no stomach disorder, the 
feeding presents no difficulty. If the patient had 
previously fed too exclusively on bread and tea, 
from the first the light diet of the hospital should 
be given, tea being provided once daily ; eggs, 
meat juice, and oatmeal in the form of porridge, 
may shortly be added, as these are relatively rich 
in iron. 
4. The Teeth.-In many cases a pronounced 
degree of pyorrhoea exists and forms a septic 
focus ; this must be attended to, extraction being 
often desirable. Steps should be later taken to 
supply a plate. 
5. Administration of Iron.-The patient may 
be given a pill containing 2 grs. protochloride of iron, 
and A grain arsenious acid. Many other pre- 
parations of iron can be used. It is advisable not 
to use a liquid preparation of iron which discolours 
the teeth. 
6. Treatment of Constipation. - Measures 
should now, if possible, be taken to promote a 
complete cure of the constipation. This can be 
done by a course of special massage, and remedial 
exercises carried out under supervision for six weeks or thereby. This would render the patient inde- 
pendent of the use of drugs, and permanently 
improve her general health. As these patients 
usually take too little fluid, the drinking of water 
on an empty stomach should be encouraged. 
PRIMARY OR PERNICIOUS ANEMIA. 
We now pass to the consideration of primary or per- 
nicious anaemia. As already indicated, this is a disease 
of adult life, seen generally between the ages of thirty 
and forty-five, men being more frequently affected. 
If a sufficiently thorough investigation is made, it will 
be invariably found that there is some latent focus of 
septic mischief, which is, in all probability, the primary 
cause of the disease. In its typical form the disease is 
characterised by general weakness and breathlessness, 
accompanied by marked pallor, the skin often having 
a faintly yellowish tint, an evidence of general anaemia ; 
the blood is thin and watery, the red cells being 
enormously reduced in number, while the proportion 
of haemoglobin is relatively or actually high. In a 
typical case 
R.B.C. 1,120,000 in place of 5,000,000. 
Haemoglobin, 1.2 per cent. 
The proportion of haemoglobin is actually higher than 
usual, this being a distinctive feature of the blood in 
this disease. The teeth and gums often reveal a pro- 
nounced condition of sepsis, and the stools are exceed- 
ingly offensive. The temperature may be slightly 
irregular. 
The general principles of treatment are similar to 
those laid down for simple anaemia- 
DISORDERS OF THE BLOOD AND DUCTLESS GLANDS 
49 50 
CLINICAL LECTURES EOR NUivSES 
1. Rest is the first essential, and may require 
to be carried out for one to three months. 
2. The second essential is to direct attention to 
the removal of any sepsis in the mouth, the cor- 
rection of any abnormal putrefaction in the large 
bowel, and the removal of any catarrhal condition 
in the uterus or bladder. Among measures which 
are useful in this direction are the internal ad- 
ministration of intestinal antiseptics, such as salol, 
creosote, calomel, kerol; these are useful though 
of limited value. Intestinal lavage, carried out 
daily for some weeks, is often a valuable measure, 
and the use of a vaccine prepared from the stools 
is a useful measure in selected cases. 
3. The third point is the administration of a diet 
adapted to diminish the abnormal fermentation. 
(See lecture on Auto-Intoxication.) 
4. The administration of tonics, and very specially 
arsenic, which is most valuable in this disease. 
5. In very severe cases, transfusion, using salines, 
or in some cases blood, saves the patient's life, at 
any rate for a time. 
A special feature of this disease is the liability to 
recurrence; this liability, however, diminishes in 
proportion to the extent to which all foci of septic 
mischief have been removed. DISORDERS OF THE BLOOD AND DUCTLESS GLANDS 
51 
ADDISON'S DISEASE. 
Addison's disease is a disorder of the suprarenal 
glands usually of tuberculous origin. It is a disease of 
adult life. The most distinctive feature of the disorder 
is pigmentation of the skin, induced by the diseased 
condition of the suprarenal gland. 
Clinical Features. 
The two most important clinical features are the 
pigmentation of the skin and general asthenia. The 
skin acquires a faintly yellow tint, and with this there is 
associated numerous more or less pronounced scattered 
areas of pigmentation, the size ranging from that of 
a pea to two or three inches in diameter or more. In 
pronounced cases these areas may present a deep brown 
appearance. In many cases there is an associated 
pigmentation in the buccal mucous membrane, most 
frequently observed on the roof of the mouth. 
The general muscular weakness or asthenia is the 
next most distinctive feature. The capacity of the 
patient for physical exertion is greatly restricted, this 
being due to weakness of the heart muscle and of the 
voluntary muscles. It is usually associated with weak 
circulation and a low blood pressure. Symptoms of 
gastro-intestinal derangement are not infrequently 
present, and keeping in view the tuberculous origin 
of the disease it is not surprising to find that many 
of the cases show evidence of an old lung lesion of a 
tuberculous nature. The outlook for the patient affected 
with this disease is a very guarded one, the ailment 
tending to be progressive, and death frequently occurring 52 
CLINICAL LECTURES FOR NURSES 
from the severity of the asthenia or from complications. 
The following case is a very typical example of the 
disease :- 
Mrs A. B., aged forty-five, has complained of increasing 
weakness for the last nine months. This has been accom- 
panied by a change of colour of the skin, and the presence 
of numerous small and large areas of deep pigmentation 
over the surface of the skin, most pronounced over the 
anterior aspects of the chest and abdomen, and also the 
back. She has lost about a stone in weight during this 
period. On examination the patient is a small, spare, 
rather emaciated subject, with a very sallow skin, which 
shows numerous areas of deep brown pigmentation on the 
front of the chest, over the abdomen, and on the back. 
These vary in size from that of a small bean to irregular 
areas considerably larger than a five-shilling piece. The 
abdomen is extremely flaccid ; the bowels are constipated, 
and the X-ray examination shows a marked degree of 
stasis in the terminal portion of the ileum and also of the 
colon. The temperature is normal ; the pulse rate is 
round 90, the pulse being weak in character. 
Treatment of the Disease. 
The treatment of the disease is largely the treatment 
of symptoms. There is no known method of successful 
treatment. It has to be conducted on general lines 
as follows :- 
1. Complete rest for many weeks. 
2. Careful attention to the state of the gastro- 
intestinal tract by the administration of light 
diet, the judicious use of aperients, and by the 
careful application of abdominal massage. 
3. The use of various tonic remedies, more 
especially arsenic, strychnine, cod-liver oil and 
malt, and the hypophosphites. DISORDERS OF THE BLOOD AND DUCTLESS GLANDS 
53 
4. In a few cases benefit may be obtained by 
the internal administration of suprarenal gland. 
The results of this internal secretion therapy have 
not proved, however, very satisfactory. 
EXOPHTHALMIC GOITRE. 
(Syn. Graves' disease.) 
In the group of diseases of the ductless glands one 
of the most common is exophthalmic goitre or Graves' 
disease. The disease affects specially the female sex, 
and is most common between the ages of twenty and 
thirty-five. The exact causation of the disease is un- 
known. There are two main theories of causation : 
the one the toxic theory, the disease being regarded 
as the result of a general toxaemia of undetermined 
origin ; the other the nervous theory, the disturbance 
of the gland being regarded as secondary to some de- 
rangement of the nerves controlling the gland. The 
fact that the disease sometimes develops after a fright 
or nervous shock lends some support to the nervous 
theory, but the balance of evidence is strongly in favour 
of the toxic theory. 
Symptomatology. 
The four most distinctive features of the disease are :- 
1. The enlargement of the thyroid gland. 
2. Eye symptoms, and more especially prominent 
staring eyeballs. 
3. Tachycardia or rapid action of the heart, usually 
associated with palpitations. 
4. The existence of fine tremors associated with 
general nervousness. 54 
There are in addition many lesser symptoms and 
physical signs to be found affecting the other systems. 
Of these the more important are a moist warm skin ; 
constipation, which may alternate with diarrhoea, often 
associated with symptoms of indigestion ; frequency 
of micturition, and some disturbance of the menstrual 
function, either leucorrhoea, or menorrhagia. 
The following case is a very typical example of the 
disease, the history being as follows :- 
Mrs S., age thirty-two, enjoyed fair health until five 
months ago, her only previous weakness being that her 
digestion was not very strong. About five months ago, 
without apparent cause, she noticed herself becoming 
nervous, this being accompanied with tremulousness of 
the hands, and being more easily upset than usual. Shortly 
afterwards her eyes became a little more prominent and 
staring, the whites of the eyes becoming unduly prominent. 
Her digestive weakness was still more in evidence in 
this period, flatulence being troublesome, and constipa- 
tion rather more pronounced than usual. She suffered 
from leucorrhoea, and recently from palpitations. She 
had been treated at home for three months without material 
benefit. 
Diagnosis. 
The diagnosis of the disease is easy, the symptoms 
and physical signs being quite characteristic. In the 
very early stages of the disease, however, the diagnosis 
may present some points of difficulty. Cases are com- 
monly met with of young women presenting some 
symptoms of neurasthenia, with rapid action of the 
heart, a slight fulness of the thyroid gland, and with 
doubtful eye symptoms, where there is good reason 
to believe that the condition is one of exophthalmic 
goitre in its early form. This is the stage at which 
CLINICAL LECTURES FOR NURSES 55 
DISORDERS OF THE BLOOD AND DUCTLESS GLANDS 
it is very important to recognise the disease, as it can 
invariably be cured if diagnosed early. Keeping in 
view the fact that the disease is probably of toxic origin, 
it is very important to look into every possible source 
of toxic infection, a thorough investigation being made 
in every direction. This investigation may involve 
a careful study of the digestive tract by means of the 
X-rays, so as to determine more especially the existence 
of ileal or colon stasis ; the examination of the stools ; 
the bacteriological examination of the urine ; and the 
determination and correction of any pyorrhoea which 
may be present. Attention must also be directed to 
the uterine condition. Treatment must be specially 
directed towards the correction of one or more physical 
disorders which may be present, and may be the cause 
of the toxsemia. 
Treatment. 
The first essential in treatment is a thorough in- 
vestigation along the lines laid down under diagnosis. 
Prolonged treatment is essential. The outlook for the 
patient is as a rule favourable provided adequate treat- 
ment be carried out, this being, however, necessary 
for a period of many months. The treatment may 
be considered under two headings-the immediate and 
the remote. 
The Immediate Treatment consists in giving the 
patient complete rest under as favourable fresh air 
conditions as possible, and keeping her removed from 
all worrying influences. The more completely she can, 
for a time, lead, so to speak, the life of a vegetable, 
the more rapid will the progress be. A wise restriction 
should be laid on the writing of letters and on handi- 56 
CLINICAL LECTURES FOR NURSES 
work of any kind, these restrictions, however, being 
removed as quickly as the general conditions of the 
patient and the condition of tremors will allow. The 
diet should be light, nutritious, and yet ample in amount. 
It should be framed along the lines laid down in the 
lecture on Auto-Intoxication. The state of the bowel 
frequently makes it advisable for treatment to be 
directed in that direction by means of the judicious 
use of aperients and occasionally by lavage, which 
should be continued until a satisfactorily clean con- 
dition of the bowel is established. 
Appropriate attention must be directed to the cor- 
rection of any defect in the teeth or gums, and to the 
correction of any pelvic disorder. General tonics are 
of value, more especially arsenic, the hypophosphites, 
and cod liver oil and malt. 
If the bacteriological examination has furnished 
evidence suggestive of definite bacteriological infection, 
the use of a vaccine may be indicated, as undoubted 
benefit results in some cases from its use. 
Some authorities attach value to the application 
of X-rays or radium in treatment. 
The Remote Treatment.-For a year or two after 
recovery, special care is necessary. Care has to be 
exercised in all the directions already specified : the 
avoidance of unduly hard work and of domestic and 
other worries is specially important. 
Throughout the course of the disease it is important 
for the physician and for the nurse to encourage the 
patient in every way possible, mental tonic treatment 
being of value in this disease as in many others. CHAPTER III. 
DISORDERS OF THE HEART AND 
CIRCULATION. 
THE PULSE. 
According to an old-established custom in certain 
parts of China it is imperative for the Chinese doctor 
to be able to diagnose and to treat his patients without 
seeing them, the only part of their person which he is 
allowed to see or handle being the pulse. There is no 
question that a very great deal can be learned by the 
careful examination of the pulse both in regard to acute 
and chronic disease, but it is very desirable that the 
information to be learned from it should be supple- 
mented by a knowledge of the history of the case, and 
by the results obtained from the general examination 
of the patient. We will shortly consider the method of 
examination of the pulse. It is studied in the following 
order :-we observe seriatim the rate, whether it is 
regular in time and in character, whether the pulse 
wave is small, moderate, or large in amount, whether 
it is sustained or falls quickly, whether the pulse wave 
is readily obliterated or obliterated with difficulty, 
and, lastly, we direct our attention to the condition of 
the vessel wall. Let us consider these briefly in order. 58 
CLINICAL LECTURES FOR NURSES 
1. The Pulse Rate. 
The pulse rate for a healthy adult ranges from 70 to 
75 per minute. Exceptionally it is markedly slower : 
in some perfectly healthy subjects the pulse rate seldom 
exceeds 60 or less. The condition in which the pulse rate 
is permanently low, round 50 or thereby, is termed 
bradycardia. The pulse rate is readily increased by 
nervous excitement. It is also increased, though to a 
much less degree, by exertion. If a healthy man walks up 
and down a ward sharply once or twice, the pulse rate is 
not increased, or if so, only by two or three beats per 
minute. Where there is any cardiac weakness on the other 
hand, the same amount of exercise will induce an increase 
in pulse rate of 10 or 15 or more beats a minute, and 
may be accompanied by a slight degree of breathless- 
ness. Tests of this kind are of the utmost value in 
determining the extent to which the reserve of the 
heart has been used up, and the result of such tests 
form a useful guide both for prognosis and for treatment. 
The pulse should be counted for at least half a minute : 
it is inadvisable to count it for fifteen seconds and 
multiply the results by four ; and in all cases in which 
obvious defects are revealed in the condition of the 
pulse, the rate for the full minute should be determined. 
2. Regularity in Time and Character. 
The second point to be determined is as to whether 
the pulse is regular in time and in character. The 
pulse may be regular in time and irregular in character : 
it may be irregular in time but fairly regular in character ; 
it is very frequently irregular both in time and in charac- 
ter-that is to say the time interval between each 
pulse wave varies markedly and the magnitude of the DISORDERS OF THE HEART AND CIRCULATION 
59 
pulse wave similarly varies.* A good deal of training 
is required to appreciate fully the variations in the 
pulse commonly met with. In an aggravated case 
of mitral disease, with failure of compensation, the 
pulse is frequently very irregular both in time and 
character ; there may be very long intervals between 
some of the beats, this being frequently due to the 
fact that many of the beats are missed, the heart muscle 
being so weak that it cannot convey the impulse right 
along the vessel ; similarly some of the pulse beats 
are much weaker and smaller than the others. In 
such a case there is no difficulty in detecting the great 
irregularity both in time and character of the pulse, 
but it is essential for the nurse to train her finger and 
mind in such a way as to be able to detect irregularities 
in the pulse of a much less pronounced character. 
3. The Pulse Wave. 
The third point to which attention should be directed 
is the force of the pulse beat. In health the pulse wave 
is moderate in degree; it comes up against the examining 
finger neither very quickly nor very slowly, and fades 
away in the same way, neither very quickly nor very 
slowly. In diseased conditions there are great variations 
in (a) amplitude of the pulse wave, (6) character of it, 
whether slowly attained or very quickly attained, 
and (c) the manner of fall. In cases of aortic valvular 
disease for instance with incompetence of the aortic 
valves, the pulse wave is very rapidly attained and as 
quickly disappears, giving a very characteristic pulse. 
The general characteristic of this rate is well shown on 
the sphygmographic tracing. Observe that the pulse 
rate is fairly regular both in time and character, but 
* An illustration is given in the pulse tracing on page 82. 60 
CLINICAL LECTURES FOR NURSES 
the character of the pulse is quite different from the 
normal. This tracing should be compared with a 
similar tracing from a case of advanced mitral disease. 
Observe that the amplitude of the pulse is very much 
less, and that the irregularity both in time and character 
is very distinct. 
Attention should now be directed to the ease or 
difficulty in obliterating the pulse wave. If two or 
three fingers are placed on the pulse and pressure exerted 
with the proximal finger, the pulse wave felt with the 
distal finger is normally fairly easily obliterated. In 
certain cases of disease, and more especially cases of 
chronic renal disease, a very great degree of pressure 
from the proximal finger is required to obliterate the 
pulse wave felt by the distal finger. In such a case 
we say that the blood pressure, that is the pressure 
of the blood within the artery, is increased. This in- 
crease of blood pressure is very frequently one of the 
earliest and most important evidences of organic disease. 
4. The Condition of the Vessel Wall. 
Particular attention should be directed to the presence 
or absence of thickening of the arterial wall. Healthy 
blood-vessels are not palpable, or at best indistinctly so. 
In arterio-sclerosis the vessels become thickened and 
often tortuous, this condition being frequently met 
with even in young subjects. (The clinical results of 
arterio-sclerosis are described in a separate section.) 
In cases where an aneurysm is suspected, it is desirable 
to compare carefully the radial pulse on the two sides. 
5. The Pulse as a Guide in Acute Disease. 
The pulse is of great value in prognosis, and also as 
a guide to treatment in acute disease. Take for example DISORDERS OF THE HEART AND CIRCULATION 
61 
a case of pneumonia that is giving special anxiety. 
An observant nurse will notice an alteration in the 
character of the pulse, revealed by an advance in its 
rate, by alteration in the strength, and still more by 
an irregularity in the time and character of the indi- 
vidual beats, which is very important evidence of a 
failing heart muscle, and a guide to the necessity for 
the use of special stimulating measures. 
ARTERIO-SCLEROSIS. 
It is a true and a trite saying that a man is as old 
as his arteries. Some men and women of fifty years 
of age are in reality twenty years older ; the converse 
is equally true ; we occasionally see men of sixty or 
seventy years of age whose arteries and tissues generally 
might he envied by men fifteen or twenty years younger. 
When arteries get old they lose their resiliency ; their 
walls become thickened, so that ultimately they may 
become rigid tubes-in place of soft elastic vessels. 
In healthy old age the vessels lose their elasticity to 
some extent, but a pathological degree of thickening 
of the vessel wall with all its attendant sequelae is a 
very common clinical condition, and it may begin quite 
early in life. 
Causes of Arterio-Sclerosis. 
Hereditary influences are an important factor. Some 
families have a specially strong vascular system ; in 
others the blood-vessels are less strong and more easily 
influenced by adverse conditions. The disease is, 
however, usually acquired, and is due to one or other 
of the following conditions-these often existing in 
combination. 62 
CLINICAL LECTURES FOR NURSES 
Hard physical and severe mental strain are impor- 
tant etiological factors ; thus the condition is specially 
common among miners and others whose work involves 
sustained muscular effort, and also among those who 
lead a strenuous city life at high tension, and with 
business worries. 
Long-continued indiscretions in feeding, more especi- 
ally excess of animal protein food and excess of liquor, 
are another cause; closely related to the last-mentioned is 
the condition of auto-intoxication or a general toxsemia 
dependent on chronic constipation. Extraneous poisons 
such as nicotine from excessive tobacco smoking, and 
bacterial toxins from a septic focus such as carious 
teeth, diseased gums, or a latent uterine catarrh, play 
an important role in developing the condition. 
The previous occurrence of syphilis or other infective 
disorders is in many cases the main determining causal 
factor in the disease. When once established it is 
maintained and exaggerated by the other factors above 
referred to. 
Manifestations of Arterio-Sclerosis. 
Arterio-sclerosis manifests itself by symptoms referred 
not to the vessels, but more generally to the heart, lungs, 
or kidneys. Not infrequently the disease first presents 
itself by symptoms suggestive of slight cardiac disorder. 
On examination it is found that the heart is dilated, 
this being the result of wide-spread arterial changes. 
In other cases the symptoms may be largely respiratory, 
with symptoms and signs of bronchitis and emphysema 
of the lungs. Emphysema is present in a marked degree 
in most cases of arterio-sclerosis, and predisposes to DISORDERS OF THE HEART AND CIRCULATION 
63 
bronchitis, both of these conditions being associated 
with, and to a great extent dependent upon, arterio- 
sclerosis. 
In other cases the condition first reveals itself by the 
occurrence-it may be in an apparently young subject 
-of cerebral haemorrhage or thrombosis, occurring in a 
man who may never have required to consult a doctor, 
but who has been the subject of a steadily-advancing 
arterial thickening in his cerebral and other vessels 
with associated cardiac weakness. Some intercurrent 
minor illness developing without apparent cause, such 
as sciatica or rheumatism, may also be the form in 
which arterio-sclerosis first presents itself. Its associa- 
tion with aneurysm and renal disease need only be 
mentioned. 
Enough has been said to indicate the great clinical 
importance of the subject, and the diverse ways in 
which attention may be drawn to its existence. 
The following cases of well-marked arterio-sclerosis 
may be taken as illustrations. One of these is a " heart " 
case, the second is a case of " sciatica," and the third 
a case of " angio-spasm " of a diseased cerebral vessel, 
the condition simulating cerebral haemorrhage. 
(a) A young man, a miner, admitted complaining of 
prsecordial pain and slight breathlessness of four weeks' 
duration. On examination there was found a slightly- 
hypertrophied and dilated heart, with, for his years, marked 
arterial thickening and increased blood pressure, fn his 
case the chief operative factors had probably been excess 
of tobacco-five or six ounces a week,-constipation, and 
excessive indulgence in animal food, which he took at 
least thrice daily. 
(&) The second case is that of a woman aged thirty 
suffering from sciatica of some months' duration. On 
examination the most striking clinical conditions present 64 
were the marked degree of arterial thickening, and the 
existence of constipation and very offensive stools. There 
was good reason to believe that the toxin or toxins, which 
had long been operative in inducing this arterial thickening, 
have lately been responsible for the neuritis of the sciatic 
nerve. In this case we believe the causes were consti- 
pation and the presence of teeth deficient in number, 
and very defective in character, combined with long- 
continued injudicious feeding. 
(c) Man aged fifty-eight, admitted five days ago un- 
conscious with the following history :- 
He was sitting at the fireside one night when his wife 
noticed that his speech was a little thick, and he steadily 
became unconscious. The previous history showed that the 
man had led a hard life, and had been rather intemperate 
in his habits. On admission the patient was unconscious, 
and remained so for a few hours. On regaining conscious- 
ness his speech was a little thick and confused, and there 
was some weakness, but no distinct paralysis of the right 
arm and leg, and there was no disturbance of sensation. 
The blood-vessels were markedly thickened and the blood 
pressure raised. The urine was abundant and contained 
a very faint trace of albumin. The symptoms passed off 
in forty-eight hours. The history of the case with the 
rapid recovery indicated that the condition was the result 
of a spasm of a diseased cerebral vessel-so-called angio- 
spasm ; such cases very closely simulate cerebral haemorr- 
hage and cerebral thrombosis. From their nature they 
are less serious, but the outlook for the future is always 
guarded. 
General Treatment. 
The basis of treatment is prophylactic. Keep in 
view the various causes which tend to induce the con- 
dition and remove them so far as possible. Above all, 
promote judiciously free elimination by the bowels, 
kidneys, and skin, and see that the patient is provided 
CLINICAL LECTURES FOR NURSES Radiogram of normal heart. Note 
shape and size of the heart and 
aorta. 
Radiogram of aneurysm of aorta. 
Note the great enlargement of the 
aorta. 
Radiogram of enlarged and dilated 
heart (mitral stenosis). Note the 
enlargement of the heart and altered 
shape, the enlargement being chiefly 
of right side. 
Radiogram of chest showing bilateral 
pulmonary tuberculosis. Note the 
dark areas of affected tissue in the 
middle of both lungs. 
To face p. 65. 65 
with a thoroughly clean and useful set of teeth and 
appreciates the importance of using them. 
The details of the treatment are further considered 
under various headings, such as disease of the heart 
and disease of the nerves, which are in many cases 
associated with and dependent upon the slow and in- 
sidious degeneration of the blood-vessels. 
DISORDERS OF THE HEART AND CIRCULATION 
HEART DISEASE. 
We have recently admitted into the hospital three 
typical cases of heart disease, all of them of a serious 
character. One of them is what is known as a mitral 
case, that is an affection of the heart associated with 
disease of the mitral valve, with all the symptoms 
and physical signs of backward pressure of the venous 
system. The second is a case of disease of the aortic 
valves known as aortic regurgitation, due to incom- 
petence of the aortic valve. The third case is that of 
a middle-aged woman suffering from disease of the 
heart muscle-fatty or fibroid heart--there being no 
apparent disorder of the heart valves. These cases 
form an excellent basis for the consideration of the 
principles and practice of heart affections in general. 
In every case of heart disease the vital question for 
the patient is the condition of the heart muscle. So 
long as it has a fair amount of reserve, it is capable 
of overcoming a considerable degree of disorder, either 
of the heart valves, or the heart muscle itself; but when 
that reserve is encroached on beyond a certain point, 
pronounced symptoms of cardiac disorder supervene. 
A brief introductory note on the physiology of the 
circulation will be useful. 66 
Physiology of Heart and Circulation. 
There are really two hearts, the right heart and 
the left heart. The right heart is concerned with 
receiving the venous blood from the whole of the body 
through the superior and inferior vena cava, the blood 
being sent on from the right ventricle to the lungs to 
be oxygenated. Under normal conditions all the 
blood from the right ventricle is propelled onward to 
the lungs, but when the tricuspid valve between the 
right ventricle and the right auricle becomes incompe- 
tent, the right ventricle thereby becomes dilated, 
and the blood regurgitates into the auricle and into 
the veins of the neck, thereby producing a venous 
pulse in the neck which is very distinctive. The left 
heart receives the aerated blood from the lungs, and 
is concerned with transmitting it through the aorta 
towards all the organs and tissues of the body. 
The left ventricle is thus the most important of the 
four chambers of the heart. It may be prejudiced 
in its action by disease of the mitral valve, e.g., narrow- 
ing or stenosis, which interferes with the free access 
of blood into the left ventricle, or by dilatation of the 
mitral valve (mitral incompetence or regurgitation), 
which allows, during contraction of the left ventricle, 
of some of the blood regurgitating backwards into 
the auricle in place of all being propelled forwards 
into the arterial system. Both ventricles may be 
handicapped by weakness of the muscles of the wall- 
fatty or fibroid degeneration of the heart muscle- 
the result of various causes, thus interfering with an 
efficient pumping action of the organ. 
There are other factors of great clinical importance 
in the maintenance of a normal circulation, over and 
CLINICAL LECTURES FOR NURSES DISORDERS OF THE HEART AND CIRCULATION 
67 
above the condition of the heart muscle, and the con- 
dition of the blood already considered. These are 
the state of the venous system and of the arterial system 
generally. Any tendency to stagnation in the peri- 
pheral or central veins, such as are met with in cases 
of varicose veins of the legs, or distension of the ab- 
dominal veins often met with in obese people, indirectly 
affects the efficiency of the heart in an important degree. 
The result of this defect is most commonly seen in 
people who live a sedentary life, take too little exercise, 
and eat and drink to excess. A free and healthy move- 
ment of the diaphragm is a most important factor in 
promoting a free and normal venous return from the 
abdomen and lower limbs to the heart. 
The other important factor which often prejudices 
the heart is a diseased condition of the arterial system, 
known as arterio-sclerosis, a condition characterised 
by undue rigidity and thickness of the arterial walls, 
often associated with high blood pressure ; this greatly 
increases the strain upon the left ventricle, tending 
sooner or later to dilatation of that chamber with its 
resulting serious defects. It will readily be understood 
that when the function of the heart is deranged from 
any cause, other organs are correspondingly distended, 
and this derangement is in every instance due either 
to the absence of a free arterial supply to the organ, 
or to the presence in excess of venous blood (chronic 
venous congestion), or to both combined. 
The last point that requires consideration under 
this head is the readiness with which the heart's action 
may be directly disturbed by derangement of the stom- 
ach, and more especially by distension of the stomach 
by excess of air (flatulence), or excess of solid or liquid 68 
CLINICAL LECTURES FOR NURSES 
nourishment. The heart lies immediately above the 
diaphragm, the stomach immediately below it, and 
under many conditions of digestive disorder the stomach 
becomes enlarged, and presses upwards on the heart, 
producing discomfort or pain in the region of the heart, 
and other symptoms of cardiac derangement. It is 
no exaggeration to say that more than fifty per cent, 
of cases in which the patient refers symptoms to the 
heart are due to a temporary and functional derange- 
ment of the heart and circulation induced by some 
digestive disorder. 
Reference to Symptomatology of Heart Disease. 
The more common symptoms of cardiac disorder 
comprise pain, palpitations, breathlessness, oedema or 
general dropsy, and general weakness, accompanied 
by general pallor, cyanosis, oedema or dropsy, cough 
and expectoration, anuria and other symptoms. In 
cases where the disease mainly affects the aortic valve, 
pain and pallor may be very prominent symptoms. 
Pain complained of in the region of the heart-angina 
pectoris-is seen in its most typical forms in disease 
of the aorta and the left ventricle ; the pain often 
radiates from the praecordia, down the inner side of 
the left arm. So long as there is no serious disease 
of the mitral valve, there may be little or no cyanosis, 
and no symptoms arising from backward pressure. 
In cases where the disease is primarily located in the 
mitral valve, pain may be present, though it is a less 
prominent symptom, the chief symptoms being dyspnoea, 
cough, expectoration, bronchitis, oedema, general dropsy, 
scanty urine, etc. In cases of primary weakness of 
the heart muscle unaccompanied by serious valvular 69 
disease, the physical signs may, for a time, be less 
pronounced, although the actual condition may be just 
as serious. It has to be noted that the pain referred to 
the praecordia, and other symptoms-suggestive of dis- 
orders of the circulation-are very often entirely in- 
duced by disorders of the stomach or bowels. 
Etiology of Heart Disease. 
Heart disease, and more especially valvular heart 
disease, is frequently a sequel to a previous attack of 
endocarditis of bacterial origin, and more especially 
acute rheumatism. In many cases it is the result 
of a chronic toxaemia from some neglected source of 
septic infection, aggravated by physical strain, excess 
of alcohol, excess of tobacco, constipation, and pre- 
vious specific infection. 
The Management of Cases of Heart Disease. 
The management of the cases may be regarded from 
two standpoints ;- 
(a) Palliative for the immediate relief of symptoms, 
and, 
(6) Measures directed to remove so far as possible 
the cause. In this connection one must bear 
in mind that damaged valves can never be 
restored. Much, however, can be done to 
improve the condition of the heart muscle so 
as to enable it to overcome the extra diffi- 
culties associated with a valvular lesion or a 
defect in its own structure. 
The three cases recently admitted form a useful 
basis for the systematic consideration of the main 
essentials in the general treatment of these conditions. 
DISORDERS OF THE HEART AND CIRCULATION 70 
CLINICAL LECTURES FOR NURSES 
Systematic Consideration of the following:- 
I. Rest in Bed.-Complete rest is one of the 
most important essentials in the general manage- 
ment of diseased conditions of the heart. You 
have frequent opportunity of observing how, 
within from twenty-four to forty-eight hours 
after admission, and without any special treatment 
other than complete rest, the pulse rate is, in many 
cases, reduced by ten or twenty or even thirty beats 
per minute, the pulse at the same time becoming 
stronger and more regular. Complete rest may 
be required to be maintained for several weeks if 
the best results are to be obtained. In severe cases 
the patient should not even be allowed up to the 
stool. The state of the pulse and the condition of 
the patient generally, more especially with regard 
to the amount of pain, dyspnoea, and oedema, will 
be a guide for the duration of complete rest. It is 
sometimes essential to remove a little fluid from 
the chest or abdomen to start the recovery. 
2. Measures for the Relief of Pain.-The 
rest in bed is itself a useful measure in this direction. 
Relief from pain is often afforded by relieving the 
portal congestion by a dose of calomel, followed by 
a saline. If the pain is severe and recurs in parox- 
ysms, relief may be obtained by inhalation of amyl 
nitrite, or by the administration of nitro-glycerine 
or sodium nitrite, and in some cases by hypodermic 
injections of morphia. The local application of 
a belladonna plaster to the praecordia, the bathing 
of the arms with hot water, and the internal admin- 
istration of potassium iodide are other valuable 
measures for the relief of cardiac pain. DISORDERS OF THE HEART AND CIRCULATION 
71 
3. Measures for Inducing Sleep.-Sleep is 
Nature's restorative, and it is difficult to over- 
estimate the importance of a good night's rest. 
Care and discrimination are necessary with regard 
to the use of hypnotics ; among those most generally 
useful are veronal 8 to 10 grain doses, paraldehyde 
1 to 2 drams. Simpler measures are often effica- 
cious, more especially a hot drink of beef tea or 
chicken tea, or a little stimulant in hot water last 
thing at night. Great care should be taken in 
regard to the composition and amount of the 
patient's evening meal, a light meal with little 
fluid being given. 
4. Administration of special Cardiac Tonics. 
-The first point to be kept in view is that all cases 
of heart disease do not require to be treated by 
digitalis or strophanthus ; in fact in a large pro- 
portion of cases these drugs are unnecessary and 
are better withheld. Drugs of this powerful class 
are only necessary in severe cases, in which definite 
improvement does not occur under the simpler 
measures described. When necessary they may 
be given by the mouth or hypodermically ; their 
liability to derange the stomach and digestion 
must be kept in view, and otherwise their use 
should be reduced or discontinued as soon as this 
can be done judiciously. In many cases the 
best cardiac tonic we can prescribe is to reassure 
the patient that their condition is not serious, or, 
at least, not half as serious as he imagines. 
5. The Dietetic Treatment .-The dietetic treat- 
ment of a case of heart disease is of the first import- 
ance. I have already indicated that in more than 72 
half the cases in which symptoms are referred by 
patients to the heart, the condition is really 
secondary to indigestion, relief being obtained 
by careful treatment directed to the stomach and 
bowels, by the administration of a light diet with 
little fluid at meals, by reducing the amount of 
fermentable farinaceous foods, by diminishing or 
cutting off the amount of tea, and by the correction 
of the constipation. These same principles have 
to be applied in the more serious cases of heart 
disorder. The common tendency to over-feed 
these cases should be avoided. The venous con- 
gestion of the digestive tract and of the liver, with 
its associated weakness of digestive power, should 
be kept in view, and the diet adapted accordingly► 
As a general rule the meals should be given in 
small quantities, largely dry, with the farinaceous 
foods greatly restricted, the principal meal being 
taken in the middle of the day. 
6. Digestive System.-Attention has already- 
been directed to the importance of regulating 
carefully the hepatic and intestinal functions. An 
occasional dose of calomel with a morning saline 
or a suitable vegetable laxative are of special value. 
7. Massage and Exercises.-The skilled appli- 
cation of massage with various remedial exercises 
is one of the most important means of restoring 
the state of the heart muscle to a high state of 
efficiency. If the best results are to be obtained, 
this must be carried out daily under supervision 
with a carefully devised prescription, the effect 
of massage and exercises on the state of the pulse 
and on the general symptoms being carefully ob- 
CLINICAL LECTURES FOR NURSES 73 
served. The massage and exercises can often be 
advantageously combined with effervescing baths 
(so-called Nauheim treatment), the patient being 
immersed from fifteen to twenty minutes. The 
benefits obtained from these baths are partly physi- 
cal and partly mental, but in appropriate cases the 
beneficial effects are undoubted and of the greatest 
value. 
The after-treatment of cases of heart disease is im- 
portant. This involves very careful regulation of the 
life of the patient generally, diminishing the physical 
and mental strain as much as possible, with careful 
regulation of the bowels and continued care with regard 
to diet, at the same time doing everything possible to 
encourage the patient to think about his condition as 
little as possible. The occasional use of a muscle tonic, 
-e.g., arsenic, for a few weeks is advantageous. 
DISORDERS OF THE HEART AND CIRCULATION 
ANEURYSM. 
An aneurysm is a dilatation of a blood-vessel, most 
commonly affecting the arch of the aorta. The swelling 
or tumour may reach a large size, and produce numerous 
symptoms most of which arise from the pressure of 
the tumour on the surrounding structures. We have 
in the ward at present a case of aneurysm of the arch 
of the aorta which presents most of the clinical features 
seen in such cases. The history is as follows :- 
C.D., aged forty-five, brewers' lorryman, admitted to 
hospital complaining of pain in his chest, and occasionally 
in the upper dorsal region with breathlessness on exertion 
-of about two months' duration. He has lived a life of 
severe physical strain, has indulged very freely in alcohol. 74 
and many years ago he became affected with syphilis. 
The diagnosis of the case was established by an examina- 
tion with the X-rays. 
Causation. 
The main causes of aneurysm are syphilis, strain, 
and alcohol, all of which were present in combination 
in this case. 
Symptoms and Physical Signs. 
The symptoms of which the patient first complains 
are as a rule breathlessness especially on exertion, 
general weakness, and a varying degree of pain in the 
chest or back, often described as of a boring character. 
The symptoms are often those which are characteristic 
of heart disease. 
On physical examination the enlargement of the 
aorta can be made out, sometimes by inspection which 
may reveal pulsation of a distinctive kind, but more 
frequently by percussion by means of which we can 
determine that the area of dulness of the aorta is con- 
siderably extended. In doubtful cases the diagnosis 
can be cleared up by means of the X-rays, which enable 
one to determine the existence of an aneurysm, its 
size, and the particular part of the arch of the aorta 
which is most affected. In the above case it is the 
transverse part of the arch of the aorta which is most 
affected. All the structures in immediate relationship 
to the arch of the aorta may be pressed upon with 
resulting symptoms and physical signs. Thus the bone 
of the sternum or the vertebrae may be erroded by 
the aneurysm, pressure on the bone being the most 
common cause of the pain complained of. Various 
blood-vessels may be pressed upon, giving rise to in- 
CLINICAL LECTURES FOR NURSES DISORDERS OF THE HEART AND CIRCULATION 
75 
equality of the two radial pulses, and distention of the 
veins on one side of the neck. The recurrent laryngeal 
nerve which winds round the root of the aorta may be 
pressed on, inducing a paralysis of the vocal cord on 
the affected side with a characteristic brassy cough. 
The deep veins on one side of the chest may be ob- 
structed, producing marked oedema of the affected 
arm ; the sympathetic nerve may be irritated, pro- 
ducing dilatation of the pupil on the affected side, 
and the root of the lung on the one side may be pressed 
on, producing cough, difficulty in breathing, and char- 
acteristic signs on auscultation of the chest. In excep- 
tional cases the thoracic duct may be obstructed, 
this accounting for the distinct emaciation which is 
present in some cases. 
Prognosis. 
The prognosis in cases of aneurysm is always guarded. 
The affected subjects are permanently more or less 
crippled. The natural process of cure of an aneurysm 
is the establishment of a healthy clot inside the vessel : 
this occurs in some cases spontaneously, and in others 
under the influence of treatment. In less favourable 
cases the aneurysm may rupture, death being due to 
a fatal haemorrhage which may occur into the chest or 
externally. Apart from the condition of the aneurysm, 
the prognosis has to be guarded on account of the 
associated weak condition of the heart muscle, some- 
times combined with valvular disease of the heart, 
which is often present in cases of this disease. 
Treatment. 
Treatment has to be directed towards promoting 
the natural cure of the aneurysm by establishing a 76 
CLINICAL LECTURES FOR NURSES 
healthy clot inside the vessel. To this end the most 
important factor is prolonged rest in bed, the rest being 
as complete as possible. The diet must be light and 
dry, little fluid being given with meals. Any straining 
at stool must be prevented by the administration of 
suitable aperients. The clotting of the blood is favoured 
by the internal administration of potassium iodide, which 
has to be continued for a prolonged period. 
CEREBRAL HAEMORRHAGE, 
THROMBOSIS, AND EMBOLISM. 
(Syn. Stroke.) 
We will now consider the clinical condition popularly 
termed a " stroke." This arises from an acute derange- 
ment of the cerebral circulation which may take one or 
other of the following forms :- 
(a) Rupture of a cerebral vessel-Cerebral Haemor- 
rhage. 
(6) Thrombosis in a cerebral vessel-Cerebral 
Thrombosis. 
(c) Embolus in cerebral vessel-Cerebral Embolism. 
(d) Spasm of cerebral vessel-Cerebral Angio-spasm. 
The condition of cerebral haemorrhage, cerebral 
thrombosis, and cerebral angio-spasm are essentially 
diseases of adult and later life. Cerebral embolism on 
the other hand, depending as it does on the carriage 
of a vegetation from the heart valve or a piece of clot 
from the heart chamber, is not infrequently seen in 
younger subjects affected with heart disease. Causation. 
Cerebral angio-spasm, cerebral haemorrhage, and cere- 
bral thrombosis are the result of disease of the blood- 
vessels (Arterio-Sclerosis). The vessels become thickened 
and less resilient than normal, the smoothness of the 
lining membrane being impaired, with the result 
that the vessel becomes liable to a sudden contraction 
due to spasm, to an actual rupture, or to clotting of 
the blood within its lumen. This diseased condition 
of the vessel-wall is often associated with a great increase 
of blood pressure, the pulse tension being high, with 
other evidence of chronic Bright's disease. Reference 
has already been made to the fact that cerebral embolism 
is liable to occur in patients affected with disease of 
the mitral and aortic valves. A small vegetation from 
the valve, or a part of a thrombus in the chamber becomes 
detached, and is carried through the aorta and carotid 
artery into the middle cerebral artery, blocking this 
vessel or one of its branches. The left middle cerebral 
artery is, on anatomical grounds, more likely to be 
affected than the right. Any blocking of the middle 
cerebral artery on the left side produces paralysis on 
the opposite side of the body, since the cells and fibres 
controlling the muscles on one side of the body come 
from the opposite side of the brain. 
Manner of incidence of a stroke. 
A stroke may occur with dramatic suddenness, the 
patient having apparently been in his usual health up 
to the moment of its occurrence. In many cases, how- 
ever, there have been certain premonitory symptoms. 
For a short time-a few hours or a few days-the patient 
has been complaining slightly of certain minor symptoms, 
DISORDERS OF THE HEART AND CIRCULATION 
77 78 
such as headache, giddiness, or peculiar feelings in the arm 
or leg. Premonitory symptoms are usually present in 
cases of cerebral thrombosis. They are never present 
in cases of cerebral embolism, and very rarely also 
in cases of haemorrhage. The manner of incidence 
of the stroke thus yields information of diagnostic value 
as to its cause. 
Symptoms. 
The symptoms will necessarily vary in accordance 
with the size of the vessel and the area affected. As 
the left middle cerebral artery is the vessel most fre- 
quently affected, it will be convenient to discuss the 
symptoms observed in an average case of right-sided 
hemiplegia due to haemorrhage. 
Man, aged forty-eight, was in his usual health, when he 
fell down in a fit, became unconscious, and was brought 
into hospital. His previous medical history was satis- 
factory ; he had, however, worked hard and lived well, 
eating liberally, drinking rather more than was good for 
him, and smoking immoderately. He was a man of stout 
build and plethoric habit. 
On admission patient was unconscious, breathing ster- 
torously. The angle of his mouth was drawn up on the 
left side, the muscles of the lower part of the face on the 
right cheek also moved much less freely on inspiration 
than the left. Pupils were equal and slightly contracted. 
The right arm and right leg were found to be completely 
flaccid, no resistance whatever being offered to their move- 
ment. The tension of the pulse was high, the heart was 
found to be enlarged, and there was a trace of albumin 
in the urine. This history and the physical signs pointed 
clearly to the case being one of cerebral haemorrhage occur- 
ring in a man with arterial sclerosis and chronic renal 
disease. The case is instructive, as showing the insidious 
CLINICAL LECTURES FOR NURSES DISORDERS OF THE HEART AND CIRCULATION 
79 
nature of a serious disease, the development of which is 
due very largely to preventable causes-over-eating and 
over-drinking, combined in many cases with excessive 
physical and mental strain. When the patient recovered 
consciousness, it was found that the sensation on the 
right side was distinctly impaired, but not entirely absent. 
Obviously the haemorrhage was in a position to involve the 
sensory fibres in the brain as well as the motor fibres- 
the site of the lesion being the internal capsule. 
Diagnosis. 
The diagnosis is as a rule easy, especially in cases 
where the history of the case is known. When the 
history is not known, some difficulty often presents 
itself, and we must keep in view all the conditions 
which bring about unconsciousness. 
The diagnosis of " stroke " is always easy, if the 
symptoms of paralysis are clearly marked. 
Prognosis. 
