r t NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland 1-10 Gift of The New York Academy of Medicine Tl By dicine 19 With the Compliments of the Publishers W. B. Saunders Company West Washington Square Philadelphia Price BOOKS BY MINNIE GOODNOW, R.N. First-Year Nursing i2mo of 354 pages, illustrated. Cloth, $1.50 net. New (2d) Edition. Outlines of Nursing History i2mo of 370 pages, with 88 illus- trations. Cloth, $2.00 net. War Nursing i2ino of 172 pages, illustrated. Just Ready. WAR NURSING A TEXTBOOK FOR THE AUXILIARY NURSE BY MINNIE GOODNOW, R. N. War Nurse in France | TKEi, v ILLUSTRATED^ Qp \/P' Lfi Mill' PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1917 Copyright, 1017, by W. B. Saunders Company PRINTED IN AMERICA PRESS OF B. 8AUNDER8 COMPANY PHILADELPHIA Dedicated to All Nurses, Trained or Untrained, of Whatever Country, Who Have Served Their Nation in the Great War. FOREWORD With the largest part of the civilized world at war, millions of men in the fighting lines, every day bringing thousands of freshly wounded and sick, women everywhere are eager to help their country and their men. Nursing the wounded has been woman's work ever since the world began, and it is an essentially womanly work. The modern woman recognizes the need of training for war nursing, the more so that in this war medical science and surgical skill have developed to a point where special knowledge is absolutely requisite. Thousands of women, not hospital trained, have tried to prepare themselves to be of assistance in war nursing. Many of them have taken short, practical courses of one sort or another. With them all there has been a constant demand for a text-book of nursing as applied to war; more, a book on nursing as applied to this war. It is to meet this demand that the present work is put forth. It is not meant for the graduate nurse, but for the auxiliary, the Nurse's Aid, who has had little or no previous training, but who wishes to learn the funda- mental' things which will be of use to her in war service. Endeavor has been made to keep the book unencum- bered with extraneous matter not applicable to military nursing. It strives to be a work adapted to war condi- tions and to war hospitals. It is hoped that the inex- 7 8 FOREWORD perienced nurse will find it of value when she comes to actually face a ward of wounded men. It can also be used as a text for teaching Red Cross and other training classes. The author's acquaintance with war surgeons and with nurses who have served in various parts of the war zone, together with her own experience in France, with the Harvard Unit, with the auxiliary hospital at St. Valery-en- Caux, and with the American Red Cross Hospital of Paris, has given her opportunity for knowing war conditions. Minnie Goodnow, R. N. December, 1917. CONTENTS CHAPTER I PAGE Etiquette and Discipline.............................. 11 CHAPTER II The Hospital Ward.................................... 15 CHAPTER III Bed Making and Changing............................. 21 CHAPTER IV Handling and Bathing................................. 30 CHAPTER V Treatments. Diet..................................... 40 CHAPTER VI Pulse and Temperature. Medicines and Solutions..... 4S CHAPTER VII Observation of Symptoms.............................. 56 CHAPTER VIII Night Nursing. Care of the Dead.................... 60 CHAPTER IX Bacteriology. Surgical Cleanliness................... 64 CHAPTER X Bandages and Bandaging............................... 69 CHAPTER XI Surgical Dressing Materials.......................... 82 CHAPTER XII Wounds. Assisting with Dressings.................... 85 9 10 CONTENTS CHAPTER XIII PAQH Injuries to Bones. Apparatus......................... 98 CHAPTER XIV Emergencies. Special Cases........................... 108 CHAPTER XV Anatomy and Physiology............................... 124 CHAPTER XVI Anatomy and Physiology (Continueil).................... 144 Index.................................................. 163 WAR NURSING CHAPTER I ETIQUETTE AND DISCIPLINE Relation Between Patient and Nurse.—It must be borne in mind that the relationship between a sick man and his nurse is one which does not exist in ordinary life, and which must, therefore, bo governed by special rules. Nursing involves a certain amount of mothering, if you will, of handling the person, of a peculiar sort of intimacy new to both patient and nurse. There must be real friendliness without loss of respect, a fine balance between condescension and cordiality. The man must be put at his ease by a matter-of-fact manner, but never permitted to feel anything approaching familiarity. Nursing must be done without any suggestion of prudishness or embar- rassment, but with a fine reserve and dignity. Spirit of the Service.—One does not go into war nursing for the mere adventure of it, but for the purpose of serving one's country or an ally in a time of serious need. The war nurse should, therefore, maintain a dignity and purity of life commensurate with the high purpose which every- one assumes her to possess. War Hospitals.—There are many varieties of hospitals which care for wounded or sick soldiers. There is the strictly military hospital, where officials and staff, in- cluding nurses, are actually enlisted in the army and sub- ject to military discipline. There is the auxiliary hospital, in which the work is to a certain extent controlled by the War Office, but whose staff is a private concern. There is also the privately owned and managed hospital that is permitted to care for soldier patients. 12 WAR NURSING In all of them there is a certain amount of official red tape and a certain number of military regulations which must be strictly observed. Some of these may seem triv- ial, but are of vital importance when millions of men are being accounted for. Superior Officers.—The man in charge of the hospital, the commanding officer, has supreme control, and his decis- ions may not be questioned except by a devious process of protest to his chief. Inferiors of all grades must do exactly as directed by their superiors, whether there is any obvious reason or not. A quartermaster cannot issue supplies, a sergeant-major cannot provide help except in accordance with rulings from higher up; if he breaks over rules, no matter how slightly, he may be in serious trouble. The nurse, therefore, should never be guilty of asking for things that have once been refused, because by her in- sistence she is sure to subject someone to a penalty. The matron of a military hospital is supreme in the control of the nurses, but is herself subject to the com- manding officer and to the numberless regulations of the War Office. Often a thing which would seem very simple for her to do is impossible because it involves other people or interferes with army rules. The Nurse's Position.—The army nurse must, there- fore, learn to accept conditions as she finds them. She must neither protest nor attempt to evade. If she does, disaster or disgrace will fall upon her or upon some other person. She must be a good soldier, uncomplaining, un- questioningly obedient. The nurse, whether she be fully trained or an auxiliary, is not permitted to make sugges- tions to a doctor, nor must she criticize his work nor his orders. In the British army, "sisters"—i. e., trained nurses— are ranked as lieutenants, yet neither here nor in other countries is it required that a soldier or officer salute a nurse. He may do it as a mark of respect, but it is not necessary. The French are fond of saluting their nurses, but there is no disrespect if they omit it. ETIQUETTE AND DISCIPLINE 13 Etiquette.—Nurses must rise when a superior officer of any rank enters the room. This includes all military officials (commissioned),1 medical officers, the matron, and the nurse in charge of the ward. Officers are distinguished by stripes or insignia on sleeves or shoulders, matrons and charge nurses by their dress. Doctors are always com- missioned officers, ranking as lieutenant, captain, major, or colonel. They are called "medical officers." Army regulations about personal matters, dress, living quarters, where one may or may not go, what one may or may not do, should—as a matter of patriotism—be strictly observed. The nurse who breaks rules, no matter how unnecessary they may appear to her, is laying open to criticism not merely herself, but her hospital, the whole nursing service, and her country. These things should make one think twice. Ward Discipline.—In a hospital ward the nurse in charge is the commanding officer, and must be obeyed and deferred to by other nurses and by the patients. The matron and the doctors are her superior officers, from whom she takes her orders. Patients are subject to the orders of the nurses, acting under the medical officers or charge nurse. If a patient refuses a medicine or treat- ment or disobeys a ward rule the auxiliary nurse may protest, and if he persists report the matter to the charge nurse, who will if necessary report it to the medical officer. In hospitals strictly military it is usually understood that the man of highest rank in the ward is responsible for its discipline. Orderlies are primarily responsible to their military head, but are also under the charge nurse. Auxiliaries 1 Military rank in the British army is as follows, beginning with the lowest: ("Private soldier. (Second lieutenant. I Lance corporal. | Lieutenan t. Non-com- Corporal. Commissioned Captain. missioned | Sergeant* Major. Staff sergeant. Lieutenant-colonel. Sergeant-major. [Colonel. The American and French are practically the same. 14 WAR NURSING may request service from them, but cannot command it. Women orderlies are under the head or charge nurse, but are hired by, and therefore responsible to, the house- keeper or hospital head. Entertaining Patients.—There are many dull hours in a soldier-patient's life, and a nurse may do much toward relieving their tedium. The men themselves sometimes take the initiative, but they need assistance and materials. Nurses should see that those who want to write letters have paper and pencil; that those who like to read have books or magazines of the sort they find interesting. Pic- ture puzzles of from 75 to 150 pieces, checkers, cards, and mechanical puzzles will be much used. A gramophone is of inestimable value; even an accordion or a mandolin will be kept busy. Most established hospitals have a supply of these things, but it is the nurse's business to see that they are made available to the patients. If there is a lack, a letter to friends at home will bring a substantial response. Auxiliaries can do much valuable work in providing materials and instructing disabled men in light occu- pations, such as macrame, wood-carving, weaving, and knitting in all their forms, etc. Soldiers are always ready to help in preparing hospital dressings and sup- plies; they usually make cotton balls, fold sponges, and roll bandages with great exactness. It is always good form to give cigarettes or tobacco to soldiers, but one must see that the ward rules in regard to their use are observed. Wines or liquors are forbidden. Chocolate, cakes, fruit, or flowers are always welcome and permissible. Birthday and holiday treats are appreciated and are in order. CHAPTER II THE HOSPITAL WARD Cleanliness is godliness when the care of the sick or wounded is concerned. A good nurse will secure clean- liness under the most difficult conditions. Removal of dust and dirt from a hospital ward is im- portant because disease germs are invariably present in it. In ordinary life dirt merely looks badly; in a hospital it is a distinct menace to the patients. A clean ward is one in which the floor, the bedside tables, the cupboards and store closets, the outside of the beds, the inside of the beds, the patients' clothing and their persons are clean, and in which everything is in order so far as is consistent with the work going on and with the patients' recreation. Nurses are the ones primarily responsible for the clean- liness of a ward and its contents. There are usually or- derlies to do the rough cleaning. The sweeping may be done by convalescent patients; before it is begun the floor should be lightly sprinkled to prevent dust flying about. The beds should be wiped with a damp cloth; the bedside tables or lockers should be wiped off and put in order; window sills, door moldings, and base-boards should also be cleansed, and the charge nurse's desk put in order. Plants and flowers should have fresh water daily. All rubbish, such as old papers, cigarette ashes, bits of food, medicine glasses, etc., should be removed; patients' small effects and clothing should be folded and arranged; the men who are able do this for themselves. Books, maga- zines, and games that are not being used should be col- lected and put into one place. Beds, tables, and chairs should be set in proper position, the beds on a line. 15 16 WAR NURSING Good ventilation is necessary where a number of people live day and night in one room. Tent wards present no difficulties in this respect, as it is impossible to close them tightly, but in huts or buildings of any sort the nurse must look after it. Though soldiers are accustomed to an outdoor life, in cold or damp weather they are likely to close everything as tightly as they can. It is difficult in crowded wards to open windows without drafts coming on Fig. 1.