The outlook for the patient depends on the severity 
of the lesion and its cause. Much depends on the degree 
of the recovery in the first three or four days. The 
most favourable results occur in cases due to angio- 
spasm. Here the symptoms may all pass off within 
a few days, leaving the patient little or none the worse, 
though very liable to recurrence. Recovery in the case 
of cerebral thrombosis is seldom satisfactory, if the 
thrombosis is at all complete ; a more satisfactory 
recovery follows a partial thrombosis, the circulation 
in the vessel becoming restored. The outlook in cases 
of cerebral haemorrhage and embolism is always very 
guarded. After a haemorrhage there may be a distinct 80 
improvement which may mislead ; this improvement 
being due to disappearance of the oedema and irritation 
around the haemorrhage. In the case of a right-sided 
hemiplegia of average severity, the outlook for complete 
recovery is always unfavourable, marked permanent 
weakness of the affected side usually remaining. The 
patient subsequently has a distinct hemiplegic gait, 
and is very liable to secondary contracture of the par- 
alysed muscles. There is always the further risk of 
a recurrence of the haemorrhage, thrombosis, or angio- 
spasm, the risk being in great part proportionate to the 
extent of the disease of the arteries, heart, and kidneys 
present. 
Treatment. 
The treatment requires to be considered from two 
points of view-the immediate and the remote treat- 
ment. With regard to the immediate treatment, we 
have to keep in view the immediate risks to which the 
patient is subject. The first and most important is 
the risk of extension of the haemorrhage or thrombosis, 
this extension taking place towards the base of the 
brain and affecting the vital centres, and death 
superseding within an hour or so of the stroke. 
The second risk is the development of bronchitis or 
pneumonia, arising from inhalation of septic matter 
from the upper part of the respiratory tract. A further 
risk is that of sepsis, arising from decomposition of 
urine, retention of urine, and incontinence of faeces in 
severe cases. Yet another point which has to be guarded 
against from the outset is the development of bed-sores. 
In view of the low vitality of the tissues resulting from 
the removal of the normal nerve influences regulating 
CLINICAL LECTURES FOR NURSES 81 
their tone, bed-sores are specially prone to occur. Keep- 
ing these points in view, therefore, we may now summarise 
the essential points in treatment. 
1. Keep the patient perfectly quiet at complete 
physical and mental rest, often in a shaded room 
for some time, after consciousness has returned. 
2. Strict hygiene of the nostrils, gums, and 
tongue, so as to lessen the risks of an inhalation 
bronchitis, or pneumonia. 
3. Careful attention to the bladder, the water 
to be drawn off with great care periodically as 
required. 
4. Clear the bowel well out either by means of 
enemata, or, in sthenic cases, by the administration 
of one or two minims of croton oil. 
5. Prophylactic treatment directed to harden 
the skin against bed-sores. 
6. With regard to feeding : no harm will accrue 
in most cases from withholding food altogether 
for one or two days, after which nourishment may 
be given, by the bowel if necessary, or by the mouth 
when practicable. 
A few days usually suffice to give an indication 
of the future progress of the case. If the patient 
survives, measures must be taken to maintain the 
nutrition of the paralysed muscles, and to prevent 
a secondary contracture which is Hable to develop. 
At the same time measures must be taken to pro- 
mote as far as possible absorption of the effused 
haemorrhage or clot, and to remove so far as may be 
practicable the causes of the arterial sclerosis. These 
DISORDERS OF THE HEART AND CIRCULATION 82 
CLINICAL LECTURES FOR NURSES 
measures may be effected by the very careful 
application of massage, with passive movements, 
to the affected limbs, the duration and severity 
of the application being regulated with great care. 
As a rule, massage of the requisite gentle character 
can be begun within a few days of the onset of the 
illness. The internal administration of iodide of 
potassium is often helpful in promoting absorption 
of the haemorrhage. Special care must be main- 
tained in regard to the regulation of the bowels, 
a mercurial pill followed by a morning saline being 
specially advantageous. The diet must be of a 
light, non-stimulating kind, with little or no 
alcohol. The line of treatment subsequently is 
that laid down for arterio-sclerosis, chronic ne- 
phritis, or the heart conditions which are usually 
associated with the stroke. 
Pulsus alternans a a a a, feeble pulsations preceded by a 
stronger beat: diastolic intervals equal. At b, premature 
contraction (extra systole) followed by prolonged diastole. CHAPTER IV. 
DISORDERS OF RESPIRATION. 
BRONCHITIS. 
Bronchitis is one of the commonest diseases, and is 
met with in every grade of severity, from a slight cold 
on the chest to an acute and rapidly fatal disease attended 
with dyspnoea, cyanosis, and collapse. It occurs as a 
primary disorder, and also as a secondary affection 
in the course of chronic nephritis, chronic heart disease 
and chronic lung disease. Clinically it may be con- 
sidered in two main forms :- 
1. Acute bronchitis. 
2. Chronic bronchitis. 
We will discuss these seriatim. 
ACUTE BRONCHITIS. 
Causation. 
Acute bronchitis occurs as a result of exposure to 
cold, " catching cold " in the popular sense. This is 
due to bacterial action, the chill or cold depressing 
the vitality of the tissues, and allowing the bacteria, 
which are normally present in the upper part of the 
respiratory passages, to become pathogenic. Acute 
bronchitis is also frequently set up by infective fevers 
83 84 
CLINICAL LECTURES FOR NURSES 
such as whooping cough, scarlatina, measles, and 
influenza. It also frequently develops as a secondary 
affection in chronic nephritis, gout, and chronic disease 
of the heart or lungs. A variety of bacteria may be 
responsible for the catarrh, the more common being 
pneumococcus, micro-coccus catarrhalis, various diplo- 
cocci, influenza bacillus and others. 
Clinical Features. 
The condition develops like an ordinary cold, with 
soreness in the chest, and may be slight chilliness and 
a feeling of out-of-sorts generally. There is slight in- 
crease of pulse rate, respiration rate, and temperature, 
with dry skin, febrile urine, and loss of appetite. Cough 
is at first harsh and dry, and, later, with expectoration. 
The sputum is at first thin, watery, and frothy, and 
later muco-purulent. The dyspnoea is seldom pro- 
nounced when the larger bronchi only are affected. 
The symptoms and physical signs are more pronounced 
where the bronchitis occurs as an intercurrent affection 
in disease of the heart, lungs, or kidneys. 
Diagnosis. 
The diagnosis is always easy, but it is important 
to keep in view that bronchitis is a prominent symptom 
in the early stages of typhoid fever and whooping- 
cough ; it is further essential to ascertain whether the 
bronchitis is a simple primary disorder, or is secondary 
to chronic nephritis, heart disease, pulmonary tuber- 
culosis, or other disorder. 
Treatment. 
In its simpler forms the case responds readily to the 
application of ordinary domestic remedies : a mustard DISORDERS OF RESPIRATION 
85 
and hot-water footbath, the application of a mustard 
poultice to the chest, the use of an aperient, a simple 
diaphoretic mixture, and a Dover's powder may be 
relied on to promote recovery in a few days. In more 
severe cases the patient may require to be confined to 
bed for a week or longer, and treatment conducted 
along the following lines :- 
1. Careful regulation of the temperature of 
the room, avoiding draughts on the one hand and 
undue stuffiness on the other. 
2. The application of light linseed poultices to 
the front and back of the chest, to relieve the 
distressing cough and to promote easy expectora- 
tion. 
3. Where the breathing is embarrassed and the 
strain of coughing severe, the use of a steam-kettle 
producing a moist antiseptic vapour gives consider- 
able relief. (One teaspoonful of compound tincture 
of benzoin to two pints of boiling water.) 
4. Expectorant remedies.-At the onset much 
relief is afforded by the administration of ipecacu- 
anha or antimony, and when the discharge is more 
free, by stimulating expectorants,-e.g., ammonium 
carbonate and squills. 
5. The diet.-The diet should be a light fever diet. 
6. Oxygen inhalation, stimulants, and cardiac 
tonics are useful in more serious cases. 
The after-treatment in cases of bronchitis is important, 
more especially in cases where the condition is second- 
ary to chronic disease of the heart, kidneys, or lungs. 
Climate may be important, and a change of occupation 86 
CLINICAL LECTURES FOR NURSES 
may be indicated so as to lessen the strain on the 
heart or kidneys and minimise the chance of recurrence. 
Care in regard to clothing and careful habits as to 
eating, drinking, and smoking are indicated. 
Chronic bronchitis is one of the commonest disorders 
met with. It consists in a chronic catarrh of the lining 
membrane of the bronchi, and is invariably associated 
with and complicated by emphysema of the lungs. 
Like acute bronchitis it may occur as a primary dis- 
order of the chest, or as a secondary affection in the 
course of chronic disease of the heart, kidneys, or lungs. 
It is essentially a disease of adult and later life, but is 
also met with not infrequently in younger subjects, 
especially those affected with mitral valvular disease 
of the heart. 
The following is a very typical example of the disease, 
the history and physical signs alike being character- 
istic of the condition. 
Man, aged forty-five, on admission complained of breath- 
lessness, weakness, cough, and expectoration, the symptoms 
being of three weeks' duration. For many years the patient 
has had a " winter cough " to which he paid little heed. 
He has been accustomed to hard work, is a temperate 
man but a heavy smoker. His nutrition is somewhat 
poor. Pulse on admission 110 rather weak and irregular. 
His sleep was much disturbed by the frequent cough and 
expectoration. The chest was altered in shape, being 
distinctly barrel-shaped, showed very little expansion, 
of the lung, and numerous rales were audible all over 
more especially at the bases. There were three ounces 
of expectoration in twenty-four hours, being of a muco- 
purulent character and frothy on the top. The heart 
was distinctly dilated especially on the right side. The 
liver was slightly enlarged, and the urine was scanty. 
CHRONIC BRONCHITIS. DISORDERS OF RESPIRATION 
87 
Causation. 
Chronic bronchitis is a direct result of a catarrh of 
the bronchial tubes induced by bacteria. Under normal 
conditions the few bacteria in the upper part of the 
respiratory tract are harmless, and do not invade the 
mucous membrane ; in bronchitis, they become patho- 
genic and produce both local and general effects. The 
local catarrh stimulates nature to expel the irritant 
by coughing. This coughing when prolonged and 
severe throws a great strain upon the lung, and distends 
the air vesicles producing a condition of emphysema. 
The development of this emphysema in return still 
further weakens the lung by impeding the circulation, 
this producing a strain upon the right side of the heart. 
The effect of this strain is cumulative, and sooner or 
later, through the recurrence of the bronchial attacks, 
the heart dilates, as in the above case, which illustrates 
the symptoms and physical signs of a dilated heart, 
the symptoms being proportionate to the degree of the 
dilatation. The dilatation of the right heart induces a 
backward pressure in the venous system, which in the 
later stages is revealed by enlargement of the liver, by 
diminution of the quantity of urine (which may contain 
albumin), and by slight or marked oedema or general 
dropsy. 
The existence of valvular heart disease, arterio- 
sclerosis, chronic renal disease, or chronic pulmonary 
tuberculosis are marked pre-disposing causes of chronic 
bronchitis. 
Clinical Features. 
In its slighter degrees chronic bronchitis manifests 
itself by a slight cough and expectoration, with marked 88 
CLINICAL LECTURES FOR NURSES 
liability to colds. In more severe cases, owing to the 
secondary involvement of the heart, the symptoms 
become much more pronounced as in the above case. 
The cough, expectoration, and the slight breathlessness 
on exertion become very much more pronounced, 
owing to the failure of compensation of the right side 
of the heart, and the resulting development of the 
symptoms and physical signs of backward pressure. 
The symptoms include : general weakness which may 
be pronounced, great breathlessness on exertion, and 
possibly oedema of the feet and legs. The physical 
signs include : cyanosis, an enlarged dilated heart, 
with weak heart sounds and possibly murmurs of in- 
competence, a weak, rapid, and often irregular pulse, 
marked emphysema of the lungs, copious expectoration, 
rales present all over the chest, and scanty urine which 
may contain albumin. 
Prognosis. 
In slight cases the prognosis is good if the patient's 
social circumstances are favourable. In severe cases 
it is more guarded. The prognosis is chiefly influenced 
by age, the social circumstances of the patient, the 
severity of the lung mischief, and the degree of involve- 
ment of the heart. In the case mentioned the outlook 
for the future was a very guarded one, because the 
social conditions of the patient were not very favourable, 
the emphysema was very pronounced and remained 
a permanent weakness after the immediate attack 
subsided, and also because the pulse was rather 
weak indicating a distinct degree of permanent cardiac 
disability. 89 
DISORDERS OF RESPIRATION 
Treatment. 
Keep in view the principles of treatment which are 
as follows :- 
(a) To restore the tone of the heart and circula- 
tion by securing adequate rest. 
(6) To relieve symptoms and give relief to parox- 
syms of coughing, dyspnoea, and sleeplessness 
associated with the disease. 
(c) To diminish the bacterial activity in the 
respiratory tract and at the same time increase 
the resistance of the blood and tissues to the in- 
fecting organisms. This may involve the use of 
vaccines. 
(d) To maintain the general strength of the 
patient by suitable feeding and careful regulation 
of the excretory functions. 
In the case of the patient referred to above, practical 
application was made of these principles in the following 
way :- 
1. Complete rest in bed for a fortnight. 
2. Insomnia was relieved by an occasional dose 
of paraldehyde (two drams), and veronal (eight 
grains). For two days light jacket linseed poultices 
were applied to the front and back of the chest, 
which was subsequently kept warm by light jackets 
of cotton wool. 
3. A tonic was given containing small doses 
of digitalis, ammonium carbonate, and senega to 
steady the circulation and promote expectoration. 90 
CLINICAL LECTURES FOR NURSES 
4. Diet.-Little fluid was given with meals, red 
meats were withheld, and no food of any kind 
given after seven o'clock p.m. 
5. A mercurial pill at night followed by a 
morning saline was given occasionally in ten ounces 
of hot water the first thing in the morning. The 
hot water alone was repeated in the middle of the 
forenoon. 
Under these measures the condition of the patient 
improved very markedly in a fortnight, his nights 
became good, his breathing much better, the expectora- 
tion greatly reduced, and the heart and pulse con- 
siderably improved. If the further progress of such 
a case is not equally satisfactory and the cough and 
expectoration remain troublesome, a further bacterio- 
logical examination of the sputum must be made with 
the view of preparing a vaccine. In many cases the 
careful administration of a vaccine is of very great 
value in relieving the symptoms and diminishing the 
subsequent susceptibility to fresh " colds." Some 
skill and experience is required to regulate the doses 
or frequency of the vaccine administration if the best 
results are to be obtained. Careful attention has to be 
directed to any local reaction at the site of injection, 
and to the general reaction, including the effect on the 
cough, expectoration, and physical signs in the chest. DISORDERS OF RESPIRATION 
91 
PNEUMONIA. 
There are two varieties of pneumonia : one in which 
the lobes of the lung are affected by a characteristic 
inflammation-lobar or croupous pneumonia ; the other 
affecting the small lobules of the lung in relation to 
the terminal bronchi-broncho-pneumonia or catarrhal 
pneumonia. The two conditions are essentially dis- 
tinct both in their pathological and clinical features. 
The term pneumonia is more commonly restricted to 
the first variety. We will now discuss them seriatim. 
PNEUMONIA. 
Pneumonia, or as it is perhaps more correctly called 
pneumonic fever, is a specific infection of the system 
by a particular micro-organism called the pneumococcus. 
It is an eight-day fever, the inflammation running its 
course in favourable instances in eight days, the tem- 
perature falling suddenly on the eighth day. The 
most distinctive pathological and clinical feature of 
the disease is as a rule the inflammation of the lung ; 
but there are many exceptions to this rule. There 
are many cases of pneumonic fever in which the general 
constitutional symptoms are very pronounced, though 
the amount of lung involved is small. The disease is 
essentially one of adult life. The exciting cause of the 
disease, the pneumococcus, is usually present in the 
upper part of the respiratory tract in healthy people, 
and it is only under some adverse condition, which 
lowers the resistance of the system, that the organism 
assumes pathogenic properties. 92 
CLINICAL LECTURES FOR NURSES 
Clinical features. 
The disease sets in suddenly as a rule with a chill 
or rigor, and it may be, sickness with vomiting. This 
is accompanied by fever, increased pulse rate, hurried 
respiration, and very frequently pain in the affected 
side, more especially when the patient attempts to 
take a deep breath. Distension of the alee nasi, with 
movement on respiration may be observed. In many 
cases there is a characteristic herpetic eruption round 
the mouth. On physical examination, at the outset 
there may be little manifestation except the general 
evidence of fever, shown by quickened respiration, 
increased pulse rate, flushed skin, febrile tongue, and 
concentrated urine. In a day or two the physical signs 
of lung disease are developed in typical cases, con- 
sisting of consolidation of the lung, altered breath 
sounds, with marked pleurisy and expectoration of 
a peculiar prune-juice character whiSh accompanies a 
short and painful cough. In a typical case there are 
few clinical pictures more distinctive than that of the 
patient at the height of the illness-e.g., about the fifth 
day. The pulse rate will be found to be about 120, 
the pulse full, bounding, and soft in character, and the 
respirations 45 to 50 per minute. 
Diagnosis. 
The diagnosis is as a rule easy, but in exceptional 
cases there is difficulty. The following conditions 
may be simulated : cerebro-spinal meningitis, typhoid 
fever, and appendicitis. (The pain induced by an 
inflamed pleura is sometimes referred to the appendix 
region, and, conversely, the pain induced by an inflamed 
appendix may be referred to the lower part of the right 
side of the chest.) 93 
Prognosis. 
The prognosis is usually favourable in healthy sub- 
jects, but in patients who have been addicted to alcohol 
the outlook is much more unfavourable. Subjects 
who have been in the habit of taking liquor to excess 
are very prone to develop pneumonia and to succumb 
to its effects. The chief risk is that of heart failure, 
the right side of the heart being especially embarrassed 
by the obstruction in the flow of the blood through 
the solidified lung. Other risks are the development 
of abscess and gangrene of the lung, and there is the 
additional risk of imperfect resolution of the inflamma- 
tion with the later development of tuberculous mischief. 
Cases in which the pulse rate exceeds 120 must always 
be looked upon with suspicion, and if that is associated 
with failure on the part of the blood to produce an 
adequate number of white blood corpuscles to cope 
with the infection, the outlook is all the more grave. 
Management. 
In straightforward cases of pneumonia in healthy 
subjects, the general treatment consists in careful nurs- 
ing, with a policy of masterly inactivity on the part of 
the doctor. The disease tends to right itself. Complete 
rest, warmth, encasing the chest in cotton-wool, attention 
to the skin and bowel, a milk regime with ample fluid 
to drink to flush out the system, and a simple diaphoretic 
and diuretic mixture, are all that is required throughout. 
Details regarding feeding will be found in the chapter 
on " Diet in Fever." Where the pain and the cough 
are severe, relief is afforded by linseed poultices. In 
cases of robust people-so-called sthenic cases-relief 
may be afforded by blood-letting, the abstraction of 
DISORDERS OF RESPIRATION 94 
from six to eight or ten ounces of blood from the vein of 
the arm. Special stimulation may or may not be re- 
quired. Where necessary it may take the form of 
small doses of ammonium carbonate, which is a useful 
stimulant to the circulation, also a special heart tonic 
such as digitalis or strophanthus, as prescribed by the 
doctor, and stimulants in the form of whisky or brandy. 
The condition of the pulse is the most reliable guide 
to the necessity of stimulant. Stimulants in the form 
of alcohol are not now employed in the treatment of 
pneumonia to anything like the extent of former years. 
After the crisis, which takes place as a rule on or 
about the eighth day, is over, the condition of the 
patient very rapidly improves, but prolonged care 
should be taken in the convalescence, and in all cases 
where there is any indication of defective clearing up 
of the lung condition, special attention should be devoted 
to the systematic use of breathing exercises to restore 
the normal lung functions. 
CLINICAL LECTURES FOR NURSES 
Broncho-pneumonia is a serious affection, more 
especially at the extremes of life. It is a form of pneu- 
monia which is most commonly observed in children 
and in elderly subjects. It is caused by infection by 
various bacteria, the pneumococcus, the influenza 
bacillus, and other bacteria which are found normally 
present in the upper part of the respiratory tract. It 
is not an eight-day fever ; on the contrary it may last 
many weeks. It does not terminate by crisis, as in 
the case of most cases of croupous pneumonia, and 
there is a special risk of the subsequent development 
of pulmonary tuberculosis. 
BRONCHO-PNEUMONIA. 95 
Management. 
The principles underlying treatment are the same 
as those outlined for croupous pneumonia. The more 
free use of stimulants is frequently indicated. In trouble- 
some cases relief to the breathing is afforded by the use 
of a steam-kettle with mild antiseptic, e.g., half a tea- 
spoonful of compound tincture of benzoin to a pint of 
hot water, and in the case of children very special 
attention should be devoted to breathing exercises 
during convalescence. If this point were thoroughly 
attended to, there would be fewer cases of pulmonary 
and other forms of tuberculosis following on the bron- 
chitis and broncho-pneumonia so commonly present 
in measles and other infectious diseases in children 
DISORDERS OF RESPIRATION 
ASTHMA. 
The term asthma was originally applied to every 
form of dyspnoea, and it covered cases of dyspnoea 
occurring in the course of cardiac disease, renal disease, 
or diseases of the blood. The term is not now applied 
to such cases, but to a special affection of the bronchi 
associated with changes in the mucous membrane, 
and attacks of dyspnoea of a special type. 
Origin and Cause. 
Asthma may develop from a bronchial catarrh, in 
the course of which a sudden paroxysm of dyspnoea 
occurs, which may last for many hours. The character 
of the attack is distinctive. It frequently occurs during 
the night. Occasionally the paroxysm develops without 
apparent cause, though in such cases it can usually 96 
CLINICAL LECTURES FOR NURSES 
be attributed to indigestible food, emotion, or excite- 
ment. It is frequently associated with a catarrhal 
condition of the nose in hay-fever. 
The course of the disease is very variable ; it tends 
to recur at shorter or longer intervals, and persists 
throughout life. In severe cases it becomes compli- 
cated by emphysema of the lungs, which tends to shorten 
life. Some cases make a good recovery, the disease 
apparently disappearing. 
Symptoms of an attack. 
The patient is usually wakened during the night 
by severe dyspnoea and wheezing ; sleep is impossible. 
The patient sits up in bed with head bent forward and 
shoulders raised, so as to give the extraordinary" muscles 
of respiration the best chance of acting. The countenance 
is anxious and pale, with slight cyanosis, and the face 
is often bedewed with cold perspiration. The pulse 
is frequent and small. On examining the chest, the 
extraordinary muscles of respiration are found in full 
play, the expiration being markedly prolonged. There 
may be numerous bronchitic signs over the chest. 
When the expiration subsides, opalescent masses of 
mucus are usually expectorated. The paroxysm may 
last half an hour or much longer. There is every degree 
of severity between very slight cases, and those of a 
very severe character. The confirmed asthmatic patient 
usually loses flesh. 
Etiology of the condition. 
Indigestible articles of diet, or a hearty meal taken 
late in the day, are often responsible for an attack. 
Constipation is also an important factor. The in- 97 
halation of an irritating substance is the predisposing 
cause in some cases-e.g., fog, smoke, irritating gases, 
or even the smell from different animals. Habit 
has an influence both in the occurrence and the form 
of the attack. There is great variability however ; a 
place which invariably brings on attacks in one sufferer 
may be found to suit another admirably. In many cases 
there is a hereditary history, a neurotic tendency being 
doubtless an important predisposing cause. 
Diagnosis. 
Asthma must be differentiated from the paroxysms 
of difficult breathing met with in chronic renal and 
cardiac disease. The concomitant symptoms usually 
prevent these being mistaken for asthma. The diagnosis 
between bronchitis with dyspnoeic attacks and genuine 
asthma, complicated with bronchitis and emphysema, 
is sometimes more difficult. Assistance in diagnosis 
is obtained from the history of the ailment, the nature 
of the expectoration, and the results of careful bacterio- 
logical examination. A careful investigation should 
always be made for a peripheral source of irritation, 
which is most usually found in the nose, in the digestive 
tract, or sometimes in a faulty uterine condition. 
Prognosis. 
The outlook for an asthmatic patient varies with the 
age of the patient, the severity of the condition, and 
the association of emphysema with cardiac embarrass- 
ment. 
General Treatment. 
From the above it will be evident that the first essential 
in all cases of asthma is a very thorough examination 
DISORDERS OF RESPIRATION 98 
CLINICAL LECTURES FOR NURSES 
of the patient, to ascertain whether or not there is any 
peripheral source of irritation of a mechanical or toxic 
kind, special attention being directed to the condition 
of the nose, digestive tract, and, in women, state of the 
pelvic viscera. Whilst adopting means for the cure of 
the condition, that is for the prevention of the attacks, 
alleviation of the paroxysms requires attention. The 
remedies of special value are : the subcutaneous in- 
jection of adrenalin solution, or the inhalation of nitrites, 
and more especially nitrite of amyl, also smoke derived 
from the burning of a large number of substances in 
the form of powders and papers, most of which contain 
nitrites in some form. The relief afforded by the sub- 
cutaneous injection of adrenalin is very frequently 
of the most striking character. Belladonna and stramon- 
ium are sometimes of value when given internally ; 
these ingredients bulk largely in many proprietary cures. 
The removal of certain conditions on which the 
attack depends is the first point to be aimed at in the 
preventive treatment, and the importance of this has 
already been emphasised. Special remedies include 
a suitable climate : some find sea-air most suitable ; 
some can only live comfortably in the country ; some 
like dry air ; others are only well when it is moist. 
A suitable place for each person can only be selected 
by experience. The prevention of constipation, avoid- 
ance of any irritation of the gastro-intestinal tract, 
correction of any colitis which may be present, and the 
careful regulation of diet, to prevent the stomach or 
bowels being at any time overloaded with solid food, 
with liquid food, or by gases resulting from fermentation, 
are of the first importance. In severe cases the dietetic 
treatment should be along the lines laid down in 99 
4' Dietetic Treatment of Heart Disease." Among medi- 
cinal remedies mention may be made of potassium iodide 
and arsenic. 
The use of an autogenous vaccine prepared from the 
bacteria in the expectoration which are responsible for 
maintaining the catarrh, is in not a few cases attended 
by very gratifying results. 
DISORDERS OF THE RESPIRATORY ORGANS 
PULMONARY TUBERCULOSIS. 
Tuberculosis is due to the invasion of the tissues 
by the tubercle bacillus. Infection of the system takes 
place through the following channels:-by air infection, 
by direct infection, and through milk. Milk infection 
is very common in infancy and childhood. Tubercu- 
losis is acquired through faulty hygiene or insanitary 
and unhealthy milk supply, and is essentially a pre- 
ventable disease. Its prevention is now attracting 
the attention of public authorities in all parts. 
There are two great factors of importance in the 
disease, the infecting agent-the tubercle bacillus ; 
and the soil-the human tissues in which the tubercle 
finds lodging. There is abundant proof that very 
large numbers of people, who have never obviously 
suffered from tuberculosis in any form, have actually 
a small focus of healed tubercle in their system, usually 
in the bronchial or other glands or in the lungs. This 
fact has been established over and over again at post- 
mortem examinations. It is also confirmed clinically 
by the results of the application of the cutaneous tuber- 
culin test. These people have obviously had a high 
degree of resistance to the tubercle bacillus, in other 100 
words the soil was unfavourable for the active growth 
of the organism. A natural degree of resistance to 
the organism is therefore a factor of the very greatest 
clinical importance. This quality of resistance in 
turn depends on two factors, firstly, the hereditary 
history, and the social conditions-hygienic and 
dietetic-of the individual. It is obvious that a child 
with a delicate family history, brought up under ideal 
open air conditions and well fed, has a greater chance 
than another child brought up under less hygienic 
conditions, who continues to drink milk infected by 
tubercle. 
Manner of Incidence of Pulmonary Tuberculosis. 
The manner of onset varies somewhat. It may be 
revealed for the first time by haemorrhage from the 
lungs. More commonly it is revealed by a chronic 
cough, with or without expectoration, and some general 
debility. In other cases the symptoms may be those 
of simple anaemia, indigestion, and general lassitude, 
no definite lung symptoms being present. Fever is 
usually absent; the fever which is present in cases of 
tuberculosis is usually the result of a mixed infection, 
the condition being complicated by superadded in- 
fection by^various pyogenic bacteria. 
The General and Local Condition. 
These vary in proportion to the severity and duration 
of the infection, and to the extent to which the tuber- 
culous toxaemia is aggravated by a co-infection by 
staphylococci or other pyogenic organisms. In a moder- 
ately advanced case, cough, breathlessness, often with 
CLINICAL LECTURES FOR NURSES DISORDERS OF THE RESPIRATORY ORGANS 
101 
pains in the chest, loss of appetite and general asthenia 
are prominent symptoms, these being associated with 
some fever, the temperature going up at night, in- 
creased pulse rate, some sweating, expectoration which 
may be copious and contain tubercle bacillus in small 
or large numbers and other bacteria. Cases in which 
the lung involvement is considerable are not necessarily 
any more serious than cases where the lung involvement 
is very slight. Everything depends upon the degree 
of the systemic intoxication, and that is determined 
by a survey of the general condition rather than by 
the state of the lungs alone. 
The Prognosis. 
The prognosis depends on various factors, but chiefly 
on the degree of systemic disturbance. The two most 
important factors in prognosis are the state of the 
digestion and the condition of the circulation. If the 
digestion is little disturbed and the patient can digest 
and assimilate food well, the prognosis is, as a rule, 
favourable. Conversely, if the digestive system is 
involved and the appetite feeble or capricious the out- 
look is more guarded. Similarly, cases where the 
heart's action is rapid, associated with a quick feeble 
pulse are, as a rule, unfavourable, as this shows that 
the poison has damaged the heart muscle. Other 
points of value in the prognosis are the family history 
and the social circumstances of the patient. If the 
family history is favourable and the patient has the 
means available to do the best to promote recovery, 
the outlook is naturally much more favourable than 
when the reverse holds good. A typical example of 102 
pulmonary tuberculosis in moderately advanced degree 
is now in the ward. Her history and condition is 
as follows :- 
Girl, aged twenty, sent into the ward for the treatment 
of indigestion ; known to have suffered from a weak chest 
for at least four years. The patient complained for some 
months of loss of appetite, distaste for food, and feeling of 
distension after food, with slightly increasing loss of weight. 
Eighteen months ago she was in a sanatorium for some 
months, but the improvement made was not maintained. 
For the last month or two her voice has been somewhat 
husky due to a catarrhal condition of the larnyx. 
The patient is a fairly well nourished girl, rather pale, 
and lips slightly cyanosed, the pulse rate runs between 
90 and 100. Respirations 24 to 26, slight cough with some 
muco-purulent expectoration containing tubercle bacillus 
and pyogenic organisms in abundance. The chest is flat 
and shows unmistakable signs of chronic disease in both 
lungs ; there is no fever. The tongue is slightly dry and 
rather furred and reddish at the tip and edges. Examina- 
tion of the abdomen reveals a general flabbiness of the 
abdominal wall with a little splashing on palpation in the 
epigastric and ileo-caecal region. Examination with the 
X-rays reveals the existence of marked ileal stasis and a 
lesser degree of general colon stasis. 
General Principles of Treatment. 
Remedies must be directed in three directions :- 
(a) against the tubercle bacillus ; (6) against associ- 
ated bacterial infection of pyogenic organisms ; (c) 
to improving the nutrition of the tissues in every way 
possible. All the measures commonly employed for 
the relief and cure of pulmonary tuberculosis are directed 
in one or other of these directions. Abundance of 
sunlight and fresh air, the latter both by day and by 
night is the first essential. Complete rest in the re- 
cumbent posture, preferably in the open, may be indi- 
CLINICAL LECTURES FOR NURSES 103 
cated or may not be advisable, dependent upon the 
amount of general toxaemia, and especially upon the 
condition of the circulation. Abundance of good food 
is desirable and more especially a diet containing a 
suitable amount of proteins and fats, carbohydrates 
being given in judiciously restricted amount on account 
of the tendency to induce flatulence. Animal protein 
foods, such as meat, eggs, chicken and game are probably 
of greater value than the proteins of the vegetable 
kingdom. In cases where the digestion is capricious 
or weak, special care in the selection and preparation 
of the foods is indicated ; the forced feeding and the 
giving of lavish excess such as was in vogue a few years 
ago should be carefully avoided. 
The system of graduated exercise which consists in 
allowing the patient to walk for ten to twenty minutes, 
half an hour, or longer, or do a certain amount of light 
work for a given time, noting carefully the effects of 
that exercise upon the temperature and the pulse, is 
of the very greatest value. There is good reason to 
believe that the slight increase in the pulse and 
temperature, which follows judiciously prescribed 
exercise, arises from autogenous vaccination of a kind 
favourable to recovery. Careful attention to the 
functions of the skin and bowels are necessary ; the 
judicious use of a cold spray has a useful invigorating 
action on the system. Drugs occupy a subordinate 
role in treatment; among those that are useful may 
be cited quinine, hydrocyanic acid, creosote, morphia 
in some form occasionally, and cod liver oil and malt. 
Vaccine treatment should be tried in appropriate cases, 
and from two points of view ; (a) a vaccine prepared 
from the pyogenic organism present in the sputum ; 
DISORDERS OF THE RESPIRATORY ORGANS 104 
this may be useful for getting rid of the mixed infection 
which is a troublesome complication of the disease ; 
and (6) the use of tuberculin to artificially raise the 
resistance to the tubercle bacillus. 
When judiciously used vaccines are very decidedly 
helpful in many cases. Their use must at all times 
be carefully watched, the dosage and frequency of 
administration being determined by a careful study of 
the reaction. If this latter point is not attended to 
the disease may be accelerated rather than retarded. 
It may be useful to summarise very briefly the salient 
points in the treatment of the case under consideration: 
1. Complete rest in bed for a few weeks, and 
preferably under open-air conditions. Arrange- 
ments are being made for this being attained in 
the country. 
2. Special care must be taken, in the interests 
of others, to prevent infection, the sputum being 
either immediately destroyed by burning, or care- 
fully collected into a disinfecting solution. 
3. The patient should have a room to herself, 
and avoid close contact with children and others. 
4. The voice should be rested on account of the 
slight hoarseness due to catarrh. The more 
complete the rest the more rapid the rate of re- 
covery. 
5. Careful regulation of the bowels, and pro- 
motion of the function of the skin by means of a 
daily spray or " dip " followed by brisk friction. 
6. Diet.-Three good meals a day should be 
aimed at; if this is obtainable no other meals need 
CLINICAL LECTURES FOR NURSES Remittent fever; from a case of phthisis pulmonaris. 
Decline of fever by crisis on the Sth day ; 
from a case of lobar pneumonia. 
Gradual rise of tempera- 
ture at onset of enteric fever. 
Decline of fever by lysis; 
from a case of broncho-pneumonia. 
To face p. 105 107 
be given, but if not, two additional lighter meals 
of the nature of snacks may be given in the fore- 
noon and afternoon. Proteins and fats are specially 
indicated, more especially red meat foods, raw 
meat juice, eggs, and milk from unquestionable 
sources. Useful snacks may consist of a little 
hot milk and white of egg and a little sherry, or 
a bowl of strong meat soup. 
7. Abdominal massage is valuable to improve 
the condition of the bowel and abdominal wall, 
and after a week or two's rest special value would 
attach to judiciously regulated walking and other 
exercises. 
8. Vaccine treatment.-Under conditions appro- 
priate for vaccine administration an autogenous 
vaccine, prepared from the pyogenic organisms in 
the sputum, and later tuberculin might be given 
in a tentative way and its effects very carefully 
observed. 
The prognosis in this case is a guarded one. An 
unfavourable outlook is indicated, largely because the 
state of the digestive functions is not very satisfactory, 
and the maintained increase of pulse rate shows that 
the condition of the circulation has been markedly 
prejudiced. 
DISORDERS OF THE RESPIRATORY ORGANS 
On facing page will be found Temperature Charts 
illustrating the various types of Fevers. CHAPTER V. 
DISORDERS OF THE KIDNEYS. 
THE URINE. 
I propose to-day to show you a number of specimens 
of urine from various diseased conditions, and to present 
to you the main points about the urine which it is 
important for you to know, if you are to follow the 
cases intelligently and to give the maximum assistance 
in their management. 
Introductory note. 
In health about fifty ounces of urine are excreted daily. 
The amount varies with external atmospheric con- 
ditions. In warm weather the skin acts more freely 
and less urine is voided : conversely in cold weather 
the kidneys are more active. Another important factor 
which influences the amount of urine passed is the 
amount of fluid ingested : if much water or other 
fluid be taken, and more especially if that be taken 
on an empty stomach, the amount of urine is pro- 
portionately increased. The great majority of people 
drink too little water and take it at the wrong time. 
If the beneficial effects of water in assisting to purify 
the system are to be obtained, water should be taken 
on an empty stomach. It is important to note and 
record carefully the total amount of urine passed. 
108 DISORDERS OF THE KIDNEYS 
109 
Composition of the urine. 
Urine consists of water containing various solids 
in solution. The mam solid ingredient is urea, which 
is the end product of the chemical changes produced 
by the digestion of all nitrogenous food stuffs. Other 
important ingredients that occur in the urine are 
uric acid and phosphates. The normal sp. gr. of the 
urine is 1020. It is acid in reaction. When examined 
in a glass vessel, it should appear perfectly clear except 
for the presence of a small amount of mucus suspended 
in the solution, and when submitted to simple chemical 
analysis it should be free from albumin, sugar, blood, 
pus, and bile-these being the chief pathological con- 
stituents met writh in the urine. It will be convenient 
to discuss some of the main changes in the mine. We 
will illustrate these by referring in the first place to 
the naked-eye appearances of the urine, and then shortly 
to the simple chemical tests which it is desirable for 
you to know. 
Urates in the urine. 
In cases of fever and in certain other disorders of 
nutrition, the urine presents a characteristic turbid 
appearance due to the presence of urates. I show 
you here two specimens of turbid urine, each with a 
copious deposit of urates In both of these there is 
a fairly dense deposit of half an inch in the test tube, 
in the one case the deposit being of a typical brick- 
red character, and in the other more salmon-coloured. 
In both instances the urine itself is slightly turbid, 
due to the suspension of urates which have not yet 
fallen to the bottom. If the urine be shaken up and a 110 
little put in a test tube and gently heated, it will be 
observed that the marked turbidity completely dis- 
appears on heating. (This heat test should be applied 
very slowly, otherwise if albumin is present, a pre- 
cipitate of albumin may form in the test tube before the 
urates have become completely dissolved.) The presence 
of urates in the urine is not a serious condition : it 
is only indicative of functional derangement. 
Phosphates in the urine. 
I show you here a specimen of a urine containing 
a deposit of phosphates in the form of a whitish, not 
very dense, deposit. This deposit is a combination 
of phosphates and mucus. The distinguishing chemical 
test for phosphates is the addition of a mineral acid. 
Tf a little of the urine is heated the phosphates are 
precipitated. This precipitate may be due to albumin 
or to phosphates. If it is due to phosphates the addition 
of a mineral acid such as nitric acid dissolves the pre- 
cipitate ; if on the other hand it is due to albumin, 
the precipitate is increased by the addition of the acid. 
The presence of phosphates in the urine in excess is 
met with in some derangements of nutrition of a tem- 
porary kind, and in itself is of no great clinical signifi- 
cance. 
Pus in the urine. 
The presence of pus in the urine, or pyuria as it is 
termed, is a common and serious clinical condition. 
Pus may be present in large amount, and be visible 
in the form of a definite naked-eye deposit, such as that 
shown to you. In less marked cases it may only be 
revealed on microscopic examination of the urine. 
CLINICAL LECTURES FOR NURSES The presence of pus in the urine is indicative of catarrh 
in some portion of the urinary tract. Its source may be 
the urethra, the bladder, the ureter, or the kidney : 
the most common causes being cystitis, urethritis, 
pyelitis, stone in the kidney, and tuberculous disease 
of the kidney. In doubtful cases, the source of the 
pus has to be determined by examination of a catheter- 
drawn specimen of urine, or by cystoscopic examination 
of the bladder, and by the application of the X-rays 
to the kidney region. I show you a specimen of urine 
illustrating the presence of pus in large amount, and 
one in which pus is present, but is only determined 
on microscopic examination. You will observe a solid 
white deposit at the bottom of the glass. On micro- 
scopic examination of that deposit, it is found to be made 
up of pus cells. In the other specimen, in which the 
pus is present in small amount, there is a very slight 
deposit, but the urine is turbid throughout, this tur- 
bidity being due to the presence of pus cells and catarrhal 
cells from the bladder, and from bacteria suspended 
in the urine. When a little of this urine is centrifuged, 
a very definite deposit is obtained in the bottom of 
the centrifuged tube : this deposit is seen to consist 
mainly of pus cells and bacteria, the condition being 
due to a bacillus coli communis infection. 
Blood in the urine, or haematuria. 
The presence of blood in the urine imparts a character- 
istic appearance. When present in large amount the 
urine is turbid and of a reddish colour. More commonly, 
when present in moderate or small amount, the urine 
presents a characteristic smoky tint. After standing, 
there is a brownish-red deposit, due to the presence 
DISORDERS OF THE KIDNEYS 
111 112 
of blood pigment colouring the catarrhal and other 
cells present in the deposit. Blood in the urine may 
be due to a variety of conditions : its source may be 
the urethra, the bladder, the ureter, or the kidney. 
The most common causes are acute nephritis, calculus, 
and a tumour of the bladder or of the kidney, either 
of a simple or of a malignant nature. The source and 
nature of the bleeding is usually determined by cysto- 
scopic examination, by which it can be determined 
whether the blood is coming from one or other or both 
kidneys, and by the use of the X-rays. The distinctive 
chemical test of the presence of blood is the guaiacum 
and ozonic ether test. To an inch of this urine, I add 
two or three drops of dissolved guaiac resin : the resin is 
precipitated in the urine as a whitish precipitate. If I 
then add excess of ozonic ether, you will see in one or 
two minutes a marked blue ring develop : this is due 
to the oxidation of the resin by the haemoglobin. The 
presence of blood in the urine is further determined 
by microscopic examination. 
Bile in the urine. 
The presence of bile in the urine imparts a distinctive 
appearance to the fluid. This varies from a slight olive- 
green tint, which is best seen on the surface of the fluid, 
up to a dense greeny-black colour. Bile appears in the 
urine where there is definite obstruction to the outflow 
of bile from the liver into the bowel. The most common 
causes are catarrhal jaundice, gall-stones in the common 
duct, and malignant disease. The distinctive chemical 
test for the presence of bile is the play of colours which 
is obtained by adding impure nitric acid to the urine. 
You will observe the delicate play of colours, which is 
CLINICAL LECTURES FOR NURSES DISORDERS OF THE KIDNEYS 
113 
obtained at the junction of the two fluids, this being 
due to the oxidation of the bile pigment. 
Albuminuria. 
Albumin is frequently present in the urine. It may 
be of serious import, indicative of organic disease of 
the kidney, or it may be of little significance, the con- 
dition being simply dependent upon a temporary con- 
gestion of the kidney. The condition, however, is not 
one which should ever be taken lightly ; the most 
common conditions which give rise to it are some acute 
nephritis or chronic nephritis. The presence of albumin 
is recognised chemically (a) by boiling the urine, and 
(6) by the addition of a mineral acid, e.g.,-nitric acid. 
I show you two test tubes, each containing about two 
inches of clear urine. I heat the upper part of the 
fluid, and you will observe that at once there is a definite 
white precipitate : this must either be due to the presence 
of albumin or of phosphates, and we differentiate 
between these two conditions by the further addition 
of a mineral acid. I add a little nitric acid, and 
you will observe that the precipitate is increased. 
If the deposit had been due to phosphates, the pre- 
cipitate would have dissolved. The second useful test 
for albumin is the addition of nitric acid in the cold. 
I show you this other tube containing an inch of clear 
urine. I add an equal amount of nitric acid. You 
now observe that there is a delicate white precipitate 
at the junction of the two fluids : this is indicative 
of the presence of albumin in moderate amount. 
Sugar in the urine. 
Sugar in the urine is usually found in cases of diabetes, 
and also in cases of glycosuria. The term glycosuria 114 
CLINICAL LECTURES FOR NURSES 
simply means sugar in the urine, and is applied to that 
condition of sugar in the urine in which no other symp- 
toms of diabetes are present. This glycosuria is met 
with in subjects who take sugar or starches to excess. 
I show you a very typical example of the urine from 
a case of diabetes at present in the ward. You will 
observe that it is remarkably clear and pale, and has 
a curious sweet fruity odour which is characteristic. 
When tested with the urinometer the sp. gr. is found 
to be 1040 in place of 1020. This is due to the large 
amount of sugar dissolved in the urine. The distinguish- 
ing chemical test is the use of Fehling solution, which 
is a solution of copper. I take a test tube containing 
an inch of urine and add to it an equal amount of Fehling 
solution. I heat the upper part, and you will observe 
that the blue colour disappears and gives place to a 
reddish precipitate : this reddish precipitate is the result 
of the sugar reducing the copper salt. 
Other abnormalities in the urine. 
Occasionally uric acid is met with in the urine in a 
definite crystalline form, and is seen in the bottom of 
the vessel as a fine deposit resembling cayenne pepper 
grains. On microscopic examination these are shown 
to present the appearance of the characteristic yellow 
crystals shown to you under the microscope. 
Crystals of oxalate of lime are also frequently met 
with in the urine, and are detected on microscopic 
examination. They take the form of small, whitish, 
clear crystals usually square-shaped like envelopes. 
Oxaluria, as it is termed, is frequently found in associa- 
tion with chronic intestinal catarrh with excessive 
putrefaction in the bowel. DISORDERS OF THE KIDNEYS 
113 
ACUTE NEPHRITIS. 
(Syn. Acute Bright's Disease.) 
Acute inflammation of the kidney is usually the 
result of bacterial infection, the bacteria getting into 
the system as a rule from the tonsils, respiratory tract, 
or bowel. It is met with both in young and old people; 
a familiar example in young people is seen in the ne- 
phritis which develops in the course of scarlet fever. 
In cases occurring in adult and later years the condition 
is frequently not a primary infection, but is an acute 
exacerbation of inflammation occurring in kidneys 
already the seat of chronic nephritis. 
As a result of inflammation of the kidneys the waste 
products of the body, normally eliminated in the urine, 
are retained in the system. The retention of the water 
in the system leads to the development of oedema of 
the tissues ; this oedema may be slight, or may assume 
the characters of a general dropsy. The retention in 
the system of the solid matters, normally dissolved 
and excreted in the urine, induces constitutional symp- 
toms of toxaemia, affecting mostly the nervous and 
digestive systems, inducing headache, feeling of las- 
situde, and sickness with vomiting. The symptoms 
frequently develop after a chill or undue exposure to 
cold. In the severer cases the onset may be sudden, 
with marked rigors, vomiting, headache, pains in the 
loins, gastric disturbance, and slight fever. Not in- 
frequently the first symptom to attract the patient's 
attention is the development of the oedema, most marked 
below the eyes and face. 114 
CLINICAL LECTURES FOR NURSES 
Objectively the following physical conditions are 
met with :- 
1. Some swelling and puffiness of the face, most 
marked below the eyes, with oedema of the feet 
and legs, and in severe cases marked general dropsy 
-the skin readily pitting on pressure. The 
whitish waxy appearance of the skin characteristic 
of acute nephritis is well illustrated in many 
cases. Not a few cases of acute nephritis, how- 
ever, occur unattended with dropsy. 
2. A deficiency of urinary secretion, which may 
be reduced to a few ounces or less. 
3. The examination of the urine shows alteration 
in colour, due to the presence of blood, also albumin, 
and on microscopic examination numerous casts 
of the damaged tubules of the kidney, with cells 
and bacteria are found. 
4. Marked dryness of the skin. 
5. In cases where the kidneys have previously 
been the seat of chronic inflammation, there are 
associated cardiac and vascular changes, e.g., 
enlargement or dilatation of the heart, alterations 
in the pulse, and thickening of the vessel wall 
(arterio-sclerosis). 
The patient shown to you, a man aged twenty-seven, 
caught a " cold " four weeks before admission, and was 
off work for ten days, when he returned to duty. A week 
ago slight oedema of the face and feet was observed, and 
on examination the urine was found to contain blood, 
albumin, and casts. For the first twenty-four hours after 
admission the total urine passed was six ounces. 115 
After a week's treatment there was a marked improve- 
ment in the oedema and in the general appearance of the 
patient. The urine increased to fifty ounces per day, 
and the amount of blood and albumin, though still con- 
siderable, was much reduced. His skin became satisfactorily 
moist, the tongue remained furred and the breath offensive, 
due to elimination of toxins from the lungs. The tempera- 
ture, which averaged 99.2° F. for a few days, became 
normal. 
Principles of Treatment. 
The principles of treatment are as follows : - 
1. To relieve the strain on the inflamed kidney, 
by making the diet as light as possible, and more 
especially restricting strong nitrogenous foods. 
2. To get rid of the waste products of the body 
by other channels-the bowels and the skin. 
3. Where dropsy is excessive the fluid may require 
to be drawn off. 
Before giving treatment in detail a few words may 
be said about the prognosis. The great majority of 
cases of primary acute nephritis recover under appro- 
priate treatment. The prognosis is always more guarded 
in adult and later life in cases where the acute nephritis 
supervenes on chronic nephritis. The prognosis depends 
largely on the rate at which the blood, albumin, and 
tube casts disappear from the urine, and on the con- 
dition of the cardio-vascular system. 
Treatment. 
]. Complete rest in bed is usually required for 
many weeks, until the entire disappearance of 
DISORDERS OF THE KIDNEYS 116 
the oedema, and of the blood and albumin from the 
urine. 
2. The bowels should be kept free by the judicious 
use of morning salines, following an occasional 
mercurial pill. 
3. Free diaphoresis should be promoted by hot 
bottles, hot packs, hot air baths, and occasionally, 
in special cases, the use of pilocarpin. 
4. Any obvious source of infection, such as en- 
larged tonsils, pyorrhoea, or intestinal disorder 
should be corrected. 
5. During convalescence general tonics are of 
value, especially preparations of iron. Care should 
be taken on first going out to avoid cold winds 
and wet. 
Diet. 
In strong individuals withhold all food for the first 
twenty-four to thirty-six hours, but diluents to the 
amount of two to four pints may be given in the form 
of plain water, or potash, soda, salutaris, or apollinaris 
water ; barley water, rice water, and toast water may 
also be given if preferred. 
After this the diet should consist exclusively of milk : 
from one to three pints, increasing up to four to five 
pints in the twenty-four hours, diluted with water, as 
above. It will be found that milk is more easily digested 
when given in a small quantity, such as eight to ten 
ounces every one-and-a-half hours. Some patients show 
marked intolerance to an exclusively milk diet: such 
patients may be able to take buttermilk, whey, or the 
CLINICAL LECTURES FOR NURSES 117 
various pancreatised preparations. In some cases the 
fermented milks, koumiss and kephir, may be recom- 
mended. The constipating effects of a milk diet may be 
counteracted by the use of Phillip's milk of magnesia, 
Dinneford's fluid magnesia, or plain sulphate or citrate of 
magnesia. Any tendency to diarrhoea may be checked 
by the addition of lime water. (The total amount of 
urine should be carefully noted.) 
If the albumin, casts, and blood persist in the urine 
after six or eight weeks, it may, as a rule, be assumed 
that there is some permanent damage to the kidney- 
some degree of chronic nephritis remaining, and treat- 
ment should accordingly be directed along the lines 
laid down for that condition. 
DISORDERS OF THE KIDNEYS 
CHRONIC NEPHRITIS. 
(Syn. Chronic Bright's Disease.) 
Chronic nephritis occurs as a sequel to acute nephritis 
and also as a primary affection, with a slow, insidious 
onset of many months' or even years' duration. The 
essential nature of the disease is a loss of the natural 
secreting elements of the kidneys, which become re- 
placed by fibrous tissue. In its primary form it is 
essentially a disease of adult and later life, and is usually 
associated with disease of the heart and blood-vessels. 
Etiology of the Disease. 
There are various causal factors. Of these the most 
important are the accumulation in the system of 
excessive waste products of chemical and bacterial 118 
CLINICAL LECTURES FOR NURSES 
origin, which are met with chiefly as a result of ex- 
cessive eating and over-drinking, often combined w th 
constipation, and seen more especially in people who 
live a life of strain and take too little exercise. These 
waste products accumulate in the blood, irritate the 
vessel wall, and lead to thickening-called arterio- 
sclerosis. They also strain the heart, leading to hyper- 
trophy and later to dilatation, and induce the degener- 
ation of the kidney, characteristic of chronic Bright's 
disease. Hence the clinical picture of Bright's disease 
usually includes symptoms and physical signs of de- 
rangement of the heart and blood-vessels, as well as 
actual disease of the kidneys. 
Manner of Onset. 
There are very great variations in the manner of 
onset of chronic Bright's disease. The great variety 
of symptoms, which are referred to systems other than 
urinary, often leads to a wrong diagnosis. The symp- 
toms are the result of a chronic poisoning of the system, 
or toxaemia, due to the retention of waste products or 
toxins. The presence of these toxins affect different 
people in different ways ; in many cases the first 
symptoms observed in adult or elderly people are a 
slight failure of physical power, perhaps associated 
with some loss of weight; in others troublesome head- 
ache, often accompanied by defective sight, first attract 
attention ; the diagnosis in these latter cases is some- 
times first made by the oculist when consulted on 
account of the eyes. Gastric symptoms predominate 
in other cases, more especially loss of appetite with 
occasional sickness and vomiting, often associated with 
irregularity in the action of the bowels. In others. 119 
DISORDERS OF THE KIDNEYS 
symptoms of bronchitis are chiefly complained of, 
the catarrh of the bronchi being really a manifestation 
of renal disease. In not a few cases the symptoms 
remain latent, and the disease is first revealed by the 
development of cerebral haemorrhage or uraemia, the 
latter condition being really a specially acute form of 
toxic poisoning. (Edema and dropsy may be present 
or may be absent throughout the whole course of the 
disease. 
In a case of chronic nephritis in a girl of seventeen, the 
patient complained a fortnight before admission to hospital 
of headaches, giddiness, loss of appetite, and feeling of 
sickness with occasional vomiting. This was followed 
by slight cedema of the ankles and later puffiness of the 
cheeks. Nine months previously she suffered from acute 
nephritis, recovery from which had obviously been in- 
complete. The patient was fairly well-nourished but 
decidedly pale, rather puffy looking, with slight cedema 
of the feet and ankles. The urine on admission was slightly 
reduced, between 30 and 40 ozs., containing albumin, 
casts, and also traces of blood, some acute nephritis being 
present. The heart was slightly enlarged and the blood- 
vessels somewhat thickened, the blood pressure being 
increased. The patient was constipated. 
Prognosis. 
The outlook for these cases is guarded at all times, 
especially so in younger subjects. Their standard 
of health and their capacity for physical or mental 
effort is permanently lowered, and they are specially 
susceptible to unfavourable climatic conditions. The 
duration of life is variable. Death may supervene 
from cerebral haemorrhage, due to the rupture of a dis- 
eased blood-vessel under the influence of the high 
blood pressure, which is frequently present. In numer- 
ous cases death occurs from heart failure, the heart 120 
CLINICAL LECTURES FOR NURSES 
dilating under the influence of the long-continued 
over-strain, the clinical picture being one of combined 
cardiac and renal disease. In other cases death occurs 
as a result of acute uraemia, characterised by convul- 
sions, coma, etc. ; and in others, respiratory com- 
plications-bronchitis, and broncho-pneumonia, con- 
tribute largely to the termination of life. 
Principles of Treatment. 
The principles of treatment are to lessen in every 
way possible the strain on the diseased kidneys by 
means of diet, and to increase the activity of the skin 
and bowels. Where possible, residence in a warmer 
climate is specially advantageous on account of its 
favourable effect on the skin excretion, freedom from 
chills, etc. Complete rest is often advisable, and often 
inadvisable, dependent upon the condition of the heart 
and circulation. A lessening of the physical and mental 
strain is always essential. As the condition is usually 
aggravated by a disordered state of the bowel-con- 
stipation-with a varying degree of catarrh of the 
bowel, special attention must be directed to keeping 
the prima via in a healthy condition. Similarly the 
state of the teeth and gums often requires correction. 
In cases where the oedema and dropsy does not readily 
disappear with rest and other measures, special value 
attaches to the use of a chloride free diet. 
The following measures are applicable in a case of 
moderate severity :- 
1. Complete rest in bed for a month, until the 
oedema of the tissues and the blood in the urine 
has disappeared, and the albuminuria has become 
largely reduced. 121 
2. The administration of a diet for a few weeks 
in which all meat foods and whites of eggs are 
restricted, the diet being selected from milk, barley 
water, milk foods, bread and jellies. Later, meat 
foods of any kind to be taken in great moderation, 
white meat foods being used in preference to red 
meat. 
3. A suitable diet, largely vegetarian in character, 
for a working-man who is off work, or engaged in 
light work only, is as follows :- 
Breakfast-Porridge and milk, tea, bread and 
butter. 
Midday-Bowl of soup (made entirely from 
vegetable stock), bread and cheese, macaroni, 
vegetables, or fruit. 
Evening-Milk, egg, bread and butter, cheese 
or jam, and vegetables or fruit, if these were 
not taken at the midday meal. Eggs should 
be partaken of sparingly, and should not form 
a part of each day's dietary. White meat 
may later be added to the dietary, in the form 
of fish, chicken, tripe, or sweetbread. 
In the case of well-to-do patients a good alter- 
native dietary is as follows :- 
Breakfast-Cafe au lait, with plenty of cream ; 
Vienna rolls or toast and butter, marmalade. 
Lunch-To be selected from the following (not 
more than two courses to be taken) : (a) 
vegetable soup, (5) steamed fish, fish souffle 
DISORDERS OF THE KIDNEYS 122 
CLINICAT LECTURES FOR NURSES 
(made up with cheese or savoury sauce), or 
eggs occasionally in the form of omelet or 
souffle, (c) light farinaceous pudding or stewed 
fruit, with cream. 
Dinner-Repetition of the midday meal, three 
courses, however, being allowed. Sweetbread, 
tripe, chicken, rabbit, or game may occasionally 
be allowed. 
If a chloride free diet is indicated, it is obtained 
from the following :-milk, bread made without 
salt, eggs, chicken, cereals cooked without salt, 
butter, fruits, jellies, tea and coffee. 
4. The amount of fluid to be taken must be 
regulated by the amount of oedema and by the 
state of the blood pressure, being markedly re- 
stricted in the presence of oedema and by high 
blood pressure. In the present instance a diet 
which is largely dry in character and the adminis- 
tration of ten ozs. of water hot or cold on an empty 
stomach is advisable. 
5. The bowels require special attention by the 
use of an occasional mercurial pill and a morning 
saline given regularly in appropriate doses. 
6. The function of the skin is promoted by hot 
bottles, sponging of the skin, and occasionally 
a liver pack or hot air bath. Warm clothing, 
especially for the abdomen and feet, is always 
advisable. 
7. General tonic treatment-more especially 
strychnine or iron-directed to improve the appe- 
tite or counteract any anaemia present. DISORDEBS OF THE KIDNEYS 
123 
In cases of chronic nephritis associated with failure 
of compensation of the heart, prolonged treatment is 
necessary, and has to be largely directed to the weakened 
state of the cardiac muscle. 
URAEMIA. 
Uraemia is a convenient and comprehensive term 
for numerous toxic symptoms met with in the course 
of serious renal disease. The symptoms are due to 
the retention in the system of various toxic products, 
which should normally be excreted by the kidneys. 
The symptoms may affect different systems, those 
most affected being the nervous, digestive, and resir- 
atory systems. The condition may present itself in 
an acute, sub-acute, or chronic form. 
The basis of uraemia being disease of the kidney, 
there will frequently be present an antecedent history 
of acute nephritis. Very often, however, more especially 
in adult and later life, no such history is obtainable, 
the disease of the kidneys having developed insidiously, 
often in combination with disease of the blood-vessels 
(arterio-sclerosis) and heart. 
The onset may occur without any warning, or there 
may be premonitory symptoms, such as headache, 
mental apathy, giddiness, nausea, and in some cases 
dyspnoea. The acute attack may be marked by sudden 
paroxysms of convulsions of an epileptiform type, 
which may occur with or without premonitory symptoms. 
In some cases these are violent and general, the whole 
body being shaken with convulsions, the respirations 
being faltering and stertorous, the patient foaming 124 
CLINICAL LECTURES FOR NURSES 
at the mouth, grinding his teeth, and passing urine and 
faeces involuntarily. The convulsive attack may be 
single and of short duration, or multiple ; one patient, 
a man of fifty-five years, had forty such convulsive 
seizures in two hours. The temperature is usually 
sub-normal, but exceptionally there may be a great 
rise. The pupils most frequently are dilated, but 
there is no constant change. In certain cases there 
are no convulsions, the acute uraemia being character- 
ised by vomiting, and a profound general apathy, 
gradually passing into a deep and fatal coma. In 
acute cases the urine may be greatly reduced even to 
complete suppression. In chronic cases the urine may 
or may not be reduced in amount, but its examination 
will reveal evidence of serious disease of the kidneys. 
In chronic uraemia the symptoms are referred to 
the respiratory, digestive, and nervous systems. Dys- 
pnoea of an asthmatic type, cough, and hiccough, are 
the most common respiratory symptoms usually asso- 
ciated with some physical signs of bronchitis ; sickness 
and vomiting which cannot be traced to any error of 
diet, often combined with diarrhoea, are the symptoms 
of digestive disorder most frequently observed ; dull 
headache, giddiness, and general langour and inertia 
are the most common nervous symptoms. These 
last may pass into more severe mental derangement- 
a quiet or excited delirium with general motor irrita- 
bility and enfeeblement. The pulse in uraemia varies 
with the stage of the disease. In the earlier stages 
the pulse may be slow or slightly increased in rate, 
but its chief characteristic is usually the greatly in- 
creased blood pressure. In later stages, when dila- 
tation of the heart has set in, the pulse is rapid and may DISORDERS OF THE KIDNEYS 
125 
be irregular, the blood pressure usually remaining 
increased. 
Diagnosis. 
In acute cases differential diagnosis must be made 
from the coma met with in cerebral haemorrhage, various 
infective fevers, such as cere bro-spinal or typhoid, 
diabetes, and alcoholism (the eclampsia of pregnancy 
is really a form of uraemia). In chronic cases the differ- 
ential diagnosis has to be made from chronic disease 
in the chest or the abdomen, of a kind unassociated 
with renal disease. 
Prognosis. 
The prognosis is for the most part unfavourable ; 
not a few cases, however, recover under appropriate 
treatment. The prognosis in the two cases shown 
to you is unfavourable, this being based on the age 
of the patients, the antecedent unfavourable histories, 
the condition of the kidneys and heart, and the pro- 
nounced nature of the nervous and mental symptoms 
present. 
Treatment. 
The principle underlying treatment is to relieve 
the work of the kidneys by appropriate diet, and to 
promote vicarious elimination of toxins by means of 
the bowels and skin. 
The following are the essential points in the manage- 
ment ;- 
1. The promotion of warmth, and free stimu- 
lation of the skin by means of hot bottles, hot 
packs, and, occasionally, the use of pilocarpine. 126 
CLINICAL LECTURES FOR NURSES 
2. Judicious free purgation, e.g. the occasional 
use of calomel, followed by appropriate saline 
remedies. 
3. Administration of a light diet, giving at the 
outset the minimum amount of food in the lightest 
form possible. A little judicious starvation is 
useful. Milk and milk foods should form the 
staple articles of diet. 
4. Venesection. In some cases the general con- 
gestion with its associated increased blood pressure 
may be relieved by venesection, after which the 
above remedies may be more efficacious. 
5. If the uraemic coma is prolonged special care 
in nursing is essential, so as to minimise the risk of 
infection from incontinence of urine and of bowels, 
and from a septic condition of the mouth. 
6. In chronic cases associated with excitement, 
various nerve sedatives may be called for, e.g., 
chloral hydrate, bromide, and, exceptionally, 
morphia in some form. 
If recovery from the acute condition takes place> 
prolonged convalescence is required in which the most 
important essentials are- 
(a) The administration for a long period of light 
feeding-restriction in all meat foods, and more 
especially red meats, and avoiding much fluid 
with meals. 
(6) Maintaining a free action of the skin and bowels, 
with general tonic treatment; and, 
(c) Adapting the life and work of the patient to 
the weakened condition of the kidneys. CHAPTER VI. 
DISORDERS OF THE NERVOUS SYSTEM. 
NEURASTHENIA. 
(Syn. Nervous Exhaustion.) 
From the modern standpoint Neurasthenia is to be 
regarded as a symptom of disease, rather than as a disease 
in itself. It means debility of the nerves, a state of 
nervous exhaustion, with pronounced fatigue of the 
nervous system. 
In Neurasthenia there are two etiological factors :- 
(a) Diminished resistance (bad heredity), and, 
(6) Influence of strain-overwork, injury, toxaemia. 
Frequently a direct physical cause can be traced, 
as in Traumatic Neurasthenia, the debility of the 
nervous system arising directly from an injury, or from 
the fear of an injury. Traumatic neurasthenia often 
arises as a result of fright without any recognisable 
physical injury having been received. Typical examples 
are met with in railway accidents. Neurasthenia also 
frequently arises as a result of prolonged physical and 
mental strain, or from a chronic toxaemia, due to some 
disorder of one or other of the mucous membranes of 
the body, the mouth-oral sepsis ; the bowel-con- 
stipation, colitis, or appendicular disorder ; and from 
derangement of one or other of the pelvic viscera. 
127 128 
CLINICAL LECTURES FOR NURSES 
Neurasthenia in some of its forms is very closely 
allied to hysteria ; both of them are real diseases, 
and both call for great skill and tact in their manage- 
ment. The first essential is to keep in mind that neuras- 
thenia is to be regarded more as a symptom of disease 
than as a disease itself, very careful investigation being 
necessary by the doctor, assisted by the nurse, to dis- 
cover the main or the contributory causes of the nervous 
breakdown. 
As in many other affections, the disease is complicated 
by vicious circles. In many cases, as already stated, 
the condition is induced by a primary disturbance of 
the digestive or other tract; here the weakened con- 
dition of the nervous system still further lowers the 
vitality of the gastro-intestinal and other secretions, 
and the faulty chemistry arising therefrom still further 
weakens the nervous system. 
Symptoms. 
The symptoms are of the most varied kind. In 
some cases the disease only affects the higher nerve 
centres, the physical powers of the patient being un- 
affected. Such a patient can walk and take active 
exercise with no more fatigue than other people, but 
he has ceased to be able to accept responsibility, or 
to apply his mind continuously to any one subject, 
active attention being one of the last acquired mental 
powers, and one of the first to be lost. Loss of sleep, 
irritability or depression, with a general loss of self- 
control are distinguishing features, morbid fears of 
many kinds are common, such as fear of being alone, 
travelling in a train, mixing with people in the street, 
and the like. DISORDERS OF THE NERVOUS SYSTEM 
129 
A second group comprises cases in which the fatigue 
affects especially the spinal nerves. Here the capacity 
for physical exertion of any kind is markedly reduced, 
the patient is chronically tired, this being associated 
with various aches and pains, sometimes with a definite 
localised weakness. 
This condition is often combined with extreme cold- 
ness of the extremities, and sleeplessness; loss of self- 
control and depression are common symptoms. This 
group, much more than the former, is associated with 
visceral symptoms, such as constipation, flatulence, 
abdominal pain, and evidence of chronic colitis, and 
sometimes uterine trouble. Most of the cases in this 
group are the direct result of a chronic toxaemia. 
Diagnosis. 
The diagnosis is usually easy. The first point to be 
determined is whether there is any organic disease of 
the nervous system. If a neurasthenic patient is 
encouraged to describe his experiences and symptoms, 
these will, as a rule, in their variety and manner of 
expression, give ample evidence against organic disease 
of the nervous system. The symptoms of organic 
disease vary little from day to day, while those of neur- 
asthenia are usually changing and recurrent. 
The next point to be determined is the cause. Is 
there a physical basis for the nervous disorder ? This 
involves a thorough medical investigation, more especi- 
ally of the digestive tract, respiratory, and renal systems. 
Such investigation frequently involves an X-ray ex- 
amination of the stomach and bowels, examination 
of the stools, and the bacteriological examination of 130 
CLINICAL LECTURES FOR NURSES 
the urine. The possibility of a latent tuberculous 
toxaemia has also to be kept in view. 
Hysteria is a closely allied disorder, the principles 
of its treatment being the same. Other conditions 
have to be kept in view, more especially malingering, 
melancholia, some moral defect such as indolence and 
selfishness, and the early forms of Graves' disease. 
A good illustration of neurasthenia is furnished by 
the following case :- 
Mrs P., aged sixty, admitted seven weeks ago, com- 
plaining of general nervousness, sleeplessness, " trembling 
feelings " in the abdomen, as if her inside " vibrated," 
difficulty in swallowing, and general physical weakness, 
these symptoms being of some months' duration. She 
was in the hospital about a year ago for seven weeks 
with the same symptoms, when she made a fair recovery. 
She attributed her illness to a severe attack of influenza 
which she had two years previously. Her mother suffered 
all her life from " nerves." 
On admission the patient was nervous, rather depressed, 
and very easily excited. All her bodily functions were 
depressed. There was no evidence of organic disease. 
The bowels were markedly constipated. After seven 
weeks' treatment the patient looks and feels better, eating 
and sleeping well, more vigorous physically, and com- 
plaining very much less of symptoms. Longer treatment, 
however, would be necessary if the best results are to be 
obtained. 
Treatment. 
The first essential in treatment is to recognise and 
correct any existing source of toxaemia. In some 
cases an operation may be necessary for the complete 
correction of some forms of septic mischief, e.g., teeth, 
appendix, etc. Thereafter the most important essen- 
tial in treatment is the skilled application of psycho- DISORDERS OF THE NERVOUS SYSTEM 
131 
therapy. The mental factor in treatment is all-important, 
the personality of the doctor and of the nurse making 
for rapid recovery, slow recovery, or no recovery as 
the case may be. The patient's power of normal self- 
control must be re-established. The main essentials 
in treatment are sympathy and tact; the patient 
should be treated as an intelligent being, the rationale 
of the treatment being explained to her by the doctor, 
and repeatedly reinforced judiciously by the nurse. 
Nothing so much retards the progress of these patients 
as a casual and unconsciously unsympathetic attitude 
on the part of those about them. They have got to 
be half coaxed and half compelled to recovery. Re- 
moval from home influences for a time is essential, 
so that complete rest from all home worries may be 
obtained, the patient having no opportunity of dwelling 
on her symptoms to unwisely-sympathetic friends. 
Abundance of good food is essential, but harm often 
accrues from giving the forced feeding at one time in 
vogue (Weir-Mitchell Treatment). In cases of so-called 
gastric neurasthenia, special attention to the feeding 
is required, as many of the opinions which the patient 
may have in regard to food are ill-founded. 
The following is an epitome of the general treat- 
ment :- 
1. Judicious isolation of the patient for at least 
four weeks. It is usually advisable for the patient 
not to return home directly after the treatment. 
2. Careful regulation of the patient's daily 
regime so as to combine the maximum of rest 
and the minimum of ennui and self-study. 132 
CLINICAL LECTURES FOR NURSES 
3. Simple nourishing food ; three meals a day, 
with, in addition, a glass of milk in the forenoon 
(cases of gastric neurasthenia require special treat- 
ment). 
4. Hydropathic measures with massage are very 
useful, the merits of these being fully explained to 
the patient. Massage with exercises for the cor- 
rection of constipation is specially valuable. The 
personality of the masseur or masseuse is im- 
portant. 
5. A general tonic, e.^., strychnine, arsenic, or 
iron. 
All these measures have to be applied with skill; 
the nurse can render invaluable service in supplement- 
ing the influence of the physician, so as to get the best 
possible results in the quickest time. A combination 
of sympathy, a sense of humour, and tact in the appli- 
cation of these qualities make for speedy recovery. 
UNCONSCIOUSNESS. 
We have admitted into the ward lately a variety 
of patients in a state of unconsciousness more or less 
complete. In this clinique I propose to discuss the 
main features in the diagnosis and management of 
these cases from a nursing point of view. Unconscious- 
ness may be partial or complete. We are here con- 
cerned with that condition of unconsciousness often 
termed coma, in which the loss of consciousness is DISORDERS OF THE NERVOUS SYSTEM 
133 
complete. The following tabular statement of causes 
will serve as a useful guide :- 
1. Convulsions. 
2. Epilepsy. 
3. Traumatism (due to injury or sunstroke). 
4. Organic Brain Disease. 
(a) Vascular conditions-haemorrhage, embol- 
ism, thrombosis, angio-spasm. 
(6) Meningitis (cerebro-spinal meningitis or 
tuberculous meningitis.) 
(c) Tumours and abscesses. 
(d) General paralysis. 
5. Of toxic origin (poisons, e.g., morphia, alcohol, 
haschish, carbonic oxide, and others). The 
toxins may be of endogenous origin due to 
auto-intoxication, as in some cases of chronic 
Bright's disease and diabetes. 
6. Artificial, e.g., Hypnotism or Anaesthesia. 
The Differential Diagnosis. 
The diagnosis is not as a rule difficult. Exception- 
ally, in cases where no history is obtained, a day or two 
may elapse before a definite diagnosis is possible. In 
cases where a definite history of the manner of 
incidence of the unconsciousness, and of the previous 
medical history are obtainable, the diagnosis, is, 
as a rule, a very simple matter. Thus if the patient 
is known to be affected with chronic Bright's disease or 
diabetes, that would be presumptive evidence of the 
condition being due to uraemic or diabetic coma, and 
this diagnosis would readily be established by the 134 
examination of the urine. Then, again, if the patient 
is known to have been the subject of valvular heart 
disease, and the unconsciousness developed quite 
suddenly, that would point to cerebral embolism, or 
possibly cerebral haemorrhage, and if the onset was 
a little less rapid and attended by slight premonitory 
symptoms occurring in a person with obviously diseased 
vessels, and possibly high blood pressure, a cerebral 
thrombosis would be indicated. 
The frequency with which unconsciousness is induced 
by drugs and various poisons must also be kept in view, 
Of these the most important are, opium in the form 
of laudanum, or a morphia preparation, or cocaine, 
chloral hydrate, haschish, carbon oxide, alcohol, lead, 
and some irritant poisons. 
Quite recently we have seen in the wards two in- 
structive illustrations of mistaken diagnosis. One a 
young man who was sent up to the Ear and Throat 
Department in an unconscious condition, supposed 
to be suffering from epilepsy with oedema of the larynx 
necessitating operative treatment. The incorrectness 
of this diagnosis was recognised, and he was immediately 
transferred to our ward, where he died within eighteen 
hours in a condition of uraemic coma. The second 
was that of a man admitted as a case of acute alcohol- 
ism a short time ago. The man, who was a heavy drinker 
was suddenly taken ill, became unconscious with a 
little delirium, and was sent in to the ward as a case 
of delirium tremens. The condition proved to be one 
of cerebro-spinal meningitis, from which he died in 
two days. 
When first seen the diagnosis is often by no means 
easy, but mistakes will be few in proportion as one 
CLINICAL LECTURES FOR NURSES DISORDERS OF THE NERVOUS SYSTEM 
135 
remembers the conditions which have to be excluded. 
It will be convenient to put in tabular form the points 
that have to be kept in view in the recognition of these 
cases :- 
1. Get as complete a history as possible with regard to- 
(a) The conditions of the development of the 
unconsciousness. Carefully exclude frac- 
ture of the skull from injury, and if the 
breath is alcoholic ascertain if alcohol was 
given since the illness started. 
(b) Particulars with regard to the antecedent 
medical history of the patient. These, 
when obtainable, provide important evi- 
dence of diagnostic value. A history of 
epileptic fits, or of renal and cardiac 
disease, or diabetes, are specially important. 
2. The breath and tongue of the patient should be 
examined for evidence of poisoning by alchohol, 
various irritant poisons, or diabetes. Con- 
firmatory evidence in favour of one or other 
of these being looked for in other directions, 
e.g., pharynx, pupils, urine. 
3. The pupils should be carefully examined. Marked 
contraction of the pupils, equal on both sides, 
would suggest opium poisoning. In cases of 
severe cerebral hsemorrhage, especially at the 
base of the brain, the pupils are often pro- 
foundly altered, being either contracted or 
sometimes much dilated. 
4. The urine should be obtained as a matter of routine 
as soon as possible, with a view to determining 
the existence of albumin or sugar. 136 
CLINICAL LECTURES FOR NURSES 
5. The condition of the heart and blood-vessels are 
examined for evidence in favour of the con- 
dition being due to cerebral haemorrhage, 
cerebral embolism, or cerebral thrombosis. 
A hypertrophied left ventricle with arterial 
sclerosis but no valvular lesion would point 
to cerebral haemorrhage, or cerebral throm- 
bosis. The presence of premonitory symptoms 
for a few minutes or a few hours before un- 
consciousness has set in would suggest throm- 
bosis rather than haemorrhage. The sudden 
development of unconsciousness in a patient 
with valvular heart disease would point to 
embolism. 
6. The comatose attack may be indicative of general 
paralysis of the insane, a meningitis of cerebro- 
spinal or tuberculous origin, or more rarely, 
disseminated sclerosis, and typhoid fever. 
7. The unconsciousness may be of functional origin ; 
here the age of the patient, the sex, the history, 
and the absence of evidence of organic disease 
will be a sufficient guide. 
Treatment. 
The treatment will necessarily vary with the cause. 
If the condition is a serious one, and not speedily fatal, 
careful nursing is of the first importance. Attention 
has specially to be directed to the following points :- 
1. Promoting the warmth of the patient. 
2. Attention to the bowels and to the urine, the 
latter being retained for examination. DISORDERS OF THE NERVOUS SYSTEM 
137 
3. The prevention of bed-sores, and careful hygiene 
of the Ups, tongue, teeth, and nostrils, so as 
to diminish the chance of added septic com- 
plications. 
4. As soon as the cause has been determined, the 
treatment and general management must be 
directed accordingly. 
PERIPHERAL NEURITIS. 
(Syn. Alcoholic Neuritis.) 
The most frequent cause of multiple peripheral 
neuritis is the action of some toxic substance on the 
nervous system. The most common form, of which 
we see many examples in hospital, is alcoholic neuritis 
produced by excess of alcoholic beverages, spirits, and 
beer. Other causes are lead and arsenic, the tropical 
disease beri-beri, diabetes, and various infective fevers, 
more especially typhoid, rheumatism, malaria, and 
dysentery. For practical purposes we may regard 
alcoholic neuritis as the typical form of multiple peri- 
pheral neuritis. 
Symptoms of Disease. 
The onset is usually gradual. The patient complains 
of numbness and tingling in the hands and feet. He 
suffers from cramp, especially in the calf muscles, the 
pain being increased by movement and by pressure. 
When the muscles of the calf are grasped great pain 
is induced (muscular hyperalgesia). Slight consti- 
tutional disturbances with a little elevation of temper- 138 
ature may be present. Soon signs of muscular weakness 
are noted, the feet become dropped, and the patient 
cannot dorsiflex them. In walking, therefore, the 
knees must be raised unusually high to clear the dropped 
feet from the ground, this producing a characteristic 
high-stepping gait ; occasionally the gait is ataxic ; 
knee jerks are usually absent; the weakness in the 
legs gradually increases, until walking is impossible. 
Psychical symptoms are often present, such as mental 
confusion, impairment of memory especially for recent 
events, and delusions about recent actions. In some 
cases sensory symptoms, in others motor symptoms are 
most pronounced. In most cases the sensory and 
motor symptoms are combined. 
The diagnosis of the condition is, as a rule, easy. 
The history with the physical signs, usually gives an 
unmistakable picture; the most common error in 
diagnosis is to regard the sensory symptoms in the 
early stages of the disease as due to slight touches of 
" rheumatism." 
Course and Prognosis. 
This to a great extent depends on the history, and 
the stage in the disease at which the symptoms develop. 
Usually the termination is in partial or complete re- 
covery, but some muscles often remain weak. In many 
cases, however, a fatal termination occurs, this being 
due to other effects of chronic alcoholism, more especially 
cardiac failure, pneumonia, paralysis of the diaphragm, 
and tuberculosis of the lungs. 
Treatment. 
The first essential in cases of peripheral neuritis is 
to ascertain the cause and remove it. The most difficult 
CLINICAL LECTURES FOR NURSES DISORDERS OF THE NERVOUS SYSTEM 
139 
part of treatment is the correction of the alcoholic habit. 
In cases of alcoholic neuritis the effects of the chemical 
toxin, alcohol, are in nearly all cases considerably 
aggravated by other toxins of a chemical or bacterial 
nature, produced in the digestive tract as a result of 
damage done by alcohol. The condition is in reality 
a mixed one, and due regard must be paid to this when 
considering treatment. The treatment must be directed 
not only to the cure of the neuritis, but to the restoration 
of normal functional activity of most of the organs and 
tissues of the body, all of which are more or less seriously 
involved. In well marked cases the most important 
factor in treatment is the psychical one ; the person- 
ality of the doctor and the nurse is of the very greatest 
importance in correcting the alcoholic habit, and in 
giving the patient much-needed encouragement for 
the future. This subject is further referred to in the 
lecture on Alcoholism. 
The details of treatment may be discussed after 
referring to a typical case - 
A young married woman, aged twenty-eight, was admitted 
to a medical ward as a case of alcoholic neuritis. The 
history showed that she had been drinking heavily off and 
on for ten weeks, during which time she had been in bed 
practically continuously. No facts of importance were 
elicited with regard to the family history. Her domestic 
life had not been very happy. Constitutionally she appeared 
to be of a nervous temperament. In the course of treat- 
ment in the medical ward marked mental symptoms de- 
veloped which led to her being transferred to another ward. 
On admission she was unable to stand or walk, and com- 
plained much of pains in the legs. Her memory was very 
defective, she suffered from delusions of various kinds, 
was rather excited and emotional, and there was incon- 
tinence of urine and faeces. 140 
CLINICAL LECTURES FOR NURSES 
Physical examination showed her to be a small, thin 
woman, and rather pale. Intense pain was complained of 
on pressure over the calves of the legs. Knee jerks were 
abolished, the pulse rate was increased, and the heart 
sounds weak. The tongue was heavily furred, and there 
was very marked atony of the abdominal wall and intes- 
tinal muscles. There was incontinence of urine and faeces, 
the latter being extremely offensive. The general con- 
dition was a very serious one, which justified the recom- 
mendation that had been made as to her being transferred 
to an asylum. Under rest and appropriate treatment 
her condition has improved very markedly, the pains have 
to a great extent disappeared; there, is, however, still pain 
complained of on pressure. She can walk a little, but the 
gait is still distinctly unsteady. Her mental condition is 
very greatly improved, but she is still a little emotional. 
She has now complete control over the bladder and rectal 
functions. She ultimately made a good recovery. 
In addition to careful nursing required owing to the 
incontinence of the urine and faeces, the essential points 
in the treatment have been as follows :- 
1. Complete rest in bed for a month. 
2. Special attention to the skin, by means of 
sponging and baths, to promote a healthier con- 
dition of the skin glands, and better nutrition of 
the skin generally. Strict attention must be paid 
to oral hygiene, any decayed teeth or septic con- 
dition of gums being corrected. 
3. A light diet, consisting of milk, milk foods, 
and white meat foods. 
4. Elimination promoted by (a) occasional doses 
of calomel, followed by a morning saline, and 
(6) diluents, e.g., hot or cold water given on an 
empty stomach. DISORDERS OF THE NERVOUS SYSTEM 
141 
5. Massage. After the more acute symptoms 
of the neuritis had subsided, massage was applied 
with great care, so as to get both the sedative and 
tonic properties of this useful measure. In cases 
where the paralysis of the extensor group of muscles 
is pronounced, bandages and splints may be necessary 
to prevent deformity. 
6. General tonic remedies, e.g., strychnine, arsenic, 
and iron. 
7. Mental tonics. The value of all the foregoing 
remedies will be enormously increased by the 
judicious exhibition of sympathy and tact in the 
whole management of the case on the part of the 
nurse. The importance of the mental factor in 
the treatment of these cases cannot be over-esti- 
mated. 
DISEASES OF THE SPINAL CORD. 
Introduction. 
The spinal cord is the nerve trunk connecting the 
brain and the peripheral nerves. It is composed of 
nerve cells and nerve fibres. The nerve cells are located 
in grey matter in the centre of the cord ; the nerve 
fibres are arranged in columns around this grey matter. 
The nerve fibres are of two main groups, one conveying 
impulses from the periphery to the brain-sensory 
nerve fibres-and one conveying impulses from the 
brain to the periphery-motor nerve fibres. Some of 
the sensory nerves are concerned with the conducting 
of impulses involved in the sensation of touch : others 142 
CLINICAL LECTURES FOR NURSES 
are concerned with the impulses involved in the sensation 
of heat and cold ; others again are concerned with the 
sensation of pain ; and a further group with what is 
known as the muscular sense-this being the sense which 
enables the limbs to gauge their relationship to outside 
objects. The different fibres subserving these functions 
are localised in different regions of the cord. In some 
diseased conditions the motor fibres in the cord may- 
alone be deranged ; in others, the sensory fibres are 
affected ; frequently both sets of fibres are involved. 
It is further not uncommon to find a marked impairment 
of tactile sensibility in a patient in whom the response 
to heat and cold, or the response to painful stimuli, 
is defective, and vice versa. 
The nerve cells in the grey matter have three functions: 
they act as receiving and transmitting stations ; they 
receive ingoing impulses from without and transmit 
them to the appropriate nerve fibres in the cord 
going upwards; they also act as receiving stations 
on the downward path, the impulses from the brain 
being transmitted through them to the spinal nerves. 
Secondly, the nerve cells control the reflexes : 
(a) they directly control the organic reflexes of the 
bladder and the bowels ; and (b) they are concerned 
in other reflexes of which the knee-jerk is the most 
typical example, these reflexes being muscular actions 
which are independent of the volition of the patient. 
If the integrity of these cells is interfered with, imperfect 
control of the bladder or of the bowels ensues. Similarly 
if the particular cells concerned in the knee-jerk or 
other reflexes are interfered with, that reflex may 
become exaggerated or it may become impaired, the 
actual condition depending on the situation and nature DISORDERS OF THE NERVOUS SYSTEM 
143 
of the lesion. The third important function of the 
nerve cells in the cord has reference to the nutrition 
and tone of the muscles, skin, and other tissues supplied 
to them. This is the trophic function. If these cells 
are damaged in any way the nutrition of the muscles, 
skin, etc., supplied by them is impaired, the muscles 
waste, and the skin becomes devitalized, with resulting 
bed sore formation. In addition to looking carefully 
into the question of motor defect due to disturbance 
of the motor fibres, or sensory disturbance-touch, 
heat and cold, pain-due to defect in the sensory fibres, 
we have to examine carefully into the condition of 
the organic reflexes, bladder and rectum, and the other 
reflexes of which the knee-jerk is the most typical 
example. By carefully investigating the nature and 
defect in any given case, we are usually able to deter- 
mine the site of the lesion in the cord and its nature. 
We will describe three cases which illustrate well 
the clinical features present in three of the most common 
diseases of the spinal cord. One of these is the result 
of an inflammation of the cord, which involves both 
the grey and the white matter, and is known as myelitis 
-a transverse, myelitis, because the whole of the cord 
is affected. The second is a case of disseminated sclerosis, 
or multiple sclerosis, which is characterised by little 
patches of chronic inflammation scattered indiscrimin- 
ately throughout the cord. The third is a case of loco- 
motor ataxia, or tabes dorsalis; here the disease is 
chiefly located to the posterior part of the cord, the 
part concerned in the conveying of sensory impulses 
upwards. The clinical features and general manage- 
ment of these three diseases will now be discussed. 144 
CLINICAL LECTURES FOR NURSES 
1. TRANSVERSE MYELITIS. 
This is an inflammation which involves both the grey 
and the white matter of the cord. It is induced by injury 
and also by disease. In traumatic cases there is usually 
a fracture or fracture-dislocation of the spine, the cord 
being lacerated right across at the site of the injury. 
In non-traumatic cases, the disease arises as the result 
of bacterial infection, or as the result of a haemorrhage 
in the cord, or more rarely from pressure by a tumour 
of a tuberculous, syphilitic, or malignant nature. 
Symptomatology. 
The symptoms vary in accordance with the causation 
and the severity of the inflammation. In a very pro- 
nounced case, such as that of one of the patients above- 
mentioned, he is quite unable to move the lower limbs, 
being completely paralysed from the waist downwards. 
On testing his sensibility we found that the lower limbs 
were quite insensitive to touch, to heat and cold stimuli, 
or to painful stimuli,-e.g., from pin-pricks. There was 
incontinence of the urine and incontinence of faeces, 
and the other reflexes,-e.g., knee-jerks, were completely 
abolished. The loss of power, the loss of sensation, 
the loss of control over the bladder and bowel, and the 
disappearance of the deep reflexes arise from the fact 
that the nerve cells and nerve fibres in a particular 
part of the cord have been destroyed right across. 
Prognosis. 
The outlook for the patient depends largely upon 
the nature of the disease, on its duration, and on the 
degree of recovery which takes place in the first few DISORDERS OF THE NERVOUS SYSTEM 
145 
weeks after the disease develops. The onset is usually 
sudden ; it was in this case due to an acute bacterial 
infection. The disease developed four weeks ago. 