—Window with "hopper" top. patients who are near them. The British army huts have windows which are ideal, the top sash being arranged as a "hopper" (Fig. 1). How to Ventilate.—A blanket may be pinned or tacked by one corner high on the window casing, the next corner being fastened to a chair or bedside table, thus making a screen which protects the patient from a direct draft (Fig. 2). French windows, the sort which one nearly always finds abroad, may be opened slightly and tied, leaving THE HOSPITAL WARD 17 a good-sized crack all the way up and an opening top and bottom. One can always leave the door of the ward open and thereby secure a certain amount of indirect ventila- tion. Or, one may several times a day ask the men to cover up warmly, open all the windows, and air out for a few minutes. Since wards of war hospitals are rarely heated, any waste1 of fuel that might be involved in the ventilating process need not be considered. Fig. 2.—Screen made with blanket and chair (Aikens). Heating.—If there are any means of heating the wards they are only for occasional use, and should be employed with care and judgment. Fuel is usually expensive and hard to get. The fires, whether they be of coal, wood, or oil, should be lighted only when most needed, as for baths or dressings. Ordinarily a hot-water bottle and an extra blanket are more readily available than a fire. Care of Plumbing.—The ward plumbing may be com- 2 18 WAR NURSING plicated, simple, or none at all. There will rarely be more than one or two sinks and a toilet. The orderly usually cleans the toilet, but the nurse should see that there is a brush kept for the purpose, also that the toilet-paper sup- plied is in pieces small enough not to block the waste-pipe. The nurse usually cares for the sinks. She should see that no improper substances, such as tea leaves, coffee- grounds, fruit skins, remains of poultices, etc., are ever put into it. Frequent rinsing does much toward keeping a sink clean. Do not use sand-soap or sapolio for cleaning a sink, as it spoils the enamel; use yellow soap or a little kerosene or petrol if it can be had. Sal soda (washing soda) removes grease. If there1 is a bath-tub it should have the same care as the sink. Care of Utensils.—Bed-pans and urinals are usually cleaned by the orderly, or the nurse may have to do them. If they are thoroughly rinsed as soon as emptied the cleaning will not be difficult. Bed-pans may be scrubbed out with the brush used for the toilet and afterward well washed; disinfectants are too expensive to be used for these utensils. Hand basins should be rinsed out as soon as used and scrubbed with soap and water. Irrigating cans should not need scrubbing if they are emptied and well rinsed after using; let clear water run through the tubing. Mackintoshes from the beds or pieces of rubber sheet- ing used in doing dressings should be spread on a table and washed with a cloth, using either soap and water or a dis- infecting solution. (A brush is better for cleaning rough surfaces, a cloth for smooth surfaces.) Care of the Hands.—A nurse must care for her hands when doing cleaning or rough work and after using disin- fecting solutions in dressings, etc. If she allows them to become chapped or irritated, it will be impossible to get them thoroughly clean, and they become a source of danger to herself and others. One may wear rubber gloves for THE HOSPITAL WARD 19 cleaning; they should be the heavy (the so-called "post- mortem") kind, as the lighter surgeons' gloves wear out very quickly. A nurse should aim to keep her hands out of infectious matter-and away from discharges of any sort so far as possible, should scrub them thoroughly when she has finished any dirty work, and should wash them carefully before going to meals. Dry the hands thoroughly, as this is an important factor in keeping them from becoming chapped. It is advisable to provide oneself with a bottle of hand lotion and keep it on the ward for use several times a day. If there is the slightest tendency to chilblains on the hands, report it to the charge nurse or matron and ask for a remedy; if neglected, they quickly become serious. Do not allow the hands to remain cold for a long period.1 Care of Linen.—Neither bed nor body linen should be changed unnecessarily, as laundry is always expensive and frequently hard to get done at all. Whenever possible a towel or a sheet should be made to do for another day. Beds and wards should be kept as clean as may be, but almost never should a thing be changed merely for ap- pearance; on the other hand, a shirt or any article which comes into direct contact with the patient's body should never be left on when it is really soiled. Soldiers disregard dampness, and think that a little liquid spilled in the bed does not matter; the nurse must use her judgment in these cases. Torn articles should not be used, but laid aside to be sent to the linen-room for the "stitch in time"; or the nurse her- self may find time to do a simple repair. Linen stained with blood, feces, or other discharges should be put to soak in plain cold water; after an hour or so a thorough rinsing, preferably under a faucet, will re- move practically all of the stain. In some hospitals such articles must be dried before sending to the laundry. 1 A good remedy for chilblains is to soak them in a hot, strong solu- tion of washing soda and apply an ointment of two-fifths beeswax and three-fifths olive oil. 20 WAR NURSING Economy.—Rigid economy must be practised by every- one in a war hospital. Supplies of all sorts must be used as sparingly as is consistent with good work, since one never knows when a certain material may be impossible to get or the price become prohibitive. One should also economize in the matter of labor, since it is neither sen- sible nor right to employ labor that may be more needed elsewhere. CHAPTER III BED MAKING AND CHANGING Beds.—Military hospital bedsteads are ordinarily about 30 inches wide, of iron, with a low headpiece and no foot, or only enough to prevent the mattress from slipping. In an emergency one may have to use canvas cots or even nurse patients lying on stretchers. In rare instances the beds may consist of straw laid on the floor. Sometimes one must use hotel beds or any sort that is at hand and adapt them to hospital purposes. Army mattresses are usually good, though somewhat hard, but even the worst is better than what the soldier is accustomed to when in service. In the British army mattresses are in three pieces.1 French and British army beds are provided with bol- sters, which serve as a second pillow. Army beds are usually allowed two sheets, one or two pillow cases, and three heavy single blankets. There may or may not be a spread or counterpane. Making the Empty Bed.—Spread the lower sheet—the largest you have if there is a difference in size—over the mat- tress, right side uppermost, placing the middle fold of the sheet exactly in the middle of the bed; tuck it well under the top, even if it comes a little short at the bottom. If a bolster is used, extra long sheets are provided, so that they may be turned up over the bolster and tucked under its front instead of being tucked under the* head of the mat- tress (Fig. 3), or the bolster may be treated as part of the mattress, the sheet put over it, and tucked in as usual. In some hospitals bolster cases are provided. Tuck in the bottom of the lower sheet, pulling it tight; then tuck in one 1 Three-piece mattresses are easier to handle and transport. 21 22 WAR NURSING side, making it smooth underneath and firm, so that it will not pull out when the patient moves about in bed. Fold the corners neatly, making a "box" (perpendicular) or "hospital" (diagnonal) fold.1 Go to the other side of the bed, pull the sheet tightly, and tuck it under as far as you can, adjusting the corners as above. The lower sheet must be tight, smooth, and firmly adjusted if it is to stay in place or be comfortable. If the bed is to be protected by a mackintosh or rubber sheet (an eminently desirable arrangement, but only pos- sible in a war hospital for part of the cases), it should be spread smoothly over the portion to be protected—head, Sheet Mattress _ Jl ^ Fig. 3.—Bolster covered by sheet. foot, or middle—covered with a smaller (draw) sheet, and the whole tucked far under so smoothly and tightly that it shall appear like part of the lower sheet. If the mackintosh is too small to be tucked under, it must be pinned to the side (not the top) of the mattress with a large safety-pin, taking a large bite so that it shall not tear out. The ad- justment of mackintosh and draw-sheet is the most difficult part of bedmaking, as they must be so placed and fastened that they will remain absolutely smooth. Put on the top sheet with the right side down, exactly in the middle of the bed. Make it tuck well under at the 1 These are best taught by demonstration. BED MAKING AND CHANGING 23 foot or it will be quickly pulled out. It should come to the top of the mattress or a little more; pull it smooth; tuck it in at the foot only. Spread smoothly over it the blankets, one or two, ac- cording to season and weather. Pull each one free from wrinkles and tuck in at the bottom of the bed; the top edge should come about 6 inches below the top of the mattress. If there is to be a counterpane, turn the top of the sheet over the edge of the blankets so as to protect them and keep them from rubbing against the patient's face. Make a hospital corner at the foot and tuck the sides in smoothly. A bed looks better if each piece of covering is put on and tucked in separately, but a war nurse does not always have time for this. If a spread or counterpane is used, tuck the blankets in about halfway up before putting it on; place the spread exactly in the middle of the bed, tuck it well under the foot, making a hospital corner, and let the sides hang.1 At the top, put it under the folded-down sheet, folding in its edge if necessary. The corners of the pillow should be put carefully into the corners of the case. Lay the pillow on a table, press it flat and smooth with both hands, then transfer it to the bed. The open end of the pillow case should be away from the door or from the charge nurse's desk. If a pillow case is too large, the slack should come at the bottom of the pillow; if put at the top, it soon becomes a mass of wrinkles. A fracture bed has boards put over the springs, under the mattress, so as to make it firm and stiff. These are used only in thigh and hip fractures. A convoy2 bed is made exactly like an ordinary bed, except that it is not tucked in at the sides; it is then opened—i. e., the top covers turned down to the foot and a 1 In British military hospitals counterpanes are tucked in all the way up. 2 A convoy is a large group of wounded or sick sent by hospital train or ambulances. In war hospitals patients are almost never admitted singly, but in groups. A convoy numbering 50 is considered very small—100 to 300 at once is much more common. 24 WAR NURSING "receiving" blanket or sheet put into it, This may be a dark blanket, folded lengthwise, so that it may be put both under and over the patient, or it may be an extra clean sheet if laundry is plentiful. After this is adjusted the bed is either closed or left open, according to when the wounded are expected to arrive. When the wounded come they are usually fully dressed. The beds are opened and the patients, whether "stretcher" or "walking" cases, are placed on the receiving sheet or blanket, wrapped in it, and covered with the upper bedding until one has time to undress and bathe them. The re- Fig. 4.—Ether bed. A bed arranged for return of a patient from operation (Sanders). ceiving-sheet is removed after the admitting bath has been given. An ether bed is one for a patient coming back after an anesthetic and operation. It is made as usual except that it is not tucked in at the foot nor one side; the sheet is folded neatly back over the other covers, and the whole mass of bedding rolled or folded from one edge over to the tucked-in edge (Fig. 4), thus leaving the bed open and the BED MAKING AND CHANGING 25 covers where one movement of the arm will pull them over the patient. The pillow is laid aside and a towel pinned flat on the bed in its place. An extra blanket is placed— usually folded lengthwise—inside the bed so as to come next the patient. Two or three hot-water bottles or cans are placed in the bed to warm it; these are not removed until the patient arrives; they should not be put into the bed again so long as the patient is unconscious except by order of the charge nurse or the medical officer. On the table beside the bed put a small basin (a "pus" or kidney-shaped Fig. 5.—Changing the under sheet and draw-sheet (from Sanders' "Modern Methods in Nursing"). basin is best) for use in case of vomiting, and some small pieces of gauze or soft cloth to wipe the patient's mouth. Changing an Occupied Bed.—Draw-sheet.