As little or no improvement has occurred in that time, 
the prospects of recovery are unfavourable. It is pro- 
bable that the nerve cells and nerve fibres have been 
damaged beyond repair, and little further improvement 
may be looked for. In less severe cases, the cells and 
fibres are not so completely destroyed, and a consider- 
able degree of recovery may be obtained, if the patient 
is carefully nursed and the treatment is carried out 
for a prolonged period. There are two special risks 
to which patients affected with myelitis are subject : 
one is the occurrence of bed-sores, and the other is 
the development of cystitis with septic complications- 
death occurring from exhaustion, or from bladder, 
kidney, or pulmonary complications. 
General management. 
From the outset, careful nursing is of the greatest 
importance, special attention being paid to the pre- 
vention of bed-sores, and care being taken to avoid 
burning the insensitive skin surface with hot bottles. 
Special care is also necessary in regard to the prevention 
of sepsis in connection with the use of the catheter, which 
is so frequently necessary in these cases. The general 
principles of treatment may be stated as follows :- 
1. Keep up the nutrition of the skin so as to 
prevent the formation of bed-sores ; exercise special 
precautions with regard to the use of hot bottles. 
2. Guard against septic complications in con- 
nection with the incontinence of urine and of 
faeces, cleanliness and rigid asepsis being essential. 146 
CLINICAL LECTURES FOR NURSES 
3. Keep up the nutrition of the paralysed part 
by means of judicious massage and, in appropriate 
cases, electricity. 
4. Regulate the bowels carefully by means of 
aperients, or occasionally lavage. 
5. Special measures may be indicated in special 
cases. These include the use of vaccines in cases 
of bacterial infection, where the causal bacteria 
can be determined; and, in exceptional cases, 
operation. 
2. DISSEMINATED SCLEROSIS. 
(Syn. Multiple sclerosis.) 
Disseminated sclerosis or multiple sclerosis is one of 
the commoner forms of chronic disease of the nervous 
system. It affects the spinal cord and also the brain. 
It is characterised by a patchy inflammation throughout 
the spinal cord and the brain, of undetermined origin, 
the inflammation resulting in the development of small 
areas of connective tissue. This degenerative tissue 
replaces the nerve cells and nerve fibres at the affected 
areas. The disease commonly affects people between 
the ages of twenty and thirty-five, and more especially 
females. It is often overlooked in its early stages, 
the condition being erroneously regarded as due to 
neurasthenia or hysteria. 
Symptomatology. 
In the early stages of the disease, the chief symptoms 
met with are eye symptoms, more especially paresis 
or paralysis of one of the external eye muscles, fine DISORDERS OF THE NERVOUS SYSTEM 
147 
tremors, some degree of general weakness, and general 
nervousness. Some gastro-intestinal derangement is 
very frequently present, notably flatulence and con- 
stipation. At this stage of the disease diagnosis is 
difficult, and the true nature of the condition is fre- 
quently overlooked, the malady being regarded as of 
functional or neurasthenic origin, and no trouble being 
taken to ascertain the cause of the neurasthenia. In a 
fully developed case the diagnosis is perfectly clear. 
The clinical picture is quite characteristic. The 
little patches of inflammation scattered throughout the 
spinal cord and the brain produce the following symp- 
toms and physical signs :-disturbance of walking ; 
gait is very much interfered with, this being due partly 
to actual paralysis of the nerves and partly to loss of 
control on the part of the nerves. The feet are raised 
and put down in a spastic manner, which is character- 
istic. The second great clinical symptom is the coarse 
muscular tremor, the result of the inco-ordination in 
the nervous system induced by the patches of inflam- 
mation. In the later stages of the disease the patient 
may be unable to feed herself on account of the shak- 
ing of the hand, the shaking becoming aggravated 
the more nearly the hand approaches the mouth. A 
third characteristic symptom is the affection of the 
eye muscles. The tremor of the eye muscles is shown 
in the form of constant movement of the eye, so-called 
nystagmus, also by a paralysis of one or other of the 
external ocular nerves, inducing in some cases a squint, 
and in other cases a drooping of the upper lid or ptosis. 
There may be few, if any disturbances of sensation. 
There is usually some slight lack of control of the bladder. 
The brain is often affected, the patches of degeneration 148 
CLINICAL LECTURES FOR NURSES 
in the brain substance revealing themselves clinically 
by an evident loss of mental power. 
Diagnosis. 
In the well declared type of disease the diagnosis 
is very easy as the picture is characteristic. The diag- 
nosis at this stage is, however, of relatively little import- 
ance because the damage is done and little is to be 
looked for from the treatment. An accurate diagnosis 
is specially important in the early stage of the disease, 
as at this stage much can be done permanently to 
arrest the diseased tendency. The cause of the disease 
is unknown, the balance of evidence in the opinion 
of experts being in favour of its toxic or infective origin, 
the source of toxaemia being usually the digestive tract. 
The frequency with which minor gastric or intestinal 
symptoms are present was referred to above ; special 
attention should be directed to any such symptoms 
and their cause ascertained. These symptoms have 
as a rule preceded and have not merely followed the 
nervous symptoms. Careful examination of the digestive 
tract should always be made, including examination 
of the stools, X-ray examination after a bismuth meal, 
and a bacteriological examination of the mine. These 
are essential before correct lines of treatment can be 
laid down. 
General management. 
There are two sets of conditions which the doctor 
and nurse have to manage. One is to control as far as 
possible the nervous temperament of the patient, and 
the other is to direct attention to any underlying physical 
condition giving rise to the toxaemia. Attention must 149 
be directed to improving any defect of the stomach, 
small intestine, or large intestine, which may have 
been revealed on investigation. Any local pelvic 
disorder, or any source of toxaemia from the teeth or 
gums should be similarly attended to. 
Massage with judicious application of exercises care- 
fully carried out occupy a prominent place in treat- 
ment, care being taken to see that these are not 
overdone. Great care must be employed with regard to 
the use of massage and any electrical treatment to the 
limbs, as more harm than good is sometimes done by 
these means. Medicinal remedies are of little value. 
In cases associated with anaemia, a course of iron or 
arsenic is frequently useful. If the cases are adequately 
investigated in the early stages of the disease, and 
treatment directed along the appropriate lines, the 
disease can be arrested almost before its diagnosis 
can be determined with certainty. That is the stage 
at which the doctor and the nurse can do most valuable 
work for the patient. When the clinical symptoms of 
the disease are fully established, the ailment is far 
advanced, and treatment is comparatively of little 
avail. 
DISORDERS OF THE NERVOUS SYSTEM 
3. LOCOMOTOR ATAXIA. 
(Syn. Tabes dorsalis.) 
Locomotor ataxia, or tabes dorsalis, is a disease of the 
spinal cord which mainly affects the male sex between 
the ages of twenty and forty. The causation of the 
disease is unknown, but it is most commonly seen in 
subjects who have previously been infected with syphilis. 
According to some investigators the disease is the 150 
result of a particular bacterial infection derived from 
the bladder or the bowel, chiefly occurring in people 
who have had syphilis. 
Symptomatology. 
The clinical features of the disease are well illustrated 
in the case of one of the patients referred to. The 
history of the case is briefly as follows :- 
A. B., aged thirty, enjoyed good health until about 
nine months ago, when he became slightly unsteady on 
his legs. He first observed a slight unsteadiness on his 
feet in the morning when he was drying his face with 
the towel after washing. About the same time he observed 
that he did not walk so well in the dark. Shortly after- 
wards he had a peculiar feeling in the soles of his feet, 
the ground appearing to be soft and woolly under him. 
He has suffered from two attacks with his stomach, charac- 
terised by vomiting lasting two days, the vomiting having 
no relation to food. (These attacks are distinctive: they 
are of nervous origin, and they are known as gastric crises.) 
Lately he has had slight difficulty with his water, the 
chief difficulty being inability to retain it normally, and 
defective control over micturition. 
On examination the man is well nourished, has a good 
colour and presents generally little evidence of disease. 
His walking power is greatly impaired. He walks with 
the feet wide apart; he has a high stepping gait and brings 
down his heels sharply on the ground. When asked to 
stand with his toes and heels together and his eyes shut, 
he sways from side to side, and would fall if not supported. 
His motor power in the arms and legs is quite good, the 
defect in walking being due to defective co-ordination 
and not to actual paralysis. There are areas of defective 
sensation both to touch and to heat and cold in the lower 
limbs. The knee-jerks are abolished. The pupils are 
small and do not react to light. (Argyll-Robertson 
symptom). This last symptom is one of the most 
important signs of the disease. 
CLINICAL LECTURES FOR NURSES 151 
All these symptoms are the result of a chronic de- 
generation of the posterior part of the cord-the sensory 
columns of the cord-this inducing the marked inco- 
ordination which is the special feature of the disease, 
and the disturbance of sensation, and other symptoms 
and signs. When a sample of blood was withdrawn 
and tested by the Wassermann's test, it gave a positive 
result, indicating previous specific infection. 
Prognosis. 
The prognosis as regards cure is unfavourable, the 
condition tends to steady deterioration ; but in some 
cases the disease remains arrested for many years. 
The chief risks are (a) complications associated with the 
bladder, and especially the development of a septic 
cystitis, and (6) the extension of the disease to the 
remaining parts of the cord and also to the brain. 
There is a close relationship between tabes dorsalis, 
which is a disease of the cord, and general paralysis of 
the insane, which is a disease of the brain cortex. In 
the later stages of tabes dorsalis alteration in the mental 
functions are frequently present. 
General treatment. 
The primary defect being one of co-ordination, the 
main object in treatment is to seek to promote co- 
ordination of the various muscles by exercises adapted 
for the purpose. Thus, for ten to fifteen minutes twice 
a day, the patient should be encouraged to walk on 
a marked floor : this exercise being useful in the training 
and co-ordination of the sense of sight and the muscular 
sense. Additional exercises of the lower limbs directed 
to promote better co-ordination of the muscles should 
DISORDERS OF THE NERVOUS SYSTEM 152 
also be prescribed. Medicinal remedies have little 
or no influence on the course of the disease. The use 
of salvarsan to counteract the previous specific infection 
is advocated by some authorities. If the careful bac- 
teriological examination of the urine gives any evidence 
of bacterial infection, attempts should be made to 
correct and remove that by appropriate vaccine treat- 
ment. Throughout the course of the disease, special 
attention should be paid to maintaining a healthy 
condition of the intestinal tract. 
CLINICAL LECTURES FOR NURSES 
GENERAL PARALYSIS OF THE 
INSANE. 
General paralysis of the insane, or as it is commonly 
termed general paralysis, is a progressive and incurable 
disease of the nervous system, characterised by bodily 
symptoms which end in Paralysis and mental symp- 
toms which end in Dementia. The disease runs 
a fairly definite course of development, and as a rule 
terminates fatally in a few years. There is great varia- 
tion in the nature and duration of the earlier symptoms 
of the disease in different cases, this being one of its 
characteristic features. It is specially a disease of 
the adult male. Its causation is unknown, though 
syphilis is a very important predisposing cause. Many 
authorities hold the view that a superadded infected 
element plays an important role in this disease. The 
course may be somewhat arbitrarily divided into three 
stages : (1) the prodromal or earlier symptoms ; (2) 
the acute stage ; and (3) the stage of dementia. 153 
(1) The prodromal symptoms. 
The disease may develop suddenly without warning, 
but more commonly there are some mental, sensory, 
or motor symptoms. The mental warnings are : loss 
of power of attention, restlessness, changes in temper, 
and loss of control often associated with boastfulness 
and expansive benevolence or extravagance. The 
motor symptoms include some hesitation in speech, 
blurring of articulation, changes in the handwriting, 
tremor, alteration in gait, with inequality of the pupils 
which fail to react to light. The sensory warnings in- 
clude hallucinations and defects of the special senses. 
The average duration of the symptoms in this period 
is about a year. 
(2) The acute stage. 
During this stage all the physical and mental symp- 
toms described above become more developed. This 
may be ushered in by an attack of melancholia or mania, 
or by convulsive seizures, followed by confusion or 
stupor. Impulsive acts which bring the subject under 
the care of the police are not uncommon. The state 
of exaltation or megalomania may become more pro- 
nounced, the patient imagining himself extremely 
wealthy, and offering to distribute the millions which 
he does not possess. The eye symptoms become more 
developed. The hand-writing is often characteristic ; 
the letters are shaky, incomplete, detached, or illegible. 
In the early stages the patient often writes voluminously 
and quickly. Seizures of various kinds are not uncommon 
at this stage : they vary in severity from simple con- 
gestive attacks to seizures of an epileptiform character. 
All the bodily functions become depressed, the bowel 
DISORDERS OF THE NERVOUS SYSTEM 154 
being deranged, and some difficulty being experienced 
in controlling the bladder and the rectum. A remission 
of the symptoms is very common during the earlier 
stages of the disease-this remission may be complete, 
so that the patient may resume work for a time. 
(3) Stage of dementia. 
The stage of dementia is the third and final stage, 
and extends over a period of about a year. There is 
loss of special and common sensation ; objects, persons, 
and places are no longer recognised ; the patient cannot 
take care of himself ; ataxia gives way to paralysis, 
and the patient becomes bedridden. Brief attacks of 
excitement may occur. All the bodily functions become 
seriously lowered, death occurring through intestinal, 
renal, or vesical derangements, often accompanied 
with bed-sores, oedema of the lungs, or pneumonia. 
Diagnosis. 
The diagnosis of this disease is often very difficult 
in the early stages. It should be kept in view that the 
disease may start with almost any form of mental or 
physical disorder. The diseases most likely to be con- 
founded with it are : alcoholism, disseminated sclerosis, 
tabes dorsalis often associated with mental symptoms, 
paralysis agitans, and syphilitic affections of the brain 
other than distinctive general paralysis. Assistance 
in the diagnosis is given by the history of the case, 
previous infection by syphilis, result of the Wassermann 
reaction, the remission in symptoms, and the results 
of the examination of the cerebro-spinal fluid. Reference 
has already been made to the great variation in the 
manner of development of the symptoms. While the 
CLINICAL LECTURES FOR NURSES 155 
clinical features in an average case have been described 
above, not a few cases run a more acute course, and 
terminate within six months of the onset. The disease 
cannot be diagnosed from the presence of one or two 
symptoms. A careful review of all the mental symptoms 
and physical signs is required, and much information 
can be obtained from the patient's relatives or friends 
as to alterations in his habits or mode of life. Before 
making a diagnosis great care should be taken to eliminate 
the factor of alcohol. 
It may be useful to illustrate the disease by short 
reference to the history of two patients at present in 
hospital. 
J. G., car conductor, aged thirty-three, came into the 
hands of the police on a charge of theft, the theft being 
a very petty affair without any benefit to himself. The 
patient's previous character had been uniformly good, 
and he had been in the service of the company for eighteen 
years. The circumstances of the charge against the man 
led the doctor acting for the police to suspect some mental 
disorder. On inquiring into the history we learned that 
the patient had been in a medical ward four years ago, 
suffering from what was termed a " slight attack of creeping 
paralysis," from which he made a good recovery. He kept 
well until a month before admission, when he complained 
of giddiness in his head, and was off duty for three weeks. 
Both of these physical conditions were clearly a part of 
his general paralysis. 
On examination there was slight inequality of the pupils 
which failed to respond to light, and with the exception 
that the patient was, for him, uncommonly quiet, no 
mental symptoms were observed. Examination of the 
cerebro-spinal fluid showed a considerable excess of cells, 
and examination of the blood gave a marked Wassermann 
reaction. 
After a few weeks' rest the patient was put on probation. 
DISORDERS OF THE NERVOUS SYSTEM 156 
CLINICAL LECTURES FOR NURSES 
He was, however, quite unfit for his work and forgot every- 
thing he was told. On re-admission his habits had now 
become objectionable, he was inclined to be violent, his 
memory much impaired, he had forgotten that he was 
a car conductor, and he was certified. 
The second patient is equally typical, but presents 
a slightly different history. 
Man, aged forty-four, admitted to the ward a short 
time ago having been acting strangely for some time; 
was out one evening for many hours apparently wandering 
in an aimless manner and unable to find his way back. 
When examined shortly after admission, the patient pre- 
sented all the characteristic features of a case of general 
paralysis. He had delusions of grandeur; he insisted 
in presenting the nurses daily with diamonds and millions 
of pounds ; dined with royalty constantly; took a pleasure 
jaunt in an airship of his own construction with one of the 
nurses. The patient was in a slightly hilarious mood; 
his speech was affected, stammering in character; his 
knee-jerks were absent; his pupils did not react to light; 
the Wassermann reaction was positive; and there was 
considerable excess of cells in the cerebro-spinal fluid. 
As the patient did not improve he was sent to an asylum. 
The combination of clinical features here, notably 
the megalomania, delusions of grandeur, defects in 
speech, alteration of pupils, with the strange conduct 
and loss of memory which brought him into the hands 
of the police, point clearly in the direction of general 
paralysis. 
Treatment. 
The results of treatment of the disease are unsatis- 
factory. Periods of remission in the severity of the 
symptoms are common, and it is therefore difficult to appraise the value of any special measures that may 
from time to time be tried. There are cases on record 
where the symptoms have remained in abeyance for many 
years, the results suggesting cure. In such cases there 
may be room for doubt as to the original diagnosis, 
but the undoubted existence of such cases should lead 
us not to be too pessimistic, and to devote all our energies 
to getting the best results. From the nature of the 
symptoms, treatment is as a rule only satisfactorily 
carried out in an institution. Keeping in view the 
theory, held by some authorities, that the disease is 
the result of a slow infection by pathogenic bacteria, 
located either in the urethra, intestinal tract, uterine 
tract, or naso-pharynx, special attention should be 
directed to the correction of any defect which on careful 
investigation may be found in these regions. This 
investigation may involve a careful bacteriological 
examination of the urine, stools, and nasal mucous 
membrane. Treatment has to be conducted on general 
lines. Fresh air, freedom from mental worry and excite- 
ment, good food, careful regulation of the bowel and 
simple tonic measures constitute the general lines. 
DISORDERS OF THE NERVOUS SYSTEM 
157 158 
CLINICAL LECTURES FOR NURSES 
TUMOUR OF THE BRAIN. 
The following case is a good example of tumour of 
the brain :- 
A young man, aged twenty-eight, was quite well until 
a few months ago, when he began to complain of severe 
headaches, becoming irritable and depressed, and his mental 
condition generally different from formerly. This mental 
dulness increased, and was later followed by unsteadiness 
in gait, with a tendency to fall, sometimes to one side 
and sometimes to the other. He vomited occasionally, 
the vomiting having no apparent relation to food. Optic 
neuritis was present. There was no paralysis and no 
disturbance of sensation. The patient became comatose 
and died a few days later, no localising symptoms having 
developed. At the post-mortem examination a large 
tumour was found involving the lateral ventricles of the 
brain. 
This case is a fairly typical example of " Tumour 
of the Brain," and may be taken as a basis of lecture 
on that subject. 
The Symptoms of Brain Tumour. 
These may be cons:dered under the headings of 
" General Symptoms " and " Localising Symptoms." 
The former are the more important, because they are 
invariably present. Localising symptoms may be absent 
as in the above case. 
The three cardinal general symptoms are :-Headache, 
vomiting, and optic neuritis. The headache is very 
severe, may last for some hours, and is relieved 
with difficulty by sedatives. The vomiting comes on 
suddenly without apparent cause ; it has no relation DISORDERS OF THE NERVOUS SYSTEM 
159 
to food. The optic neuritis is only determined on 
ophthalmoscopic examination. 
The vision may not be interfered with till the later 
stages of disease. Other general symptoms which 
may be present include : mental disturbance as in 
the above case, giddiness, and convulsions. The pulse, 
temperature, and the respiration are usually unaffected, 
in some cases the pulse may be slow. 
The localising symptoms include paralysis of various 
kinds, the nature of the paralysis depending upon the 
situation of the tumour. Hemiplegia is sometimes 
present, this being met with in cases where the tumour 
presses on the internal capsule. Disturbances of 
sensation may similarly be present if the sensory tract 
in the brain is affected. A paralysis of one or other 
of the cranial nerves is not uncommonly present in 
cases where the tumour involves the origin of the 
nerve or the fibres in its course at the base of the brain. 
The reflexes are disturbed, the knee jerk, abdominal 
reflex, and others being altered ; also the organic 
reflexes. The last-named are more especially involved 
in the later stages of the disease. 
Lumbar Puncture will usually reveal an increase of 
pressure in the cerebro-spinal fluid. 
The Nature of the Tumour. 
The tumours usually belong to one or other of the 
following classes :- 
(a) Tuberculosis. 
(6) Specific Tumour. 
(c) Glioma-a connective tissue tumour. 
The rarer tumours include various cysts and secondary 
cancerous or sarcomatous growths. An injury to the 160 
CLINICAL LECTURES FOR NURSES 
head is frequently an exciting cause of the development 
of tumour. 
Diagnosis. 
Three questions have to be considered- 
(a) Is a tumour present ? 
(6) What is its nature ? 
(c) What is the site ? 
It is usually possible to determine the first ; it is 
often impossible to do more than hazard an opinion 
on the second and third questions. A number of con- 
ditions may simulate cerebral tumour. Of these the 
more important are-chronic Bright's disease, menin- 
gitis, general paralysis of the insane, abscess of the brain, 
epilepsy, and in rare cases hysteria. If the symptoms 
and physical signs are carefully observed, and the 
possibility of these other diseases kept in view, little 
difficulty is usually experienced in the diagnosis. 
The Treatment. 
This may be considered from the curative or palliative 
point of view. Tumours of a specific nature are curable 
by the administration of potassium iodide and mercury. 
Tumours which can be accurately localised to the surface 
of the brain can occasionally be removed successfully 
by operation. In all other cases the prognosis is de- 
cidedly unfavourable. Relief of symptoms can be 
afforded by sedative remedies, such as phenacetin, 
antipyrin, potassium iodide, and cold applications 
to the head. More relief, though of a temporary char- 
acter, can often be given by lumbar puncture. The 
temporary reduction of pressure in the cerebro-spinal 
fluid thus effected often gives marked relief of a 
temporary kind. 161 
DISORDERS OF THE NERVOUS SYSTEM 
MENTAL DERANGEMENT. 
There are few more interesting chapters in clinical 
medicine than the study of disordered mental con- 
ditions. I have frequently drawn your attention to 
some of these cases which have come under my care 
in the special ward set aside for their management. 
It will be useful to summarise some of the essential 
features of the more common cases. A few words are 
necessary by way of introduction. 
Certain examples of derangement of the mind induced 
by acute toxaemic conditions have frequently come 
under our observation. The delirium occasionally 
present in fever is the result of the bacterial toxaemia 
produced by the fever. Here the mental disturbance is 
seldom profound ; it is a subsidiary part of the general 
picture; the mental condition clearing completely 
with a diminution in the toxaemia. The delirium of 
acute alcoholism-delirium tremens-is another good 
example of acute mental disturbance arising from a 
toxaemia of chemical origin. The clinical picture here 
comprises hallucinations, delusions, suspicion, and mental 
confusion. All of these pass off as a rule quickly when 
the cause is removed. 
The class of case which we are considering includes 
two groups : (1) patients admitted to the ward in a 
state of excitement, classified as cases of mania ; and 
(2) patients whose main symptom is that of mental 
depression, classified as cases of melancholia. 
The terms " Mania " and " Melancholia " are really 
symptoms rather than diseases. There are several types 162 
CLINICAL LECTURES FOR NURSES 
of mania as there are several types of melancholia. 
In the modern classification of mental disorders, these 
terms have to be supplemented by other terms which 
give a clue to the particular type of mental disorder. 
I propose, for instance, to illustrate to you the clinical 
features of puerperal mania, a mental disorder induced 
by an acute bacterial infection, and also the clinical 
features of a case of climacteric melancholia, where 
the mental symptoms arise as a result of a toxaemic 
condition occurring at the climacteric period. At 
this period there is a lowering of the nervous tone of 
the individual, rendering her more susceptible to the 
action of toxins or other unfavourable influences. 
There are two great determining causes of mental 
derangement : (1) a hereditary irritability of brain 
tissues, rendering the nerves less able to resist various 
strains-either physical or mental ; and (2) a toxaemic 
cause, the origin of which is to be found in some latent 
septic focus in the oro-gastric, intestinal, or genito- 
urinary tract. 
1. MANIA. 
Mrs A. B., young married woman, was recently admitted 
to the ward suffering from mania, which developed a few 
weeks after childbirth. Shortly after the child was born, 
she did one or two peculiar things, of which little notice 
was taken ; but suddenly she passed into a condition of 
general maniacal excitement, shouting and yelling, offering 
violence to everybody around her, several people being 
required to restrain her. 
This is a very typical history of puerperal mania- 
mania occurring in the puerperium-and universally 
recognised to be of bacterial origin. The careful in- 
vestigation of these cases usually reveals the source of sepsis to be in the uterus, sometimes in the bladder 
or bowel. An examination of the blood shows definite 
leucocytosis, this being Nature's attempt to overcome 
the bacterial infection. 
The Diagnosis in such cases is very clear. The 
Prognosis is more difficult. The great majority of 
patients recover in a few weeks or in a few months' 
time. Exceptionally, two or three years may elapse 
before the mental condition is fully restored. The 
prognosis depends partly on the severity of the in- 
fection, and largely on the predisposition of the patient. 
If there is a history of marked nervous instability in 
the family, other members of the family having suffered 
from mental disorders, the outlook is proportionally 
more guarded. 
Treatment. 
When a case of this kind comes under observation, 
the first point to determine is whether the mental 
condition is of sufficient severity to necessitate her 
removal to an institution. In a few cases, in which the 
mental symptoms on admission are very acute, the con- 
dition clears up within a few weeks, the patient being 
enabled to convalesce under favourable conditions 
before returning home. More commonly, however, 
the disease is of longer duration, necessitating appro- 
priate institutional treatment. Treatment must be 
carried out along the following lines :- 
1. Keeping in view the definite toxic origin 
of the disease, appropriate treatment must be 
directed to correcting any septic condition in the 
uterus, bladder, bowel, or teeth. 
DISORDERS OF THE NERVOUS SYSTEM 
163 164 
2. The state of the bowels and state of the urine 
requires investigation, including bacteriological ex- 
amination, which may throw light on the nature 
of the bacterial toxaemia and give an indication 
with regard to vaccine treatment. 
3. Treatment on general lines, directed to the 
relief of symptoms. For example the administra- 
tion of light diet, or it may be milk only, for a 
time (feeding with a nasal tube may be necessary) ; 
the administration of sedatives to correct the 
excitement, and notably large doses of bromide, 
chloral, or hypodermic injections of hyoscine. 
2. MELANCHOLIA. 
Many patients are admitted to the ward whose chief 
mental symptom is one of depression or melancholia. 
It cannot be too clearly understood that the terms 
" Mania " and " Melancholia " are merely symptoms- 
mania representing a condition of exaltation, and 
melancholia a depression of the higher mental functions. 
This condition of depression or melancholia may arise 
from different causes. The succeeding case illustrates 
the type of melancholia which occurs at or about the 
menopause, known as climacteric melancholia. The 
clinical history of this patient is fairly characteristic :- 
Mrs A. D., aged forty-six, has been somewhat depressed 
for several months past. Previously she had been a little 
moody and complained of headaches. On the day before 
admission she looked " queer " to her daughter and spoke 
of destroying herself. Her antecedent medical history 
had been quite satisfactory, with the exception that she 
suffered from one very severe attack of neurasthenia of 
many months' duration. 
CLINICAL LECTURES FOR NURSES DISORDERS OF THE NERVOUS SYSTEM 
165 
On examination the patient looks depressed and miser- 
able. She is very silent, is with difficulty roused to reply 
to any question, and sleeps badly. Her colour is bad- 
she looks anaemic and sallow. Her pulse is rather quick, 
and weak in character. The abdomen is very flaccid and 
lacking in tone. The bowels are markedly constipated, 
and on clearing out the bowel, a condition of marked 
putrefaction was found. 
This constitutes a fairly typical case of what is known 
as climacteric melancholia, the case being one in which 
the bowel disorder was perhaps more pronounced than 
it is in many such cases. 
The chief factors determining the existence of this 
mental condition are (1) the changes in the glands 
and the system generally incidental to the change 
of life, this being a period in which the nervous and 
other systems are in a condition of instability ; (2) the 
operation of toxsemic influences, more especially arising 
from the bowel, uterus, or urinary tracts ; (3) mental 
strain such as is involved in domestic worry, worry 
incidental to the war, or the like. 
Prognosis. 
The prognosis in cases of melancholia occurring at 
the climacteric is good, the great majority of cases 
recovering in from three to six months ; in some the 
duration is much longer. 
General management. 
Here the first question that arises is as to the possi- 
bility of a recovery being effected in a general hospital 
without the patient being sent into a mental instituion. 166 
CLINICAL LECTURES FOR NURSES 
In favourable cases the attack passes off quickly with 
a few weeks' hospital treatment. The principles of 
treatment are as follows :- 
1. Abundance of fresh air, cheerful surroundings, 
plenty of exercise proportionate to the general 
strength of the patient. 
2. The administration of appropriate hypnotics 
to induce sleep ; the fewer drugs used for this 
purpose the better; fresh air and exercise are 
Nature's remedies. 
3. The judicious use of calomel and salts to 
serve the double purpose of clearing the bowel 
well out and getting it into a cleaner condition 
with less putrefaction. 
4. Any contributory source of sepsis present 
in connection with the teeth, gums, uterus, or 
bladder should be appropriately dealt with. 
5. The diet should be light and nutritious, the 
amount of fluid with meals being restricted. 
6. Tonic remedies may be prescribed ; among 
the most useful being arsenic and strychnine. 
In some cases very special benefit attaches to the 
use of small doses of thyroid gland. 
7. The mental environment of the patient is 
important; cheerfulness and tact on the part of 
the nurse and doctor are valuable factors in treat- 
ment. CHAPTER VII. 
FEVERS. 
MEASLES. 
Measles is an acute specific infective fever with charac- 
teristic macular eruption, and widespread catarrh, 
affecting chiefly the respiratory, nasal, and ocular 
mucous membranes. The incubation period is ten to 
fourteen days : it may be so few as seven or so many 
as eighteen. The infecting agent is unknown. The 
infection is through the air passages. It is greatest 
during the stage of invasion. The disease is practically 
endemic in large industrial centres, and from time to 
time becomes epidemic also. 
Stages. 
1. The stage of invasion, which lasts from three 
to five days, is characterised by catarrhal symptoms, 
sneezing, running at the eyes and nose, and general 
malaise. The attack may begin somewhat suddenly. 
There may be nausea, vomiting, and headache. The 
temperature is raised to perhaps 102° F. or more, the 
skin feels hot, and after a restless night the child is 
likely to be worse in the morning. The aspect of the 
patient at this stage is often characteristic ; the eyes 
are watery and injected, the face is pale, and a few 
reddish blotches or spots may often be observed round 
the mouth and nose, which gives to the skin a measly 
167 168 
appearance ; and the child, who persistently avoids 
the light in consequence of the photophobia which is 
present, both looks and feels profoundly miserable. 
The tongue is furred ; there is reddish hypersemia of 
the throat, and there may be a distinct punctiform 
rash spreading over the whole mucous membrane of 
the mouth except the tongue. The buccal spots of 
Koplik appear as blueish-white specks, surrounded by 
a red margin at the line of the junction of the molar 
teeth when the jaws are closed ; Koplik spots often 
appear before the rash. The temperature often becomes 
normal at the end of this stage. 
2. Advance and eruption.-The eruption usually 
commences on the fourth day and lasts two to seven 
days. At the outset it consists of small discrete red 
spots, which may be usually first observed about the 
roots of the hair, on the forehead, and sides of the head 
and neck especially behind the ears. It quickly invades 
the face, neck, and upper part of the chest and arms, 
from whence it spreads downwards over the trunk 
and limbs, involving the legs in from twelve to twenty- 
four hours after its first appearance. As the eruption 
develops, the individual spots become more raised and 
larger, and coalesce with neighbouring ones, giving 
rise to irregular raised tracts of vividly injected skin. 
The rash, which is of a dusky-red colour, in most cases 
reaches its full development in from twenty-four to 
thirty-six hours, after which it rapidly subsides. As 
a rule the eruption is well marked on the face, and the 
circumoral region rarely escapes invasion-in this 
respect contrasting with scarlet fever. The eruption 
fades in the order in which it came, and when the rash 
CLINICAL LECTURES FOR NURSES has faded, more or less peeling of the skin usually follows. 
The respiration is rapid; the trachea and bronchi 
show a varying degree of catarrh ; the lymphatic glands 
in the neck are usually somewhat enlarged and tender ; 
the pulse is accelerated. In severe cases there may be 
delirium and sometimes convulsions. 
3. Resolution.-The temperature usually falls by 
slow crisis as the rash fades, resolution being complete 
in from two to eight days. Subsequently there is a 
slight branny desquamation all over the body. A 
faint brownish, mottled staining may be seen for some 
days after the temperature is normal. 
The severer forms of measles comprise two varieties : 
the pulmonary and the toxic or malignant. The former 
is characterised by specially severe catarrh of the re- 
spiratory organs, in which cyanosis may gradually 
supervene, and delirium give place to a drowsiness 
which soon merges into a fatal coma. In the malignant 
or haemorrhagic type, the rash is badly developed, 
and becomes petechial; haemorrhages occur from the 
mucous membranes; there is great constitutional 
depression-death usually occurring from the severe 
toxaemia. 
Complications and sequelae. 
The complications are mainly an aggravation and 
an extension of the catarrhal symptoms, which are 
normal accompaniments of the attack. They are 
chiefly respiratory, and include bronchitis, broncho- 
pneumonia, laryngitis, and pulmonary collapse. Other 
complications are severe stomatitis, diarrhoea due to 
enteritis, and inflammation of the glands or the middle 
FEVERS 
169 170 
ear. There is a special risk of the subsequent develop- 
ment of tuberculosis. 
Diagnosis. 
This can, as a rule, readily be made from the history 
of exposure, from the initial catarrhal symptoms, from 
the nature of the eruption, and the presence of Koplik 
spots. It is to be distinguished from scarlet fever, 
drug or septic rash, rbtheln or German measles, and 
smallpox. 
Management. 
The patient should be isolated for three weeks from 
the onset; quarantine being carried out for fourteen 
days from the exposure. The treatment is mainly 
expectant, and has as its object the placing of the 
patient in the best position for throwing off the attack, 
and for warding off the various inflammatory com- 
plications which are prone to supervene and endanger 
life. The patient should be in a room sparsely furnished, 
freely ventilated, and well warmed ; the light should 
be subdued. The patient should be encouraged to 
blow his nose at intervals in order to clear out the 
nasal passages, and benefit may sometimes be obtained 
by gentle irrigation of the nasal passages with Condy's 
fluid or boracic lotion. This helps to prevent the develop- 
ment of acute middle ear catarrh. The diet should be 
confined to milk, which may be peptonised, or diluted 
in equal portions with barley or lime water. As soon 
as the acuteness of the catarrh is over, the patient 
may be placed on convalescent diet (see p. 245). A few 
grains of Dover's powder may be given three times a 
day if necessary. In severe cases, complicated by bron- 
CLINICAL LECTURES FOR NURSES FEVERS 
171 
chitis or broncho-pneumonia, the local application of 
hot linseed meal poultices to the chest is advantageous. 
Pyrexia and restlessness are best removed by tepid 
or cold sponging. Complications in measles are very 
often fatal. Special care should be taken during the 
convalescence on account of the risk of the development 
of glandular tuberculosis. 
German Measles.-Rotheln, rubella, or German 
measles, is an acute specific fever most prevalent in 
spring or early summer. It resembles both measles 
and scarlet fever. Adults are specially liable to be 
attacked. This disease is characterised by the mildness 
of the catarrh, the absence of Koplik spots, while the 
rash is usually smaller, pinker, and more discrete than 
that of measles. The rash in rotheln is not infrequently 
absent from the face altogether. Rotheln is a mild 
affection usually unattended by any complications, 
and yields readily to simple expectant treatment. 
The patient should be isolated for about ten days ; 
quarantine period from eighteen to twenty-one days. 
SCARLET FEVER. 
An infectious disease characterised by a hyperse- 
mic skin eruption of a punctiform character diffused 
more or less over the entire surface of the body, which 
appears on the second day. It is preceded by an in- 
flammation of the fauces, and is followed by a general 
desquamation of the skin. It is attended by fever 
and nervous symptoms, and the joints, the serous 
membranes, and glands are frequently involved. The 172 
CLINICAL LECTURES FOR NURSES 
disease is due to a specific organism. It affects children 
most largely, the liability reaching a maximum about 
the sixth year. 
Means of Spread. 
The disease spreads by direct infection, and also 
indirectly through the medium of the attendants or 
visitors on the sick, or by means of the fomites con- 
tained in the room, clothes, books, etc. In addition 
to personal contact, infection can be effected through 
the medium of pet animals, and the disease is also 
disseminated through milk which has become contami- 
nated by those who are either infected with scarlet 
fever or who are attending scarlet fever patients. 
Symptoms. 
Scarlet fever, like many other affections, is one of 
the most irregular of diseases. In some cases the 
symptoms are so slight as to make a correct diagnosis 
impossible without waiting for the course of events. 
It is by no means uncommon to find cases where 
a diagnosis is only made upon peeling of the hands 
or feet, or by a development of an acute nephritis, 
occurring after a slight inflammation of the throat, 
which had been scarcely noticed. 
There are usually symptoms of invasion, such as 
feeling tired, headache, loss of appetite, and aching 
limbs. After a few hours a sore throat develops, with 
difficulty in swallowing. In more severe cases, pro- 
nounced headache and vomiting may be features ; 
convulsions may usher in the disease in very young 
children. In the milder type of disease the fever is 173 
slight, rarely reaching 100° F., and subsiding within 
three or four days. In severe cases or in presence of 
complications, the fever is higher and lasts longer. A 
very pronounced eruption is usually associated with a 
high temperature. The pulse is always markedly 
accelerated, the increase being often out of proportion 
to the increase in temperature. In the malignant 
type of scarlet fever the pulse is very rapid and feeble, 
ranging from 150 to 160 or more. The tongue 
in a well-marked case is covered in the early stages 
with an extensive white coating of epithelium through 
which the normal papillae protrude. This coat usually 
disappears by the fourth day, leaving a raw-looking 
red and fleshy condition commonly termed a " straw- 
berry tongue," which is characteristic of the disease. 
In malignant cases death may supervene before this 
condition of the tongue has developed. In the early 
stages of the disease the throat presents a uniform 
redness of the uvula, soft palate, and tonsils. Later, 
the colour becomes a deeper red, and involves the whole 
of the fauces and sometimes the hard palate. The 
tonsils are much enlarged, and become greatly covered 
with minute white dots produced by excessive secretion 
in the follicles. The lymphatic glands of the throat 
and neck are usually enlarged. In very severe cases 
abscesses may develop. The throat inflammation sub- 
sides within a few days in all cases except those of an 
unusually severe nature. 
The Eruption. 
In the mildest type of scarlet fever the rash is scarcely 
visible, forming as it does a mere diffused scarlet blush 
which is evanescent in character, may last only a few 
FEVERS hours, and may have totally disappeared before the 
visit of the doctor. The eruption is most commonly 
first seen on the neck, the shoulders, upper part of 
breast, and upper arm ; it is also visible on the fore- 
head and cheeks. The eruption appears usually about 
twenty-four hours after invasion, spreads rapidly from 
above downwards, attains its maximum in three days, 
when desquamation begins in the same order of pro- 
cess. Desquamation varies in duration with the pre- 
ceding eruption, is usually complete within six or eight 
weeks, but may be delayed longer on the palms and 
soles. 
Other Systems. 
Other systems show various affections. The urine is 
scanty, and in severe cases there is inflammation of 
the kidneys, the nephritis being induced by irritation 
due to elimination of bacterial poison through the 
kidneys. In other cases the nervous system may be 
frequently affected by a special toxaemia, with delirium, 
restlessness, sleeplessness, hyper-pyrexia, and convul- 
sions ; vomiting, constipation, and diarrhoea may be 
present. A catarrh of the Eustachian tube, middle 
ear, and nose may develop from direct extension of 
the inflammation, and in some cases is associated with 
a copious muco-purulent nasal discharge. Occasionally 
a muco-purulent catarrh of the vagina is present which 
may be a source of infection. 
Varieties of the Disease. 
1. Scarlatina sine eruptions.-This is an abortive 
attack characterised by its mildness, and the absence 
174 
CLINICAL LECTURES FOR NURSES 175 
of certain symptoms. There is usually present a well- 
marked desquamation. 
2. Scarlatina simplex.-A case attended by slight 
sore throat, characteristic eruption, temperature up to 
101° F. or 102° F., pulse 120 to 130 per minute. The 
fever is at its height in three or four days, and the entire 
symptoms subside within a week, without complication. 
3. Scarlatina anginosa.-This is more commonly 
seen in children, and is characterised by great severity 
of the faucial inflammation with great involvement of 
glands and general septicaemia. The temperature re- 
mains high and pulse very rapid and irregular ; in- 
somnia and delirium are common. If no improvement 
occurs in the symptoms in the second week, the prog- 
nosis is very guarded. 
4. Scarlatina maligna.-Cases characterised by a 
great severity of the toxaemia, death occurring within 
twenty-four or forty-eight hours, even before the de- 
velopment of well-marked physical signs. 
5. Surgical scarlet fever and puerperal scarlet 
fever.-A scarlatina eruption occurring after operation 
(surgical scarlet fever) is doubtless a manifestation of 
sepsis from an organism similar in its nature to that of 
scarlet fever. This is usually of a mild type. A similar 
condition is seen in the puerperium (puerperal scarlet 
fever), where a similar infection is much more serious 
and is often fatal. 
The Complications of the Disease. 
These are numerous and important. They may 
develop suddenly or their advent may be insidious. In 
FEVERS 176 
the order of their frequency and importance, these may 
be stated as follows :- 
(a.) Albuminuria and acute nephritis. The urine 
should be carefully observed throughout all 
stages of the disease. 
(6.) Rheumatism, involving the joints with inflam- 
mation of the pericardium and endocardium. 
As in the case of the kidneys, the heart 
should be very carefully watched through- 
out the course of the disease. 
(c.) Ear disease, more especially middle ear catarrh, 
with liability to mastoid infection and 
implication of the meninges and lateral 
sinus. 
(d.) Ulcerative stomatitis. 
(e.) Bronchial catarrh and broncho pneumonia. 
These are special dangers, more especially in 
cases associated with albuminuria. 
(/•) A later complication is chronic disease of the 
lymphatic glands and other tissues of a 
tuberculous nature. 
The diseases with which scarlet fever is mostly con- 
founded are an acute tonsillitis, erythema, diphtheria, 
syphilis, influenza, and what is sometimes termed the 
" fourth disease." An acute erythema induced by the 
use of a soap and water enema may closely simulate 
the eruption of scarlatina. The diagnosis is as a rule 
easy if the various possibilities are kept in view. 
The Treatment. 
The management of cases of scarlet fever may be 
considered from the points of view of firstly, prophy- 
CLINICAL LECTURES FOB NURSES FEVERS 
177 
laxis and isolation; and secondly, the more strictly 
medical treatment. 
Prophylaxis and Isolation in Scarlet Fever. 
An accurate diagnosis is sometimes impracticable 
until the third or fourth day. Doubtful cases should 
therefore be quarantined, until a definite decision on 
the nature of the attack is possible. Immediate trans- 
fer to a scarlet fever ward on mere suspicion is to be 
avoided, and on the other hand the retention of a 
doubtful case in the home without special precautions 
is unwise. Patients should be isolated, this isolation 
extending to the nurse and attendant. In a private 
house the most suitable place is the highest storey ; a 
large airy room should be selected, the windows should, 
if possible, be open night and day, but without placing 
the patient in a draught. A three-feet-wide bedstead 
on a wire mattress is the most convenient for nursing. 
All unnecessary furniture and hangings should be re- 
moved from the room. 
General Management. 
The surface of the body should be washed with soap 
and water every morning, with tepid sponging at night. 
At the end of a week, if all fever is gone, a daily bath 
may be taken, with due precautions against chill. 
Cold sponging and the wet pack is of value in cases 
with cerebral symptoms. It reduces the fever, 
diminishes the pulse rate, quietens the cerebral symp- 
toms and induces sleep. Drinking of cold water should 
be encouraged in order to allay thirst and promote 
thorough elimination through the kidneys. A little 178 
CLINICAL LECTURES FOR NURSES 
lemon juice in soda water with a little sugar is an al- 
ternative refreshing draught. During the febrile stage, 
milk should be the staple food, the diet being added to 
after the preliminary symptoms have subsided, and in 
absence of any kidney complications. In an average 
case the following is a good dietary rule :- 
1. For the first four days the nourishment should 
consist exclusively of milk-not exceeding two or 
three pints with as much water as is desired-with 
the exception perhaps of some lemonade and soda 
water. 
2. For the next four days an egg and farinaceous 
foods may be added. 
3. During the ensuing four days the diet may 
include some weak broth, fish, fruit, and vegetables. 
4. After this period poultry, game, and meat may 
be gradually allowed, and the food administered 
as freely as desired. The urine should be care- 
fully tested for albumin, and the diet adapted 
accordingly. 
Stimulants are seldom necessary, and their adminis- 
tration must be regulated according to the age of the 
patient, and the nature of the attack. A careful ob- 
servation of the urine should be made throughout the 
course of the disease, and for a week or two after the 
patient is allowed up. The patient should be kept in 
bed for the first three weeks. 
Medicinal Treatment 
In a simple uncomplicated case there is little needed 
in the way of medicinal treatment with the exception FEVERS 
179 
of a preliminary laxative to clear the bowels out, re- 
peated judiciously as required, and the administration 
of a simple febrile mixture to promote elimination 
from the skin and kidneys. The value of water drink- 
ing, as a means of elimination by the kidneys, has been 
already referred to. During convalescence a general 
tonic, especially iron, is indicated. 
Disinfection. 
Careful attention should be paid to disinfection 
during the illness and after the illness. All the excreta, 
expectoration, and urine should be received into vessels 
which are kept scrupulously clean and frequently dis- 
infected. Any nasal secretion should be removed 
by clean rags and should be immediately destroyed. 
The body clothes and bed clothes and nurse's clothes 
should be changed as often as is required for cleanli- 
ness, and thoroughly disinfected. All linen and wash- 
able material should be placed in an antiseptic solution 
before being sent to the special laundry. After the 
illness, disinfecting baths are advisable for several 
days before the patient is allowed full liberty, fresh 
clothes being worn when this liberty is granted. 
Opinions vary as to the necessity and value of anoint- 
ing the peeling skin with an antiseptic oil during later 
stages of convalescence. This may be a useful measure 
provided everything else necessary is being attended 
to. Great care should be taken in the later stages of 
the convalescence; change of air where possible is 
advisable, and an iron tonic is useful to counteract 
aneemia. A thorough convalescence diminishes the risks 
of subsequent development of tuberculosis. 180 
CLINICAL LECTURES FOR NURSES 
DIPHTHERIA. 
Diphtheria is a specific infectious disease characterised 
by a local fibrinous exudation on the tonsils and fauces, 
and by constitutional symptoms due to toxins pro- 
duced at the site of the lesion. It is due to a specific 
micro-organism-the Klebs-Loeffler bacillus. The in- 
fection by this organism is usually conveyed direct 
from person to person, but it is also carried by milk, 
fomites, by domestic pets, and by clothing. 
Incubation. 
This extends from two to eight days. The bacillus 
may be found in the throats of healthy subjects for 
long periods. 
The stages of the disease. 
1. Invasion.-This may be insidious, characterised 
by loss of appetite, vomiting (in children), and general 
malaise, the temperature being variable. In other 
cases the onset is more severe, the patient being rapidly 
felled by the severity of the toxin. 
2. Advance.-This is characterised by the presence 
of a false membrane on the tonsils and fauces. This 
is usually adherent, and leaves bleeding points when 
forcibly detached. The membrane may be thin and 
translucent or it may be fairly dense. The cervical 
glands are usually enlarged. As a rule there is not much 
redness, pain, or oedema in cases of pure diphtheria, but 
these may be present where there is a mixed infection. 
The pulse is rapid, soft, and often irregular. The tern- FEVERS 
181 
perature is variable, seldom high, and may become 
subnormal after forty-eight hours. 
3. Stage of convalescence.-Convalescence is slow, 
and there is great liability to complications, more especi- 
ally paralysis of various kinds, especially of the heart 
and the diaphragm. There is a distinct risk of heart 
failure throughout the course of the disease. 
Varieties. 
The most common situation is the tonsils and fauces ; 
the mucous membrane of the larynx, nose, and vulva 
may also be affected, inducing laryngeal diphtheria, 
nasal diphtheria, and vulvar diphtheria respectively. 
The type of disease varies from a mild, with little or no 
membrane visible, to a severe type, where the tonsils 
and palate are covered with a thick membrane, the 
cervical glands enlarged, sometimes associated with 
haemorrhages in the skin, subcutaneous tissue, and 
nose. The haemorrhagic variety is nearly always fatal. 
Diagnosis. 
Diphtheria must be distinguished from tonsillitis, 
scarlet fever, syphilis, and, in children, from a 
simple laryngitis with laryngismus. A bacteriological 
examination is essential. 
Complications. 
The chief complication throughout is the risk of 
heart failure. There is further the risk of suffocation 
in cases of laryngeal diphtheria. Broncho-pneumonia, 
middle ear catarrh, and acute nephritis are not in- 
frequent complications, and in the later stages various 182 
CLINICAL LECTURES FOR NURSES 
paralyses may supervene during the eight or ten weeks 
after invasion. These may take the form of paralysis 
of the eye muscles, shown by various forms of squint, 
or by inability to read ; paralysis of the palate, shown 
by a nasal voice and regurgitation of fluids through 
the nose ; paralysis of the diaphragm and of the 
vagus nerve-the two last being rarer and more serious 
forms of paralyses. 
The prognosis is always guarded. No cases should 
be treated lightly : the risks of heart failure and other 
complications should always be kept in view, and special 
care taken during convalescence. Patients should be 
isolated until the special bacilli can no longer be found 
on culture. Swabs should be examined from the nose 
as well as from the fauces. 
The management of diphtheria cases. 
After the diagnosis has been established by bacterio- 
logical examination-and in some cases even before this 
-anti-toxin should be given at once ; the minimum 
dose should be 2000 units given subcutaneously, pre- 
ferably under the skin of the abdomen, under anti- 
septic precautions. Local treatment of the throat 
is of comparatively little value, and should not be 
carried out unless it can be done easily and without 
any struggling on the part of the patient. Rest in a 
recumbent position should be insisted on for at least 
three weeks, great care being subsequently taken in 
regard to the liberty allowed to the patient, the effect 
of sitting up and of gentle exercise on the pulse being 
very carefully observed. The bowels should be regu- 
lated by means of an enema, aperients being withheld 
until the throat is clean. The judicious use of stimu- FEVERS 
183 
lants is advisable from the outset, in the form of small 
doses of strychnine and small doses of whisky or brandy, 
given three or four times daily-the dose being regu- 
lated by the age of the patient and the severity of the 
toxaemia. The diet should be as liberal as is possible, 
consistent with the throat condition. It should be 
fluid only until the throat is clean. In the early stages 
of the disease reliance should be placed on milk, beef- 
tea, egg-flip, and bovril. When the throat is clean, 
oat-flour porridge and various milk puddings may be 
added. When the patch is fully cleared off, light diet 
may be substituted, and in the absence of kidney or 
other complications, the patient may be gradually 
placed on the full diet. 
Laryngeal diphtheria. 
This may be a primary affection, or the larynx may 
be involved secondarily to the fauces. It is character- 
ised by croupy respiration, restlessness, cyanosis of the 
lips, pronounced action of the extraordinary muscles 
of respiration. Death supervenes from asphyxia. 
The condition is always a very serious one. Trache- 
otomy should be performed when the respiratory embar- 
rassment and restlessness become pronounced. 184 
CLINICAL LECTURES FOR NURSES 
CEREBRAL-SPINAL MENINGITIS. 
(Syn. Spotted Fever.) 
This is an acute infective disease which occurs (a) in 
an epidemic form, and (6) in a sporadic form in many 
communities. It is associated with a specific germ- 
a diplococcus. Children and young adults are most 
frequently affected ; the disease is slightly contagious. 
The disease sets in as a rule with great abruptness, the 
patient complaining of sudden headache or severe 
sickness when at work or play. In children convulsions 
are common. In very severe cases the patient dies 
in a comatose condition a few hours from the onset of 
the symptoms. 
Symptoms. 
Headache is an early and a prominent feature, usually 
very severe, and chiefly frontal in character ; backache 
is also common. Some rigidity of the neck and back 
is usually present, and this may be associated with 
active spasm of some of the neck and back muscles. 
Convulsions are common at the outset, and minor 
contractions of the muscles of the arms and legs are 
not infrequently present. General cutaneous hyper- 
sesthesia is a characteristic feature. The temperature 
shows no constant change ; it is usually febrile, but 
may be sub-normal, and in some cases the pyrexia is 
of a remittent type. The pulse is usually increased in 
rate, but variations in rate and character are common. 
Skin lesions are frequently observed, and include herpes FEVERS 
185 
of the lips and nostrils, an acute erythema resembling 
erysipelas, more especially over the joints, and a petechial 
rash met with on the extensor surfaces, more especially 
over the abdomen and joints. The presence of these 
spots gave rise to the term spotted fever. Nasal catarrh 
is met with frequently, the breathing may be slow, 
but if pneumonia is present the respirations are increased. 
Nausea, vomiting, and constipation are common symp- 
toms in the early stages. An arthritis or inflammation 
of the joints is occasionally met with. 
A study of the history of the following fatal case 
well illustrates the disease :- 
The man, a ship's carpenter, aged thirty-four, of very 
pronounced alcoholic habits, was taken ill when at work, 
two days before admission to hospital. He complained 
of headaches, and felt sick and vomited twice. In a few 
hours he became delirious, and later violent. He was 
seen by his doctor, and sent up to the infirmary as a case 
of delirium tremens. 
On admission forty-eight hours after the onset of the 
illness, the patient was exceedingly ill. The pulse was 
112, respiration 32, temperature 98°, which gradually rose 
to 102° F. There was marked tremor of the hands and 
tongue, the patient being slightly delirious, and somewhat 
violent. There was marked head retraction with very 
pronounced general hypersesthesia of the skin. On attempt- 
ing to extend the leg and thigh there was contraction of 
the flexor muscles, which prevented the full extension of 
the leg (Kernig's sign), and an acute erythema resembling 
erysipelas developed on the extensor aspects of several 
joints. Bronchitis supervened, and the patient died 
within forty-eight hours of admission, the pulse rate then 
being 128, and respiration 56. 
Diagnosis. 
The differential diagnosis must be made from the 
following :-delirium tremens-as in the present case, 186 
CLINICAL LECTURES FOR NURSES 
typhoid fever, tuberculous meningitis, pneumonia of 
the cerebral type, influenza, typhus fever, and smallpox. 
The combination of symptoms and physical signs met 
with in the above case were distinctive, but complete 
confirmation can only be obtained by lumbar puncture, 
and determining the presence of the specific organism 
in the cerebro-spinal fluid. 
Prognosis. 
Mortality is high, ranging from thirty to seventy per 
cent, of cases. Of late the proportion of recoveries has 
been greatly increased by the use of special vaccine 
and serum preparations. 
Management of Cases. 
1. Careful nursing is essential, as the patients 
are difficult to feed, and there is marked tendency 
to bed-sore formation. 
2. Special attention should be directed to keeping 
the mouth and nostrils clean. 
3. Diet should be light, consisting of milk, 
albumin, water, and meat broths. 
4. Stimulants in the form of whisky or brandy, 
with special heart tonics may be indicated. 
5. Repeated immersion in a warm bath two or 
three times a day has a useful sedative effect. 
6. Drugs.-Opium in some form as a sedative 
is the most serviceable drug. 
7. Two measures are of special value, more 
especially if applied in the early stages of the 
disease- FEVERS 
187 
(a) Repeated application of lumbar puncture, 
drawing off some of the cerebro-spinal 
fluid ; and, 
(6) The use of a special vaccine, or serum prepara- 
tion. Within the last year or two the 
results obtained by this means have been 
very encouraging. 
In view of the degree to which the disease is con- 
tagious, and keeping in view the fact that some people, 
not themselves affected, may act as carriers of the 
disease, it is advisable to make a bacteriological exam- 
ination of the nose and throat of those who have been 
in contact with the patient at the outset of the illness. 
TYPHOID FEVER. 
Typhoid fever is an acute continued fever caused by 
the entry of a specific micro-organism-the bacillus 
typhosus-or of poisons arising from it, into the blood ; 
characterised, anatomically, by enlargement and usually 
ulceration of the lymphoid tissue of the intestines 
(Peyer's patches), enlargement of the spleen, and swelling 
of the mesenteric glands; clinically manifested by 
some or all of the following symptoms : pyrexia, evi- 
dences of general toxsemia, enlargement of the spleen, 
roseolous eruption, and symptoms due to local lesions 
situated for the most part in the ileum and mesenteric 
glands. 
The infection is conveyed most commonly through 
drinking water which has become infected with the 
excreta of a previous case. This may secondarily affect 188 
CLINICAL LECTURES FOR NURSES 
milk, shell-fish (especially oysters), and other foods. 
Infection may be carried from typhoid excreta by flies. 
Direct infection from patient to attendant may occur, 
but is rare. 
The incubation period is the interval between the 
time of infection and of invasion; most commonly 
it is from eight to ten days, but it may be only two or 
three days or as long as three weeks. The typhoid 
organism presents itself in a variety of forms-the 
variations depending largely on the cultural character- 
istics of the germ. The three most common are known 
as typhoid bacillus and para-typhoid A and B. 
Stages. 
1. Symptoms of invasion (1st week).-The invasion 
is usually gradual. The most constant symptom is 
pyrexia. The temperature rises first in the evening, and 
on each succeeding day increases, the evening tempera- 
ture being higher than the morning, the chart presenting 
a characteristic step-like ascent (see p. 105). Chilliness, 
headache, general lassitude, dyspepsia, abdominal pain, 
diarrhoea, and constipation, cough and bronchitic 
symptoms, pneumonia, and occasional epistaxis are 
characteristic symptoms during the stage of invasion. 
The tongue is coated and white ; the pulse is slightly 
quickened from the start, although not as a rule in 
proportion to the degree of fever : occasionally the 
pulse is slow throughout. 
2. Advance.-During this period there is continued 
pyrexia with the morning remission already referred to. 
The languid, apathetic condition of the patient with FEVEJRS 
189 
hectic flush may be very characteristic. The abdomen 
is tumid and tender. An eruption is present in a large 
proportion of cases ; it rarely appears before the eighth 
day of the disease ; it consists of spots of a delicate 
pink colour, slightly raised, with a margin shading 
into the surrounding skin and fading on pressure. Each 
spot develops in a few hours, lasts four or five days, 
and fades gradually. They are chiefly seen on the 
back or front of chest or abdomen. In severe cases they 
may be haemorrhagic. The bowels may be constipated, 
or diarrhoea may be present with typical " pea-soup " 
stools. The tongue tends to get more coated and mark- 
edly dry in the centre. In mild cases the temperature 
may decline, and become normal by the fourteenth 
day. In very severe cases death may occur with pro- 
nounced nervous symptoms, or from serious haemorrhage 
or perforation. The stage of advance may last for one 
to five or six days. 
3. Resolution and convalescence.-'The temperature 
falls by lysis; intestinal symptoms disappear; the 
tongue clears ; the appetite returns, and convalescence 
sets in. This is usually prolonged, and there is distinct 
liability to relapses. 
Dangers.-Death may occur from nervous exhaustion 
or from heart failure due to the severity of the toxaemia ; 
or serious haemorrhage with perforation, due to ulcera- 
tion of the intestines. Later, complications and sequelae 
include phlebitis, jaundice, cystitis, arthritis, pleurisy, 
and other inflammations set up by the typhoid 
bacillus. 190 
Types of the Disease. 
The disease presents itself in the most varied forms, 
the mere enumeration of these will suffice :- 
1. Mild or abortive. 
2. Latent or ambulatory. 
3. Ordinary, three or four weeks' form. 
4. Prolonged ; and 
5. Haemorrhagic. 
Diagnosis. 
The diagnosis is sometimes a matter of difficulty 
especially in the early stages. The symptoms of typhoid 
fever may be closely simulated by the following diseases : 
-influenza, tuberculous meningitis, appendicitis, pneu- 
monia, malaria, ulcerative endocarditis, and gastro- 
enteritis. 
The most valuable diagnostic test is the Widal re- 
action. A small part of the patient's blood is mixed 
with a pure culture of typhoid bacteria in the laboratory : 
if the bacilli agglutinate, it indicates that the patient 
has, or has had, typhoid fever. A negative Widal test 
does not necessarily contra-indicate the presence of the 
disease. A negative Widal's reaction is useless for 
diagnostic purposes until the tenth day. Similar tests 
should in doubtful cases be applied to organisms of 
the para-typhoid group. 
Prognosis. 
The prognosis is always guarded. Especially un- 
favourable features are the persistence of muttering 
delirium, marked abdominal distension, persistent diarr- 
CLINICAL LECTURES FOR NURSES 191 
hoea, continued dryness of the tongue, and a low tem- 
perature in cases where the infection is obviously serious. 
Treatment. 
In treating typhoid fever it is desirable to keep in 
view the chief dangers. Perforation of the bowel causes 
about 18 per cent, of the deaths ; haemorrhage about 
15 per cent. ; respiratory complications, bronchitis, 
and pneumonia about 20 per cent. ; so that at least 
50 per cent, of the deaths in typhoid fever occur from 
other general conditions-asthenia, hyperpyrexia, or by 
general septic poisoning. Keep in view the importance 
of treating the patient and not the disease. Remember 
that enteric fever is essentially a toxaemia for which 
there is no anti-toxin, except that which is manufactured 
in the patient's own blood. The aim of treatment 
therefore is to maintain, and if possible raise, the resist- 
ance of the patient. 
All patients should be kept in bed from the earliest 
possible moment. The use of the bed-pan is essential, 
so that the maximum of rest may be obtained. All 
excreta should be passed into vessels containing dis- 
infectants. Careful attention to oral hygiene must be 
enjoined. 
The dieting of the patient is all important. Various 
systems of feeding are advocated by different authorities. 
In no disease is the question of diet of greater importance 
than in typhoid fever. The disease is a serious one, 
on account of its usually protracted nature, with its 
corresponding drain on the patient's general strength. 
It is, therefore, of paramount importance to maintain 
the strength of the patient, but in doing so due regard 
must be paid to the lesion in the intestine (ulceration) 
FEVERS 192 
which is usually present, and also to his impaired diges- 
tive powers. At the same time we must recognise that 
it is perhaps more true of this disease than of any other 
that we must treat the patient and not the disease. 
The truth of this is shown by a reference to the different 
systems of diet that have proved undoubtedly successful 
in its treatment. Some recognised authorities find 
good results from the use of a fairly full diet containing 
much solid food, throughout the whole course of the 
illness ; others adhere to the time-honoured system 
of a milk diet during the acute phases of the disease. 
Both systems appear to be equally successful, and from 
this we may conclude that the diet has to be judged, 
more from the nature and amount of the residue which 
it leaves in the small intestines, than from the form 
in which it is taken into the stomach. It is probable 
that in certain cases a residue of undigested solid curd, 
from an exclusive milk regime, produces much more 
local and general disturbance of an unfavourable nature 
than the residue from a fish, chicken, or meat diet. 
In this connection it must also be borne in mind that 
in some cases the local lesion in the bowel is of a very 
slight character, there being little or no demonstrable 
ulceration. In the present state of our knowledge, 
it may be said that the most judicious system of feeding 
is that which relies largely on a milk regime. 
We shall therefore first describe this system in detail, 
and thereafter consider the other dietetic regimes that 
are recommended. 
Milk regime,.-Milk should form the chief food, and 
much attention to detail is necessary in its administra- 
tion. It is specially important to watch the stools 
closely. If the motions contain undigested curd, it 
CLINICAL LECTURES FOR NURSES FEVERS 
193 
is clear that the amount of milk given, or the form 
in which it is administered, is unsuitable, and an imme- 
diate change in the diet is called for, on account of 
the risks to the patient from the mechanical presence 
of lumpy curds, and from the abdominal distension 
due to the fermentative changes in the food. If atten- 
tion be paid to the following points, milk will seldom 
fail as a diet in typhoid fevers. It should be given 
well diluted, it should be administered at regular in- 
tervals only, the total amount should not exceed from 
two to three pints per day, and the motions should 
be inspected daily for the presence of undigested 
curds. 
The milk should be diluted with plain hot water 
in the proportion of one to three, or one to four. The 
warmth of the mixture assists digestion by not chilling 
the stomach, and the dilution prevents the curd being 
too hard. If the bowels are costive, fluid magnesia 
(Dinneford's) can be used as a diluent and added to 
the warmed milk ; if the bowels have a tendency to 
be loose, lime-water is the best diluent. The amount 
of milk administered in twenty-four hours is important. 
It must never be used as a quencher of thirst, but always 
as a food : it must be taken at regular intervals and 
in stated amounts. The prescribed quantity should 
be taken at the proper time, and no milk should be 
allowed to stand at the bedside ; this precaution ensures 
the stomach having time to empty itself. The amount 
of milk given should be limited ; three ounces every 
two hours, i.e., under two pints in the twenty-four 
hours, is enough at. first; if this does not cause curd 
in the stools the quantity may be increased up to three 
or four ounces every two hours. No interval of longer 194 
than three to three and a half hours should be allowed 
during the night without food. 
The presence of undigested curd, whether in large 
masses or flakes, shows that either sufficient attention 
to detail in the administration is not being observed, 
or that the patient is getting more milk than he can 
digest. A reduction of half an ounce from the two- 
hourly feeds will often be sufficient to stop the presence 
of curd, and the improved digestion will probably put 
an end to the slight diarrhoea that may be present. 
If this does not prove sufficient, malted milk may be 
used, or the milk may be partially or completely pep- 
tonised. These modifications in the manner of adminis- 
tration are helpful in patients troubled with meteorism. 
Whey is a good substitute for milk if the latter is not 
tolerated. During this period very special attention 
is necessary to the toilet of the mouth. 
Milk diet is very monotonous, and if a patient is not 
suffering from diarrhoea or blood in the stools, there is 
no reason why this monotony should not be relieved 
after twenty-fours hours by the administration of some 
of the meat broths. An allowance of chicken or beef- 
tea, or clear consomme, is much appreciated, and can 
be given well salted. Most enteric patients crave for 
salt, and there is no reason why it should not be supplied. 
The actual food value of these preparations is small, 
but they help digestion by acting as stimulants. A 
well-recognised method of administering the meat-tea 
juices is to give a daily allowance of a pint, divided into 
three portions. One portion should be given as the dinner 
meal, the second portion, given hot< about nine o'clock 
p.m., helps the patient to go to sleep, and the third 
quantity may be given in the early hours of the morning. 
CLINICAL LECTURES FOR NURSES FEVERS 
195 
If diarrhoea is persistent, the warm meat-broths tend 
only to aggravate it; it is then better to use raw-meat 
juice, or one of the many meat extracts on the market. 
Meat juice may be prepared at home, and given in 
two-teaspoonful doses, slightly salted. The meat 
extracts should be given cold, and mixed with a little 
water. Bovinine and Wyeth's meat juice are excellent, 
but the strong meaty flavour is much disliked by some 
patients. Brand's chicken jelly is very agreeable, 
and so is home-made chicken essence. 
Indication for increasing the diet in convalescence.- 
Assuming a patient has satisfactorily passed through 
his fever, and his temperature is approaching the normal 
line, when is the first increase of diet to be made ? 
Much depends upon the circumstances of the individual 
case. Unless he is really hungry, there is no particular 
advantage in making any addition to the diet till the 
temperature is steadily normal. By " real hunger " 
is to be understood a genuine craving for food ; that 
is to say, it is not enough for the patient to reply that 
he is hungry when asked. He must volunteer the in- 
formation himself. If his hunger is real, and all pre- 
cautions to satisfy a false appetite have already been 
taken, some addition to his food may be allowed when 
his temperature is normal in the mornings, the evening 
readings being disregarded. Should his diet, up to 
this point, have consisted exclusively of milk and meat 
broths, with a few extras that may have been permitted 
in prolonged cases, it is obvious that, before he is allowed 
solid food, he must be content with semi-solids and 
" sloppy " materials. Benger's food or boiled bread 
and milk is usually the first addition, and the effect 
of even this slight increase of diet on the temperature 196 
CLINICAL LECTURES FOR NURSES 
of the patient should be carefully noted. If the morning 
temperature remains normal, the bread and milk is 
continued for two or three days, the amount given 
being gradually increased, and a little well-made oat- 
flour porridge being added to give variety. 
Value of water-drinking in typhoid fever.-Thirst 
should be assuaged by the drinking of a large amount 
of plain water, from four to six pints of water being 
given daily. In addition to assuaging thirst, an abun- 
dance of water-drinking promotes elimination of the 
toxins. When an insufficient amount of water is taken, 
the tongue gets very dry, even when the mouth is being 
carefully attended to. Aerated waters should be avoided, 
as tending to induce flatulence. Imperial drink, or an 
acidulated drink made with a few drops of hydrochloric 
acid and a little syrup of lemons, is also of value in 
allaying thirst. Weak tea made with milk is permissible, 
except in cases troubled with insomnia. 
Other systems of feeding.-1The system of feeding 
above outlined may be taken as the one generally 
recognised as the most suitable for the feeding of typhoid 
fever cases. Reference must, however, be paid to 
other systems which have found favour with recognised 
authorities. Many American authorities approve of 
a full diet along the following lines :- 
1. Milk in various forms, such as hot or cold, 
with or without salt ; may be diluted with lime- 
water, magnesia, or plain water, or with the aerated 
waters-e.g., Apollinaris, Vichy, soda-water. Pepto- 
genic milk or peptonised milk, milk with white of 
egg, buttermilk, koumiss, whey, milk with tea, 
coffee, or cocoa. 197 
2. Soups-beef, veal, chicken, tomato, potato, 
oyster, mutton, pea, bean; carefully strained 
and thickened with rice flour, arrowroot flour, 
milk, cream, egg, or barley. 
3. Horlick's malted milk, Mellin's food, somatose, 
etc. 
4. Beef juice, meat juices, bovinine, peptonoids. 
5. Gruels (strained), barley-water, toast-water, 
and albumin water. 
6. Eggs, soft-boiled, raw, or with egg flip. 
7. Finely minced beef, scraped beef, oyster, 
well-boiled puddings, blancmange, and jellies. 
A liberal dietary is held to be a very important fac- 
tor in the treatment of convalescence. As soon as the 
morning temperature is satisfactory, solid food should 
be increasingly given, provided the patient be genuinely 
hungry. This increased dietary is not only of special 
service in the treatment of convalescence in cases running 
a normal course ; it may be of great service in cases 
which show a prolonged swinging temperature in the 
convalescent period. 
Medicinal treatment.-In simple uncomplicated cases 
there is little call for medicinal treatment. Tepid 
sponging or immersion in a cool bath should be relied 
upon to reduce the temperature and to relieve any 
delirium which may be present. A low delirium is 
often an indication of the need of stimulants. Sedative 
drugs are seldom advisable. The best is bromide of 
potassium combined with a little chloral. The hypo- 
dermic use of strychnine is occasionally useful as a 
stimulant. If constipation is at all troublesome, it 
is best treated by an occasional enema. Tonics are 
useful during convalescence. 
FEVERS CHAPTER VIII. 
GENERAL CONDITIONS. 
RHEUMATISM AND 
RHEUMATOID ARTHRITIS. 
These disorders are of bacterial origin, the sources 
of infection being, as a rule, the teeth and gums, tonsils, 
digestive tract, or the genito-urinary tract. As in other 
infective disorders, attention must be directed not only 
to the infective agent, but to the soil, hence the im- 
portance of hereditary influences. The influence of 
chill and faulty feeding are additional factors of import- 
ance. The former acts by lowering the resistance of 
the tissues to the bacteria in the throat and respiratory 
tract, and also by its depressing action on the skin. 
Faulty feeding acts mainly through its action in inducing 
an abnormal bacterial flora in the digestive tract, with 
resulting formation and absorption of bacterial toxins. 
In rheumatism the poison affects the muscular tissues, 
the subcutaneous fibrous tissues, or the nerves, pro- 
ducing either myositis, fibrositis, or neuritis ; a com- 
bination of the two former is quite common, leading to 
a fibro-myositis most frequently observed in the region 
of the neck, back, buttocks, and thighs. 
In rheumatoid arthritis the poison settles largely 
in the joint structures, inducing an arthritis of a character- 
istic type. Too much attention, however, must not 
198 199 
be directed to the joint condition. Many other tissues 
are involved which are of primary significance. The 
joint deformities characteristic of rheumatoid arthritis 
are to be regarded as the result of the disease, and are 
preventable, if the condition is properly investigated 
and treated in its early stages. The advanced cases 
of rheumatoid arthritis that we see in the wards and 
in private practice are a serious reflection on the medical 
profession. If the cases are adequately investigated 
along modern lines in the early stages of the disease, 
the condition can be cured. 
Course of Rheumatoid Arthritis. 
The course of the disease varies very widely. The 
disease may commence insidiously and without fever ; 
in other instances it is ushered in by fever which may 
last for days or for weeks, the clinical condition closely 
simulating an attack of simple rheumatic fever, but 
differing from that condition in so far as the pain is 
not relieved by simple anti-rheumatic remedies (drugs 
of the salicin series). A painful enlargement of various 
joints sets in, the joints most affected in the earlier 
stages being, as a rule, the fingers, wrists, ankles, and 
knees. In severe cases, nearly every joint may be 
more or less involved, a condition of very marked 
crippling and deformity being induced. There may 
be some difficulty in mastication, due to involvement 
of the temporo-maxillary joints. In association with 
the joint involvement there is muscular atrophy and 
corresponding general asthenia, anaemia, increased pulse 
rate, general debility and ill-health. Physical examina- 
tion generally reveals some well-marked focus or foci 
GENERAL CONDITIONS 200 
CLINICAL LECTURES FOR NURSES 
of infection in the teeth and gums, tonsils, digestive 
tract, urinary tract, or uterus. This focus of infection 
is only determined by a careful routine examination 
into the state of the different mucous surfaces. Long- 
standing constipation or digestive trouble is frequently 
noted in the history, and examination by means of the 
X-rays often throws valuable light on the source of the 
trouble. A bacteriological examination of the urine 
or other secretion is also frequently necessary. 
Principles of treatment. 
The first essential is the investigation into the source 
of the infection ; this often involves investigation for 
a week or two on the part of the physician aided by the 
nurse ; this may involve the careful and repeated 
examination of the stools, a bacteriological examination 
of the urine, examination of the digestive tract by 
means of the X-rays, and careful investigation into 
the condition of the teeth, gums, and tonsils. The 
results of this investigation will necessarily guide the 
physician to a large extent in regard to treatment. 
It may be that the results of this investigation point 
clearly to the advisability of a preliminary operation 
on the teeth, tonsils, appendix, or the uterus. Valuable 
time may be wasted by neglect of this essential, and 
by prolonged treatment merely directed to relieve 
the symptoms of the disease. Keeping this point in 
view we may now pass to the detailed consideration 
of the medical measures that are generally applicable 
in all cases. The extent to which each and all of these 
are applicable will necessarily vary in proportion to 
the severity of the condition. 201 
GENERAL CONDITIONS 
Detailed consideration of medical measures in a 
case of Rheumatoid Arthritis. 
1. Rest.-This may be complete or partial in 
proportion to the number and nature of the joints 
affected and the degree of asthenia. Careful dis- 
crimination is necessary in the selection of cases 
that are to be kept in bed. 
2. Change of climate.-There is no question that 
there is an advantage in living in an atmosphere 
of sun and heat, under conditions which promote 
free diaphoresis and tend to maintain suppleness 
of tissues. Unfortunately the change of climate 
or even change of district is often impossible in 
cases where it might be desirable. 
3. Attention to the prima via-the digestive 
tract. In as much as in most cases the bacterial 
infection arises from the digestive tract, it is impera- 
tive that attention should be assiduously directed 
in this direction. The possibility of there being 
a focus of disease in the appendix has already been 
referred to. Dilatation of the stomach or colon, 
with constipation and colitis, is very commonly 
present. These have to be combated by a judicious 
use of the following :-aperients including calomel, 
salines, petroleum, intestinal lavage, and skilled 
massage, with exercises directed to restore the 
tone of the abdominal and intestinal muscles. 
4. Diet.-This must be adapted to modify the 
abnormal bacterial flora which is present in most 
cases, its presence being revealed by the persistently 
offensive condition of the stools. No hard and fast 202 
rules can be laid down with regard to diet. Occasion- 
ally a few days preliminary semi-starvation is of 
great value. Similarly for a few days a diet re- 
stricted to milk-which may be diluted, and butter- 
milk may prove serviceable. As a general rule 
meat foods should be much restricted. The judicious 
restriction of starches and sugars is usually indicated, 
so as to diminish the tendency to flatulence which 
is frequently present. Puddings may be advan- 
tageously selected from custard, curds, jellies, 
stewed fruit without added sugar. All foods should 
be simple, fresh, and appetising, avoiding condi- 
ments and made-up dishes. Soups are often best 
avoided, or at most a little clear soup allowed. 
Assistance in the feeding of these patients is given 
in the chapter on Auto-Intoxication (see Chap. IX.). 
5. Drugs administered for their antiseptic action, 
direct or indirect. These include calomel, salol, 
kerol, quinine, and liquid paraffin. 
6. Measures for the temporary relief of pain.- 
These include drugs such as phenacetin, antipyrin, 
and aspirin, also external applications such as hot 
fomentations or local application of hot air. In 
some cases benefit is obtained by ionisation. 
7. The function of the kidneys is promoted by 
giving ten ounces of hot or cold water twice a day 
on an empty stomach, with or without a little 
alkali such as potassium acetate, or sodium bi- 
carbonate. 
8. The excretory function of the skin should be 
stimulated by occasional hot baths of short duration,. 
CLINICAL LECTURES FOR NURSES 203 
and by a daily dip into cool to cold water, followed 
by a thorough shampoo. Massage under a spray 
is often a valuable therapeutic measure. 
9. Massage and exercise.-The skilled use of 
massage with physical exercises is one of the most 
important agents we possess at certain stages of 
the disease. For many cases, however, it is useless 
and contra-indicated. Much depends upon the 
degree of involvement of the joint, upon the amount 
of structural change which has resulted, and upon 
the degree of muscular atrophy associated with it. 
Great care is required in prescribing massage in 
these cases. 
10. Dentifrices.-The use of an antiseptic denti- 
frice may be indicated. Attention has already been 
directed to the fact that operative measures may 
be required to remove decayed teeth, to correct 
severe pyorrhoea, or to evacuate the local abscesses 
in the gums, which are often present. 
11. The use of bacterial vaccines.-In many 
cases an autogenous vaccine, prepared from bac- 
teria isolated from the urine, from the diseased 
gums, or from the stools is strikingly beneficial. 
12. In many cases where the infection is obviously 
coming from the bowel, a course of lavage is indi- 
cated. Where that fails to effect improvement 
the desirability of operative procedure requires 
consideration. The operation may take the form 
of an appendicostomy, and subsequently washing 
out the colon, or a colectomy which may be partial 
or complete. 
GENERAL CONDITIONS 204 
CLINICAL LECTURES FOR NURSES 
All the measures above described in treatment are 
directed either to eliminate the rheumatic poison directly, 
or to improve the resistance of the tissues in such a way 
as to counteract its effects. An autogenous vaccine 
acts in the latter direction, only on rather more specific 
lines. Greater value attaches to the use of an auto- 
genous vaccine than to the various preparations known 
as stock vaccines, and phylacogens. 
The measures outlined above are applicable in the 
treatment of a number of rheumatic conditions, such 
as sciatica, lumbago, neuritis of rheumatic origin, and 
so-called simple rheumatism. 
GLYCOSURIA AND DIABETES. 
In health the ingestion of a mixed diet containing 
a moderate amount of sugar and starchy foods is not 
attended by the passage of sugar in the urine. The 
sugars and starches of the food undergo a series of 
chemical changes, being burnt up in the tissues, and 
forming a source of energy and heat production. In 
disease there is a defect in the mechanism of digestion 
and assimilation of carbohydrate foods, with the result 
that sugar appears in the urine (glycosuria). Even 
under normal conditions the power of sugar destruction 
in the body is not unlimited, since, if a large excess 
of sugar be taken in the food, sugar appears in the 
urine. This is known as alimentary glycosuria. In 
all probability this alimentary glycosuria is simply 
the mildest form of the diseased state, which in an 
advanced stage is true diabetes, or diabetes mellitus. 
In this condition the sugar in the urine is derived from GENERAL CONDITIONS 
205 
the starches of the food as well as from the sugars. 
Diabetes may be of a mild or a severe type. In the former 
the amount of sugar in the urine can be controlled to 
a very great extent by diet; in the latter, sugar con- 
tinues to be excreted in the urine, it may be in large 
amount, even although the diet is free from sugar and 
starchy food. 
In every case in which there is doubt as to the severity 
of the disease, recourse should be had to a test diet. 
If a diet free from carbohydrate does not cause the sugar 
to disappear from the urine, the patient is suffering 
from a severe form of the disease. Care must be exer- 
cised in the application of this test, and it is as a rule 
advisable not to apply this rigid test suddenly ; the 
carbohydrates should be cut off from the diet gradually 
over a period of several days. In every case we must 
ascertain what amount of carbohydrate food the patient 
can tolerate without the appearance of sugar in the 
urine ; in other words, given the presence of sugar 
in the urine, we must determine whether the condition 
is one of (a) alimentary glycosuria, (6) mild diabetes, 
or (c) severe diabetes. 
Clinical features. 
(a) Glycosuria, or the passage of sugar in the urine, is 
frequently met with in adult life, more especially in 
stout subjects who indulge freely in sugar, starchy 
food, and who take too little exercise. It is usually 
unaccompanied by any symptoms, and is frequently 
only detected during examination of the subject for 
life insurance. The presence of sugar in the urine in 
such cases is an indication that too great a strain is 
being thrown on the patient's power of digesting and 206 
assimilating sugars and starches, and is an indication 
that the patient should be suitably dieted to correct it, 
otherwise a genuine diabetic condition may result. 
(6) The clinical features of true diabetes are distinc- 
tive. The disease affects subjects ranging in age from 
eighteen to twenty up to forty. Exceptional cases are 
met with both in younger and in older subjects. The chief 
symptoms complained of are great thirst, the passage of a 
large amount of water, general weakness, and loss of 
weight. Associated symptoms which are frequently 
present are cough with expectoration, disturbances 
of the skin, more especially boils, constipation, and 
disturbance of vision-the last-mentioned being due 
to disease in the lens or the retina. Symptoms of peri- 
pheral neuritis are not uncommon. The urine is increased 
in amount, of high specific gravity, contains sugar in 
large amount, and in some cases acetone and diacetic 
acid are present. 
Prognosis. 
The prognosis is always a guarded one ; the younger 
the subject the more grave the prognosis. The chief 
risks are (1) the development of diabetic coma, (2) 
death from pulmonary and other forms of tuberculosis, 
(3) septic complications-abscess formation or gangrene, 
and (4) general exhaustion with pulmonary complications. 
Principles of treatment. 
The main essential in treatment is to restrict so 
far as possible the amount of carbohydrates to the 
amount which the patient can assimilate without the 
appearance of sugar in the urine. This involves the 
use of foods rich in proteins and fats, and the restriction 
CLINICAL LECTURES FOR NURSES 207 
of, or it may be the abstention from, all sugars and 
starchy foods. The deprivation of starchy foods in 
the form of bread and bread foods is a great trial to the 
patient. Most of the substitutes prescribed as diabetic 
foods are not very palatable ; they are, further, ex- 
pensive, and to many the restriction becomes so irksome 
that the strictness of the dietary has to be relaxed. 
The diet must not be regulated exclusively by its effects 
on the urine. On a given diet the sugar may steadily 
diminish, while at the same time the general condition 
of the patient deteriorates. Further, the type of the 
disease has to be considered. Thus the dietetic treatment 
of diabetes in an obese adult, or in an elderly subject, 
is a simpler matter than the treatment of the severe 
form of the disease met with in young subjects in whom 
there is much wasting and general weakness. The 
weight of the patient is a very important guide in the 
treatment, and has to be continually noted throughout 
the progress of the disease. The toleration limit for 
carbohydrates is another factor to be noted. We must 
determine the extent to which the excretion of sugar 
can be affected b;y dietetic means. A further point 
that should be attended to is to make the changes in 
the dietary gradually ; in many cases of diabetes there 
is danger associated with the sudden removal of carbo- 
hydrates. Lastly, it is important to make the food as 
appetising and varied as possible. 
In the successful dieting of diabetic patients the 
principle to follow is to exclude as much as possible 
the starches and sugars from the food ; to replace 
these important articles of food by fat, so that the 
body may not lack entirely fuel food. To do this, and 
still allow the diet to be varied and appetising re- 
GENERAL CONDITIONS 208 
quires a considerable knowledge of foodstuffs and 
cookery. 
The main rules to be observed are as follows :- 
1. No sugar or articles of food containing sugar. 
2. Restriction of all foods that contain starch. 
3. The great deficiency caused by the above 
restriction to be made up by fat, and not by excess 
of meat. 
The lists below give the allowable foods, and those that 
are not permissible, and upon this the menus are framed. 
It is unfortunately almost impossible to get a satis- 
factory diabetic diet that is not expensive.1 
CLINICAL LECTURES FOR NURSES 
* These should be boiled in a large amount of water. 
FOODS. 
May Eat. 
Butcher meat of all kinds 
except liver. 
Tongue, ham, bacon, or 
other smoked, salted, dried, 
or cured meats. 
Poultry, game. 
Fish of all kinds, fresh, 
salted, or cured ; shellfish, 
except the bodies of lobsters 
and crabs. 
Animal soups, not thick- 
ened with any starchy 
materials; beef-teas and 
broths. 
Eggs, dressed in any way. 
Cheese, cream cheeses, 
butter, cream. 
May not Eat. 
Sugar in any form. 
Wheaten bread, and 
ordinary biscuits of all 
kinds.v 
Toast, rice, arrowroot, 
cornflour, oatmeal, sago, 
tapioca, macaroni, vermi- 
celli. 
Potatoes, carrots, pars- 
nips, beetroot, peas, Span- 
ish onions. 
Pastry and puddings of all 
kinds and honey. 
1 A full list of dietaries is given in the author's text-book, "Food 
and Feeding in Health and Disease." GENERAL CONDITIONS 
209 
FOODS-continued. 
May Eat. 
Greens, spinach, turnip- 
tops, French beans,* Brus- 
sels sprouts, * cauliflower. * 
Broccoli,* cabbage,* as- 
paragus,* seakale,* vege- 
table marrow, lettuce, cu- 
cumber, tomatoes, mush- 
rooms, mustard and cress, 
watercress, endive, spring 
onions, leeks, celery, rhu- 
barb, pickles. 
Oil, vinegar. 
Savoury jelly ; jellies and 
custards, sweetened with sac- 
charin ; blancmanges made 
with isinglass or gelatine. 
All nuts, except chest- 
nuts ; olives. 
May not Eat. 
All fruit, fresh and pre- 
served except lemons and 
unripe fruit. 
Liver. 
Oysters. 
Cockles and mussels, and 
crabs. 
BEVERAGES. 
May Drink. 
Tea, coffee, cocoa from 
nibs, dry sherry, claret, 
dry Sauterne, Burgundy, 
Chablis, hock, brandy, 
whisky, and other unsweet- 
ened spirits; unsweetened 
aerated waters ; milk (limit- 
ed to 1 or 1| pints daily) ; 
kephir, sugar-free milk. 
May not Drink. 
Milk, except in limited 
quantities ; sweet ales, por- 
ter, stout, cider ; all sweet 
wines, port, Tokay, cham- 
pagne, liqueurs; fruit juices 
and syrups; cocoa and 
and ordinary chocolate. 
In these tables we see that milk is allowed only in 
limited quantities, on account of the four per cent, 
of carbohydrate in the form of lactose. This is the 
most assimilable form of sugar, and in severe forms of 
diabetes when there is much impairment of digestion, 210 
it is probably often the best food, on account of its 
protein, its richness in fat, and the solubility of its 
sugar. 
If milk is considered inadvisable, an artificial milk 
can be procured free from sugar ; this can be diluted 
with mineral water. Cream has mainly to replace milk 
in the special cookery, being almost free from lactose, 
and it has the great advantage in containing the most 
easily digested form of fat. 
The following recipe of home-made artificial milk 
prepared from cream can be taken in unlimited quantity 
by diabetics, and is a most useful article of food :- 
Sugar-free Milk.-Place four tablespoonfuls of 
cream in one pint of water. Mix well. Allow to 
stand for twelve hours. Then skim off the fat and 
place in a second vessel ; to this add water 
(cautiously), a pinch of salt, a trace of saccharin, 
and a little white of egg, until the fluid has the 
consistence and colour of ordinary milk. 
A second form of milk containing only a little sugar, 
may be made by dissolving cream, and especially Devon- 
shire clotted cream in water. 
A third artificial milk, practically free from sugar, 
can be made from biogene powder and milk albumin, 
as follows :- 
To a glass of water a teaspoonful of cream and 
one or two tablespoonfuls of biogene powder is 
added, and well mixed. 