—Loosen both edges of the sheet, turn the patient on his side, roll the soiled sheet up as tightly as possible against his back (taking care that any wet or soiled portion is inside the roll), lay the fresh sheet lightly over the bed so as to get it in the center, and tuck it smoothly and snugly in at 26 WAR NURSING the side. Roll the rest of the fresh sheet tightly against the soiled sheet, push it down firmly, turn the patient to his other side right over the two rolls of sheet, remove the soiled sheet, pull the fresh one smooth, and tuck it in (Fig. 5). To be sure that the draw-sheet is smooth under a patient's back; pull it gently until you can sec it pull on the other side of the bed; if this is not done, it may look all right, but leave several unsuspected wrinkles in the middle of his back. If the patient is not allowed to turn, as in fracture of the hip or thigh, it is more difficult to change the draw- sheet. It takes two nurses to do it properly, one to lift the patient a trifle, the other to adjust the sheet. With a very heavy patient it may be necessary to remove the soiled sheet first and afterward adjust the clean one. The lower sheet is managed in exactly the same manner as the draw-sheet, but is a little more trouble to change dextrously. With practice the lower sheet and the draw- sheet may be changed at the same time, turning the patient but once. To change the top sheet without exposing the patient loosen the covers all around, all but the sheet and one blanket, spread the fresh sheet smoothly over these and an extra blanket over it; then, holding the two outside covers with one hand (the patient may do this for you if he is able), pull the inside covers—the soiled sheet and blanket —from underneath and off the bed. Or, the fresh sheet may be placed across the patient's chest, folded back and forth crosswise1; by slipping the hand under the covers, the clean sheet may be pulled down to the foot and the soiled one removed at the same time. Or the changing may be done from side to side. All these methods take considerable practice. To change a pillow, place the fresh one at the head of the bed where you can reach it, slip your hand down under the patient's back, between the shoulder-blades, so that the back of the neck and the head rest on your arm, lift the patient gently, slip the pillow out with the other hand, lay it aside, and slip the fresh one in (Fig. t>). BED MAKING AND CHANGING 27 Usually the pillow should go just under the edge of the patient's shoulders. If two pillows are used the top one goes under only the head. Patients have many pecu- liarities in regard to the arrangement of pillows, and what is Fig. 6.—Changing pillow. comfortable for one is not necessarily so for another. If a patient looks comfortable he is likely to be so, and vice versa. Fig. 7.—Back-rest. Back-rests, or bed-rests (Fig. 7), are usually frames of wood with canvas stretched on them. They are used to 2S WAR NURSING prop a patient when he sits up in bed. They are adjust- able to different slants. Bed cradles (Fig. 8) are frames of iron or wood used to take the weight of the bedding off some portion of the Fig. 8.—Bed-cradle for protecting patient from pressure of bed- clothes (Stoney). body. They may be small enough for a leg or arm or large enough for both legs or the body. Circular air-cushions (Fig. 9) are used chiefly to re- lieve pressure on the lower part of the back when the Fig. 9.—Circular air-cushion. patient is obliged to lie flat for long periods. They should be filled full enough to afford support, but not made too hard; the metal inlet should come at the side, never under the patient's back. They should be covered when in use with a pillow-case, bandage, or cover made to fit. Protecting Pillows.—A pillow used under a wounded BED MAKING AND CHANGING 29 limb or near a wound or a wet dressing should always be protected by a rubber pillow-case under the white one. A pillow once wet or soiled is almost impossible to clean. Bed-sores.—Patients who are very thin, who have wet dressings on or near the body, who have high fever, whose nutrition is bad, who are paralyzed, whose circulation is poor, who have involuntary bowel movements or urina- tion, or who for any reason have to lie long in one position (as with fractures of the hip, thigh, or leg) easily develop bed-sores. These usually appear at the lower part of the back, over the sacrum; they may occur over the hip bones or shoulder- blades or wherever a bone comes near the surface. They begin,with mere redness of the skin and may develop into a raw ^ore, hard to heal. Bed-sores are due to pressure, moisture, and lack of cleanli- ness. Except in the rarest instances they are a mark of poor nursing. As a rule they are absolutely preventable. Pressure may be avoided by using circular cushions, by frequent change of position (wrhen this is possible), and by frequent and thorough rubbing to stir the circulation. Except with wet dressings or freely draining wounds, or in cases of incontinence of urine or feces, there is no excuse for moisture and uncleanliness. Wrinkles and crumbs may cause bed-sores. Bathing with soap and water and rubbing with alcohol and with talcum powder are useful in preventing bed-sores. If a case is constantly wet, powder is not useful, but some substance which resists moisture, such as zinc-oxid oint- ment, etc., may be used. A coating of flexible collodion often helps. Frequent attention is the best preventive. No matter how thorough one may be, once or twice a day is not enough. Difficult cases must have care every few hours if success is to be expected. If there is a redness of the skin over a bone or an excori- ation it should immediately be reported and shown to the nurse in charge of the ward. CHAPTER IV HANDLING AND BATHING Undressing a Patient.—Before commencing to undress a wounded man ask him the location of his wounds, so that you may handle him with regard to them. Put away his cap or helmet, remove his shoes, setting them temporarily under his bed, so that they shall not become mixed with others. Take off his socks. Then remove trousers and drawers together, his shirt meantime cover- ing the genitals. If one leg is wounded, loosen the clothing of the uninjured one first, so that you may have it free for careful handling of the injured one. If the trousers will not slip off, rip the leg from the bottom up, or cut it very close to the seam. (It takes only half a minute1 longer to do it so that the garment can be repaired and used again.) Pull the bedding quickly up to the man's waist. Take off his coat, remembering that the injured side must come out last. Remove shirt and undershirt to- gether if possible. If a shirt must be cut, let it be straight down the front or along the seam. Wrap the man in the receiving-blanket or sheet until you can give him a bath; or, if the bath is to be left until later, put a hospital shirt on him and cover him well. In putting on a shirt or other garment dress the injured limb first. Care of Clothing.—Clothing worn by the soldier upon admission to hospital must be labeled carefully, so that it may be returned to him upon his discharge or accounted for to the army. This accounting is managed in various ways, according to the class and location of the hospital. The nurse's duty is to see that all articles belonging to a patient are put together and labeled with his name or 30 HANDLING AND BATHING 31 number and are delivered to the person who is responsible for them. Confusion of bundles or any mistake involves much trouble and embarrassment, Small belongings are retained by the patient and kept in his locker or bedside table. The nurse must see to these for a badly wounded patient. Bed Bath.—A soldier is always ready to help with his own bath as much as he can. A man injured only in the leg can usually take his entire bath by himself, except that he may need help with his back. Before beginning a bath, see that you have everything in readiness for it. You will need soap, a wash cloth, one or two towels (most hospitals provide a bath and a face towel for each man), a good-sized wash-basin, a slop-pail, and a pitcher of hot water. Have the water as hot as you can bear your hands in, as it will cool very quickly. Spread the face towTel over the pillow to avoid wetting it, and bathe the face and ears first. Rub gently, but get into all the corners. Keep the wash-cloth well spread out over your hand and do not let the ends drag. Be careful about soap near the eyes. Wash also the front of the neck. Some men, if the hair is short, like the whole head washed; in doing this, support the head by placing your hand at the back of the neck. Expose one portion of the body at a time, bathe it, using soap, rinse, dry, and cover. It is usually convenient to observe the following order: right arm, left arm, chest, abdomen, right thigh and leg, left thigh and leg, back and back of neck, feet; or the back may be done before the legs and the shirt put on. This order of procedure will have to be altered according to the location and severity of the wounds. The patient will wash the genitals him- self unless both hands are disabled. Give him the wash- cloth and request him to do it. The water in the basin will need changing when you are about half through with the bath. If possible, finish by rubbing the back with alcohol and afterward with powder (talcum). It is impossible to get hands and feet clean by washing 32 WAR NURSING them with a cloth; put them into the basin and scrub them with a brush if they are very dirty. For the feet the man must be able to bend his knees and the basin must be held with one hand while the bathing is done with the other (Fig. 10). They may be put into the basin one at a time or both together. Be sure to cleanse thoroughly between the toes. Fig. 10.—Foot bath in bed. Trim finger- and toe-nails and clean them. Washing Hair.—Have the man put his head out over the edge of the bed; protect it with a rubber sheet fas- tened about his neck; scrub his head with soap and hot water, using a brush to get the scalp clean. Rinse with plenty of warm water, applying it by means of a cloth. Handling Patients.—In moving a patient consider the body as having two parts, the shoulders and hips. The HANDLING AND BATHING 33 head, feet, and arms, if not injured, will take care of them- selves. Any wounded part must have special support. Think that you are to move not only the patient's flesh but his bones. Be sure that you have a firm hold not merely of the exterior of the body, but of its framework, otherwise your hands will slip and pull. A wounded leg is lifted by putting one hand at the back of the ankle, the other under the knee (Fig. 11). Do not lift a leg by grasping the foot or toes. A wounded arm is lifted by placing one hand under the elbow, the other under the wrist. Fig. 11.—How to lift an injured leg Lifting About in Bed.—Lift shoulders and hips sepa- rately; slide one arm diagonally over the shoulder nearest you, the other arm under the opposite shoulder until the fingers of the two hands touch or overlap at the back; this gives a firm hold and makes the lifting of even a heavy patient comparatively easy (Fig. 12). For the hips use the same method, one arm going diagonally under one hip, the other diagonally over the other until the fingers meet. Always have the patient bend one or both knees if pos- sible when you are lifting the hips, as it takes off much of the weight; without this precaution, lifting may be impos- sible or you may need help. 3 34 WAR NURSING Turning Patient in Bed.—To turn a patient in bed, slip one hand well under the hips, the other well under the shoulders, so that the fingers go beyond the spine. Lift slightly and roll him over. (Practise doing it from both sides of the bed, rolling the patient both toward and away from you.) Then, standing at the back, slip one hand well under the hip, the other just below the buttock, get a firm hold of the hip bone and pull the hips gently back toward Fig. 12.—Lifting patient in bed. you; this gives the bend of the body which is necessary for comfort. When a patient lies flat on his back he is usually more comfortable with the knees drawn up. If they need sup- port, a large, rather firm pillow or knee-roll filled with hair is used. Setting a Patient Up in Bed.—If you are to use pillows or back-rest practise first with someone to place them for you. Slip one arm diagonally over the shoulder nearest you, the other under the shoulder away from you. Have HANDLING AND BATHING 35 the patient take hold of your shoulder. After you have learned to do it in this way, try holding the patient with one arm and placing the pillows or back-rest with the other. As a matter of fact a soldier is a very athletic man, and even when wounded is able and willing to help himself in ways that would be impossible to a civilian or weak- muscled person. Sick soldiers are, strange to say, usually less able to help themselves than are the wounded ones. Support in a Sitting Position.—A patient sitting up in bed needs a firm support under his thighs to prevent him slipping. This may be a pillow, roll, triangular stool, etc. © © BED Stretcher © BED © ■Stretcher First position. Second position. Fig. 13.—Transferring patient from stretcher to bed. It will need to be tied with a bandage to the bed rails or in some way fastened firmly. Or the feet may be placed against a firm pillow. Lifting from Bed to Stretcher, or Vice Versa.