The supply of abundance of fat is often a difficulty, 
but fish and vegetables should be cooked and served 
with a liberal amount of butter. The fat of beef, mutton, 
CLINICAL LECTURES FOR NURSES 211 
and bacon is very suitable. Many patients can readily 
take the fat of cold roasted beef, and ham, or bath 
chaps (pig's cheek) ; and large quantities of fatty food 
can be taken in this way. Bone-marrow, which con- 
sists almost entirely of fatty material, may be used in 
various ways. 
Medicinal and other measures. 
Drugs play a subordinate role in treatment, but 
they are undoubtedly useful. The most useful are- 
aperient remedies directed to the careful regulation 
of the bowel, this being one of the most important 
points in treatment. The development of constipation 
is very liable to be followed by symptoms of diabetic 
coma which as a rule is speedily fatal. Opium in the 
form of morphia or codeine is frequently employed 
to reduce the sugar formation : it is undoubtedly 
beneficial in some cases, but cannot be regarded as 
curative. An occasional starvation for twenty-four 
or thirty-six hours is of great value in at any rate tem- 
porarily reducing the sugar in the urine, and in some 
cases this expedient has some permanent value. There 
are, in addition, various special forms of cure and diets 
which need not be specially described ; the number 
of these may be taken as a measure of their limited 
value. Sufficient has probably been said of the treat- 
ment under the heading of " Principles." Here as in 
other conditions, it is necessary to keep in view the 
importance of treating the patient as well as the disease. 
GENERAL CONDITIONS 212 
CLINICAL LECTURES FOR NURSES 
POISONS. 
An introductory note on the nature of poisons and 
on their general treatment will help to explain their 
clinical features and their management. 
The Nature of Poisons. 
A poison is a substance which, either on being absorbed 
into the living organism, or by its chemical action on 
the tissues, injures health and destroys life. Among 
the conditions which have to be taken into consideration 
when estimating the injurious effects which may be 
produced by poisons are: age, idiosyncrasy, habit, 
state of health, presence of food in the stomach, and 
the mode of administration of the poison. When a 
poison is swallowed, its action tends to be materially 
modified by the presence of food in the stomach. If 
the stomach is empty, a corrosive poison exerts its full 
influence on the coats of the stomach, while if it con- 
tains solid food, some of the corrosive action of the 
poison is spent on the food. Absorption takes place 
more slowly on a full stomach than on an empty one. 
Nearly all the cases that come into our wards are 
cases of attempted suicide. The poisons most commonly 
employed are :- 
(a) Narcotic poisons,-e.g., opium, veronal, etc. 
(6) Corrosive and irritant poisons,-e.g., carbolic acid, 
turpentine, oxalic acid, ammonia, etc. 
(c) Poisonous gases, of which the best example is 
coal gas. 213 
GENERAL CONDITIONS 
The General Treatment of Poisons. 
The general indications are :- 
(a) To remove or neutralise the poison left in the 
stomach or bowel. 
(6) To counteract the effects of that which has 
been absorbed. 
(c) To promote its elimination. 
(d) To keep the patient alive until the effects of 
the poison have passed off. 
(e) To alleviate the pain and other symptoms. 
Emetics are of great value. Half a teaspoonful of 
sulphate of zinc, dissolved in a few ounces of hot water, 
is a useful emetic of a non-depressing nature ; or two 
teaspoonfuls of mustard in a little warm water. A 
hypodermic injection of one-tenth of a grain of apo- 
morphine is valuable. Tickling the fauces with a feather, 
and the administration of copious draughts of warm water 
are additional useful measures. 
The most efficacious way of emptying the stomach is, 
however, by means of the stomach tube. The alternate 
introduction and withdrawal of warm water should be 
persevered in until the washings are clear and free from 
odour. Neither the stomach pump nor the tube nor 
emetics are to be used in cases of corrosive poisoning ; 
the proper treatment in such cases is to neutralise the 
poison. Carbolic acid is an exception to this rule. 
The stomach tube is especially useful in cases of poisoning 
by opium, chloral hydrate, alcohol, phosphorus, the 
crystals and most of the mineral irritants and the 
alkaloids. In strychnine poisoning it may be necessary 214 
CLINICAL LECTURES FOR NURSES 
to administer chloroform before the tube can be passed. 
After evacuating the stomach a purgative should be 
given unless spontaneous purging has occurred. 
Antidotes are remedies which counteract the effects 
of poisons. Their action is either chemical, mechanical, 
or physiological. A mixture of flour and water is an 
example of a mechanical antidote. Magnesia acts 
chemically in the case of mineral acids ; and atropine 
is to some extent a physiological antidote to morphine. 
The means to be taken to keep the patient alive 
until the effects of the poison have passed off are deter- 
mined by the nature of the poison. External warmth, 
the administration of stimulants, artificial respiration, 
are most useful measures. So also are aperients and 
diuretics, and other measures directed to allay excessive 
pains, vomiting, or other symptom. 
The table on facing page gives a useful epitome of the 
most common poisons and their treatment. 
OPIUM AND MORPHINE POISONING. 
Laudanum and chlorodyne are the two main prepara- 
tions used in cases of opium poisoning. Laudanum 
consists of 0.75 per cent, of morph ne. Chlorodyne 
consists of four grs. of morphine hydrochlorate to the 
ounce. 
Symptoms. 
The earlier symptoms are those of excitation of the 
nerve centres. These develop within a few minutes 
to an hour or two, depending upon the amount taken. 
The action of the heart and lungs is accelerated, the 
face is flushed, and the mental condition is exalted. TABLE OF POISONS AND TREATMENT. 
Poisons. 
Emetic. 
Stomach Tube. 
Antidote. 
General. 
Acids- 
Sulphuric Acid. 
(Oil of Vitriol.) 
No. 
No. 
Carbonate of magnesium; 
whiting, or wall plaster; 
soapy water if above 
not obtainable. 
Nitric Acid. 
No. 
No. 
As above. 
Hydrochloric Acid. 
No. 
No. 
As above. 
(Spirits of Salt.) 
Oxalic Acid. 
(Salts of Lemon.) 
No. 
No. 
Chalk or whiting sus- 
pended in small quan- 
tity of water or milk. 
Salts of Sorrel. 
No. 
No. 
As above. 
Acetic Acid. 
No. 
No. 
Magnesia or the alkalis, 
(Vinegar.) 
Carbolic Acid. 
No. 
Yes; with 
special care. 
Magnesium sulphate or 
saccharated lime. 
White of egg 
and milk may 
be given. 
Hydrocyanic Acid. 
(Prussic Acid.) 
Yes. 
Yes. 
Antidotes of little value. 
Free stimulation. 
Artificial res- 
pirationmay 
be necessary. 
Alkalis- 
Caustic Soda. 
Caustic Potash. 
Ammonia. 
Zinc. 
No. 
No. 
Vegetable acids in form of 
dilute vinegar or lemon 
juice, with olive oil and 
demulcents. Also milk, 
white of egg, olive oil. 
Opium if 
necessary. 
Metallic- 
Arsenic. 
Yes. 
Yes. 
Freshly prepared ferric 
oxide, prepared by add- 
ing solution of ammonia 
and tincture of per- 
chloride of iron. 
Stimulants. 
Morphine. 
Antimony. 
(Tartar emetic.) 
Yes. 
Yes. 
Tannic acid or some sub- 
stance containing it, 
e.g., stewed tea. 
Tea and mor- 
phine. 
Phosphorus. 
Yes. 
Yes. 
Turpentine 1 dram, in 
1 oz. of water, repeated 
every twenty minutes 
for three doses. 
Epsom salts. 
No oils. 
Alkaloids- 
Opium, including 
Yes. 
Yes. 
Potassium permanganate, 
Stimulants. 
Chlorodyne, etc. 
Using with 
Condy's 
fluid. 
gr. x., in 8 oz. of water. 
Electricity. 
Hot coffee, etc. 
Artificial 
respiration. 
Strychnine. 
Yes. 
Yes. 
Chloral hydrate, gr. xx. 
Artificial 
(Vermin killer.) 
(under Chloro- 
form.) 
Pot. bromide, gr. xxx. 
respiration. 
Belladonna. 
Yes. 
Yes. 
Pilocarpin, to | gr. 
Morphia, gr. 
Strong tea or 
coffee. 
Artificial 
Cocaine. 
Yes. 
Yes. 
Free stimulants. 
[respiration. 
Sulphonal. 
Trional. 
Veronai. 
No. 
No. 
Stimulants, e.g., digitalis 
or strychnine. 
Heat. 
Artificial 
respiration. 216 
CLINICAL LECTURES FOR NURSES 
This stage is very short-lived, and may indeed escape 
observation. The next stage begins with a feeling of 
lassitude, heaviness of the head, giddiness, and pro- 
gressively increasing tendency to sleep. The patient 
becomes drowsy and sinks into a condition of stupor. 
The pupils are contracted, the pulse is slow, and the 
breathing deep and regular. He can be roused only 
with great difficulty. The muscles are relaxed, the 
surface cold and clammy, the face pale or cyanotic, 
the coma deepens, the pulse becomes slower, and the 
breathing irregular and stertorous. All the secretions 
save that of the skin are diminished. If laudanum be 
taken its odour may be perceptible in the breath. 
In fatal cases death occurs in from six to twelve 
hours. 
Treatment 
If the poison has been swallowed, the stomach should 
be well washed out with a very weak solution of Condy's 
fluid. Attempts should be made to arouse the patient 
by means of external stimuli, such as flapping the face 
or chest with a wet towel, or the application of the 
faradic current to the skin surface. In the milder 
forms the patient should be kept continuously awake, 
by being walked about with the aid of assistants. In 
severe cases, he should be put to bed, warmth applied 
to the surface, artificial respiration resorted to if need be, 
and stimulants given in the form of hot coffee injected 
into the stomach and hypodermic injections of atropine 
and of strychnine. 
The following illustrative cases were recently in the 
hospital :- GENERAL CONDITIONS 
217 
Opium Poisoning. 
W. T., aged sixty-two, complained for some time of 
pain in the side and sciatica, which he endeavoured to 
relieve by taking laudanum, obtained in two different 
shops. He remembered buying laudanum and of boarding 
a car in Edinburgh, but nothing more. He was found 
by the police on the rocks at Portobello ; he had fallen 
into the sea, and the immersion had wakened him. 
On admission he was very collapsed ; pulse feeble but 
regular, rate 80, respirations 20 ; pupils contracted. 
Treatment. 
Warmth and hot bottles; hypodermic injection of 
^th gr. of strychnine ; stomach washed out with Condy's 
fluid ; hot sponge applied to the praecordia, and frequent 
hot drinks. Gentle stimulation of the skin surface by 
faradic battery kept up at intervals, for over five or six hours 
to keep patient awake. 
Patient improved steadily and was discharged on eighth 
day. 
Chronic Opium Poisoning. 
J. 8., aged forty-two, had been taking six ounces of 
laudanum each day before admission. Was in the ward 
three years ago for treatment of morphia habit. After 
discharge began to drink whisky instead, and in the interval 
has been treated for delirium tremens. 
On admission, patient was in a deplorable condition 
both physically and mentally, very degenerate looking, 
always pleading for drugs, many hallucinations of sight 
and hearing, anaemic, very nervous, tremulous, and 
frightened looking. Pupils contracted, muscles generally 
wasted, very restless, continually getting out of bed, but 
not violent. No albumin in the urine. 
Treatment. 
Rest in bed, warmth, administration of two drachms 
of laudanum, given in a little water, the dose being gradu- 
ally reduced and stopped on the fifth day. Thirty grs. of 218 
CLINICAL LECTURES FOR NURSES 
bromide given each night to induce sleep. Two or three 
doses of calomel, followed by morning saline ; later tepid 
baths. Diet of milk at outset with abundance of hot 
drinks. General tonics. 
Made a slow but steady recovery, and went out apparently 
well in five weeks. 
VERONAL POISONING. 
In recent years there has been an increasing tendency 
on the part of the public for self-medication. The 
restrictions laid upon the chemist with regard to the use 
of scheduled poisons are of a very inadequate nature. 
Powerful drugs like veronal are too easily obtainable, 
the drug habit becomes established, and cases of poisoning 
result. 
Symptoms. 
These are most usually observed in the case of subjects 
who have been accustomed to take veronal as a hypnotic. 
Frequently by accident or design an excessive dose 
is taken, and serious or even fatal results ensue. The 
toxic symptoms are seen chiefly on the nervous system 
and circulation. A condition of excitement of a very 
acute character is frequently induced, which may pass 
into a condition of coma. In other cases the rapid 
development of unconsciousness is the most striking 
symptom, associated with a quick and feeble pulse, 
deep respirations, and disordered tongue. If such cases 
are seen early and the stomach washed out, the remains 
of the pellets may be removed by this means. 
The following case was recently in the ward :- 
F. T., aged thirty-three, found on the street unconscious 
with an empty box marked " Veronal " in his pocket. GENERAL CONDITIONS 
219 
Had been worried over recruiting, and suffered from sleep- 
lessness. Was naturally a little eccentric or mentally weak. 
On admission the patient was unconscious and came round 
slowly. Pulse 84, respirations 20, pupils moderate in size 
and equal. 
Treatment. 
Stomach tube was passed ; stomach washed out. Hot 
bottles were applied ; hot sponge over the prsecordia ; 
and hypodermic administration of T^th gr. digitalin. 
Consciousness returned in a few hours. One gr. of calomel 
was given each night for three nights, followed by a morning 
saline. Later tonic treatment was given. 
Patient made a good recovery and was discharged within 
eight days. 
CORROSIVE AND IRRITANT POISONING. 
A corrosive poison is one that destroys tissue by 
direct chemical action. An immediate and violent 
pain is induced on swallowing, uncontrollable retching 
and vomiting occur in a few minutes, the vomited 
matter comprising the contents of the stomach, and 
blood and mucus from the lining membrane. There 
is intense thirst and difficulty in swallowing. The 
patient is in a condition of extreme collapse, the surface 
of the skin pale, cold and clammy, the features are 
pinched, and the eyes present a terrified look. The 
mouth and tongue exhibit indications of corrosion, 
the colour and surface varying with the nature of the 
poison. The abdomen is usually distended, the pulse 
weak, of low tension and usually rapid ; the breathing 
is laboured and noisy ; the voice is hoarse ; the mouth 
may be filled with a ropy mucus. The urine is dimi- 
nished in amount. Death usually occurs within twenty - 
four or thirty-six hours, and may be preceded by con- 220 
CLINICAL LECTURES FOR NURSES 
vulsions. A corrosive poison, when administered in 
dilute form, may act as an irritant. 
An irritant poison is one which sets up inflammation. 
The symptoms here do not come on immediately after 
swallowing, as is the case with corrosives : there may 
be an interval of a half to one hour, or more. The 
symptoms induced are usually a burning sensation, 
a sense of constriction in the throat, followed by pain 
which spreads over the abdomen, severe vomiting and 
purging, the discharged matter being often blood- 
stained ; it is attended by collapse. In fatal cases 
death from exhaustion usually occurs in a few days. 
Carbolic acid poisoning. 
M. B., aged twenty-two, brought in by the police ; found 
lying on the floor, moaning, and frothing at the mouth, 
with a small vial beside her which smelt of carbc^ic acid. 
On admission she was dazed, moaning, and restless; 
appeared to be suffering pain ; extremities cold, tempera- 
ture 95° F., pulse 104, respiration 24 ; voice hoarse. No 
signs of congestion about the lips or tongue ; uvula and 
tonsils slightly oedematous. No smell of carbolic from 
the mouth ; no abdominal rigidity or tenderness. The 
urine was olive green in colour, and contained albumin 
and pus for a few days. 
Treatment. 
One ounce of Hendry's solution was given and swallowed 
without difficulty ; she complained of discomfort immedi- 
ately after. Half an ounce of ipecacuanha wine was given, 
which also failed to produce emesis. Stomach tube passed : 
contents smelt unmistakably of carbolic acid ; stomach 
washed out with Hendry's solution. Was given ^th gr. 
strychnine hypodermically; given milk and white of 
egg at short intervals, with two to three drachms of olive 
oil taken slowly every two hours ; this being specially GENERAL CONDITIONS 
221 
valuable to prevent inflammation and cicatricial con- 
traction of the oesophagus. 
The patient made a satisfactory recovery, the urine 
cleared up, and she was discharged well within three 
weeks. 
Ammonia poisoning. 
Ammonia is sometimes taken, as in the following 
case :- 
Mrs R., aged thirty-eight, swallowed some mouthfuls 
of household ammonia in mistake for lemonade; was 
admitted four hours later. Vinegar and water had been 
given by the doctor at home, also milk and water to counter- 
act the ammonia. 
On admission, vomited a good deal of blood and mucus, 
complained greatly of pain in the mouth, lips, and epi- 
gastric region ; the lips and tongue were burnt; the pulse 
increased in rate (116) and weak, respirations 20, tempera- 
ture varied between 99° and 100° F. 
Treatment. 
The treatment consisted of the internal administration 
of olive oil, given in small doses every half hour, so as to 
prevent inflammation followed by cicatricial contraction 
of the oesophagus. Nourishment was given in the form of 
white of egg and milk ; and heroin subcutaneously for 
relief of the pain. Hypodermic injection of strychnine, 
once daily, was administered for several days. 
The patient did well for the first fortnight, swallowed 
easily until the seventeenth day, when she experienced 
great difficulty in swallowing due to the development of 
stricture, and lost weight considerably. A bougie was 
subsequently passed by the surgeon at regular intervals, 
which revealed slight contraction of the oesophagus. 
The ultimate prognosis is guarded : it is possible that 
a gastrostomy may sooner or later be necessary. 222 
CLINICAL LECTURES FOR NURSES 
COAL GAS POISONING. 
The most common form of coal gas poisoning is met 
with in cases of attempted suicide, in which the patient 
-as in the case which will afterwards be described- 
shuts himself in a room, closes the windows, and turns 
on the'gas. 
Coal gas contains from four to eight per cent, of 
carbonjmonoxide. An atmosphere containing one per 
cent, of carbon monoxide would soon prove fatal to 
those who breathed it; much less might do so if breathed 
for a considerable time. The toxic effects of the carbon 
monoxide are due to its affinity for haemoglobin, with 
which it combines, and for which it has an affinity 
two hundred times greater than that of oxygen. The 
compound of carbon monoxide with haemoglobin is 
more stable than that of oxygen, and so long as haemo- 
globin is combined with carbon monoxide it is useless 
as an oxygen carrier ; if, therefore, more than a certain 
amount of the haemoglobin be thus rendered function- 
less, death results from asphyxia due to arrest of internal 
respiration. 
Symptoms of acute poisoning. 
A sensation of heaviness in the head, giddiness, 
quickening of the action of the heart and lungs, oppression 
in the chest, and occasionally vomiting occur along with 
loss of muscular power ; unconsciousness quickly super- 
venes, sometimes with rigidity, and convulsions may 
precede death. The pulse is small, the skin surface 
cold, the conjunctivae are congested, and the pupils 
somewhat dilated. The lips may be covered with froth. GENERAL CONDITIONS 
223 
In a fatal case the surface of the body is rosy red, due 
to the peculiar compound which the gas has formed 
with the blood. The symptoms are in proportion to 
the duration of the exposure, as well as the amount 
of gas present in the atmosphere inhaled. 
The dangers are :- 
1. Rapid death from asphyxia, with heart failure. 
2. Respiratory complications-bronchitis, oedema of 
the lungs, and pneumonia. 
Treatment. 
The principle underlying treatment is to supply as 
much oxygen as possible, so as to replace the poisonous 
compound formed in the blood, and to stimulate freely, 
so as to tide the patient over the first day or two. The 
details of treatment are as follows :- 
1. The inhalation of oxygen, and in severe cases 
the maintenance of artificial respiration. 
2. External warmth promoted by hot bottles. 
3. Free administration of stimulants given hypo- 
dermically, or by the rectum when the patient is 
unable to swallow-e.g., ether, strophanthin (one 
sixtieth of a grain), and in cases unaccompanied 
by rigidity, strychnine (one-sixtieth of a grain), 
these being administered two or three times a day 
according to the severity of the condition. 
4. Attention to the bladder and bowels; a 
catheter may be required, and a free purge, followed 
by the administration of a rectal saline is useful. 
5. If the patient survives twenty-four or forty- 
eight hours, and respiratory complications set in, 224 
treatment must be directed to the bronchitis or 
pneumonia which develop. 
6. Frequent change of the position of the patient, 
and nourishment administered in the form of 
small quantities of nourishing food are indicated. 
The pulse and temperature will form a guide to the 
amount and nature of the stimulant required. 
After twenty-four hours the patient referred to recovered 
consciousness and talked quite rationally. His colour and 
general appearance improved, and his temperature, which 
was 96 on admission, rose to over 101° F. The pulse rate is 
96. His lungs show now some evidence of bronchitis, 
with oedema at the base, but in view of his improved con- 
dition generally the lung complications should be 
easily overcome with care and attention. 
Unfortunately the initial improvement in the general 
condition of the patient on the second and third day after 
admission was not maintained ; the patient appeared to 
have no desire to live, respiratory complications became 
more pronounced, the heart gradually weakened, and the 
patient died six days after admission. 
CLINICAL LECTURES FOR NURSES 
ACUTE ALCOHOLISM. 
INCLUDING 
Alcoholic Coma, Alcoholic Insanity, 
and Delirium Tremens. 
Alcoholism is a disease of the nervous system due to 
alcoholic excess. The disorder is manifest in volitional 
defect in relation to the appetite for alcoholic indulgence, 
but which later becomes manifest in relation to conduct 
in general. In cases of alcoholism the highest cerebral 
functions suffer first, but there are in most cases impair- 
ments of motor and sensory power, and in the trophic GENERAL CONDITIONS 
225 
functions of nerves, frequently accompanied by definite 
visceral changes. 
A few words may be said on intoxication. After 
the first stage of general exhilaration, the normal effect 
of alcoholism on the nervous system is of the nature 
of an obliteration of the functions which constitute 
self-direction, and which imply a full consciousness. 
By degrees the person becomes less aware of everything, 
of his surroundings, and of himself. He may realise 
this as a drowiness which is creeping over him, and he 
may abstain. If he continues to drink, he will become 
comatose, or if he has drunk a great deal before, he 
falls asleep. Such a man becomes unobtrusively in- 
toxicated. He may never be suspected of drinking 
greatly to excess. 
Intoxication in the more popular sense is much more 
recognisable ; it may take the form of stimulation 
with excitement, or excess of activity, or narcosis with 
paresis or diminution of activity. This paresis may 
be unequal in its effect; thus the motor centres may 
be chiefly affected so that the man may keep his head 
but lose his legs. The most obvious type of the class 
of excess is the drunk and disorderly person who shouts 
or dances, and is destructive long before he has lost 
his head, this representing an excess of activity in the 
motor centres which is disproportionate to the general 
narcosis. The effects of intoxication depend to a 
great extent upon the person, the nature of the drink, 
and the mode of drinking. There are several types 
of acute alcoholism which merit special description, 
and which can be illustrated by cases among hospital 
patients; these comprise alcoholic coma, alcoholic 
insanity, and delirium tremens. 226 
CLINICAL LECTURES FOR NURSES 
A. Acute Alcoholism-Alcoholic Poisoning, 
or Alcoholic Coma. 
This is occasionally seen as a sequel of a silly wager 
as to the amount of liquor that a man or boy will take 
in a short time. It also occurs, however, as a conse- 
quence of lack of prudence under the influence of alcohol. 
The symptoms are those of coma, and need not be given 
in detail. The diagnosis, however should always be 
arrived at with great care. There should be a strict 
rule that all persons found comatose in the street should 
be taken to hospital or examined by a doctor before 
being confined to the prison cell. The conditions which 
require to be excluded in diagnosis are, head injury, 
cerebral haemorrhage, embolism or thrombosis, uraemic 
or diabetic coma, and narcosis from some drug other 
than alcohol. A difficulty which presents itself is that 
the case is sometimes complicated, the patient having 
taken some liquor prior to the development of one or 
other of the above conditions. In pure cases the diag- 
nosis is easy, the patient is unconscious, the pulse may 
be full and bounding while the respirations are deep 
and slow, the pupils are dilated, the temperature, in 
the absence of complications, is sub-normal and the 
same on both sides, muscular twitchings may be present, 
and reaction to stimulation may be evoked in the muscles, 
or the patient may be incited to speech. 
B. Acute Alcoholism-Alcoholic Insanity. 
Alcoholic insanity is really an incident in the general 
development of alcoholism. The disease occurs in 
persons who are predisposed to neurosis, and who have 
drunk to excess. It is most commonly seen between 227 
the ages of twenty-five and thirty-five. There are 
various types of mental derangement; melancholia is 
common, and is often associated with marked delusions, 
which frequently have a basis in hallucinations. These 
cases are often attended by impulsive violence, the 
patients being dangerous to themselves and to others. 
Another group of cases is characterised by mania which 
may be exalted, hilarious, and sometimes delirious. 
There may be difficulty in diagnosing cases of acute 
mania of alcoholic origin from the early excited stage 
of general paralysis. 
C. Acute Alcoholism-Delirium Tremens. 
This is essentially an insanity of short duration 
occurring in the course of chronic alcoholism. The 
attack may be determined by temporary excess, or may 
be precipitated by the occurrence of an accident, or an 
acute illness, e.g., pneumonia. The patient will be 
found to be a confirmed tippler, though he may never 
have been actually drunk. At the outset of the attack, 
the patient may be sleepless and show great distaste 
for food. He is markedly tremulous, conversation 
may be incoherent, and his attention difficult to fix. 
The more acute symptoms come on at night, and are 
characterised by great restlessness, delirium, talking 
constantly, and great suspicion. Visual hallucinations 
are present, usually of a terrifying nature ; small and 
large animals are seen on the wall, on the floor, or on 
the bed. The tongue is moist, tremulous, and furred 
with a thick, whitish-yellow fur, the pulse is rapid 
and soft, the temperature is slightly raised, the urine 
is scanty, and albuminuria is not infrequently present. 
After a few days, in a mild case, the symptoms subside, 
GENERAL CONDITIONS 228 
sleep and appetite return, but the tremors disappear 
more slowly. In more severe cases the disease is more 
protracted, and mental symptoms may remain. All 
patients should be carefully examined for evidence of 
acute disease, more especially pneumonia, heart disease, 
and albuminuria, the symptoms of which may be latent. 
Treatment. 
The treatment of acute alcoholism may be discussed 
under two heads, the immediate medical treatment, 
and the remote treatment which is essentially of a 
prophylactic character. We will here discuss shortly 
the practical points in treatment which we find necessary 
in the acute cases that come under our observation in 
the wards. The details of this treatment will necessarily 
vary widely in different cases ; thus the treatment for 
a man in a condition of alcoholic coma, with a fairly 
satisfactory pulse and no indication of pneumonia, is 
different from that necessary in another man suffering 
from acute delirium with a rapid, feeble, soft pulse 
and well-marked symptoms of pneumonia. It is con- 
venient to discuss the details of treatment under the 
following headings :- 
1. Measures to keep the patient quiet. 
Persuasive measures on the part of the nurse or 
attendant are of much value in many cases. In severe 
cases the patient must, however, be forcibly tied down, 
so as to diminish the strain and conserve his strength. 
Thorough sponging of the body is useful both in allaying 
any fever present and for its sedative effect. Drugs 
adapted to allay the general restlessness may be required, 
such as hyoscin gr. morphia gr. 1 and bromides with 
CLINICAL LECTURES FOR NURSES GENERAL CONDITIONS 
229 
choral hydrate. In prescribing these due regard must 
be paid to the condition of the heart and circulation, 
and to the state of the kidneys, and the effect of the 
drugs must be carefully watched. 
2. The cessation of the alcohol. 
As a general rule alcohol can be stopped entirely and 
abruptly with advantage, but in very severe cases, 
more especially where the alcohol habit has been pro- 
longed, and symptoms of respiratory and cardiac failure 
are manifest, it is advisable to give alcohol fairly freely. 
There is little doubt that in such cases the sudden 
cessation of alcohol is decidedly prejudicial, and con- 
tributory to a fatal issue. 
3. Drugs to promote sleep. 
Sleeplessness is often a troublesome symptom. A 
warm stimulating drink at bedtime should first be tried, 
and a little digitalis or strophanthus may help the 
patient to sleep. Paraldehyde in doses of two drams 
or thereby is useful, and the bromides-bromide in 
combination with chloral-are among the most useful 
drugs. Large doses may be necessary, such as 60 to 
120 grains of pot. bromide. 
4. To counteract heart failure. 
Various stimulants may be necessary to prevent 
the heart flagging and maintain strength generally, 
such as digitalis or strophanthus, ammonium carbonate, 
ether, strychnine, the two latter being given frequently 
hypodermically. 230 
5. General measures. 
These include :- 
(a) A judicious clearing out of the bowel by one 
or more doses of calomel followed by a saline. 
(6) The administration of a diet restricted to fluids, 
e.g., milk, chicken tea, and diluents, with 
stimulants if required, as above indicated. 
(c) Where the facilities are available, immersion 
in a bath at a temperature of 70° F. for 
twenty to thirty minutes or longer is useful 
. in sthenic cases. 
In most cases recovery from the acute symptoms 
takes place in from three or four to eight or ten days. 
At the end of this time the patient will have lost the 
characteristic bloated appearance, the tongue will be 
clean, the appetite restored, the general tremors will 
have disappeared or greatly diminished, and the patient 
will be keenly desirous of regaining his liberty. It 
should be kept in view that his desire to regain his 
liberty may be entirely due to a fresh craving for stimu- 
lants ; in other instances the desire admits of a more 
favourable explanation. 
An essential part of the later treatment consists in 
warning the patient judiciously as to the serious physical 
disease which is bound to follow to the heart, kidneys, 
and liver, etc.-certain symptoms present in the case 
forming a danger signal in these directions-if the 
alcoholic habit is not broken. While the prognosis 
is always guarded in these cases, good results are often 
achieved by the application of appropriate physical 
measures, combined with wise and tactful guidance 
given at the right time and in the right way. 
CLINICAL LECTURES FOR NURSES CHAPTER IX. 
DIET. 
DIETARY IN FEVERS AND ACUTE 
INFECTIVE DISEASES. 
PRINCIPLES OF FEEDING.-The following are the 
guiding principles in treatment :- 
1. An adequate supply of albumins, carbo- 
hydrates, and gelatines must be given, to neutralise 
the increased combustion in the tissues resulting 
from the high temperature. 
2. No food should be administered which can- 
not be readily absorbed and assimilated, for if 
the enfeebled digestive organs are over-loaded, 
the undigested food will undergo fermentative 
changes, which will lead to gastro-intestinal irri- 
tation. With suitable feeding, the wasting is less, 
the patient does not become so reduced, and, 
consequently, the convalescence is more rapid. 
3. An abundance of fluid should be given. This 
overcomes the dry and parched sensation in the 
throat and fauces, washes out through the kidneys 
the waste matter produced by the increased rate 
of metabolism, and promotes the elimination of 
the toxins. 
4. Food must be given in measured quantities 
at regular intervals, and should be daintily served. 
231 232 
It is specially important to attend to the toilet of the 
mouth in fever. Regular cleansing of the mouth and 
teeth with an antiseptic mouth-wash at least three 
or four times daily checks fermentative processes, and 
enables the patient to take his food to the best ad- 
vantage. 
Food, in all cases of pyrexia, should be administered 
in the fluid form, the quantity small, from three to 
four ounces at a time, and given at short intervals 
(every one-and-a-half to two-and-a-half hours) during 
the day. At night, if the strength is being well main- 
tained, simple drinks to quench the thirst are all that 
is required ; by this arrangement the digestive organs 
obtain rest. 
The diet must be selected from the following sub- 
stances, namely :-milk, whey, eggs, meat teas, meat 
infusions, meat juices, meat extracts, soups, meat jellies, 
calf's-foot jelly, grape sugar, starches, fruit juices, 
fruit soup, and beverages of low nutritional value. 
This diet may be suitably varied by changing the 
flavouring substances. 
MILK AND ITS DERIVATIVES.1-Milk is pre- 
eminently the diet for the febrile state. It is also the 
most convenient form of food, but it must be borne in 
mind that milk forms a solid curd when acted on by 
the gastric juice. On this account some persons, even 
in health, find milk indigestible. 
If there is any doubt of the milk being thoroughly 
satisfactory and fresh, it should be scalded. The 
necessary dilution of the milk depends greatly on the 
digestive powers of the patient. The milk may be 
CLINICAL LECTURES FOR NURSES 
1 The recipes given are taken from the Author's text-book. 
Food and Feeding in Health and Disease." DIET 
233 
given hot or cold, but is best to be slightly warmed. 
The following methods may be adopted :- 
(a) Simple dilution with boiling water, clear or 
thick barley-water, toast, or .rice-water, in the 
proportion of equal parts. 
(6) Dilution with an effervescent water-milk 
and Vichy or Vlas water, equal parts, or milk one 
part with two portions of potash, soda, or Apolli- 
naris water. In some patients effervescent drinks 
set up distension of the stomach and troublesome 
flatulence ; this quickly subsides when the aerated 
water is stopped. 
(c) Dilution and mixture with an alkali. This 
method is advisable if there is pain and flatulence 
after the simply diluted milk. The addition of 
ten grains of soda bicarbonate and ten grains 
common salt, added to equal parts of milk and 
water, often prevents pain and lessens the con- 
stipation. Lime-water, in proportion of one part 
lime-water to three parts of milk, is useful if there is 
pain and a tendency to diarrhoea. As to quantity, 
two ounces of the milk, diluted as recommended, 
may be given every one-and-a-half hours. If this 
does not disagree, the amount may be increased. 
Three to four pints of milk daily are readily taken 
by most adult patients. In most cases where a 
milk regime for a lengthy period is necessary, 
attention should be directed to the state of the stools, 
noting especially the presence of undigested curd. 
Repugnance to milk can be overcome by modi- 
fying the flavour of the milk ; for example, tea 234 
CLINICAL LECTURES FOR NURSES 
can be infused with boiled milk, or a very weak 
cocoa made with Allenbury's milk cocoa can be 
specially recommended for this. Horlick's malted 
milk made with milk is very palatable. A small 
amount, e.g., half a teaspoonful of a meat extract 
such as Bovril, Oxo, Lemco, or Virol, added 
to a cup of warm milk or milk and water, is an 
excellent way of varying the flavour. 
(d) Modifications of milk.-Occasionally cases 
occur where diluted milk is not digested, and whey 
will then be found useful. It will also be found 
an agreeable change in the monotony of a milk 
diet. Whey is practically an aqueous solution of 
milk sugar ; it is apt to turn sour. Whey is milk 
minus the curd and fat, which have been got rid 
of by a process of coagulation and straining. Its 
nutritive value may be increased by the addition 
of strong beef-tea, raw-meat juice, egg-water, or 
Plasmon. Koumiss and Kephir fermented milks 
can sometimes be retained by an irritable stomach 
when everything else is rejected. 
EGGS.-Eggs form another permissible food, but 
ought not to be allowed too freely. They may be 
given as a drink, either alone or in combination with 
milk, or may be used to fortify other nourishment. 
As fluid food is preferable for pyrexial patients, eggs 
are best administered raw. The lightest form of egg 
drink is an egg beaten up, added to three ounces of 
very hot water, strained and flavoured with vanilla 
essence or cinnamon, and slightly sweetened. Another 
form of egg drink, more stimulating and nourishing, 
can be given, where milk and sherry are added DIET 
235 
to the egg. Egg flip, rich or plain, is the white 
of egg added, when well beaten up, to milk or 
cream, and flavoured. A switched egg also may be 
added to a cup of tea or coffee. A whole egg, beaten 
up with three times as much water, strained, and added 
to light broth or clear soup, is also very nourishing. 
(Caution.-Do not add the egg to boiling soup, or it will 
curdle.) Albumin water, added to a clear soup or to 
a cup of Bovril is nourishing and very pleasant. 
The patent preparation of Brand's termed " Fever 
food " is most nutritive ; it consists of essence of beef, 
eggs, and cream. In appearance it resembles custard, 
and has a very agreeable flavour which is quite distinct 
from the meaty flavours of the beef juices and extracts. 
MEAT INFUSIONS, JUICES, EXTRACTS, ETC. 
This group of foods is largely administered, and their 
usefulness is universally admitted. The actual nu- 
tritive value of most of the beef-teas and clear soup is 
low, but a French authority has pointed out that the 
most suitable diet for febrile maladies is one that con- 
tains only a small quantity of albuminous matter; 
and it is the possession of the saline principles (chloride 
and sulphate of potassium, etc.), dissolved in a large 
amount of water, which constitutes the chief recom- 
mendation of broths and beef-teas. In the selection 
of a beef-tea or beef essence, it is far better to use a 
carefully-prepared home-made beef-tea than any of 
the expensive patented beef-teas and meat juices, 
which are purchased at great cost in the belief that 
they are strengthening. There are various ways in 
which beef-tea may be thickened, e.g., with tapioca, 236 
CLINICAL LECTURES FOR NURSES 
breadcrumbs, or baked flour, thus adding considerably 
to its nutritive value. Where permissible the flavour- 
ing can be improved by the addition of vegetables or 
celery seed ; or a muslin bag containing a variety of 
vegetables can be cooked with the beef-tea and after- 
wards removed. 
Special attention should be given to the means of 
thickening the teas with tapioca, breadcrumbs, baked 
flour, arrowroot, oatmeal, and yolk of an egg ; the 
last mentioned being specially pleasant to a patient 
who is improving. The nutritive value of the food 
may be greatly increased by the addition of one or 
more of these substances. 
Vegetable flavouring can also be added by cooking 
vegetables with the meat and straining carefully, with- 
out in any way injuring the digestibility of the food. 
Proprietary beef extracts, essences, and juices may 
also be given, but are not so satisfactory for fever 
patients as well-diluted foods. 
GELATINE is another important item in the diet 
of these cases. By itself it has not the same nutritive 
value as the albuminates, and in any case it is necessary 
to prescribe it in considerable quantities to attain the 
same end. Gelatine is not a tissue-builder, but it is 
a means of saving the albuminous waste from the 
tissues. From this point of view gelatine cannot be 
too strongly recommended. Gelatine may be ad- 
ministered in the form of a clear soup-" consomme " 
-or may be given as a meat jelly, calf's foot jelly, or 
as a sweet jelly. DIET 
237 
Clear Soup or Consomm£ 
1 quart of first stock. 
( This should be in the form of jelly.) 
6 ozs. lean, juicy beef. 
1 lump sugar. 
1 white and shell of egg. 
Method.-Carefully remove all fat from the top of the 
stock, and put it into a clean-lined saucepan. Wipe the 
beef with a damp cloth, and shred it down finely as you 
would for beef-tea, removing all fat and skin. Add this 
to the stock, with the white of the egg and the shell well- 
washed and crushed. Whisk these over the fire with a 
wire whisk until the soup just comes to boiling-point. 
Then remove the whisk, and let it boil well up. Draw 
the pan to the side of the fire, where the soup will keep 
warm, but not simmer, and cover it with a plate. Let it 
stand there from ten to fifteen mintues. Tie a clean cloth 
on to the four legs of a chair turned upside down, letting 
it fall slightly in the middle so as to form a bag. Pour 
some boiling water through the cloth into a basin to 
thoroughly heat the cloth. Place a clean, dry basin under- 
neath, and pour the soup gently through the cloth. The 
soup will not be clear the first time, so change the basin 
and pour the soup through again, repeating this process 
until the soup runs through quite clear. In repeating, 
add a lump of sugar, which makes the soup sparkle. 
This soup can be varied by the addition of different 
garnishes, e.g. :- 
CONSOMM^ AND EGG. 
1 quart consomme. 
1 egg. 
Method.-Put the clear soup into a saucepan, and 
bring it to the boil. Beat up the egg in a small cup or basin 
with a fork, and pour it slowly into the boiling soup, 
stirring all the time with a spoon. The egg will curdle 
in the soup, and look like threads of yellow. 238 
CLINICAL LECTURES FOR NURSES 
Consomm& with Custard. 
1 pint clear soup. 
1 yolk of egg. 
J gill of clear soup. 
Pepper and salt. 
Method.-Take yolk of egg and a small portion of the 
white, beat up with | gill of the clear soup, and season with 
pepper and salt, and strain into a greased egg-cup. Cover 
with greased paper, and steam very slowly for ten minutes, 
or until the custard feels firm to the touch ; let it cool, 
and turn it out. Cut it into small dice. Put these in 
tureen, and pour boiling hot consomme over them. 
Meat, veal, or chicken jelly can be obtained from 
preparing the meat and chicken, and serving cold. 
Also beef essence served cold makes a very nice jelly, 
but can only be taken in very small quantities, as 
it is very concentrated. 
Veal Jelly. 
1 lb. veal. 
2 thin slices of turnip. 
1 teacup of water. 
Pinch of salt. 
Method.-Slice the veal very thinly, and place a layer 
of it in a jar with a layer of thinly sliced turnip, and re- 
peat this until all is used up ; add the salt and water, 
cover the jar, put in a saucepan with boiling water to 
reach up half-way, and simmer for four hours. Strain 
and serve cold. It will be in a strong jelly. 
Sweet jelly may be made from calves' feet or from 
gelatine. Calf's-foot jelly is troublesome to make, 
but if thoroughly well made it is much more delicate 
in flavour than gelatine jelly. Both methods are 
given. DIET 
239 
1 ox foot or 2 calves' feet. 
| lb. sugar. 
4 eggs. 
4 lemons. 
Calf's Foot Jelly (Sweet). 
1 blade mace. 
1 in. cinnamon stick. 
4 cloves. 
2 glasses sherry wine. 
2 quarts of water. 
Method.-Two calves' feet are equal to one ox foot, and 
make the same quantity of jelly ; they are prepared in 
the same way as the ox foot, but need not be boiled quite 
so long. Get the ox foot broken across several times ; 
split it up between the toes ; take out the piece of fat 
between the toes and all the marrow from the bones. First 
blanch the foot, by thoroughly washing, cover with cold 
water, and bring it to the boil. Now place it in a basin 
of cold water, and scrape well. 
After again rinsing in cold water, put it in a clean pot 
with two quarts of cold water, bringing it to the boil and 
skimming it well, and boil very gently for about eight 
hours. If very gently simmered by the side of the fire, 
the stock does not reduce too much. Strain it into a 
basin, either through a towel or a sieve, and stand aside 
to get quite cold. There should be six breakfastcupfuls 
of stock. When quite cold, remove all the fat from the 
top; this must be done very carefully. 
Now put the stock into a clean saucepan, add the sugar, 
the flavouring broken into small pieces, the lemon rind 
very thinly pared off, the juice strained, two eggs and the 
whites of the other two eggs beaten up and a little egg-shell 
crushed up. 
Put this on the fire and whisk briskly until it comes to 
boiling-point. Allow it to boil very gently about seven 
minutes. Withdraw from the fire, cover it with a lid, 
and allow it to settle for five to ten minutes. 
Have a flannel or feltr jelly-bag hanging up. Pour a 
good deal of boiling water through the bag, to warm and 
cleanse it. When the water has all run out, put a clean 
basin under the bag and pour the jelly in. Pour the jelly 
twice through the bag, when it should become clear and 
a brilliant colour. This jelly is excellent without wine. 240 
But if wine is used, it is beaten up into the saucepan before 
the jelly is poured into the bag. 
CLINICAL LECTURES FOR NURSES 
Wine Jelly (Sweet Wine Jelly from gelatine). 
1^ ozs. French sheet gelatine. 
3 gills cold water. 
| gill lemon juice. 
| gill sherry wine. 
1 tablespoonful brandy. 
3 ozs. loaf sugar. 
Rind of 1 lemon, cut. 
2 or 3 cloves. 
1 in. cinnamon stick. 
White and shell of 1 egg. 
The proportion of gelatine is 2 ozs. to 1 quart. 
Method.-Put all the ingredients into a lined sauce- 
pan ; whisk until they boil; remove to the side of the 
fire when the scum begins to rise to the top. Cover the 
top of the pan with a plate, and allow it to stand fifteen 
minutes. Strain through a hot jelly cloth ; run through 
three or four times till clear, and when cold, mould in a 
scalded wet mould. 
Whipped Jelly. 
Method.-Melt the jelly by standing the basin containing 
it in a saucepan of hot water. When dissolved, put into 
a large basin ; with a whisk whip it until it is quite cold, 
and should become a firm froth and perfectly white. By 
varying the ingredients in the wine jelly, a good many 
different forms can be obtained, e.g. :- 
Port Wine Jelly. 
Method.-Take three gills port wine, one gill water, 
and one tablespoonful of red-currant jelly (instead of the 
sherry wine) lemon juice, and the large amount of water. 
Orange and Lemon Jellies. 
Are made by substituting orange or lemon juice for the 
wine. 
Farinaceous Foods containing carbohydrates in the 
form of starch or sugar can be given in moderation. 
Thin oatmeal and barley gruel carefully strained and DIET 
241 
flavoured with salt or sugar is useful. Arrowroot and 
Farola are also of value. 
Malt extract, granulated, dissolved in warm water 
or milk, or with an effervescing water, is good. These 
supply grape sugar (maltose), soluble dextrin, and a 
small quantity of soluble albuminoids. Among pro- 
prietary foods, Benger's food is one of the most 
useful preparations, especially for cases of continued 
fever. Small quantities of arrowroot, ground rice, 
and well-baked flour can also be added to clear 
soup or beef-tea. Great care must be taken not to 
make the soup too thick. 
Baked Flour. 
Method.-Spread some white flour thinly on a dish, 
bake it in a moderate oven for about an hour, until it is 
a delicate colour. Take it out and place it on a sheet of 
kitchen paper ; when cool, roll it smooth with a rolling- 
pin, pass it through a wire sieve, and then keep it in a 
canister or bottle. 
Grape sugar, a kind of predigested carbohydrate, 
is strongly recommended, and may be added to fari- 
naceous foods, and also be used to sweeten beverages. 
Fruit juice, especially the juice of grapes and oranges, 
is quite admissible, and is usually much appreciated. 
Special stress should be laid on the point that in grapes 
the skins and stones are carefully removed, and in oranges 
that only the juice and pulp are eaten. Fruit soups 
are commended as agreeable and useful. They are 
made by boiling fresh or dried fruits with water, with 
or without the addition of sugar or lemon peel, and freed 
from the solid residue by pressing and straining. 242 
THIRST QUENCHERS-For thirst an abundance 
of refreshing drinks should be permitted. These all 
have a very low nutritive value. If made with barley 
or rice-water instead of plain water, the nutri- 
tive value is slightly increased. Again, the addition 
of a teaspoonful of milk, sugar, or lactose to the pint 
increases the value considerably without affecting the 
flavour. Iced water should not be forgotten as being 
always much appreciated by fever patients. 
Rice Water. 
Method.-Take two ounces of rice in an enamelled 
saucepan, with three pints of water, and boil for two and 
a half hours. Stir it frequently and skim carefully. Strain 
into a jug through a fine wire sieve, and rub through the 
glutinous parts, but not the hard portion. Add flavouring 
to taste. 
Apple Water. 
1 lb. apples. | lb. brown sugar. 
1 gall, boiling water. 
Method.-Cut up the apples into quarters ; put them 
into the jug with brown sugar, and pour the boiling water 
over it. Let it stand until cold; pulp the apples and 
the fluid through the colander. Bottle for use; do not 
cork the bottle ; keep it in a cool place. 
Apple Toast Water. 
Method.-Toast a piece of bread slowly until it gets 
quite black. Place it in a jug of apple water for three- 
quarters of an hour, then strain it. This makes a verv 
nice and refreshing drink. 
Apple Barley and Apple Rice Water. 
Method.-Boil | lb. of rice or J lb. of barley, blend with 
the apple-water, and then strain. 
CLINICAL LECTURES FOR NURSES DIET 
243 
In spring and summer, rhubarb, green gooseberries, 
black and red currants, and raspberries may all be made 
into nice cooling drinks, if used in the same proportions. 
Imperial Drink. 
| oz. cream of tartar. 
Juice of 1 lemon. 
2 tablespoonfuls of sifted sugar. 
Method.-Place the ingredients in a jug, pour over a 
quart of boiling water, and cover until cold. 
Lemonade. 
Juice of 1 lemon. 
1 pint of water. 
1 oz. of sugar. 
1 egg. 
Method.-Dissolve the sugar in the water ; add the 
juice of the lemon ; beat up the white of egg, and add it. 
(This makes a very palatable drink, with slight nutritive 
value.) 
Lemonade (2). 
4 lemons. 
| lb. of loaf sugar. 
3 pts. boiling water. 
Method.-Rub some sugar on the rinds of two of the 
lemons until it is yellow. Strain the juice of the four 
lemons ; put the sugar and juice into a jug, and pour it 
over the water. Cover it until it is cold. 
Orangeade. 
2 oranges. 
Juice of 1 lemon. 
2 or 3 lumps of sugar. 
1 pint of boiling water. 
Method.-Wipe the oranges with a damp cloth, and 
peel the rind of one of them very thinly. Put this into a 
jug with sugar, and strain in the orange and lemon juice. 
Pour on the freshly boiled water. Cover closely until 
cold, and then strain. 244 
CLINICAL LECTURES FOR NURSES 
Black Currant Drink. 
2 tablespoonfuls black-currant jam. 
1 teaspoonful arrowroot. 
Method.-Take the black-currant jam and boil it in a 
quart of water. Cover it and stew gently for half an hour, 
then strain it, and set the liquor again on the fire. Mix 
the arrowroot in cold water, pour over it the boiling liquor 
and keep stirring. Then let it get quite cold. (This is a 
very pleasant drink, and specially nice for an inflamed 
throat.) 
Tea and coffee freshly made with milk may be given 
also as beverages with a certain food value. (These 
are better withheld until pyrexia is gone.) Peptonised 
foods are not unusually called for in fever cases. They 
are described on page 
STIMULANTS.-The advisability of administering 
or withholding stimulants depends entirely on the 
condition of the patient. The indications for its ad- 
ministration are as follows :-After a long continued 
pyrexia, if the circulation shows signs of failure, the 
pulse becoming weak and irregular ; or if the digestive 
powers flag, with sordes forming on the lips, with a 
foul tongue and loss of appetite. Hyper-pyrexia may 
also necessitate the use of alcohol. 
Champagne, brandy, or whisky may be used ; the 
two latter are the best in the acute stages. It may 
be given in plain water, in milk, or in an effervescing 
water. When ordered, the exact quantity should be 
stated : it is best given at regular intervals by day 
and night. A half or one ounce every two or three hours 
is usually sufficient; it is seldom necessary or advisable 
to give more than six ounces in twenty-four hours to DIET 
245 
an adult. A larger quantity causes over-stimulation ; 
this can be recognised by a feeling of discomfort, a bad 
taste in the mouth, and an offensive breath. Children 
show a distinct toleration for relatively large doses 
of alcohol. In cases of vomiting, dry champagne is 
often the best form of stimulant. 
DIET DURING CONVALESCENCE. 
INDEX. 
Principles . . . 245 
Seven Days' Dietary 247 
Farinaceous Foods 250 
Milk Puddings. . 252 
Egg Dishes . . 254 
Jellies . . . 258 
Soups .... 260 
Fish . . . .263 
Meats . . . 267 
Tripe . . . .271 
Sweetbreads . . 272 
Vegetables . . 274 
The digestive tract being more or less weakened 
in all cases of acute illness, patients convalescing from 
an acute disease may be regarded as dyspeptics for 
the time being. Great care is therefore necessary in 
regard both to the quantity and quality of the food. 
The digestive capacity of convalescents, however, 
varies widely. There is, for instance, the healthy young 
adult recovering from some sharp attack of infective 
fever, in whom the digestive organs are only weakened, 
not organically affected. His convalescence is rapid, 
and he is soon capable of eating and digesting every- 
thing. In this class of case there is no necessity to try 
and tempt the appetite, and the food may be simply 
prepared ; the danger is that the patient will over-eat. 
On the other hand, the patient may be a delicate child 246 
recovering from scarlatina, complicated by nephritis. 
Here it would be absolutely wrong if we did not limit 
the quantity, and give very strict injunctions as to the 
quality of the food. Similarly, after typhoid fever, 
when convalescence is established, a mass of undigested 
food,-e.g., potatoes or a piece of unmasticated meat, 
may cause a relapse, by setting up irritation in some 
recently ulcerated patch. 
At first, in all cases, fever diet should be continued, 
the milk and beef tea being gradually reduced, and 
thickened beef-teas and soups, egg drinks, and various 
jellies being mainly given. This can be extended to 
include the more easily digested starches, either in the 
form of some invalid food,-e.g., a simple, well-cooked 
gruel, malted gruel, or Benger's or Savory & Moore's 
invalid food. The next advance would include lightly 
cooked eggs, either plain boiled, poached, scrambled, 
or in the form of a custard ; or combined, as in milk 
puddings, with a farinaceous food. For breadstuffs, 
thin slices of toast, the crusty portion of a Vienna roll, 
sweetened and unsweetened rusks, toasted sponge 
finger biscuits, rice biscuits, and plain biscuits may be 
recommended. Many of the malted breads now on the 
market, such as Veda, Hovis, Bermaline, Bipsine, etc., 
are quite permissible, care being taken that the bread 
is not new. 
As the strength of the patient increases a more liberal 
diet is given, fish, sweetbreads, chicken, game, pigeons, 
rabbits, being gradually added to the dietary. Then 
follows mince, beef quenelles, eye of a tender loin chop, 
a slice of tender beefsteak, or a small piece from the 
undercut of a lightly cooked sirloin of beef, or a slice 
from a leg of mutton. The patient should always be 
CLINICAL LECTURES FOR NURSES 247 
reminded of the necessity of eating slowly and masticat- 
ing well. Vegetables and fruits must be cautiously 
added to the dietary. 
The following seven days' dietary is sketched to give 
an indication of what is permissible. Doubtless, in 
some cases a more rapid return to ordinary diet could 
be made, while in others the change would require 
to be more gradually effected. This scheme of dietary 
is followed by an account of the manner of preparation 
of farinaceous and other foodstuffs of special value in 
convalescence. 
DIET 
SEVEN DAYS' DIETARY. 
First Day. 
7 a.m.-If awake early, a small cup of freshly-made tea, 
with cream. 
8.30 a.m.-Milk and thick barley-water, half a slice of 
toast cut in fingers. 
11.30 a.m.-Calf's-foot jelly, about 2 oz. 
1 pint thick beef-tea (egg and tapioca grout). 
A few grapes (juice and pulp only). 
4 p.m.-Cup of tea, with milk and cream, thin slice of 
bread and butter. 
6.30 p.m.-Cup of Benger's food (or other invalid food). 
9 p.m.-Cup of beef-tea. 
Second Day. 
7 a.m.-A small cup of coffee, with milk. 
8.30 a.m.-Malted gruel. 
11.30 a.m.-Milk and soda-water, with plain biscuits. 
1 p.m.-Beef-tea puree with strip of toast. 
Blancmange. 248 
CLINICAL LECTURES FOR NURSES 
4 p.m.-Cup of tea, with milk and cream. 
One slice of bread and butter. 
One sponge finger. 
6.30 p.m.-Plain egg flip with biscuits. 
9 p.m.-Cup of chicken soup or chicken jelly. 
Third Day. 
7 a.m.-A small cup of freshly-made tea, with cream 
and small half slice of toast. 
8.30 a.m.-Breakfast-Saucerful of oatmeal gruel with 
cream, and a little piece of Vienna roll (crusty 
part). 
11.30 a.m.-A teacupful of beef-tea (unthickened), either 
hot or cold. 
1 p.m.-Steamed whiting, half slice of bread. 
Semolina or ground rice pudding. 
4 p.m.-Potash and milk, with rice biscuit or sponge 
cake. 
A little fruit. 
6.30 p.m.-An invalid food in any form. 
9 p.m.-Some variety of meat tea or infusion. 
Fourth Day. 
8 a.m.-Saucerful of hominy porridge or barley-meal 
gruel, etc. 
A small cup of tea, toast, and a very little butter. 
11.30 a.m.-A teacupful of chicken tea with milk and 
potash, or a little fruit. 
1.30 p.m.-Baked or steamed fish. 
Spinach. 
Apple cream. 
4 p.m.-Potash and milk, or a small cup of fresh tea, 
bread and butter, and sponge cake. 
6.30 p.m.-Peptonised cocoa and milk, or custard. 
9 p.m.-Some variety of meat infusion,-e.g., veal tea. 249 
DIET 
Fifth Day. 
8 a.m.-A lightly-boiled egg, toast or roll with butter. 
A small cup of tea. 
11.30 a.m.-Teacupful of soup, or a little fruit, and a 
drink of milk and potash. 
1.30 p.m.-Rabbit, chicken (roast) two slices from breast, 
or pigeon served with bread sauce. 
A small helping of vegetable marrow or cauli- 
flower, not potatoes. 
Pudding-apples cooked in water sago, eaten 
with cream. 
6.30 p.m.-Oysters. 
9 p.m.-Some variety of soup. 
Sixth Day. 
8 a.m.-A piece of boiled or steamed haddock, whiting, 
or sole. 
Tea bread (plain or toasted), and butter. 
11 a.m.-Soup, or egg drink. 
1.30 p.m.-Sweetbread or tripe. 
Vegetable, stewed tomato (pulp only). 
Stewed fruit with custard. 
4 p.m.-Afternoon tea (avoiding rich cakes and pastry). 
6 p.m.-Poached egg on toast, or spinach. 
Milk and potash. 
9 p.m.-Cup of soup. 
Seventh Day. 
8 a.m.-A few rolls of well-fried streaky bacon. 
Toast and tea. 
11.30 a.m.-Egg flip, or soup, or milk and potash. 
Fruit. 
1.30 p.m.-A small slice of tender roast mutton, or 
the eye of a tender mutton chop. 
Vegetable. 
Jelly. 250 
CLINICAL LECTURES FOR NURSES 
4.30 p.m.-Afternoon tea (avoiding rich cakes and 
pastry). 
6.30 p.m.-Fish. 
Milk pudding. 
9 p.m.-Cup of soup. 
Farinaceous Foods.-The value of different farin- 
aceous foods is often much interfered with by defective 
cooking. In the preparation of gruels and other farin- 
aceous foods, prolonged boiling is required in order to 
burst the starch granules. The stomach can do very 
little with uncooked starchy food. There are now 
many half-cooked cereal preparations in the market 
which do not require such prolonged cooking. 
1 tablespoonful fine 
oatmeal. 
Oatmeal Gruel. 
| pint cold water. 
Salt or sugar. 
Put the oatmeal into a clean basin and pour the water 
over it. Cover the basin and let it stand for at least half 
an hour, stirring occasionally, then straining the liquid off 
into a small clean saucepan, pressing the oatmeal as dry 
as possible. Stir the strained liquid over the fire until 
boiling, and let it boil from fifteen to twenty minutes. 
The thickness of the gruel is very much a matter of taste ; 
if too thick add more water, or if too thin use more oatmeal. 
Season with salt or sugar. The addition of a little cream 
is a great advantage, improving the taste and increasing 
the nutritive value. 
Milk Gruel. 
1 tablespoonful fine 
oatmeal. 
pint milk. 
Salt or sugar. 
Made in the same was as last recipe, except that milk 
is used instead of water. DIET 
251 
Malted Gruel. 
This gruel may be made of any of the farinaceous sub- 
stances-quaker oats, farina, arrowroot, barley, or lentil 
flour. Make in the same way as oatmeal gruel. When 
cold enough to swallow, add the malt infusion or an extract 
of malt; about one tablespoonful of the infusion or a tea- 
spoonful of the extract is sufficient to digest a plateful 
of gruel. The action is very rapid, and in a few moments 
the gruel becomes thin from the transformation of the 
starch into maltose. 
1 dessertspoonful barley-meal, 
i pint milk. 
Barley-meal Gruel. 
A small piece of butter. 
Sugar or salt. 
Mix the milk very gradually with the meal, stirring until 
quite smooth. Take a small lined saucepan, and after 
rinsing with cold water, pour the barley and milk into it. 
Stir constantly over the fire until boiling, let it boil for ten 
minutes, season, and serve very hot. 
Port Wine Gruel. 
Make a gruel with oatmeal or barley-meal and water, 
then thin it down with a glass of port wine ; heat thoroughly, 
but do not boil again. 
Caudle. 
Beat up an egg to a froth, add a glass of sherry and half 
a pint of hot gruel; flavour with lemon peel, nutmeg, 
and sugar. 
Water Arrowroot or Cornflour. 
| oz. arrowroot or 
cornflour. 
| pint cold water. 
1 teaspoonful of sugar. 
Seasoning, either nutmeg, 
sherry, or brandy. 
Put the arrowroot into a small basin, add to it a table- 
spoonful of cold water, break it with a wooden spoon until 
quite smooth. Then pour on the rest of the water, mix 252 
CLINICAL LECTURES FOR NURSES 
well, and pour into a small lined saucepan. Stir this over 
the fire until it boils and thickens, then let it boil for ten 
minutes to thoroughly cook the arrowroot. Sweeten to 
taste, and serve in a cup or small basin. A little nutmeg 
may be grated on the top, and wine or cream added if 
desired. 
Milk Arrowroot or Milk Cornflour. 
2 oz. arrowroot or cornflour. 
| pint milk. 
£ teaspoonful of sugar. 
Make as above, using milk instead of water. 
Water Sago or Tapioca. 
| oz. sago or tapioca, 
f pint cold water. 
Sugar, brandy, or fruit 
juice to taste. 
Place the sago and water into an enamelled saucepan, 
and boil gently for an hour and a quarter, adding a little 
water to make up for evaporation. Skim when it comes 
to the boil, and stir frequently. Sweeten to taste ; this 
may be flavoured with brandy or sherry, or may have added 
to it a puree of prunes with a glass of claret, or stewed 
apples with a few cloves. 
Farinaceous or milk puddings.-In the following 
recipes we have boiled farinaceous foods which are 
further cooked by baking ; eggs can be added if desired. 
The presence of eggs in a pudding greatly improves 
the flavour and appearance, but they make it richer 
and more difficult to digest. The essential for a good 
milk pudding is to have the starchy food sufficiently 
boiled, and the eggs lightly cooked. It is best to beat 
up the white of the eggs separately, as this introduces 
air into the pudding and causes it to rise. For flavouring, 
the most suitable substances are fresh lemon rind or 
juice, essence of vanilla, grated nutmeg, and ground 
cinnamon. DIET 
253 
| oz. arrowroot or 
cornflour. 
i pint milk. 
Arrowroot or Cornflour Pudding. 
1 egg. 
1 teaspoonful of sugar. 
Make in the same way as the arrowroot and milk, and 
thoroughly boil the mixture for ten minutes. Remove 
the pan from the fire and add the sugar and any flavouring. 
Separate the yolk from the white, add the yoke to the 
arrowroot whenever it has slightly cooled, also a pinch of 
salt to the white, and beat it up to a stiff froth. Stir this 
lightly into the mixture, and pour into a greased pie-dish, 
wiping round the edges of the dish. Bake in a moderate 
oven until well risen, and of a nice light-brown colour. 
Sprinkle some white sugar over it and serve at once, as 
it soon falls if allowed to stand. 
Semolina or Ground Rice Pudding. 
| oz. semolina or ground rice. 
1 teaspoonful of sugar. 
1 egg. 
J pint milk. 
Put the grain into a small lined saucepan, and the milk 
with it. Stir these over the fire with a wooden spoon 
until boiling, and boil for a few minutes until the semolina 
swells and thickens. Remove the pan from the fire, add 
sugar and seasoning, and when it has cooled, mix the 
yolk of the egg well into it. Beat up the white on a plate 
to a stiff froth and mix into pudding, pour into a pie-dish 
and bake for ten minutes, sprinkle with sugar, and serve 
at once. 
Rice Pudding. 
1 oz. whole rice. 
| pint milk. 
1 teaspoonful of sugar. 
1 egg. 
Flavouring as required. 
Wash the rice thoroughly in water ; put it into a lined 
saucepan with cold water to cover it; bring it to the boil, 
and pour the water off. This helps to burst the rice more 
quickly. Then pour in the milk, and let the rice simmer 
by the fire until quite soft; add the yolk of the egg and 254 
the white as described in the last recipe, and bake in a 
well-greased pie-dish. 
CLINICAL LECTURES FOR NURSES 
Tapioca and Sago Pudding. 
f oz. tapioca or sago. 
| pint cold milk. 
1 egg. 
1 teaspoonful of sugar. 
Flavouring as preferred. 
If small crushed tapioca or sago is used, the directions 
are the same as for semolina pudding. If not, the recipe 
is as follows :- 
Cover the grain with milk, and soak for an hour. Rinse 
out into a small lined saucepan, turn the tapioca and milk 
into it, and stir over the fire until it comes to the boil. 
Then simmer slowly until it turns clear, stirring every now 
and then. This takes from twenty to thirty minutes. 
If it becomes too thick while cooking, add a little more 
milk. Then finish off the pudding with eggs, etc., as in 
semolina. 
1 or 2 slices thin bread and butter. 
1 teaspoonful sugar. 
Baked Bread and Better Pudding. 
| pint milk. 
1 egg. 
Grated nutmeg. 
Cut some bread and butter rather thin, remove the crusts, 
and cut into pieces about an inch square. Lay these into 
a small greased pie-dish, making the dish just about half 
full; beat up the egg in a small basin and add the nutmeg, 
sugar, and milk. Mix well together and pour over the bread 
in the pie-dish. Allow the pudding to stand about ten 
minutes until the bread gets thoroughly saturated, then 
bake in a moderate oven from ten to fifteen minutes until 
nicely browned on the top. Sprinkle with sugar. 
Eggs may be given raw or cooked. When given 
alone they may be given as prairie oyster, boiled egg, 
poached egg, scrambled egg, or baked egg. They can 
be added to soups as thickenings,-e.g., thick beef-tea, DIET 
255 
consomme with eggs, consomme with custard. The 
following recipes may be used for custards :- 
Custard Sauce. 
2 yolks of egg. 1 dessertspoonful sugar. 
1 white of egg. | pint milk. 
A few drops flavouring. 
Rinse out a small lined saucepan with cold water, and put 
the milk into it, and let it heat over the fire. Put the 
yolks and white of egg into a basin with sugar, and mix 
them well together with a wooden spoon. Then pour the 
hot milk gradually on to them, stirring all the time and 
mixing thoroughly. Return all to the saucepan, and stir 
carefully over the fire until the sauce thickens. On no 
account must it be allowed to boil, or it may curdle. Have 
ready at hand a clean basin and strainer. As soon as the 
sauce shows signs of thickening, and it is almost boiling, 
remove the pan from the fire, continue stirring for a few 
moments, and then strain into a basin. Add flavouring to 
taste-lemon, vanilla, nutmeg, or cinnamon. This can 
be made richer by increasing the proportion of yolks to 
white. It can be served as a sauce, or in a custard glass, 
with flavouring grated on the top. 
Baked Custard. 
2 yolks and 1 white of egg. 
1 gill of milk. 
1 teaspoonful of sugar. 
Flavouring. 
Beat up the eggs in a basin with the sugar and flavouring ; 
pour in the milk and mix again ; strain the custard into 
a greased pie-dish. Stand the pie-dish in a Yorkshire 
pudding-dish with some cold water round it. Bake in 
a moderate oven from fifteen to twenty minutes until 
firm and nicely browned. A thin slice of sponge cake 
may be placed on the top of the custard before baking. 
Omelets. 
Eggs may also be advantageously used as omelets, as 
follows :- 256 
CLINICAL LECTURES FOR NURSES 
For an omelet of 2 eggs, break them into a bowl, add 
salt and pepper, and beat them with a fork for about a 
minute, not longer as a rule. When the eggs are sufficiently 
beaten they " run " off the fork in a homogeneous liquid, 
without any glutinous appearance. It is not necessary 
to beat for several minutes, with the idea that the more 
the eggs are beaten the lighter the omelet. This is a great 
mistake, as too much beating causes eggs to lose their 
consistency. It is, however, better to beat too much than 
too little. Place the pan on the fire to warm it, put in a 
small piece of butter-about the size of a hazel-nut for an 
omelet of 2 to 3 eggs. Add the contents of the bowl when 
the butter steams. If this precaution is taken, the omelet 
will not catch, as the high temperature of the butter isolates 
the eggs. It is therefore a mistake to shake the eggs directly 
they are poured into the pan. But a second or two later, 
the fork must be passed round the sides of the pan to 
loosen the eggs, and then they are worked in all directions 
with the back of the fork as if they were scrambled. When 
they are sufficiently cooked they look in fact almost like 
scrambled eggs ; but now the omelet is shaken on to one 
side of the pan, and with the fork one half is folded on to 
the other and slid on to the dish. The shape of the omelet 
is thus obtained without difficulty, and the heat of one 
half just finishes the cooking of the other as it rests upon it. 
A.-Omelet Souffle (Sweet). 
Sweet Omelets. 
White sugar, 1 table- 
spoonful. 
Pinch of salt. 
2 eggs. 
A little powdered vanilla. 
Take two bowls. Put into one of them 1 teaspoonful 
of white sugar; into the other a pinch of salt. Break 
2 eggs, separate the yolks, and drop one yolk at a time 
into the bowl containing the sugar ; whip them well with 
a wooden spoon and they become creamy like a mayonnaise. 
Add a little powdered vanilla to another | teaspoonful 
of sugar, and mix with the yolks. Put the whites of the 
eggs into the bowl containing the salt, and whip into a DIET 
257 
stiff froth. Mix with the yolks as lightly as possible, and 
pour the contents into a buttered dish in the shape of 
a pyramid. Cover it with sifted sugar and leave it for 
three or four minutes on the side of the stove. Then put 
it into the oven for ten to twelve minutes, turning the 
dish occasionally to colour it on all sides. Make two or 
three incisions with a knife, and serve immediately. This 
omelet must be eaten as soon as it is cooked, or it loses both 
its shape and its delicacy. 
B.-Snowball Eggs. 
3 eggs. 
li tablespoonfuls powdered 
white sugar. 
1 pint of milk. 
Rind of lemon, or vanilla. 
Sugar to taste. 
Place 1 pint of milk in a saucepan on the fire with the 
rind of a lemon or a little vanilla, and sufficient white 
sugar to sweeten. 
Break 3 eggs, separating the white from the yolk. Put 
1| teaspoonfuls of powdered white sugar on a plate. Beat 
the whites of the eggs into a stiff froth, adding a small 
pinch of salt. When sufficiently stiff add the sugar, and 
mix briskly. Take a teaspoonful of this mixture and throw 
it into the boiling milk in the saucepan ; turn it three 
minutes later; remove it with a skimmer and place it 
on a dish. Take as many spoonfuls of the white of egg as 
remain and cook them in a similar manner, three or four 
at a time. (If the white has been beaten sufficiently 
stiffly, when cooked each spoonful will be a compact mass.) 
Dress the snowballs in a pyramid dish. Pour the remainder 
of the milk from the saucepan into the yolks of the eggs ; 
put this mixture into another saucepan on the fire, turn 
it constantly with a spoon, and let it thicken without 
boiling. Pass it through a strainer, and when cold pour 
it over the snowballs in the dish. 
Savoury Omelets. 
A.-Omelet with Tomatoes. 
Break the eggs into a bowl, with salt and pepper ; beat 
them for a few minutes with a fork, place the omelet pan 
on the fire to warm, add a lump of butter. When the butter 258 
CLINICAL LECTURES FOR NURSES 
steams pour in the eggs. Make little incisions with a fork 
to let the heat reach the eggs in all parts ; pass a knife 
round the edge of the pan to prevent the eggs from " stick- 
ing " ; fold one half on the other as soon as they begin 
to get firm, and shake the omelet on a hot dish. Pour 
over it a good tomato sauce. 
B.-Bread Omelet. 
Put 1 tablespoonful of crumbled bread into a saucepan 
with -J gill of cream, salt, pepper, and nutmeg. When the 
bread is swollen with the cream, break 3 eggs, beat them, 
and make an omelet. 
Jellies.-Jellies are a pleasant change to the ordinary 
milky foods, and are much appreciated by invalids. 
They may be taken with whipped cream, which 
increases their value as a food substance. 
Calf's-foot Jelly (Sweet). 
1 ox foot or calf's foot. 
J lb. sugar. 
4 eggs. 
4 lemons. 
1 blade mace. 
1 inch cinnamon stick. 
4 cloves. 
2 glasses sherry wine. 
2 quarts of water. 
Two calves' feet are equal to one ox foot, and make the 
same quantity of jelly; they are prepared in the same 
way as the ox foot, but need not be boiled quite so long. 
Get the ox foot broken across several times ; split it up 
between the toes ; take out the piece of fat between the 
toes and all marrow from bones. First blanch the foot, 
by thoroughly washing, cover with cold water, and bring 
it to the boil. Now place it in a basin of cold water, and 
scrape well. 
After again rinsing in cold water, put it on in a clean 
pot with 2 quarts of cold water, bringing it to the boil, 
skimming it well, and boil very gently for about eight hours. 
If very gently simmered by the side of the fire, the stock 
does not reduce too much. Strain it into a basin, either 259 
through a towel or sieve, and stand it aside to get quite 
■cold. There should be six breakfastcupfuls of stock. When 
quite cold, remove all the fat from the top ; this must be 
done very carefully. 
Now put the stock into a clean saucepan, add the sugar, 
the flavouring broken into small pieces, the lemon rind 
very thinly pared off, the juice strained, 2 eggs and the 
whites of the other 2 eggs beaten up and a little egg-shell 
crushed up. 
Put this on the fire and whisk briskly until it comes to 
the boiling-point. Allow it to boil very gently about 
seven minutes. Withdraw from the fire, cover it with a lid, 
and allow it to settle for five or ten minutes. 
Have a flannel or felt jelly-bag hanging up. Pour a good 
deal of boiling water through the bag, to warm and cleanse 
it. When the water has all run out, put a clean basin 
under the bag and pour the jelly in. Pour the jelly twice 
through the bag, when it should become clear and of 
a brilliant colour. This jelly is excellent without wine. 
But if wine is used, it is best put into the saucepan just 
before the jelly is poured into the bag. 
DIET 
1 gill of milk. 
1 gill of cream. 
Cream Jelly or Blancmange. 
£ oz. isinglass. 
Rind of lemon. 
1 oz. sugar. 
Rinse out a small saucepan and put into it the milk, 
isinglass, and thinly-peeled rind of half a lemon. Let this 
stand by the side of the fire until the isinglass is dissolved 
and the milk well flavoured with the lemon. Stir occasion- 
ally to prevent boiling. Add the sugar, and strain into a 
basin to keep back the lemon rind. Add the cream, and 
stir occasionally until nearly cold. If not stirred, the milk 
and cream will separate. Pour into a small basin, that has 
been rinsed out with cold water, and place in a cool position 
to set. Turn out and serve with a little red- or black- 
currant jelly. 260 
CLINICAL LECTURES FOR NURSES 
4 oz. gelatine. 
1 egg. 
Egg Jelly. 
3 oz. lump sugar, 
j pint cold water. 
J pint orange or lemon juice. 
Soak the gelatine in water for twenty minutes. Rub 
the sugar on the oranges to extract colour and flavour. 
Put the sugar, gelatine, and water into a clean saucepan, 
and stir it over a slow heat until quite dissolved. Then 
add the juice (strained), let it just get hot, remove it from 
the fire, have the egg ready beaten in a basin, pour the 
jelly over it gradually, stirring well. Let it cool, stirring 
a few times to let it mix thoroughly with the egg. Pour 
into a small basin that has been rinsed in cold water to 
set. Turn out and serve with a little cream. 
Soups.-The following recipes are those in which the 
ingredients are not too rich for the digestive capacity 
of convalescent patients. They form a delightful change 
after the monotony of the beef-teas and extracts. These 
recipes are also useful for the dietary of the aged. 
Broth-Mutton, Chicken, or Veal. 
1 lb. neck or knuckle of 
mutton, or veal, or 
1 chicken. 
2 pints cold water. 
1 dessertspoonful of rice. 
1 teaspoonful chopped 
parsley. 
1 teaspoonful salt. 
Wipe the meat well with a damp cloth. Cut into small 
pieces and remove it from the bone, and take away as 
much fat as possible. Put meat, bones, water and salt 
into a clean lined pan, put on the lid, and bring it very 
slowly to the boil. Remove with an iron spoon all the 
scum that rises. Simmer slowly for four hours, skimming 
when necessary. When cold, remove all fat. Return it 
to a saucepan well washed. Allow it to cook again twenty 
minutes, until the rice is soft. Add the parsley at the 
last, and it is ready for serving. 
Tapioca grout or arrowroot may be used for thickening 
instead of rice. DIET 
261 
Rice Soup. 
1 pint of mutton, veal, or 
chicken soup. 
Yolk of egg. 
1 tablespoonful of cream. 
1 tablespoonful of Patna rice. 
Strain the broth and remove all the fat from it; put 
it into a clean saucepan with the rice well washed, and 
boil till the rice is perfectly soft. Then rub all through 
a fine sieve, rinse out the pan, and return the soup to it. 
Beat up the yolk and cream with a fork, strain them into 
the soup, and stir carefully over the fire until thoroughly 
hot, but it must not be allowed to boil. Tapioca or sago 
may be used instead of rice to thicken with. Also three 
tomatoes might be boiled with the rice, and then rubbed 
through the sieve. This would make a tomato soup. 
1 rabbit. 
Rabbit Soup. 
| oz. flour. 
A few pieces of parsley. 
1 bay leaf. 
6 peppercorns. 
1| pint cold water. 
| pint milk. 
| ounce butter. 
| teaspoonful of salt. 
Wash and clean the rabbit well. Let it lie in salt and 
water for half an hour. Lift out, dry it, and cut into joints. 
Cut the flesh into small pieces, and chop the bones. Put 
all these into a saucepan with cold water, bay leaf, parsley, 
salt, and peppercorns. Bring to the boil and skim well. 
Simmer slowly from five to six hours ; then strain through 
a fine sieve. Put the meat into a mortar ; pound it well 
with a little liquid, and rub it through a wire sieve. Rinse 
out the pan; melt in the butter; add the flour, and 
mix smooth. Then add the sieved meat, soup, and milk, 
and stir until boiling. Boil for ten minutes. 
Game Soup. 
1 bird (grouse, pigeon, wood- 
cock, partridge), or re- 
mains of game. 
| lb. lean juicy meat. 
i teaspoonful arrowroot. 
A pinch of celery seed, 
pepper, and salt. 
1 pint cold water. 
Wipe the game and meat with a cloth ; shred the meat 
as for beef-tea ; cut the game into neat pieces. Put all 262 
CLINICAL LECTURES FOR NURSES 
these into a lined saucepan, with cold water and seasoning ; 
bring slowly to the boil, and skim thoroughly. Allow 
the soup to simmer for four hours. Strain and allow to 
cool, and then remove the fat. Mix the arrowroot with 
cold water ; add this to the soup. Boil for two or three 
minutes, until the arrowroot turns quite clear. 
Fish Soup. 
Small haddock or whiting, 
or piece of cod. 
| oz. butter. 
| oz. flour. 
3 gills or 1 pint cold water. 
1 gill of milk. 
1 yolk of egg and J gill 
cream. 
1 teaspoonful finely chopped parsley. 
Wash and scrape the fish very clean ; see that there is 
no black skin lining the inside parts. Remove the eyes. 
Cut the fish across into several pieces, and put them into 
a lined saucepan. Cover with cold water, add the salt, 
bring to the boil and skim. After the fish has boiled for 
a few minutes, lift out a few nice little pieces of fish free 
from skin and bone, and reserve them for serving in the 
soup at the end. Allow the rest to simmer from three- 
quarters to an hour. Then strain through a wire sieve, 
and rub some of the white pieces through. Rinse out 
the pan the soup was cooked in. Melt in the butter, 
add the flour, and mix these two smoothly together, being 
careful they do not brown. Then pour on the soup that 
has been sieved, and stir until boiling. Beat the yolk 
of egg and cream and milk together ; and, when the soup 
is off the boil, beat these ingredients into it ; then strain 
through a fine strainer, stirring all the time. Do not let 
the soup boil after the egg is added, or it will curdle. The 
pieces of fish that were reserved and the chopped parsley 
are now added. 
1 dozen oysters. 
1 pint fish stock or white 
stock. 
1 oz. butter. 
1 oz. flour. 
Pinch of cayenne. 
Oyster Soup. 
1 gill cream. 
1 egg- 
A few drops of anchovy 
essence. 
A squeeze of lemon juice. 
White pepper and salt. Place the oysters in a small saucepan with their liquor, 
bring them almost to the boil, then strain. Beard the 
oysters (that is, remove the piece like a fringe that encircles 
them), cut them in two, and put them aside for stewing 
in the soup. Put the beards into a saucepan with the 
liquor and the stock, and let them simmer for half an hour, 
to extract all the flavour from them. If the stock is not 
previously well flavoured, small pieces of the different 
flavouring vegetables should also be cooked in it. Strain 
through a fine hair sieve or piece of muslin, and rinse 
out the saucepan ready for use. First melt in the butter, 
being careful it does not brown, add to it the flour, and mix 
together until it is quite smooth. Pour on the stock, and 
stir constantly over the fire until boiling. Skim if necessary. 
Season to taste with a little white pepper, salt, anchovy 
essence, and pinch of cayenne. Beat up the yolk of egg 
in a basin with the cream, strain into the soup, when 
off the boil, stirring all the time. Place oysters in the soup 
tureen, pour the soup over them, and serve. 
diet 
263 
1 lb. veal. 
1 small knuckle of veal. 
6 breakfastcupfuls water. 
Veal Soup. 
1 tablespoonful tapioca grout. 
1 gill cream. 
Yolks of 2 eggs. 
2 square inches of turnip. 
Cut the veal up in small pieces, and break the knuckle 
up well. Put all on with the cold water. Bring to the 
boil, and skim carefully: add the turnip cut into small 
pieces, and boil steadily for at least five hours. Strain 
the soup, then add the tapioca previously soaked in cold 
water, and boil again for fifteen minutes, stirring frequently. 
Place the yolks and cream in a basin, and stir well. Gradu- 
ally add the hot soup to the yolk and cream mixture, 
stirring constantly to prevent curdling, and season to taste* 
Fish.-Raw oysters, whiting, haddock, and sole are 
the most easily digested members of the fish group, 
and as such should come first in the dietary. 264 
CLINICAL LECTURES FOR NURSES 
Oysters. 
Pepper and salt. 
Oysters aij Naturel. 
Cayenne. 
Lemon juice. 
Open the oysters carefully and serve them in their shells. 
Season with pepper, salt, and a pinch of cayenne. Garnish 
with parsley or cut lemon. Serve directly they are opened, 
or the flavour will be spoilt. They are best eaten with 
a little brown bread and butter. Oysters may be pepton- 
ised and then given, and are an excellent and easily digested 
food. 
This is richer and not so digestible as above, but is 
quite suitable for many convalescent patients :- 
Oysters Scalloped. 
| doz. oysters. 
' oz. butter. 
Breadcrumbs. 
Pepper and salt. 
Lemon juice. 
Put the oysters and their liquor into a small saucepan, 
and bring them to the boil. Remove the beards from the 
oysters, and strain the liquor. Grease china or well-washed 
oyster shells. Sprinkle into each dish a few breadcrumbs, 
then put in three oysters into each shell. Season to taste 
with pepper and salt. Pour over a little oyster liquor. 
Cover with more breadcrumbs. Pour some melted butter 
over the top. Brown in the oven or in front of the fire, 
and serve hot. 
The white fish can be steamed and served without 
any sauce, or stewed in a little milk and served with 
a white sauce, as follows :- 
White Sauce (French). 
| oz. butter. 
| oz. flour. 
| gill cream. 
Pepper and salt. 
Small | pint fish stock or seasoned milk. 
Method.-Melt the butter in a lined saucepan, add the 
flour, and mix smoothly with a wooden spoon. Cook for 
four minutes over the fire, but do not brown. Draw the DIET 
265 
pan to the side of the fire, and add the stock or milk gradu- 
ally, then return to the fire, and stir constantly until boiling. 
Add the cream and seasoning, and boil for a minute or two 
longer. Remove the pan from the fire before adding the 
lemon juice, and strain before using. More or less milk 
may be added according to the thickness of the sauce 
required. If considered too rich, the cream may be omitted. 
Seasoned milk.-Put as much milk as is required into 
a lined saucepan, with a small piece of carrot, turnip, 
onion, and a few parsley stalks. Let the pan stand by the 
side of the fire until the milk is well seasoned, then strain 
and cool before using. 
Steamed Fish. 
This is the lightest and simplest mode of cooking fish 
for an invalid. 
1 filleted haddock, whiting, 
or sole. 
A small piece of butter. 
A squeeze of lemon juice. 
A pinch of salt and white pepper. 
Cut the fillets of fish into neat-sized pieces ; grease a 
soup-plate or muffin-dish with a little butter, and place 
the fish on this. Sprinkle with a little salt and white pepper 
if it is allowed, and squeeze over some lemon juice, which 
helps to keep the fish firm and white. Cover with a piece 
of greased white paper, and then with a lid or basin. Place 
this over a pan half-full of boiling water, seeing that the 
plate fits well on the pan. Keep the water in the pan 
boiling, so that there may be plenty of steam, and cook 
from twenty to thirty minutes, until the fish loses its 
clear, transparent appearance and looks quite white. 
If the pieces are thick, it is better to turn them while cook- 
ing. The liquid that is on the plate when the fish is cooked 
is the juice from the fish, and should be served with it. 
Serve with a little plain cold butter and a piece of plain 
bread or toast. 
1 filleted fish, whiting, haddock, 
sole, plaice. 
1 tablespoonful breadcrumbs. 
1 teaspoonful chopped parsley. 
Stewed Fish. 
1 gill milk. 
1 oz. butter. 
White pepper. 
1 gill cold water. 266 
CLINICAL LECTURES FOR NURSES 
Wipe the fish with a damp cloth and cut into small,, 
neat pieces. Rinse out a lined saucepan with water, and 
place the pieces of fish at the foot. Sprinkle over them 
a little salt and white pepper, pour in the milk and water ; 
put the lid on the pan, and let the fish cook slowly by the 
side of the fire until it is ready, which will be about fifteen 
minutes. Do not overcook, or the fish will be hard. Lift 
out the pieces on to the plate on which they are to be served, 
and keep them hot. Add the breadcrumbs and butter 
to the water and milk in the pan. Stir over the fire for a 
few minutes until the breadcrumbs swell and thicken the 
sauce. Sprinkle in the parsley, and then pour this sauce 
over the fish. 
Baked Fish. 
| lb. uncooked fish. 
2 tablespoonfuls breadcrumbs. 
Pepper, salt, and a little lemon 
juice. 
1 egg. 
gill milk. 
| oz. butter. 
Grease a small pie-dish with a little of the butter. Have 
the fish free from skin and bone, and cut it into neat pieces. 
Lay half of these pieces at the foot of the pie-dish, sprinkle 
over them a little white pepper, salt, and a squeeze of 
lemon juice, and then put on a layer of breadcrumbs. 
Next, put in the rest of the fish, seasoning, and more crumbs. 
Beat up the egg in a small basin, add the milk to it, and 
strain this into the pie-dish. Put the rest of the butter 
in small pieces on the top and wipe round the edges of the 
pie-dish, and bake in the oven until nicely browned. 
Nothing is nicer for an invalid than a really well-fried 
fillet of sole or small whiting, with a slice of lemon to 
squeeze over it. 
Fried Fish. 
Soles to fry. 
Pepper and salt. 
Egg and breadcrumbs. 
Frying fat. 
1 sole. 
A little flour. DIET 
267 
Skin and fillet the fish, and wipe the fillets with a damp 
cloth. Trim neatly and cut across in slanting direction 
into two or three pieces. Dip each piece in flour mixed 
with pepper and salt, then egg and breadcrumbs, and 
fry in boiling fat until well browned. Drain on kitchen 
paper and serve very hot. Garnish with lemon. 
Small whiting and haddocks, small flounders and plaice, 
can be cooked whole in this way. Large flounders, plaice, 
and haddocks are better filleted whole. 
Quenelle of Fish. 
1 lb. haddock. 
1 slice bread, 
i oz. butter. 
1 teacupful milk. 
1 teaspoonful parsley. 
1 egg and 1 yolk. 
Pepper and salt. 
Remove the skin and bones from the haddock, and 
scrape it down, putting aside any part that is not white. 
Soak the breadcrumbs in milk, and when quite soaked, 
strain and place in a small saucepan with the butter, parsley, 
and the yolk of one egg, and stir over the fire till a thick 
paste is produced ; mix in thoroughly a beaten-up egg, 
also pepper and salt. Place in a buttered shape, and 
steam for an hour and a half. 
Meats.-Of this class of food, poultry {e.g., chicken 
and turkey), game (e.g., pheasant and partridge), tripe, 
sweetbreads, and rabbit are the most easily digested. 
They can be served in the usual manner of roasting, 
boiling, or stewing. Tripe and sweetbreads form most 
excellent dishes, and only require to be more thoroughly 
known to be appreciated. Beef and mutton may be 
served as " minced beef," " meat-juice mince," or 
beef quenelles, and are very digestible ; mutton chops, 
roast leg of mutton, grilled rump-steak, require more 
digestive power. 
A few recipes for the preparation of chicken, game, 
rabbits, and sweetbreads are given, and also the method 
of preparing and serving tripe. 268 
CLINICAL LECTURES FOR NURSES 
1 small chicken. 
Broiled Chicken. 
1 oz. butter. 
Pepper and salt. 