—This requires two or three persons, and a fourth may be of advantage in some circumstances. In a war hospital there is usually plenty of help to be had at the time of trans- ferring patients. (1) Assume the stretcher to be on wheels and of the same height as the bed. Pull the bed out and a little to one side; place the stretcher at right angles to the bed, the head being toward the bed (Fig. 13). The two persons 36 WAR NURSING who are to do the lifting stand inside the angle. One person grasps the upper part of the patient's body, one arm being under his shoulders—into the armpit on the other side—the other arm well under the waist. The second person places one arm just below or at the buttocks and the other at the knees. A third person may be needed to support an injured leg or arm. At a signal the two persons lift in unison, take one or two steps backward and to the side, so as to come alongside the bed where the patient is to be deposited. (2) If there is a low stretcher of the usual army type for carrying the wounded—one with very short legs, prac- tically on the ground—three persons are needed. Bring the stretcher alongside of the bed and rest it on the edge. The two stretcher-bearers stand at the side and, support- ing the stretcher with one knee and one arm, lift the patient as much as possible with the other arm, one at the patient's shoulders, the other at his thighs; the third person, stand- ing on the opposite side of the bed, reaches across it, puts both hands well under the patient's hips, and assists in transferring him. (3) Or the stretcher may be placed, patient and all, on the bed, the patient lifted from it by two persons, while the third removes the stretcher, permitting them to deposit the wounded man on the bed. (4) If, as often happens where a building has to be adapted for hospital purposes, the stretcher cannot be brought to the bed, but must be set down on the floor at a little distance or in the hall, four persons are needed in order to avoid hurting a patient if he is much wounded. They proceed as follows. Three stand on one side of the patient (Fig. 14), kneel on the left knee, pass their hands beneath him—at shoulders, hips and knees (Fig. 15), and with the help of the fourth person on the opposite side, who also takes the hips, lift him to their knees (Fig. 16); as they rise with their load the fourth person removes the stretcher; at a signal he is carried to the bed and de- posited. HANDLING AND BATHING 37 In a great number of cases all that is needed is sup- port of the injured part while the soldier lifts himself Fig. 14.—Transferring patient from low stretcher to bed. First position. Fig. 15.—Transferring patient from low stretcher to bed. Second position. Bearers kneeling to lift the patient. quickly and easily from the stretcher to the bed, or vice versa. Getting into Chair.—In getting a patient for the first 38 WAR NURSING time up into a chair, he should sit on the edge of the bed and drop his feet to the floor, then, with the nurse holding him firmly under the arms and lifting slightly, he may swing himself off the bed and into the chair, which has been placed as close as possible. If there is an injured leg it must be supported during the transfer. Putting back to bed is the reverse of the above process, but is more difficult, as the bed is usually higher than the chair, and some lifting is required to pull the patient up to Fig. 16.—Transferring patient from low stretcher to bed. Third position. Patient lifted on the knees. its level. Soldiers, however, help themselves as civilians cannot. Slipping down in bed is always a serious symptom, as it indicates great weakness and low vitality. Two nurses are needed to pull a man up in bed; one stands at each side, each places one hand under the shoulder and the other under and slightly below the buttock; at a signal they partly lift and partly pull the patient toward the head of the bed. How to Give a Rub.—A good rub is most appreciated by a tired or restless patient, especially a medical case. To give a good rub takes skill and practice; the touch is all-important; it should be light yet firm. For arms and HANDLING AND BATHING 39 legs use both hands in rubbing; on the chest and back usu- ally but one. The stroke should be rather long, not too quick, firm enough to stir the circulation, yet light enough to glide over the skin without pulling. Forget the skin as far as possible, except that you are not to pinch or pull it; use the whole hand, palm and fingers, grasping the flesh as you rub. Think all the time of the muscles and blood-vessels and endeavor to reach and stir them. Getting Patients Ready for the Night.—Bed patients should be made ready for the night as follows: (1) Loosen the bedding at the sides and brush out all crumbs and loose dirt, having the patient move, lift, or turn as the case may be, so that you may find every bit. Crumbs under the back are most uncomfortable, and are a common cause of irritation and bed-sores. (2) Loosen the lower sheet and pull it smooth—and the draw-sheet and mackin- tosh if they are used—being quite sure that not a wrinkle remains. (3) Rub the patient's back gently but thoroughy with alcohol, followed by talcum powder (or whatever the hospital provides). The lower part of the back, over the sacrum, is the most important. Try to relieve the tired- ness of lying all day and to stir the circulation. (4) See that the shirt is smooth under the back and that the pillow is comfortable. (5) See that a urinal is placed within reach unless there is a night orderly who makes frequent rounds. (6) Pick up and put away all articles not in use during the night. Practically the same routine should be carried out in the morning for bed patients Much rubbing and a clean, smooth bed are the best preventives of bed-sores and the greatest factors in comfort. CHAPTER V TREATMENTS. DIET EXTERNAL APPLICATIONS Dry heat is a common means of relieving pain. It may be applied by means of rubber hot-water bags, metal cans, stone or glass bottles, hot bricks or stones, heated Fig. 17.—Closing hot-water bag. porcelain plates, bags of hot salt or sand, etc. Rubber hot-water bags should have the air pressed out of them before the stopper is screwed in, so that they will lie flat (Fig. 17). Stone or glass bottles should never be filled 40 TREATMENTS. DIET 41 more than three-fourths full, as the cork may be pushed out by the steam, the bed wetted, and the patient burned. Moist heat, or fomentations, are applied by means of a compress of several folds of thick woolen cloth wrung out of hot water, placed next the skin, and well covered to retain the heat. (It is almost useless to try to use cotton material for a fomentation, as it holds heat for only a few minutes.) A piece of old blanket is best. Fold the Fig. 18.—Wringing fomentation in towel. compress in a towel, place in a basin with the ends out, pour very hot water over it, grasp the ends and twist them to wring the compress (Fig. IS). Carry the fomentation, still wrapped, to the patient's bedside, expose the part of the body upon which it is to be placed, open and unroll the compress to the required size, test its heat with the back of your hand or the inside of your arm, and put it on as hot as the patient can endure it. Cover it quickly with a piece 42 WAR NURSING of some impervious material—oiled muslin, light rubber sheeting, etc.—and over this place a folded bath towel. See that the corners of the fomentation do not drip. If a fomentation is applied around a limb or joint it should be wrapped from the bottom up, the rubber or oiled muslin being spread underneath, the hot, moist flannel upon it, brought up and fastened; if wrapped from above downward it is sure to drip and wet the bed. A fomentation may be kept hot for a long time if a rubber hot-water bag—less than one-half full, so as not to be heavy—is placed over it; care must be taken that it does not burn the patient, and such an arrangement must never be used except with a person who is in good condi- tion; unconscious, paralyzed, or very ill patients are easily burned. If the fomentation is to be renewed, do not remove it until a fresh, hot one is at hand ready to be placed. Make the exchange as quickly and deftly as possible. When fomentations are discontinued, dry the part thor- oughly with a towel and rub it with alcohol to prevent chilling. Hot dressings are prepared and applied as are fomen- tations, except that they must be made and kept sterile. A thick, sterile dressing is wrapped in a clean towel, boil- ing water poured on it, the basin placed over the fire and the water allowed to boil for a few minutes. In apply- ing do not touch the inside of the dressing, the part which comes upon the wounds. Cover with waterproof material. Renew as ordered. Poultices.—Linseed (flaxseed) meal is the material most commonly used for poultices. They should be made amply large and thick so as to hold their heat. The poul- tice cloth should be too large rather than too small, of two thicknesses of gauze or one of very thin muslin. Use a good-sized saucepan for cooking the poultice; have the water boiling and stir into it the linseed meal, sifting it through the fingers to avoid getting lumps. When it drops from the spoon without stringing it is done. Re- TREATMENTS. DIET 43 move from the fire and beat well with the spoon for a minute or two to make it light. Spread thickly in the center of the cloth,1 fold the edges up to enclose the poul- tice, roll it in a towel, and carry to the patient, Poultices must be changed often enough to keep them thoroughly warm—one-half hour to two hours. A cold poultice does harm. After poulticing is discontinued wash the surface with clear or soapy water, dry, and rub with vaselin or olive oil. A mustard poultice is made with water that is merely lukewarm, as hot water volatilizes the oil which is the essential principle. Mix thoroughly in a bowl about one- fourth ground mustard and three-fourths flour, dry; be sure that there are no lumps of the mustard or they will cause burns. Stir in the water until you have a paste that will spread nicely. If vinegar can be had, use it in place of the water, as it keeps the mustard from blistering. Spread the paste on a cloth or gauze thinly, fold in the edges, and it is ready to apply. A mustard poultice is left in place fifteen to thirty min- utes, until the skin is well reddened. When removed sponge the place with warm water, dry, and rub with oil or vaselin. Mustard leaves—i. e., ready prepared plasters—need simply to be wetted in lukewarm water and applied to the skin. If the skin is sensitive place a layer of gauze be- tween it and the plaster. Tincture of iodin is often used as a counterirritant to draw blood to the surface away from an inflamed area. It is painted on the skin with a soft brush or with an ap- plicator made by twisting a bit of cotton on the end of a tooth-pick, a match, or a probe. Do not use it too wet; paint with long even strokes, covering the surface entirely. Allow it to dry before the clothing is put over it. Cold Applications.-—If ice can be secured, an ice-bag is the best method of applying cold. Crush the ice by 1 Do not spread a poultice on metal or marble, nor on a polished wood surface, but use an unfinished piece of wood or table. 44 WAR NURSING wrapping it in a strong piece of canvas or other heavy cloth (a towel is ruined by such a procedure) and pounding it with a hammer or against a stone or brick wall. Put a thin towel or cloth between the ice-bag and the skin. Cold compresses are of two sorts: One a cloth wrung out of ice water, covered thickly, and bound in place; it very soon becomes, of course, a warm compress. The other, a thin cloth wrung out of cold water, placed on the part to be treated, left uncovered, and changed often enough to keep it cold. Very frequent changing—i. e., every few minutes— —is necessary. A patient can often attend to this himself or another patient can do it for him. Enemata, or rectal injections, for the purpose of un- loading the lower bo we), may be given by the orderly if he is trained, or by the nurse. For a simple enema, soapsuds made with laundry soap is commonly used. Prepare about 3 pints of the solution, making it comfortably warm to the hand. Use a short, hard-rubber rectal tip, or a long, soft-rubber rectal tube, whichever is ordered. Take with you a bed-pan. Hang the can or bag of solution rather low, have the patient turn on his left side if possible, anoint the tube with vaselin, release the shut-off, and let the' water run through the tube into the bed-pan until it comes warm; close the shut-off, lift the bedding and the patient's shirt far enough for you to see the rectal opening (anus) and gently insert the tube. (The patient may do this for himself if he can reach and you are sure he under- stands what is wanted.) If the tip is hard rubber, push it in as far as it will go; if soft rubber, insert it about 6 inches. Release the shut-off and ask the patient to tell you if he feels the solution running into the bowel. Let it run very slowly; if there is distress, stop it for a moment; continue giving small amounts slowly until a pint or more has been taken. Bear in mind that unless a considerable quantity of fluid is introduced the desired result will not be secured.- A common fault is to give an enema too rapidly, causing distress and forcing the patient to expel TREATMENTS. DIET 45 it before he has taken enough to be effective. When a proper quantity is taken, close the shut-off and withdraw the tube. Ask the patient to retain the enema for a few minutes if possible in order to permit it to work up into the bowel. Then give him the bed-pan. Some hospitals use the Davidson or bulb syringe (Fig. 19) for giving enemata. In this case put the soapsuds into a deep basin. Insert the rectal tip, place the other end Fig. 19.—Bulb syringe. of the apparatus in the basin and gently pump with the bulb until the required amount is taken. Placing and Removing Bed-pan.—A bed-pan should if possible be warmed before being given to a patient. Most men will place the pan for themselves, but very ill patients will need help. Put the hand under the lower part of the back, have the patient bend the knees if possible, and lift with the patient's help; slide the pan into place before you release your hand, letting the patient be the judge of its position. In removing a bed- pan always put the hand under the back, so that the skin shall not be pulled or bruised. With men wounded about the upper thigh or buttock, the bed-pan may be more comfortable if placed sideways or reversed. DIET Serving Meals.—In war hospitals meals are served by the orderlies or by convalescent patients. Patients who can walk go to a common table. For bed patients the dishes are distributed beforehand—usually a plate, bowl, knife, fork, and spoon. A towel is used in place of a nap- kin. The food is passed and served direct from the 46 WAR NURSING kitchen containers, soup being brought in a pail, meat in a baking pan, vegetables in a covered kettle, etc. In this way the food arrives hot and palatable, even though it may have to be brought a considerable distance. The nurse should see that the salt is passed. Kinds of Diet.—Three classes of diet are usually recog- nized: liquid, special, and ordinary. Patients on liquid diet should be fed often, at least five or six times a day, and twice at night. The nurse should see that a sufficient amount of food is actually taken and that it is of a really nourishing character. The following liquid foods are excellent if they can be obtained: Thick soups of almost any sort, Milk, cold or hot, not boiled, Cocoa or chocolate made with milk, Malted milk, Egg-nog, made without liquor, except by special order, but with vanilla, lemon, chocolate, or other flavor, Gruel of any sort, made with or without milk, Egg lemonade, Buttermilk, Koumyss. Tea, coffee, lemonade, etc., do not count as nourishment, though they are usually allowed. Special diet usually includes: Eggs, poached or soft boiled, Milk toast, Cereals, cooked, Gelatin preparations, Custards, boiled or baked, Simple puddings, such as bread, rice, sago, tapioca, cornstarch, etc., Chicken, Oranges, apples, or stewed fruits. Regular or ordinary diet consists, in strictly military hospitals, of army rations with a few extras. In any case, it is usually plain, wholesome, and sufficient. It includes: meat (once or twice a day), bread, rice, potatoes, other TREATMENTS. DIET 47 vegetables when obtainable, sometimes eggs or fish, stewed dried fruit (rarely fresh), etc. Wounded men are practically always on ordinary diet. The sick are those on special or liquid diet. Feeding Patients.—Very ill patients must be fed. If the food is liquid, it may be given through a bent glass tube or a straw or by means of a feeding cup (a covered cup with a spout), or the patient may drink directly from a glass or cup if it is not more than half full. In feeding, prop the patient's head and shoulders up a little with the pillows and spread his towel smoothly under his chin. Do not give too large mouthfuls, and watch that the spoon does not drip. A patient whose right arm is disabled may feed himself if his food is cut up and prepared for him. Or, another patient may be willing to do this, or even to feed a com- rade; but the nurse must see that he himself does not get a cold meal in consequence. Watching Appetite.—Sick patients—i. e., those in medi- cal wards—may not have an appetite and may need to be urged or coaxed to eat. It is the nurse's business to see whether the patient is getting sufficient food. If he is not, it should be reported; she should at the same time endeavor to secure articles of food that he fancies. CHAPTER VI PULSE AND TEMPERATURE. MEDICINES AND SOLUTIONS Pulse, temperature, and respiration are called the three vital signs. Of these, pulse is the most important. In diseased conditions all three may be affected; in wounds, not necessarily. Pulse.—Every beat of the heart sends a wave or im- pulse through all the arteries. This wave is called pulse. When an artery lies near the surface one can feel the pulsa- tion and so judge of the quality and frequency of the pulse. Pulse-rate is modified by age, being faster in children and slower in old persons; by position, being slower while lying down, faster when standing; by exercise; by emotion; by temperature, it increases 10 beats per minute to each degree of temperature; by disease, and by personal peculiar- ity, some persons having a naturally Slow or fast pulse. A pulse-rate of 70 beats per minute is considered normal for men, 80 for women. However, pulses of 50 to 60 are common among men, even young men. A pulse of 40 is very unusual. A pulse-rate of 100 should be reported. One of 120 is alarming. Pulse rarely goes higher than 150. Quality of pulse is more important than rate. It re- quires experience to judge of quality, but the nurse should lose no opportunity to gain that experience; she should not take a pulse without observing its quality as well as its rate. The points to be observed are force, volume, tension, and rhythm. Pulse may be full, thin, hard, compressible, weak, bounding, soft, wiry, thready, vigorous, sluggish, etc. Pulse is irregular when the beats vary in force and 48 PULSE AND TEMPERATURE 49 length; this may be discovered by counting by quarter or half minutes and noting whether each is the same; it should be reported if found. Pulse is intermittent when beats are dropped or omitted; it should be reported. If the beats are not distinct, report it. For convenience, pulse is taken at the radial artery. (It may also be counted at various other points, as in the temporal artery, the facial, the carotid, etc.) Feel for the wrist pulse just below the root of the thumb, placing the first two fingers over the artery (Fig. 20). See that Fig. 20.—Counting pulse. the patient's hand and arm are relaxed and lying com- fortably, not held up or on a strain. Temperature, or bodily heat, does not depend upon external conditions, but upon internal. It is the result of the balance between the chemical reactions taking place in the tissues, muscular action, etc., and the loss of heat by radiation, evaporation, etc. Normal temperature is about 98|° F. or 37° C. It is slightly higher at night than in the morning. Temperature varies very little in health—not more 4 50 WAR NURSING than a degree—and only about 10° F. in disease (Fig. 21). Subnormal temperature, indicating a lowered vitality, is from 94° to 98° F. Temperature above normal indicates an active process of disease; 101° or 102° F. is considered fever; 104° F. is alarming. Temperature rarely goes above 105° F.1 For convenience, temperature is taken by the mouth, the bulb of the thermometer being placed well under the tongue and the lips kept closed for the required time, one to five minutes. It may also be taken in the armpit (ax- illa), though this is less accurate. If so taken, one must be sure that no clothing touches the thermometer bulb, and that it is well up between the arm and the chest. Axillary temperature is about | degree lower than that of the mouth. Temperature taken by rectum is usually the most correct. 95 IOO 105 Fig. 21.—Clinical thermometer (Pyle's "Personal Hygiene"). It is about \ degree higher than mouth temperature. The thermometer should be oiled or vaselined and inserted gently for an inch. The patient may be permitted to do this himself if he understands what is wanted. Clinical thermometers are made so that they remain at the highest point until shaken down; to do this, grasp the thermometer firmly between the thumb and two or three fingers, the bulb end being free and downward; give a quick, sharp wrist-jerk, repeating as necessary. Keep thermometers in some disinfecting solution. Wash them in cold water before and after use. Do not attempt to take a delirious person's temperature by mouth. Do not take temperature without observing both pulse and respiration. Temperature charts (Fig. 22) are graphic records of the course of a patient's temperature. 1 In sunstroke it may be 109° or 110° F. PULSE AND TEMPERATURE 51 Respiration.—Normal respiration is 18 to 20 breaths per minute. Respiration slower than 14 per minute should be reported, also anything above 24; 35 to 40 is alarming. Below 10 is serious. To count respiration watch the rise and fall of the chest or abdomen. Do not place your hand upon the chest nor Fig. 22.—Temperature chart of lobar pneumonia (Paul). let the patient know that you are counting, as it is almost impossible for one to breathe naturally when observed. Quality of respiration should be noted, whether it is deep or shallow, regular or irregular, smooth or intermittent, easy or difficult. MEDICINES Ward medicine cases are supposed to be kept locked, and in any case patients are not allowed to go to them. Giving medicines constitutes a definite responsibility; it is very easy to make a mistake. To avoid getting the wrong medicine, do not attempt to remember either the bottle or its location, but always read the label of a medicine bottle or box twice, once as you reach for it and again after you have measured out the dose. Liquid medicines should be poured from the side of �659574741�86755�8455875 52 WAR NURSING the bottle opposite the label, so that it shall not be soiled. A medicine-dropper or a "drop-bottle" may be used to measure small quantities of medicine. Pills, tablets, etc., should not be touched by the fingers. Use a spoon, tip the bottle, and roll it gently to get the pill out. A glass of water should always be offered with a medi- cine, whether it be liquid, pill, or powder. Medicines of disagreeable taste may be followed by a bit of orange or a mouthful of bread. When a number of medicines are to be given at one time, as in a large ward, some exact system must be es- tablished in order to avoid mistakes. No one but a druggist or head nurse should take the responsibility of relabeling bottles of medicine. A nurse should study the effect of the common drugs, so as to note whether or not they are accomplishing their object. Doctors will always be found ready to explain why certain drugs are being given. Hypodermic Injections.—Drugs given hypodermically (i. e., under the skin) act more quickly and surely than those taken by mouth. Hypodermic tablets are specially prepared so as to dis- solve readily. Liquids for hypodermic use often come in ampules—tiny sealed bottles, containing but one dose. If tablets are used, one should be very sure that she esti- mates the dose correctly.1 In giving a hypodermic injection strict surgical cleanli- ness must be observed, or an irritation, even an abscess, may result. W^ash the hands, boil the syringe, the needle, and a teaspoon. (If the syringe has leather washers it 1 A mistake may occur when one has not at hand a tablet of the exact dose ordered. For example, \ gr. of morphin may be ordered and only |-gr. tablets be on hand; one must therefore divide the tablet with great accuracy, or dissolve it in a measured amount of water and use only the required amount—in this case two-thirds. Or ^5 gr. of strychnin may be prescribed and the tablets available be TV gr.; in this case one must not become confused over the fraction, but remember that two tablets will be required. PULSE AND TEMPERATURE 53 must be sterilized by soaking in a disinfecting solution.) Take out the needle by means of the spoon, set it in a safe place with the point up. Fill the syringe about half full of the sterile water, place the correct tablet in the spoon, add the water from the syringe, and dissolve the tablet by gently shaking or stirring with the syringe point. Be sure that every particle is dissolved. Draw the fluid up into the syringe, fit on the needle, being sure that your fingers do not touch the point, but only the collar. Hold the syringe with the point of the needle straight up, and push the piston slowly until all air is expelled. Lay the prepared syringe on the table, with the point off the edge or wrapped in a sterile sponge, while you prepare the patient for the injection. Choose a fleshy portion of the body, where there are no bones nor blood-vessels of any size. The outside of the arm Fig. 23.—Method of giving a hypodermic injection (Thornton). or thigh, the buttock, or the back are usually chosen. Scrub a small area with a bit of clean cotton wet with alco- hol or iodin. Grasp the flesh firmly with the left hand, take up the syringe, and push the needle quickly into the flesh, preferably at an angle (Fig. 23). Then press the piston slowly to inject the fluid, being sure that every drop is given. Withdraw the needle and rub over the place with the alcohol or iodin sponge. Clean the syringe by drawing up into it (1) sterile water and (2) alcohol or ether. Put a wire through the needle to keep it from becoming stopped with dust. Keep in a covered box. 54 WAR NURSING The Nurse's Personal Medicine.—A nurse should not take drugs of any sort without the advice of her head nurse or a physician. Xo nurse should administer to herself any pain-dispelling drug. WEIGHTS AND MEASURES A knowledge of the simpler apothecaries' weights and measures is necessary if one is to give medicines or make up solutions. APOTHECARIES' FLUID MEASURE 60 minims = 1 dram (oj); 8 drams = 1 ounce (5j); 16 ounces = 1 pint; 8 pints = 1 gallon. (The English pint contains 20 ounces.) APOTHECARIES' WEIGHT 60 grains = 1 dram. ^?JJJtf^''ift~JsgXU^tit/iTfiT?