Prepare a young chicken for roasting, split it down the 
back, lay it open, and take only half at a time. Rub the 
piece of chicken over with a little butter to keep the skin 
from cracking, and season with pepper and salt. Grease the 
gridiron and make it thoroughly hot. Lay the chicken 
on it with the cut side down to begin with ; broil either 
on the top of or before a clear fire for about half an hour. 
When cooked lift on to a very hot plate, and rub the rest 
of the butter over it. Serve with rolls of bacon round it. 
If broiling an older fowl, it must be partially cooked first, 
either by boiling or roasting. It may be eaten with or 
without bread sauce, made as follows :- 
Bread Sauce.-2 ounces breadcrumbs. | pint water. 
| oz. butter. 1 tablespoonful cream or milk. Salt and 
pepper. 
Pour hot water over the breadcrumbs, cover with a 
plate, and when quite cool, mash it and put in a pan with 
the butter, cream, salt, and pepper. Mix all well together 
and simmer till hot. 
Chicken SoueflL 
Breast of chicken. 
1 gill cream. 
| oz. flour. 
1 egg. 
Pepper and salt to taste. 
Skin the breast of the chicken, chop it finely, pound 
well in a mortar; melt the butter, and stir it into the 
flour with a tablespoonful of cream. Let it come to the 
boil, and pour over the pounded chicken, adding seasoning, 
pound together, and rub through a wire sieve. Switch 
the remaining cream until stiff, mix gently with other 
ingredients ; butter some cups, half-fill with the mixture, 
cover the cups with kitchen paper, and set in stewpan 
half full of boiling water. Steam for fifteen minutes. 
Serve with white sauce. The boiling water should only 
come half-way up the cups while steaming. DIET 
269 
Chicken or Veal Panada. 
j lb. breast of chicken, or J lb. fillet of veal. 
1 tablespoonful cold water. 
A pinch of salt. 
Wipe the meat and cut into small pieces ; free it from 
fat and skin. Place in a cup with a pinch of salt and cold 
water. Tie over it a greased white paper, and steam slowly 
from one to one and a half hours. Then lift it out, place 
the contents of the cup in a mortar, pound well, and rub 
through a sieve. Put the sieved mixture into a pan, add 
the cream, and heat thoroughly. This may be served 
on a piece of toast, or taken cold. 
Ragout of Fowl or Rabbit. 
Take the wings and breast of a fowl or the back and 
legs of a rabbit, soak in hot water for five minutes, then 
put into a jug with salt, and mace, or peppercorns. Cover 
with milk, seal the jar closely, set in an oven, and bake 
for three hours. Take out the meat. Pour the milk into 
a basin to cool, so that the fat may be easily removed. 
Before serving, warm in a cup set in hot water, or warm 
a little of the meat in the milk, and serve with thin toast 
or water biscuits. 
1 tablespoonful cream. 
Stewed Partridge. 
1 partridge. 
2 oz. butter. 
1 teaspoonful of flour. 
1 blade mace. 
Lemon. 
Pepper and salt. 
Cut the partridge into joints and take out the largest 
bones. Put the butter into a small stewpan ; when it gets 
hot put in the best parts of the partridge and fry it very 
carefully, then add to this a small bit of lemon peel, a 
small bit of mace, and pepper and salt; add the flour 
and one teacupful of water, and the bones that were removed. 
When this all boils up, put on the lid, and let it stew slowly 
for three-quarters of an hour, or till tender. Take up the 
best parts on a dish and strain the gravy over them. All 
game is easily digested when cooked in this way. 270 
Red Meats.-A slice of plain roast mutton or beef, 
or a lightly-grilled chop or steak, are easily digested. 
The following recipes will be found useful :- 
CLINICAL LECTURES FOR NURSES 
Minced Beef. 
i lb. best rump-steak, 
pint cold water. 
Pepper and salt. 
Snippets of toast. 
Either get the butcher to mince the steak, or, after 
removing all the fat and connective tissue, put it through 
a mincing machine. 
Never buy so-called mince collops from the shop for an 
invalid ; there is always too much fat in it. 
Take a small lined stewpan ; put the minced beef into it, 
with half the water and the seasoning. Put the pan on 
the stove, and pound the meat well until it loses its raw 
appearance. Then add the rest of the water; simmer 
gently by the fire for twenty minutes. Do not allow the 
meat to cook too quickly, or it becomes hard. Remove 
any grease that may rise on it, and serve very hot. Garnish 
the dish with some neat sippets of toasted bread. 
J lb. best rump-steak. 
Meat-juice Mince. 
I small piece of butter. 
Pepper and salt. 
Take the meat and rub through the hair sieve until all 
the red juicy part has gone through ; scrape the bottom 
of the sieve. Melt a very little piece of the butter in a 
small frying pan ; toss the meat juice in it for three or four 
minutes, until it loses its red colour. Flavour, and serve 
with toast. This looks just like mince, but as none of the 
fibre is present, it is very digestible. This meat-juice can 
be made more easily digestible by omitting the butter, 
and adopting the following method :- 
Take the scraped meat, and add a teaspoonful of beef-tea 
or simple stock, and stir in an iron pan for three or four 
minutes, when the juice granulates and becomes brown 
in colour. If an enamel pan is used, the meat has a very 
unappetising appearance. DIET 
271 
1 lb. beefsteak. 
Breadcrumbs. 
Beef Quenelles. 
Salt and pepper to taste. 
1 egg. 
2 tablespoonfuls stock. 
Pound the beefsteak, half a teacupful of breadcrumbs, 
salt and pepper, egg, and stock well in a mortar, rub through 
a sieve, shape with tablespoons, and poach in shallow pan 
for ten minutes in boiling water. Serve with sippets of 
toast, and pour a gravy made of thickened beef-tea round 
the quenelles. 
Tripe.-Methods of preparing.-The best varieties 
of tripe are those known as the " blanket " (because 
it has a folded appearance), and the dark variety known 
as the " monk's hood " ; these are best for invalids 
on account of their tenderness. The other sorts are 
known as the " book " and the " honeycomb." 
If tripe is properly prepared, it is a most delicately - 
flavoured and easily digested article of food, and should 
be in more constant use than it is at present. It re- 
quires, however, very careful cleaning and boiling. 
In Scotland prepared tripe cannot be purchased at the 
butcher's, so it is necessary to understand the whole 
process. Tripe sold in England has generally had a 
preliminary boiling. 
First wash and scrub in several waters and scrape it 
with a knife, pulling away any pieces of fat from it. 
Cut it into pieces and put it into a clean saucepan with 
cold water to cover it, and bring it to the boil. This 
is called blanching, and is repeated until the water in 
which the tripe was boiled loses all its heavy smell. 
This may require to be done four or five times. Then 
rinse the saucepan well, put in the tripe with cold water 
to cover it, bring to the boil, and cook slowly for ten to 272 
CLINICAL LECTURES FOR NURSES 
twelve hours. If cooked too quickly the tripe will 
harden. When sufficiently cooked, it ought to be so 
tender that it will pull easily to pieces. Pour it out 
into a basin and cover it with the liquor in which it 
was cooked. This pievents it from becoming hard and 
dry. It can then be made up in any way desired. 
The water in which the tiipe was boiled should never 
be thrown away, as it contains a certain amount of 
nourishment. It is sometimes served as an invalid 
jelly- 
The prepared tripe can be stewed in various sauces 
for fifteen minutes, and served in one of the following 
ways :- 
1. Tripe stewed in white sauce and onions, and served 
with snippets of toast. 
2. Tripe stewed in a thick tomato sauce, and served with 
little rolls of bacon and croquettes of fried bread. 
3. Tripe heated in a good curry sauce, and served with 
a border of rice. 
4. Baked tripe.-Grease a small pie-dish, and put the 
tripe, with thin square pieces of bread and butter, into this, 
in alternate layers. The last layer should be bread, with 
the buttered side up. Beat up an egg in a basin until it 
is frothy, add to it half a gill of tripe liquor, and season 
with pepper and salt. Strain this into the pie-dish, and 
then wipe round the edge of the dish with a cloth. Let 
the mixture stand for ten minutes, until it gets thoroughly 
soaked. Bake in a moderate oven for about fifteen minutes 
until nicely browned. Serve hot. 
Sweetbreads.-There are two varieties of sweet- 
bread-the " throat " sweetbread (thymus gland), and 
the " stomach " sweetbread (pancreas). The latter is 
much more digestible. Lambs' sweetbreads are very 
tender. This article of food must be nicely prepared, DIET 
273 
or it is very unappetising. The difficulty is to clear 
off all the connective tissue and fat between the lobules. 
Soak the sweetbread in cold water for one or two hours. 
Then put it into a saucepan with cold water to cover it. 
Bring to the boil, and boil for five minutes. Then lift 
it out and place in a basin of cold water to cool it. This 
preserves the colour of the sweetbread. Then, with 
great care, remove from it all the fat and skin, pulling 
them off with the fingers. It is now ready for cooking. 
Braised Sweetbreads. 
Prepare the sweetbreads as above. Braise them for 
one and a half hours-that is, place the sweetbreads un- 
broken into a saucepan containing a little onion, carrot, 
turnip, celery, savoury herbs, and seasoning ; add a little 
meat stock, just enough to cover the meat; cover with 
paper and a well-fitting lid. At the end of the time take 
them out, brown in the oven, and serve on a piece of fried 
toast or a bed of mashed potatoes. Pour a good sauce 
round them, such as Italienne, made as follows :- 
Sauce Italienne. 
1 oz. flour. 
1 oz. butter, 
1 bay leaf. 
Onion and sprig parsley. 
1 gill sherry. 
I pint second stock. 
Melt the butter; fry the herbs and onions and flour 
to a good brown colour. Add the sherry, and allow it to 
cook a few minutes ; add the stock when boiling, and allow 
to simmer for an hour. Strain the sauce before pouring 
round the sweetbreads. 
1 stomach sweetbread. 
1 giU white stock. 
Stewed Sweetbreads. 
1 teaspoonful arrowroot. 
1 tablespoonful cream. 
White pepper and salt. 
Break the prepared sweetbread into small pieces of 
equal size ; put them into a small lined stewpan with the 274 
CLINICAL LECTURES FOR NURSES 
stock ; put on the lid, and allow it to simmer slowly until 
tender. 
When cooked, lift the pieces of sweetbread out, place 
them on a neat square of toast on a hot dish, and keep 
them warm. Break the arrowroot into a small basin with 
a little cold water, and add it to the stock in the pan. 
Stir over the fire until boiling, and boil for five minutes, 
so as to cook the arrowroot. Add cream, and season to 
taste. Pour the sauce over the sweetbread, and serve 
very hot. 
Vegetables.-The following are the most suitable 
vegetables for convalescent patients : spinach, boiled 
lettuce, baked tomatoes, steamed asparagus, stewed 
celery, seakale, young leeks, cauliflower, onions, and 
vegetable marrow. All these vegetables can be served 
with a little well-made white sauce round them. 
Rice and Macaroni.-These carbo-hydrates are the 
basis of many nourishing and easily digested Italian 
dishes. In cooking, the directions for boiling rice and 
macaroni should be closely followed. 
Plain Boiled Rice. 
Wash well some Patna rice in several waters until the 
last water looks quite clean. If there is a pot for steaming 
the rice in, it is best to use it, but if not, boil the rice in 
a saucepan of boiling water containing salt, which is in 
the proportion of one teaspoonful to the quart. Boil quickly 
with the lid off, stirring frequently with a fork to prevent 
it sticking to the pan. Cook from ten to fifteen minutes 
until the grain will rub down easily when one is tested 
between the finger and thumb. Strain through sieve or 
strainer, and finish the cooking by drying it-either by 
putting it into the saucepan by the side of the fire, or 
putting it on to a plate in a moderate oven. While drying. 275 
stir lightly with a fork every now and then to keep the 
grains separate. 
N. B.-The water in which the rice has been boiled 
contains the best part of the rice, so that it should not be 
thrown away, but kept for the stock pot. 
Italian Rice (Cheese and Rice). 
Plain boil the rice as directed above. After straining 
the rice, pour it back into the pan. Put a sufficient quantity 
of butter into a frying pan ; when the butter is melted 
add the rice, and mix well together for two or three minutes. 
Place the rice in a dish, and cover with grated Parmesan 
cheese. 
Kl1 Milan Rice (Rice with Meat Extract). 
Place a bit of butter in a saucepan ; when melted, throw 
in the rice (2 oz. is sufficient for one person). Mix rapidly 
with a wooden spoon to prevent burning. When the rice 
begins to colour, moisten with good stock, by degrees, 
until it is thoroughly cooked. Then add a small teaspoonful 
of any meat extract. Mix with it salt, pepper, and grated 
Parmesan cheese, about 1 oz. A little of the cheese is mixed 
with the rice and the remainder served separately. 
Boiled Macaroni. 
Break the macaroni into short lengths, and throw it 
into a saucepan of freshly boiling water with salt in it. 
Boil quickly with the lid off the pan until it has thoroughly 
swelled and is tender. Stir occasionally, to prevent it 
sticking. The time depends on the variety of the macaroni 
-the large pipe will take about half an hour, the small 
much longer. Keep it well covered with water. When 
ready, drain, and this may either be served plain with 
meat, or it may be put back into the saucepan with enough 
stock to cover it and allowed to stew for half an hour. 
The pulp of a fresh tomato rubbed through a sieve 
may also be added to this. 
DIET 276 
CLINICAL LECTURES FOR NURSES 
DIET IN AUTO-INTOXICATION. 
Intestinal Fermentation and Putrefaction. 
Intestinal auto-intoxication is a toxaemia resulting 
from the absorption of abnormal food products under 
the influence of bacterial action. Intestinal auto- 
intoxication is responsible for a group of miscellaneous 
toxaemias which include cases of anaemia, headache, 
neuralgia, neuritis, arterio-sclerosis, rheumatism, neuras- 
thenia, and other conditions. Some symptoms are 
in part mechanical, due to pressure from gas. The 
toxins may frequently be recognised in the stomach 
contents (various organic acids), in the urine (excess 
of ethereal sulphates), and in the breath (acetone and 
hydrogen sulphide gas). Alcoholic fermentation of 
the food-stuffs may also occur. The bowels are fre- 
quently constipated, and the motions maj be ill-formed 
and very offensive in character. The toxic products, 
produced as a result of fermentation of carbohydrate 
foods, are chiefly C02 and various organic acids, such 
as lactic acid, acetic acid, butyric acid, and to a less 
extent formic and valerianic acid and acetone. The 
end-products of decomposition of carbohydrate foods 
are C02 and water, and no fermentation products are 
recovered from the urine with the exception of oxalic 
acid in oxaluria. The toxic products, arising from 
the abnormal decomposition of proteins under the 
influence of bacterial action, are various nitrogen and 
sulphur compounds, chiefly of the aromatic series, 
e.g., indol, phenol, skatol, and hydrogen sulphide gas. 
Other less important products are neurin, lecithin, 
and cystin. The excess of nitrogen and sulphur in DIET 
277 
these putrefactive products are eliminated in the urine 
as ethereal sulphates, and their presence may be de- 
tected in the urine. 
The dietetic treatment of cases of auto-intoxication 
is of the first importance. The fermentation cases 
should be treated with a diet chiefly protein in character. 
The diet should comprise various meat soups, fish, 
chicken, eggs, tripe, sweetbread, and scraped beef; 
farinaceous foods being restricted to dry toast, stale 
bread, and rusks. The diet must be carefully planned, 
the food given at regular intervals, and no food of any 
kind given between meals. The free use of plain water 
or other diluent should be encouraged. It is necessary 
to point out the importance of proper attention being 
paid to mastication of the food, to the state of the 
teeth, and the careful regulation of the bowels as essential 
points in the treatment. A special value attaches to 
the use of soured milk and of various lactic acid bacilli 
in many cases. 
The following dietary is appropriate to cases of auto- 
intoxication resulting from the abnormal fermentation 
of carbohydrate foods :- 
7 a.m.-Tumblerful of hot water. 
8 a.m.-Breakfast- 
Tea, one cup without sugar, and milk, 
not cream. 
Good helping of fried bacon or fish, or 
eggs (plain, poached, or scrambled) ; 
or cold ham, cold tongue, or grilled 
kidney. 
One slice of thin crisp toast, with a very 
little butter. 278 
CLINICAL LECTURES FOR NURSES 
11 a.m.-One tumblerful of soured milk, with plain 
sweet biscuit. 
1 p.m.-Lunch- 
(a) Fish, chicken, or game ; or chop, 
steak, or roast beef or mutton. 
(6) Biscuits, or dry roll with cheese 
and butter ; cup of coffee. 
4.30 p.m.-Cup of soured milk, and half-slice 
sponge cake or biscuit. 
7 p.m.-Dinner- 
Clear soup, unthickened. 
Meat as at lunch, without vegetables ; 
dry toast, and a simple gravy. 
Pudding in form of custard, curds, jelly, 
cream, or stewed fruit, without 
added sugar ; no coffee. 
10 p.m.-Drink of hot water. 
The putrefactive cases are treated with a lacto-vege- 
tarian diet. Meat, and especially red meats, are for 
the time cut off from the dietary. Meat soups are 
similarly withheld. Eggs are also excluded. The diet 
should comprise bread and milk, farinaceous foods, 
green vegetables, and fruits. An appropriate diet 
sheet is here given :- 
7.30 a.m.-Tumblerful of hot water. 
8 a.m.-Breakfast- 
Cereal, e.g., porridge, hominy, Quaker 
oats, with cream. 
Toast or roll with butter, and a little 
marmalade if desired. 
One cup of tea. DIET 
279 
11 a.m.-One glass of soured milk with biscuits. 
1 p.m.-Lunch- 
Egg in some form, vegetable savoury, 
e.g., cauliflower ah gratin, macaroni 
cheese, tomato savoury. 
Plain milk pudding with cream. 
4 p.m.-One cup of soured milk, with piece of 
sponge cake. 
7 p.m.-Dinner- 
Vegetable or milk stock soup-e.g., 
tomato, artichoke, potato, lentil, 
or onion. 
Fish occasionally, or egg in some form 
if not taken at lunch, or vegetable 
savoury. 
Pudding-simple pudding, or stewed 
fruit; no savouries and no coffee. 
10 p.m.-Tumblerful of hot water. 
Foods forbidden in all cases.-Patients who are 
specially prone to intestinal auto-intoxication have a 
relatively weak digestive power. Their diet must 
therefore be a simple one. All foods which are difficult 
to digest should be excluded from the dietary, and the 
various " extras," which can be indulged in with im- 
punity by healthy subjects, must be rigorously with- 
held. The following articles should only be given in 
the most restricted amounts : marmalade, jams, sugar, 
sweets, and confectionery ; pastry, sweet cakes, new 
bread, and hot rolls ; made-up dishes of all kinds, 280 
and all canned foods ; pickles, sauces, spices, caviare, 
and rich gravies, lobsters, mushrooms, shrimps, sardines, 
salmon, mackerel, raisins, nuts, pears, and all preserved 
fruits. 
It should be clearly understood that in all cases of 
suspected auto-intoxication accurate diagnosis is the 
first essential. This involves careful investigation of 
the whole gastro intestinal tract by modern methods, 
and also a thorough examination of the genito-urinary 
system. There is no use treating a patient by " diet " 
and other medical means if operative or other measures 
are indicated. 
CLINICAL LECTURES FOR NURSES 
DIET IN CHRONIC HEART DISEASE. 
Principles ........ 280 
Diet in Full Compensation .... 282 
Diet in Fair Compensation .... 283 
Diet in Failure of Compensation . . . 284 
Moderate Degree ..... 285 
Severe Degree ..... 286 
INDEX. 
The diet for patients with chronic organic heart 
disease usually requires more or less careful regulation, 
even before compensation is lost, for digestion is always 
more or less handicapped by the heart lesion, with its 
resulting venous stasis in the liver and other parts of 
the alimentary tract. After compensation is lost, the 
question of diet certainly becomes one of the most DIET 
281 
important factors in the treatment. The gaseously 
distended abdomen may press up the diaphragm and 
impede the already embarrassed respiration, thus 
occasioning great discomfort and restlessness. These 
symptoms can be greatly lessened and often entirely 
relieved by a carefully restricted and judiciously arranged 
dietary. The diet must be regulated to suit the con- 
dition of the patient and his special circumstances. 
General principles applicable to all cases are as follows :- 
General Directions- 
1. The meals should be small in amount. More 
should never be taken than the patient can easily 
digest. Over-distension of the stomach from food 
mechanically pushes up the diaphragm and dis- 
places the heart, causing palpitation and dyspnoea. 
In addition, if the meals are too large, the residue 
of undigested food in the intestine ferments and 
causes flatulence. 
2. The meals should be simple, and well cooked. 
A simple diet (i.e., not too large a variety of courses) 
throws less strain on the digestive functions, and 
also greatly diminishes the risk of eating to excess. 
Improperly prepared food is a cause of indigestion, 
and may itself produce flatulence and discomfort. 
3. Long intervals between the meals should be 
ordered, and eating between meals should be 
strictly prohibited, as even a small portion of food 
taken while digestion is in progress may give rise 
to flatulence. The object of this restriction is to 
permit the stomach to have time to get rid of one 
meal completely before it is again filled. 282 
CLINICAL LECTURES FOR NURSES 
4. Three meals of about equal size should be 
taken in the twenty-four hours. The midday meal 
can be the richest, but the total bulk should be 
about the same in each. 
5. The meals should be taken as dry as possible. 
This lessens the distension of the stomach, and does 
not over-dilute the gastric juice; further, fluid 
ingested tends to dilate the vessels, to raise arterial 
tension, and to increase the work of the heart. 
Fluid need not be restricted to a very small amount 
unless special indications arise, but it should be 
taken mainly between meals and sipped slowly. 
Weak tea or coffee can be taken in small amount 
with breakfast, and alone for afternoon tea. 
Diet in cases of full compensation.-In a general 
way, it may be said that, in all cases in which com- 
pensation is satisfactorily established, a diet of plainly - 
prepared food, unencumbered by too many detailed 
restrictions, is best, but a few hints may be here given 
as to foodstuffs. 
All highly seasoned food and condiments are better 
omitted, as they tempt the appetite more than is neces- 
sary. Stews and badly-fried foods are apt to cause 
derangement of the digestion. 
It will also be found advisable to restrict the carbo- 
hydrates, especially the starches and sugars; they 
need not be strictly cut off, unless causing fermentation 
and flatulence. Toast, dry bread, rolls, biscuits, may 
be taken, but should never be eaten warm. Lightly 
made and well-cooked milk puddings can be taken, 
but pastry and suet puddings are not suitable. Of the 
vegetables, potatoes (not new), cauliflower, spinach, DIET 
283 
vegetable marrow and cucumber, stewed tomatoes 
(the pulp only), boiled onions, stewed celery, asparagus 
tops, are all easily digested. The root vegetables and 
stalks of the green vegetables above mentioned should 
be avoided. 
Alcohol is not necessary in the early stages of heart 
disease, and if later indicated on account of marked 
failure of compensation, small doses of good whisky 
or good old brandy may be given in measured quantity 
twice daily. Wine and beer are better withheld. 
Diet in cases of fair compensation.-The following 
dietary is suitable for a case of chronic heart disease 
in an adult subject, when the compensation is not 
seriously disturbed.:- 
8.30 a.m.-Breakfast- 
Cup of tea or coffee (one cup). 
Fish, egg (with or without bacon), ham, 
tongue, or grilled kidney. 
Two half-slices of toast and a roll, with 
butter ; or, 
A half-slice of toast, oatcake, or crisp rusk, 
with butter. 
1.30 p.m.-Lunch-Alternative meals. 
Fish and potato. 
Fruit, with cream. 
Cheese and biscuits. 
Small cup of coffee. 
Chicken and bread sauce 
and cauliflower. 
Custard. 
Cheese savoury. 
Small cup of coffee. 
Chop or steak. 
Jelly or cream. 
Fresh fruit. 
Small cup of coffee. 
4 p.m-A cup of tea (nothing solid to take with it). 
7 p.m.-A three-course dinner, much the same as given 
for lunch. 284 
Diet rules for failure of compensation.-With 
failing compensation there arises various digestive 
disorders. Loss of appetite, flatulence, constipation, 
are the subjective indications which result from the 
congested state of the liver, stomach, and bowels which 
are now present. In later stages, albuminuria develops 
from the venous congestion of the kidneys, and the tissues 
may now become oedematous or water-logged, from the 
interference to the free return of blood to the heart. 
The general directions already given should be closely 
adhered to. The diet varies according to the degree 
of severity of the heart failure. The diet appropriate 
to cases of moderate severity will first be discussed. 
The patient, although ill, is not suffering from fever, 
and there is no necessity to place him upon a fluid diet 
given at short intervals. It is best to follow his usual 
habit, and continue having three meals a day. These 
should be, as before stated, small in amount, simple 
in character, well cooked and nutritive, and arranged 
at sufficient intervals to permit of complete removal 
of one meal from the stomach before the entrance of 
the next into it. In addition, the meals should be as 
dry as possible ; soup in these cases is better avoided. 
Breakfast is generally the best meal, as after the long 
rest there is more digestive capacity ; so with this meal 
a large cup of tea or coffee may be permitted, and a little 
carbohydrate food-stuff. Chinese tea, apparently, is much 
better for a feeble digestion than that of India or Ceylon, 
and should, where available, be taken. 
There is no need to give a tumbler of milk, cup of Bovril, 
or other food at 11 o'clock. It is better to let the patient 
sip slowly a glass of water about an hour before the next 
meal is due, at 1 or 2 o'clock. The midday meal should 
consist of a chop or fish or fowl, with some carefully pre- 
CLINICAL LECTURES FOR NURSES DIET 
285 
pared green vegetable, cooked with plenty of butter, and 
rubbed through a sieve. A second course of stewed fruit, 
sweetened with saxin, and eaten with cream junket, custard 
(baked or boiled), apple cream, lemon sponge, milk blanc- 
mange, or jelly with cream. Creams flavoured in different 
ways are allowable. No pudding containing starch is to 
be allowed. A little cheese, eaten with butter, but no 
bread or biscuit, should be taken. Half an ounce of brandy 
or whisky may be allowed with the midday and evening 
meals. 
At 5 o'clock a cup of Chinese tea, unsweetened, or with 
saxin, may be drunk, but no breadstuff should be taken 
with it. 
At 7 or 7.30 the evening meal should generally be a 
repetition of the midday one, but it is best to take chop 
or other red meat only at one of the meals. The vegetables 
mentioned above are allowable A second course may be 
permitted, and may be followed by cheese, as before, if 
this agrees. A glass of whisky or brandy in half a tumbler 
of hot water, or a small half-pint of beef tea, chicken tea, 
or good consomme may be taken after 10.30, but no bread- 
stuff of any kind should be used along with it. 
Three small meals will usually be ample for a cardiac 
sufferer ; there is no question that any laxity from this 
diet will speedily show itself by increased flatulence. 
Those patients who have been in the habit of taking 
dinner and high tea must give up the custom. It is very 
difficult to make them understand that the midday and 
evening meal should be very much the same in quality 
and quantity. 
An illustrative diet sheet is here given :- 
8 to 8.30-Breakfast- 
One large cup of Chinese tea, with plenty 
of milk and cream. 
Thin crisp toast made from " pan loaf," 
or Veda bread with butter and a little 
marmalade. 286 
One of the following ;- 
Bacon (fat, crisply cooked), or fish (steamed 
or fried or rizzard); egg, plain-boiled, 
scrambled, or poached; tongue, or 
potted meat. 
Midday meal and evening meal- 
\ Choice from- 
1. Fish, rabbit, fowl, game, raw-beef mince, steak, 
chop, slice of roast beef or mutton (hot or 
cold). 
2. Vegetable : One selected from the following :- 
Greens-e.g., cabbage, lettuce, spinach, sprouts- 
boiled, rubbed through sieve, and heated in 
butter. 
Vegetable marrow or cucumber (stewed). 
Cauliflower and asparagus (tops only). 
Celery (stewed). 
Onions (Portugal)-long stewing. 
3. Sweet-Stewed fruit, neutralised with soda bi- 
carbonate, or souffle sweetened with saxin. 
Roast apples, apple cream. 
Custards (boiled or baked), with cream. 
Junket, jelly creams. 
4. Cheese-eaten with butter or cooked with eggs, 
if found to be digested. 
Half a glass of whisky or brandy, with four ounces 
of alkaline water. 
Evening meal--A choice from 1 and 3 in the above 
midday meal. Two courses only to be taken. White 
meat in place of red meat should be taken once a day 
at the midday or evening meal. No cheese. 
Diet for failure of compensation-advanced 
degree.-The feeding of the patient suffering from 
severe dilatation of the heart is often a very difficult 
matter. The liver is in a state of congestion, and unable 
to do its usual share in the digestive processes ; the 
stomach is in a condition of catarrh, which has induced 
CLINICAL LECTURES FOR NURSES DIET 
287 
complete loss of appetite, and often sickness and vomit- 
ing. In these circumstances it is sometimes advisable 
to give the stomach complete rest for forty-eight hours, 
and feed the patient entirely by the bowel. In most 
cases the diet subsequently must for a time be entirely 
a fluid one, and should comprise milk (plain or pep- 
tonised), koumiss, Kephir, various meat preparations, 
and invalid foods. 
The following dietary is given, so as to indicate the 
amount of food and the variety of foodstuffs that may 
be recommended in these severe cases. The total 
nutritive value of this diet is small, but in many cases 
it is as much as the patient can possibly take for a 
week or two or more of his illness. In a few cases patients 
cannot even take as much as is given in this diet sheet, 
the amount of fluid that can be taken being about 
one-half of that indicated in this regime. In all of 
these cases stimulants are advisable, preferably in the 
form of best quality whisky or brandy. 
6 a.m.-Milk (peptonised), 2 oz. 
8 a.m.-Beef juice, two teaspoonfuls in a little aerated 
water. 
10 a.m.-White wine whey, 2 oz. ; or koumiss, 2 oz. 
12 a.m.-Allenbury food, 3 oz. 
2 p.m.-Beef juice, two teaspoonfuls, either given alone, 
or in a little brandy and water. 
4 p.m.-Milk (peptonised), 2 oz. 
6 p.m.-A few teaspoonfuls of chicken jelly. 
8 p.m.-Albumin water and milk, 1 oz. of each ; or 
albumin water and koumiss. 
10 p.m.-Allenbury food, 3 oz., and brandy. 
12 p.m.-Beef juice. 
1 a.m.-Milk (peptonised), and brandy. 
3.30 a.m.-Chicken jelly, a few teaspoonfuls. 288 
CLINICAL LECTURES FOR NURSES 
HOSPITAL DIETARIES. 
The American authors, Frieden wald and Ruhrah, 
in their text-book on dietetics, point out that in many 
hospitals the diet for patients is selected by the nurses, 
with the exception of a few of the more important 
diseases, such as typhoid fever, diabetes, and the like. 
There is some reason for thinking that the same 
remark may also be applied to some hospitals in this 
country. An efficient remedy for this state of affairs 
will not perhaps be found until instruction in dietetics 
is made an essential part of the medical student's cur- 
riculum. 
At the present time it is found that in many institu- 
tions, where the official dietary leaves little or nothing 
to be desired, the actual dietary is in a manner faulty. 
Use and wont has led to the establishment of an increased 
number of feeding hours, with a proportionate increase 
in the total amount of food, some of which there is 
good reason to believe is injurious rather than beneficial. 
A concrete example of this is given in the table on 
the next page which gives the official dietary of a large 
infirmary, and, for comparison, the actual dietary in 
vogue in the same institution. 
This official dietary allows for three good meals a 
day, which is ample for the majority of patients. Use 
and wont, however, has led to the following dietary 
being adopted as the average one for ordinary con- 
valescent diet in that institution :-  
Full or Ordinary 
Diet. 
Convalescent 
Diet. 
Beef-Tea Diet. 
Milk Diet. 
Breakfast. 
Coffee or tea. 
Butter, | oz. 
Bread, 6 oz. 
Porridge and | pint 
milk, if desired. 
As ordinary. 
Tea. 
Bread, 4 oz. 
Butter, | oz. 
Milk, 1 pint. 
Bread, 4 oz. 
Dinner. 
Meat, boiled or roast, 
8 oz. 
Vegetables, 12 oz. 
Bread, 4 oz. 
Soup. 
(Farinaceous or suet 
pudding once a 
week in lieu of 
soup.) 
Fish, 8 oz. or chicken, 
6 oz. (roast, boiled 
or stewed); or 
Mince coilops, 6 oz. 
or 
Mutton cutlets; or 
Tripe, if desired. 
Vegetables, 8 oz. 
Bread, 4 oz. Soup. 
Beef-tea, or chicken 
broth. 
Farinaceous pudding 
(custard occasion- 
ally). 
Bread, 6 oz. 
• 
Milk, 1 pint. 
Rice, sago, arrow- 
root, cornflour, 
etc., 2 oz. 
Bread, 6 oz. 
Tea. 
Tea. 
Bread, 6 oz. 
Butter, | oz. 
As ordinary. 
As breakfast. 
As breakfast. 
Sago, or arrowroot, 
1 oz. in addition, 
if desired. 
Note.-When meat is boiled, a portion of the vegetables to be used for the soup; no extras to be given with the two 
first diets, except stimulants. Half a pint of sweet milk, with a slice of bread for lunch, to every patient 
requiring it. 
HOSPITAL DIET, 
289 290 
CLINICAL LECTURES FOR NURSES 
For the purpose of comparison, the official and actual 
dietaries are here given side by side :- 
OFFICIAL DIETARY. 
8 a.m.-Breakfast- 
Coffee or tea. 
Butter, J oz. ; Bread, 6 oz. 
Porridge and | pint of milk, 
if desired. 
1.30 p.m.-Dinner- 
Meat, boiled or roast, 8 oz. 
Vegetables, 12 oz. 
Bread, 4 oz. 
Soup. 
(Farinaceous or suet pud- 
ding once a week in lieu 
of soup.) 
4.30 p.m.-Tea- 
Tea. 
Bread, 6 oz. 
Butter, I oz. 
ACTUAL DIETARY. 
5 a.m.-Morning Snack- 
Consisting of milk, 8 oz. ; 
or beef-tea, 8 oz. ; bread 
and butter, 2 to 3 oz. 
8 a.m.-Breakfast- 
As laid down on chart. 
10 to 11 a.m.-Lunch- 
Milk, 8 to 10 ozs. 
Bread and butter, 2 to 3 oz. 
1.30 p.m.-Dinner- 
Consisting of soup, meat, 
and pudding. (Patients 
on convalescent diet get 
white meat.) 
4.30 p.m.-Tea- 
Tea. 
Bread and butter, 3 to 6 oz. 
An egg. 
7 p.m.-Supper. 
Milk, 6 to 10 ozs. 
Bread and butter, 1J to 
2 oz. 
In this actual dietary there is no restriction to the 
amount of bread, the amount being regulated solely 
by the patient's desires. This regime is one which is 
for many patients undoubtedly excessive. It is true 
that there are some patients who thrive on it, and DIET 
291 
increase in weight in a favourable manner. These are, 
however, in a minority, and are unsually patients who 
have been underfed prior to admission to hospital. 
For the majority of patients this diet is excessive. It 
gives little rest to the digestive organs, and such a diet 
is certainly not one to be adopted as a regular routine. 
There is no doubt that too much food is often given 
to hospital patients by over-zealous nurses who are 
anxious to hasten convalescence. The desire to feed 
is a kindly feminine instinct which should be carefully 
regulated by the practitioner. The medical man should 
always explicitly indicate the nature and the amount 
of food, and the frequency of administration which he 
considers advisable for each patient. 
A useful way of classifying hospital dietaries is the 
following :- 
1. A Milk Diet, consisting of 4 to 6 pints of milk 
daily, and nothing else. This may be given in 
the form of diluted milk, whey, skimmed milk, 
or koumiss. It is best administered in six meals 
in the twenty-four hours. 
2. A Fluid Diet, consisting of milk, beef-tea, 
chicken broth, mutton broth, egg albumin. The 
milk or beef-tea may be thickened with one of the 
pre-digested invalid foods, six meals daily being 
given. 
3. A Light or Convalescent Diet, consisting of 
light, nutritive, and the more easily digested food- 
stuffs-e.g., milk, fish, chicken, tripe, bread, invalid 
foods, milk puddings, and stewed fruits ; green 
vegetables, red meats, pastry, rich sauces, etc., 
are withheld. An illustrative dietary is here given. 292 
CLINICAL LECTURES FOR NURSES 
Breakfast-Milk, flavoured with tea or coffee. 
Bread and butter, or toast and butter. 
Gruel, hominy, or farina; or lightly-cooked 
egg or steamed fish. 
Dinner- Soup; meat- or chicken-tea or broth, thickened 
with barley or rice. Dry bread or toast. 
Fish or chicken. 
Pudding made from invalid food ; or well-made 
milk pudding; or stewed fruit-apples, 
prunes, rhubarb, or gooseberries or plums 
passed through a sieve. 
Tea- Milk, flavoured with tea. 
Rusk, or sponge biscuit. 
Supper- A cupful of gruel; or malted gruel; or invalid 
food; or chicken-tea thickened, with a 
slice of toast. 
4. Lacto-vegetarian or Farinaceous Diet, from 
which animal food, with the exception of milk and 
butter, are excluded. 
5. Protein or Nitrogenous Diet, from which 
starchy and saccharine foods are very largely 
excluded, consisting mainly of meats, fish, egg, 
with a specified small amount of starchy foods in 
the form of dried bread, toast, or rusks, arranged 
as follows :- 
Breakfast-Tea or coffee. 
One slice of toast with butter, and Kalari biscuit. 
Eggs, bacon, ham, tongue, or fish. 
Dinner- Soup from meat stock, crisp toast or rusk. 
Fish, fowl, game, meat with cauliflower, 
spinach, lettuce, celery, or tomato. 
Curds, custard, jelly, souffl6, or stewed fruit. 
Supper- Repetition of dinner, two courses being taken. 
6. Ordinary or House Diet, as in hospital diet, 
p. 289. IN DEX 
PAGE 
Acute Alcoholism . . 224 
Acute Bright's disease . 113 
Acute Nephritis. . 113-116 
Addison's disease . 51, 52 
Albuminuria . . .Ill 
Alcoholic coma . . . 226 
insanity . . 226 
neuritis . 137-140 
Ammonia poisoning . . 220 
Anaemia . . . 45, 47, 49 
Angio-spasm . . .63 
Aneurysm . . . 73-75 
Antidotes .... 214 
Aortic disease . . .68 
Appendicitis . .19, 23, 24 
Appendix . . . 2, 17 
Arrowroot . . . 253 
Arterio-sclerosis 61, 62, 64, 67, 77 
Asthma . . . 95-97 
Ataxia-locomotor . 149-152 
Auto-intoxication 5, 50, 56, 62, 
276-280 
Baked Bread and Butter 
Pudding . . . 254 
Baked custard . . . 255 
Bile in the urine . .110 
Blood in the urine . . 109 
Brain, tumour of . 158-160 
Bright's disease . 113-117 
Bronchitis (acute) . 83-87 
(chronic) . 87-89 
Broncho-pneumonia . 94, 95 
PAGE 
Carbolic acid poisoning . 220 
Caudle .... 251 
Cerebral angio-spasm, embol- 
ism, haemorrhage, throm- 
bosis . . . 76-82 
Cerebro-spinal meningitis 184-187 
Chloride-free diet . . 122 
Chlorosis . ... 45 
Cholelithiasis . . .34 
Cirrhosis of the liver . 41-44 
Coal-gas poisoning . 222-224 
Colitis, mucous . . 24-27 
Colon stasis . . .20 
Constipation . . 3, 5, 8 
Constitutional conditions . 3 
Convalescent diet . . 291 
Cord, spinal, disease of 141-143 
Cornflour pudding . 251-252 
Corrosive and irritant poison- 
ing .... 219 
Custard sauce . . . 255 
Delirium tremens . . 227 
Derangement, mental . 161 
Diabetes and glycosuria 204-211 
Diet . . • b . 231 
in auto-intoxication 276-280 
in chronic heart disease 
280-287 
during convalescence"^ 
245-256, 291 
fluid . . . .291 
293 294 
INDEX 
Diet-continued. page 
lacto-vegetarian or fari- 
naceous . . . 292 
milk . .126, 232, 291 
protein or nitrogenous . 292 
Dietaries, hospital . .288 
Dietary in fevers . . . 231 
Diphtheria . . 180-183 
Disseminated sclerosis 146-149 
Duodenal ulcer 3, 15, 18, 19 
Dyspepsia . . . .1-2 
Eggs . . 234, 254, 257 
Embolism, cerebral . . 76 
Emetics . . . .213 
Exercises in disease 10, 24, 40, 
72, 103, 203 
Exophthalmic goitre . 53-55 
Farinaceous or milk pud- 
dings .... 252 
Fever, scarlet . . .171 
spotted . . .184 
typhoid . . 187-192 
Fish .... 265-267 
Flatulence . . .67 
Fluid diet . . . 291 
Gallstones . 3, 36, 38, 40 
Gastric ulcer . 3, 11, 13 
Gelatine .... 236 
German measles . . 171 
Glycosuria and diabetes 204-211 
Goitre . . . 53-55 
Ground rice pudding . . 253 
Gruel, malted . . .251 
oatmeal . . . 250 
H.ematuria . . . 109 
Haemorrhage, cerebral 76, 78 
Heart disease 65,66, 68-69,280-287 
PAGE 
Hemiplegia due to haemorrhage 78 
Hospital dietaries . 288-289 
Hyperchlorhydria . . 3 
Hypertrophic cirrhosis . 44 
Ileal stasis 20 
Indigestion 1, 4, 20 
Insane, general paralysis of, 
152-157 
Intestinal lavage . . 50 
stasis . . 5 
Intoxication, auto- . 5, 50 
Irritant and corrosive poison- 
ing .... 219 
Jaundice . . . 31-35, 40 
Jellies . . 238, 258, 260 
Lacto-vegetarian diet . 292 
Liver, cirrhosis of . 41-43 
Locomotor ataxia . 149-152 
Mania .... 162 
Massage 10,15,24,28,40, 48,72, 82, 
105, 132, 141, 149, 203 
Measles . . . 167-170 
german . . 171 
Meats . . . 267-272 
Meat infusions . . . 235 
Melancholia . . .164 
Meningitis, cerebro-spiaal 184-187 
Mental derangement . . 161 
Milk and its derivatives . 232 
diet . . 126, 232, 291 
or farinaceous puddings 252 
Mitral disease . . .68 
Morphine and opium poison- 
ing ... 214-218 
Mucous colitis . . 24-25 
Myelitis, transverse . 144-146 
Myocardial degeneration . 68 INDEX 
PAGE 
Nephritis, acute 113, 115, 116 
chronic . 117-120 
Neurasthenia . . 127-128 
and indigestion 20, 54, 127-128 
Neuritis, alcoholic . .137 
peripheral . 137-140 
Omelets . . . 255-258 
Opium and morphia poison- 
ing ... 214-218 
Ovaries .... 3 
Oxaluiia . . . .112 
Paralysis, general, of the 
insane . . . 152-157 
Pernicious anaemia . . 45 
Peripheral neuritis . .137 
Phosphaturia . . .108 
Pneumonia . . 91-95 
Poisons . . . 212-214 
Protein diet . . . 292 
Pulmonary tuberculosis 99-102 
Pulse, the . . 57-60 
Pus in the urine . . 108 
Pyorrhoea . . .26, 48, 55 
Radium ... 56 
Respiration ... 83 
Rheumatism . . .63 
Rheumatoid arthritis . 193-204 
Rice puddings . 253, 274, 275 
Sciatica .... 63 
Sclerosis, arterio- 61, 64, 67, 77 
disseminated 146-149 
Semolina pudding . . 253 
Southey' tubes ... 43 
295 
PAGE 
Soups . . . 260-263 
Spinal cord, diseases of 141-143 
Spotted fever . . .184 
Stasis, intestinal . . 5, 20 
Stomach, diseases of .67 
Stroke . . . 76-80 
Sugar in the urine . .Ill 
Sweetbreads . . 272, 273 
Tabes dorsalis . .149 
Tapioca and sago pudding 254 
Teeth .... 130 
Thirst quenchers . . 242 
Thrombosis, cerebral . 76 
Toxaemia . . . .127 
Transfusion . . .50 
Transverse myelitis . 144-146 
Tumour of the brain 158-160 
Tuberculosis, pulmonary 99-102 
Typhoid fever . . 187-192 
Ulceration . . .30 
Ulcer, gastric or duodenal 
3, 11, 15 
Unconsciousness. . 132-136 
Uraemia . . . 123-125 
Urates in the urine . . 107 
Uric acid . . . .112 
Urine, the . . 106-112 
Uterus .... 3 
Vaccines 28, 56, 90, 99, 105, 203 
Vegetables.... 274 
Venesection . . . 126 
Veronal poisoning . 218-219 
X-rays . . 6, 26, 55, 56 Printed by 
Bishop & Sons, Ltd 
Nicolson Square, 
Edinburgh,