^^^TTiTiT?fllllt|i|l|IJitllll^ll|ln^fMi|rlf^i/yi^rjTTTrijrj^ Pfff''lnr—411 llllllllliliiilmllll " '11■ ■ 1.........'.......iimtuuimiumiMommffl Fig. 53.—Rubber drainage-tube. Drains may be of (1) rubber tubing in various sizes (Fig. 53); holes are cut at intervals in the end which is placed in the wound; (2) strips of gauze folded; (3) strips of rubber tissue folded; (4) tubes threaded with gauze; (5) gauze strips loosely wrapped in rubber tissue. Drains must be carefully made. If gauze is used, no threads nor raw edges are permitted. Sterilization.—All materials which are to touch a wound or come near it should be sterilized. This is usually done in steam-pressure sterilizers (see Chapter IX). Goods which are well wrapped remain sterile for a long time. Dressings, drains, etc., which are to be used wet may also be sterilized by (1) boiling, or (2) by soaking in an antiseptic solution. When dry dressings are used only the inner pieces need be sterile. For wet dressings all except the outmost" layer must be sterile. Fluid soaking out from a wound makes a path for dirt or infection to travel in. This does not occur with dry dressings unless there is much discharge. CHAPTER XII WOUNDS. ASSISTING WITH DRESSINGS Wounds are classified as follows: (1) Bruises are wounds, strictly speaking, but they are not usually treated as such. (2) Abrasions are slight wounds, the outer skin being scratched or rubbed off. They may be cleaned and dressed with a smooth, sterile dressing. Vaselin applied to the injured surface will usually make it more comfortable. If left uncovered, dirt may get in through an abrasion and an infection result. As a rule, however, abrasions seal themselves in with serum and heal under a crust or scab. (3) Incised wounds are those made by a straight, sharp instrument. They may fall together of themselves or may remain open. There may be considerable bleeding from an incised wound, the amount depending upon the depth, size, and location of the wound. If such a wound is an operative or surgical incision, made by a sterile instrument in a properly prepared area, it is clean—i. e., not infected—and its edges may be brought together and sewed or strapped; it should heal quickly and without event. If an incised wound is made by an instrument not sur- gically clean it is ordinarily sponged or irrigated gently to remove foreign matter and bacteria so far as is possible. A wound which bleeds freely is often washed out by this means. Such wounds are, however, considered as infected and are treated accordingly. If there is hemorrhage or excessive bleeding it should be stopped by appropriate means (see Chapter XIV). One usually leaves such a wound open, that it may drain and heal up from the bottom. 85 86 WAR NURSING (4) Lacerated wounds are torn and irregular; a portion of the flesh may have been torn, pulled, or blown away. In some cases the whole limb may have been torn away, leaving a jagged stump. These are the most common wounds in war; they are caused by exploding shells, shrap- nel, bombs, etc. There is not likely to be great hemor- rhage unless large blood-vessels have been torn. Such wounds are cleansed as best they may be by spong- ing or irrigation; any pieces of shrapnel or clothing which can be seen are picked out with forceps, hemorrhage is checked by the proper measures, and sterile dressings are applied. They are usually treated by wet antiseptic dressings and must fill in from the bottom. They leave large scars. (5) Contused wounds are those caused by a blow with a blunt instrument. There is usually a large, bruised sur- face with a small open wound. (6) Punctured wounds are those made by bullets or the stab of a pointed instrument, as a bayonet, dagger, etc. There is not much hemorrhage unless a large blood-vessel has been injured. Punctured wounds are dangerous because the instru- ments which make them nearly always carry in dirt or infection; this may cause trouble deep in the tissues long after the external wound has healed. Tetanus (lockjaw) may develop in such wounds because its germ is anaerobic (i. e., grows in the absence of air). Antitetanic serum is usually given as a preventive. Bullet wounds may be merely (1) punctured, having a wound of entrance only, in which case the bullet remains in the body; it may have entered in a straight line or have been deflected in its course by bones, or it may be (2) through and through, with two external wounds, the wound of entrance and the wound of exit; the wound of exit is usually the larger. If a bullet remains in the body it is located by means of the z-ray, and may or may not be removed. If removal would necessitate cutting through or into important WOUNDS. ASSISTING WITH DRESSINGS 87 tissues, it is often better to do nothing; nature covers in the foreign body with fibrous tissue, and it quite frequently makes no particular trouble. If a bullet or other foreign body has penetrated a joint a permanent injury always results. (7) Compound fractures, in reality lacerated wounds, are wounds complicated by broken bones (see Chapter XIII). They are the most difficult injuries with which the war surgeon has to deal, and they invariably require special treatment and apparatus. They are always in- fected and long in healing. Healing of Wounds.—Clean wounds heal very quickly, sometimes in a few days, though the tissues are not solid in that time. Infected wounds are slow in healing, and may take weeks or months; the process is hastened by keeping the wound clean, by drainage, and by the use of weak antiseptics which kill or prevent the growth of the infecting bacteria. It is a common practice to keep war wounds continually wet with an antiseptic solution. This is accomplished (1) by renewing a wet dressing frequently or (2) by the use of the so-called "Carrel" tubes (named from the inventor, Dr. Alexis Carrel of France). Carrel tubes (Fig. 54) have a closed end and several small openings at the side; they are inserted directly into the wound itself. Fresh solution is poured into them at ^fegSwfp-«rfw-'T'S'»*iUrfw«^^mTm««rtHm«.....l!Mlll^lH^..^^4.^.l./j|\ *?"itaittiffirtn-' "■ ' .■■■■ffr?v",--i'l~iiinr--i............'.......'.............I"""1 Fig. 54.—Carrel tube. intervals, either by means of a hand-syringe or by letting it run from a bottle hung above the patient's bed (Fig. 55). In either case the wound is kept flushed out and wet with the desired solution. Different tissues heal at different rates of speed, ac- cording to the amount of blood-supply which each has. Flesh or muscle is repaired rapidly, and the parts of the 88 WAR NURSING body which have the most blood-vessels, as the face and hands, repair most quickly. Cartilage and bones have few blood-vessels and their repair goes on slowly. With Fig. 55.—Showing Carrel method of irrigating wounds with the Dakin fluid (Keen, modified from Carrel and Dehelly). muscle the healing is a question of days; with bones, of weeks. Blood-vessels when injured heal, but are no longer use- ful. The circulatory system is a network which permits the blood to take a fresh route when the original one is blocked; in this way blood-vessels originally small may WOUNDS. ASSISTING WITH DRESSINGS 89 :,M ■ ft become large after an injury, because they are carrying on a greater amount of work. The healing process in any tissue is retarded or pre- vented by the presence of bacteria or infection. A wound may remain unhealed for weeks or months if it is not kept clean. Until the white cells are able to overcome the invading bacteria, until the building-up process goes on faster than infection and tearing down does, a wound will not heal. We therefore dress or clean and care for a wound in order to expedite the healing. Scars and Scar Tissue.—If two clean, smooth surfaces in a wound are brought together they adhere and heal; this form of healing is said to be by first intention, and there is practically no scar. In other cases the healing process necessi- tates some filling in between the torn or cut surfaces. This filling in is by granulation, the tissue being built up a cell at a time. The tissue so formed is usually fibrous or connective tissue, and is harder and firmer than the original. It constitutes the scar. Scar tissue in muscles is not elastic to any extent. In broken bones the union is made first by fibrous tissue, which is afterward filled in with bone cells. This filling is at first excessive, and forms a ring or knob at the broken place, called the callus (Fig. 56). After seme time the callus reab sorbs, leaving the bone nearly normal in size. Fig. 56.—Repair of bone: 1, Peri- osteal callus; 2, medullary callus or dowel; 3, loos- ened periosteum. SURGICAL DRESSINGS The auxiliary nurse usually begins her work with wounds by helping with the simpler things required in 90 WAR NURSING doing the dressings. After practice and observation she learns the proper technic, becomes familiar with the ap- pearance of wounds, and is able to recognize to an extent whether the healing process is going on, and may then be permitted to do simple dressings by herself. Important dressings of large or complicated wounds usually require two persons, and may need three. When one goes rapidly from one dressing to another, as is usual in a military ward, at least three persons are needed in order to have the work go on quickly and smoothly. One nurse, usually an auxiliary, goes ahead, places mackintoshes under and around the part to be dressed, removes the bandages (many patients do this for them- selves), seeing that the dressing is not disturbed, and ar- ranges the waste-pails or basins. Sometimes she is also made responsible for providing fresh bandages—espe- cially the hip, shoulder, abdominal or scultetus—which will be needed in rebandaging. See that the patient is near enough to the edge of the bed to be reached, and that he is comfortable and properly covered. Turn the bed- ding back neatly from the part, and arrange it so that it shall not become wet or soiled. If a bandage is clean enough to be used again, have the patient or his neighbor smooth and roll it. (A special bag, pail, or basket is pro- vided for bandages which are to be washed.) Safety-pins should be saved for further use; if badly soiled they may be boiled. External dressings which are not soiled may be used again, or they may be dried and resterilized. Waste cotton is often saved for munition making. During the dressing an auxiliary may be asked to hold a leg or an arm in position, to resterilize instruments, to hand articles from the dressing carriage, to open packages of sterile materials, etc., or she may be getting the next patient ready. When a dressing is finished the auxiliary may do the bandaging and tidy the patient's bed. Do not talk while helping with dressings. If asked to remove a dressing, grasp it by the cleanest WOUNDS. ASSISTING WITH DRESSINGS 91 portion and turn it over, so that any discharge upon it may be seen. Inner dressings are, as a rule, removed with for- ceps. k~~ -Trp^yW Ma 1 \ w t, t- , ' rs »v: f''^6"*^" To open a package of sterile dressings, grasp the wrap- ping an inch or two back from the edge, so that you shall not touch the contents with your fingers. 92 WAR NURSING Do not put the fingers upon the edge of a solution basin nor even of a waste-basin; put the hands entirely under- neath (Fig. 58). If asked to pour something from a bottle into a wound or on a dressing, wipe the mouth of the bottle before pouring. If the cover of a jar or the stopper of a bottle must be laid Fig. 58.—The right way to handle a solution basin. down, turn it with the inside up and see that it does not touch anything. When handing the tubing of an irrigator, take hold of it at least 6 inches from the end, so that the doctor or other nurse need not put their hands where yours have been. All materials used in doing surgical dressings must be sterilized and kept so. The dressing carriage is a portable table, more or less elaborate in its appointments, contain- ing everything needed for doing dressings (Fig. 59). It is stocked with solutions, alcohol, iodin, green soap, etc.; WOUNDS. ASSISTING WITH DRESSINGS 93 with sponges, dressings, drainage-tubes, instruments, ad- hesive plaster, protective dressings, bandages, etc. Instruments are kept in a sterile pan or towel, and are Fig. 59.—Dressing carriage with irrigator and solution bowl (Aikens' "Hospital Management"). passed with sterile forceps to the surgeon or nurse who is doing the dressing. (If the forceps become unsterile at any time, by accidentally touching something which is 94 WAR NURSING not sterile, resterilize it by reboiling or by holding it for a moment in an alcohol or gas flame.) To sterilize instruments boil them for from three to five minutes in a 1 per cent, solution of sal soda; the soda acts as a disinfectant and also prevents them rusting. Knives are not boiled unless by special request; if they are boiled, the blades should be wrapped in cotton and the edges should not be allowed to strike against other instruments. Scissors should be boiled as rarely and as short a time as possible, as the heat takes off the edge. Dressings Done by a Nurse.—If the nurse herself is to do a dressing she should make the same preparation that she would for the surgeon and follow his methods. A second nurse may be needed to assist, or she may be able to arrange her materials so as to get along alone. Helping an older nurse with a dressing is an excellent way for the auxiliary to learn to assist a surgeon. Before beginning a dressing the hands should be thor- oughly cleaned. Put up the sleeves, use a soft, sterile brush, plenty of soap, and hot, running water if it is to be had. Keep the nails short and clean. Scrub the hands systematically, beginning with the thumb. Consider that each finger has four sides and do not forget the spaces between the fingers. Pay special attention to the nails. Include the wrists. After the scrubbing soak the hands for a minute in a disinfecting solution. For very dirty dressings, or those where there is much discharge, it is well to wear rubber gloves. In doing a dressing copy the surgeon so far as is pos- sible. Try to be deft. Cultivate a light touch, and en- deavor to cause as little pain as is consistent with good work; do not, however, let sympathy for the patient pre- vent you from being thorough. Watch a skilful surgeon, and note how he cleans a wound well but with a light touch; a clumsy person with good intentions may hurt the patient badly and still not get a good result. In dressings and in all procedures with surgically clean hands remember to keep the hands clean. This requires WOUNDS. ASSISTING WITH DRESSINGS 95 much practice and concentration of the attention. Be- fore you begin get well in mind just what things you may touch and studiously avoid all others. Do not permit yourself to make "breaks" in technic. If a sterile article touches anything unsterile reboil or discard it. In modern military nursing it is the custom to handle everything with sterile forceps. This method is quicker, leaves fewer chances for breaks in technic, and protects the hands from possible contact with pus, and, therefore, from danger of carrying infection to other patients. Fresh forceps are used for each case. Care of Instruments.—In cleaning up after dressings the instruments should be washed in soapy water (or if there is blood on them, in clear water, cold); take each one apart and scrub the joints and rough places so as to remove any accumulation of material. Boil them for five minutes in soda solution, being sure that scissors are not boiled a moment too long. Rub them well with some polishing powder that does not scratch, rinse them in very hot water, and dry them thoroughly. In damp climates the joints should be treated with vaselin to prevent rusting. Do not scour the cutting edge of knives and scissors. Preparation for Operation.—Patients who are to be operated upon usually have a cathartic given them the night before. They omit the last meal before the opera- tion, so that the stomach shall be empty; food in the stom- ach at the time of taking an anesthetic may produce vomit- ing during the anesthesia. Water may be given until two hours before the operation and it is advisable. The patient should have on a clean shirt and warm, long stockings. He should have urinated recently. If he is to go on a stretcher, he should be warmly wrapped. If he walks to the operating room, he should have a warm robe, and blankets should be sent with him for his- return. His chart is sent with him. A local preparation may be ordered—i. e., the locality to be operated upon is shaved, scrubbed well with soap, and painted with iodin. Usually a sterile dressing is put on. 96 WAR NURSING In the majority of war wounds there is no local preparation, since the dressing covers the part to be operated upon. Care After Operation.—When a patient returns from the operating room he is put into a warmed bed and well covered. Even in summer there should be considerable cover until he has reacted well from the depression caused by the anesthetic. There should be no pillow until the nausea has worn off. An unconscious patient should not be left alone even for a minute. He may fall out of bed or may injure himself by striking the bed; may vomit and get matter into the trachea; may disarrange the covers and become chilled; or may suddenly collapse. The nurse should remain at the bedside, see that he is kept covered and lies quietly. If vomiting occurs, turn his head to one side and hold the basin for him. Guard the hot-water bags which have warmed the bed. As a rule they should be removed, but if left, put them out- side the covers; it is very easy for an unconscious patient to be burned. What to Watch.—The pulse is the important thing to be watched, and any weakness or irregularity in it should be at once reported. Note the color of the face and report any special pallor or blueness. Watch the respiration, noting if it is shallow, sighing, or irregular. After water is allowed, remember to give it frequently and in small quantities. A large amount given at one time is likely to produce or aggravate nausea, whereas small amounts do not. Do not report pain until you are sure that the patient is entirely out from the anesthetic. There is some danger from hemorrhage after operation, and the nurse should know its symptoms and be on the watch for it. Paleness of the face and lips, weak pulse, faintness, "air hunger," and sighing respiration may in- dicate internal hemorrhage. Treatment of Burns.—Ambrine and similar substances are used in treating burns, and have revolutionized former WOUNDS. ASSISTING WITH DRESSINGS 97 methods. The specified technic for their application must be followed exactly if success is to be attained. The Ambrine technic includes the following points: . Raw surfaces are cleansed by gentle irrigation or by dragging over them the ends of a bit of wet cotton. Spong- ing in the ordinary sense of the word should never be done. Granulations should not be pressed upon nor made to bleed. The surface to which ambrine is to be applied must be absolutely dry. The diying must be done gently, preferably by a current of warm air. The melted ambrine is painted or sprayed quickly upon the raw surface, using it as hot as the patient can bear it. A thin film of cotton is laid over, and another coat of am- brine applied. The whole is covered quickly with a thick pad of cotton and bandaged in place. The ambrine dressing is peeled off and renewed daily. Sloughs or dead skin are to be removed only when they come off easily. 7 CHAPTER XIII INJURIES TO BONES. APPARATUS Sprains.—When a joint is wrenched or twisted, with resulting injury, it is called a sprain. There may be actual tearing of some of the ligaments which bind the bones together and even some displacement of the bones. There is always bruising, swelling, and acute pain. The immediate treatment of a sprain is the application of cold followed presently by heat. Fomentations are often used to reduce the swelling and tenderness. Sprains are usually put up in plaster casts. Snug bandaging and massage are used. They are long in healing. A dislocation is the displacement of a bone at a joint. It occurs most commonly at the shoulder. Dislocations must be reduced—i. e., the displaced bone put into place—as soon as possible, otherwise there is pain, swelling, and tenderness which prevent healing. The re- duction may have to be done under an anesthetic. There is no after-treatment except to keep the joint reasonably quiet until the surrounding tissues have re- turned to normal. A bandage may or may not be applied. FRACTURES A broken bone is said to be fractured. Fractures are: (1) simple—i. e., broken across without external injury. They may be transverse or oblique. In an oblique fracture the ends tend to slip past each other, wound the surrounding tissues, and become permanently displaced. In almost all fractures there is some wounding of the surrounding tissues and some internal bleeding. (2) A comminuted fracture is one in which the bone is 98 INJURIES TO BONES. APPARATUS 99 more or less crushed and there are small pieces between the two larger ones. The injury to the surrounding tissues is considerable. Often one or more fragments of bone die and decompose, or an abscess may form. (3) A complicated fracture is one in which a large artery, vein, or nerve is torn, or where one of the internal organs, such as the brain, lung, liver, spleen, kidney, or bladder is wounded by a broken end of bone. The damage may be slight or serious. (4) A compound fracture (see Wounds) is one in which the skin and external tissues are torn through. The ends of the bone may protrude outside the wound. These are .TRANSVERSE OBLIQUE, COMMINUTED COMPLICATE!} COMPOUND SIMPLE Fig. 60.—Various forms of fracture. always serious injuries because they are always infected. They are troublesome to care for and long in healing. (5) An impacted fracture is one in which the broken ends of bone—or two bones not broken—are driven into each other. They are rare and difficult to remedy. (6) A depressed fracture is one in which a piece of the skull is broken off and driven in against the brain. (7) Greenstick fracture is one in which the bone is cracked but not broken across. It occurs chiefly in children. The z-Ray in Fractures.—It is customary to examine fractures or suspected fractures with the z-ray in order to be sure of the exact state of affairs. 100 WAR NURSING It is usually necessary to secure at least two views of the fracture in order to locate it with accuracy. Without the x-ray fractures must be guessed at, as the pain, swelling, etc., which are always present prevent proper or thorough examination. Results of Fracture.—All muscles naturally contract; when a bone is broken the muscles which surround it and are attached to it, therefore, tend to pull on the fractured ends and displace them. When the muscles are very large -■"' Fig. 61.—x-Ray picture of stellate fracture of the ulna from gunshot wound (Spencer). and strong, as in the case of the leg or thigh, the pull has so much force that, unless special means are taken to keep the broken ends in place, they will slip past each other and the limb become permanently deformed and shortened. A bone is set by placing the ends which are broken in their proper position, and holding them there by some means until the healing process takes place. This is ac- complished by means of splints, plaster casts, sand-bags, extension apparatus, etc. INJURIES TO BONES. APPARATUS 101 Splints are made of wood or thin metal.1 They must be lined or padded so as to be comfortable, as when once ad- justed they are left in place for some time. Straight splints are made of small boards covered with cotton— preferably the non-absorbent—bandaged smoothly in place. If they are to be used near wet dressings they should be covered with some water-proof material. Flat metal splints are usually shaped like the part to which they are to be applied. They are lined with several layers of wadding or non-absorbent cotton, smoothly adjusted. Fig. 62.—Splint applied for fracture of the forearm near the wrist- joint (Scudder's "Fractures"). Splint padding and lining must be changed when it be- comes soiled or torn. Splints must be very carefully adjusted, so as to accom- plish just the purpose for which they are designed. In bandaging a splint against a limb be sure that it does not get pulled to one side during the process, and that it is firm but not too tight. Plaster casts are made with bandages impregnated with plaster-of-Paris; they are usually roller bandages of crino- line filled with dry plaster. For putting on a plaster cast there will be needed several plaster bandages of the proper width (usually 2 inches 1 Improvised splints may be of any stiff material that is at hand, as pasteboard, small limbs of trees, a sword, rifle, etc. Even a pillow may be used as a splint. 102 WAR NURSING wide for the arm or ankle, 3 inches for a knee or leg, wider for the body), a deep basin of tepid water, a few gauze bandages, and some sheet wadding (white), torn or cut into strips and rolled like a bandage. The bed should be protected with a sheet so placed as to catch all the splash- ing of the plaster; the floor may be protected with news- papers. The skin is first covered with some soft material, as a gauze bandage or the wadding; sometimes a stocking or a Fig. 63.—Applying a plaster cast (Scudder's "Fractures"). piece of knitted underwear is used as a foundation. These absorb perspiration and prevent pressure and discomfort from wrinkles. The plaster bandages are put to soak, one at a time, in the basin of water; they should be stood on end and left in only until the bubbles stop coming from them; the water must be deep enough to entirely cover them. As one bandage is handed to the surgeon, put in another, but do not soak more than are needed, as they will be wasted. INJURIES TO BONES. APPARATUS 103 Plaster casts are always put on by a surgeon, as they require skill, exactness, and a knowledge of the condition to be remedied (Fig. 63). Granulated sugar or coarse salt will remove plaster which has gotten on the hands or skin. The sheet which protects the bed should be rinsed out quickly so that the plaster will not set on it. Any spots on the floor should be quickly wiped off. A fresh cast is left exposed to the air so that it may dry out. It "sets" in a short time and becomes stiff and hard. When it is thoroughly dry the edges are trimmed if necessary; it is the nurse's business to see that the edges remain smooth and that they do not cut into the flesh or irritate the skin. Any crumbs of dry plaster in the bed are very irritating. In moving a patient who is wearing a plaster cast re- member that the cast is heavy, that the limb is injured, and must be supported and lifted with great care. Sometimes starch bandages are used in place of plaster when a very light, small cast is needed. They are made by passing gauze bandages through boiled laundry starch and are used wet. For removing a cast, a strong, stiff knife is used, some vinegar, and a medicine-dropper. The surgeon will mark a line where he wishes to cut, and the nurse will follow the fine with vinegar trickled from the dropper: this softens the plaster and renders it easy to cut. Sand-bags are long, narrow sacks filled with sand or earth and covered with rubber sheeting or other water- proof material. They are used to keep a fractured limb in position when for some reason a cast or splint is not desirable. They are usually temporary measures. They must be kept in the exact position in which the surgeon places them. The patient can be allowed to turn or move but very little. Extension apparatus is a means of applying weight to a fractured limb so as to exert a continuous pull and over- come the muscle contraction. It is necessary in order to 104 WAR NURSING prevent deformity and shortening of the limb. Many vari- eties of extension apparatus are in use, some very simple, some elaborate. Whatever form of apparatus is used, its adjustment must be kept exactly as the medical officer places it, and bed-making, bathing, etc., managed so as not to interfere INJURIES TO BONES. APPARATUS 105 with it. Do not remove weights without permission, and watch that the patient does not slip down in bed in such a way as to take off the pull: if he complains, notify the medi- cal officer (see Fig. 65). In cases of compound fracture all apparatus, casts, and appliances are much more complicated. There is a great Fig. 65.—Forearm extension apparatus. The weights are in the bags at lower part of the frame. deal of special apparatus employed which can be best understood by seeing it in use (Fig. 66). Nursing fracture cases requires the greatest possible exactness and skill. The patient must be kept clean and dry, assisted to the comfortable use of bed-pan and urinal, or given enemata, etc., without pulling on the injured part or disarranging splints and apparatus. Bed-sores can only be prevented by beginning the very first day of the 106 WAR NURSING patient's residence in the hospital with measures to relieve pressure and to prevent dampness or irritation. For changing the bed of a patient with a fractured thigh or hip two nurses are necessary; much care should be exercised so that not the smallest wrinkle be left in mackintosh or sheets; they should be adjusted and smoothed many times a day. INJURIES TO BONES. APPARATUS 107 Patients with fractures of the leg often complain of pain in the heel due to pressure on the bed. It may be relieved by putting a small, firm pad under the ankle so as to leave the heel free. The pain from fracture, though not severe, is pretty continuous and therefore hard to bear. Being compelled to lie in one position day after day is of itself productive of aching and discomfort. It may be relieved by slight changes in position and by rubbing. CHAPTER XIV EMERGENCIES. SPECIAL CASES It is not the province of this book to deal with occur- rences outside a hospital; therefore only accidents and emergencies likely to be met with in hospital work and needing to be handled by the auxiliary will be mentioned. For other emergencies, see a text-book on First Aid. General Principles of Action.—When anything goes suddenly wrong with a patient and the condition seems serious, the auxiliary should send at once for help, but should not go. She owes it to the patient to remain with him; and as a rule immediate help, though unskilfully given, is more effective than skilled help which arrives a little late. If the nurse is unable to summon help and must go her- self, it becomes a matter for judgment as to whether she shall first attempt to control the situation alone or run the risk of what may happen while she is gone. Soldiers are, as a rule, cool-headed enough to do as they are told while one goes for help, and it is rare that some one in the ward is not well enough to help. The nurse must exercise self-control in an emergency. She must learn not to lose her head, but to think before she acts, and not to let the patient become alarmed by any exhibition of anxiety on her part. HEMORRHAGE Hemorrhage—i. e., bleeding to a dangerous extent—is one of the more common accidents in hospital practice. It takes experience and judgment to know whether a cer- tain amount of bleeding is dangerous or not. The auxiliary should always give the patient the benefit of a doubt. 108 EMERGENCIES. SPECIAL CASES 109 Soldiers are less disturbed than civilians by the sight of blood and may lose a serious quantity without much con- cern. Signs of hemorrhage are: (1) visible escape of blood in quantity; (2) feeble pulse; (3) pallor of face and lips; (4) faintness or fainting; (5) "air hunger"; a feeling of suffocation; (6) yawning or sighing respiration; (7) thirst; (8) giddiness, dizziness, ringing in the ears, etc. External hemorrhage is easy to recognize. Internal hemorrhage must be judged by symptoms. They are as above stated. Bleeding may be recognized as arterial when it is light red and comes in spurts; as venous when it is darker and flows or wells out; as capillary when it oozes slowly. Hemorrhage may be checked: (1) By elevating the part. (2) By direct pressure upon the bleeding point. This may be done with the fingers or by means of a pad and tight bandage. Fig. 67.—Compression of carotid artery with the fingers. (3) By pressure upon the artery which supplies the part. This may be done with the fingers (Figs. 67, 68) by flexing the limb with a pad in the joint (Figs. 69, 70), or by means of a tourniquet—a band around a limb with some means of tightening it; it may be a handkerchief and a stick or a piece of rubber tubing, etc. (Figs. 71, 72). 110 WAR NURSING Fig. 68.—Compression of femoral artery. Fig. 69.—Compression of Fig. 70.—Compression of poplit- brachial artery by flexion and eal artery by flexion and pad. pad. Fig. 71.—Tourniquet on brachial artery. EMERGENCIES. SPECIAL CASES 111 (4) By the application of styptic drugs—rarely used. Hemorrhage from a wound is usually best controlled by direct pressure upon the bleeding point; a hard roll or pad of sterile gauze should be held tightly against the bleeding Fig. 72.—Tourniquet applied to femoral artery. Patient's body is turned to show application. place until the blood has had time to clot. If the bleeding is in a wound of the leg or arm, elevate the part, or flex the limb strongly, or try pressure over the brachial or femoral artery, as the case may be. Fig. 73.—Pressure on wound in palm of hand. If the bleeding is from the stump where an amputation has been done, send for help at once. Hemorrhage in typhoid or from the intestines must usually be recognized by symptoms, though there may be blood passed from the bowel. The symptoms are as for 112 WAR NURSING any internal hemorrhage (see above). Keep the patient lying quietly, put an ice-bag or cold compresses upon the abdomen, and send for the medical officer at once. Hemorrhage from the lungs may be recognized by the bright color of the blood and by its frothy consistency; it comes up with cough, though it may be slight. Prop the patient into a sitting position and keep him absolutely quiet. Send word to someone in authority. Hemorrhage from the stomach is always very dark, even brown, the blood is mixed with food or mucus, is clotted, never frothy, and is vomited or regurgitated. Have the patient lie flat and keep very quiet, controlling any desire to retch or vomit. Hemorrhage from mouth, nose, or throat may be bright in color and is apt to be stringy, having mucus or saliva mixed with it. (It may be confused with hemorrhage from the lungs if the characteristics of each are not in mind.) It is rarely serious. In nasal bleeding have the patient keep the head upright in preference to bowing it over a basin. Apply cold to the outside of the nose and to the back of the neck. Do not allow the patient to blow the nose. Pulse in Hemorrhage —Remember that the condition of the patient's pulse tells better than anything else of the severity of the hemorrhage. Stimulation in Hemorrhage—Do not give stimulants to a patient who has recently had a hemorrhage. They increase the heart action and render the bleeding likely to continue or recur. Collapse is marked by weak, rapid pulse, anxious ex- pression, and marked symptoms of weakness and pros- tration. It is to be treated by warmth, quiet, rubbing, etc. The foot of the bed may be raised. Stimulation is given upon the order of a doctor. Convulsions.—Very little can be done except to keep the patient from biting his tongue or injuring himself by falling, etc. The duration of the seizure should be noted bv a EMERGENCIES. SPECIAL CASES 113 timepiece, and its characteristics observed so that the physician may be told of them with exactness. Epileptic fits may be confused with convulsions. The patient is unconscious, twitching, frothing at the mouth, and may cry out. The attack may be followed by a short period of delirium. No special treatment can be given. The nurse should remain with the patient, keep him from incurring an injury, and note the length of the attack. Fainting is due to a deficiency of blood in the brain. Nature suggests the treatment by causing the patient to Fig. 74.—Sylvester's method of performing artificial respiration (expiration). fall. He should be laid flat with the head low, no pillow, or even with the head hanging over the edge of the bed, the clothing about the neck and chest loosened, the face bathed with cold water, the window opened, etc. Note the length of time that he remains unconscious. Artificial Respiration.—If a patient from any cause sud- denly ceases to breathe, the nurse should send for help and meantime attempt artificial respiration. For an adult Sylvester's method is probably the easiest. Place the 8 114 WAR NURSING patient flat on his back, remove the pillow, stand at his head, and, grasping his elbows, press them close to his sides (Fig. 74), striving to push in the ribs and expel the air from the chest. Then pull the arms slowly up over the head, permitting the chest to expand to its fullest capacity (Fig. 75). Lower the arms and repeat the pressure upon the chest. Continue, alternately raising and lowering the arms. Be careful not to make the movements more rapid than a person breathes, 18 to 20 times per minute. Artificial Fig. 75.—Sylvester's method of performing artificial respiration (inspiration). respiration is often ineffective because given too rapidly, so that the chest does not have time to expand. Fire.—If anything catches fire, do not attempt to pick it up or remove it to another place; this is sure to result in badly burned hands. Throw a rug, blanket, or coat over it. Water is not always effective, though it may be tried, likewise salt solution. Blankets or a heavy coat are usually available in a hospital, and smothering out a flame is the quickest mode of extinguishing it. EMERGENCIES. SPECIAL CASES 115 Burns.—For the immediate treatment of a burn from hot water, steam, or fire, apply sterile vaselin freely. If the burn is from an acid, apply a strong solution of baking or washing soda. If the burn is from an alkali or caustic, as lye, caustic soda, etc., use dilute vinegar or any weak acid which is at hand. For burns by carbolic, either internally or externally, use plenty of alcohol. If this is not at hand, whisky or brandy will do. Denatured alcohol may be used, but not wood alcohol. Mistakes in Medicine.—If a wrong dose of medicine has been given, report it immediately. If you are not sure that a mistake has occurred it is best to act as though it had. Induce vomiting by some means (unless the drug swallowred was carbolic or a caustic), by giving mustard and water, salt and water, or try running the finger down the patient's throat. If help does not arrive shortly the nurse is justified in giving the following—for bichlorid, the raw whites of eggs, 1 to 4 grains of the drug; for carbolic, alcohol or whisky. Small Wounds of the Hands.—The nurse herself should be very careful about scratches or punctured wounds which she may get in the course of her work. Safety-pins used about a wound are especially dangerous. No matter how slight the injury may appear, institute prompt treatment for it. Many doctors and nurses have lost their lives from the prick of a needle or the scratch of a pin, and one cannot afford to take chances. Scrub the wound thoroughly and apply a wet dressing of peroxid, alcohol, or almost any strong antiseptic. Keep the place wet for twenty-four hours or longer if necessary. If one has acquired a slight infection, as a pustule on the hand, open it with a sterile needle and apply a wet anti- septic dressing. 116 WAR NURSING EYE, EAR, NOSE, AND THROAT NURSING THE EYE All handling of the eye must be deftly and gently done. Clumsy handling causes pain and may result in injury to the delicate tissues. Thoroughness is essential and is not easy to combine with gentleness. It takes a certain amount of practice to become at all expert. Opening the Eye.—In holding the eye open be careful not to put any pressure upon the eyeball. Pull the skin of the lid up or down, as the case may be, and hold it firmly Fig. 76.—Examination of upper eyelid. against the edge of the orbit. Do not let your fingers press into the soft parts (Figs. 76, 77). To evert, or turn out, the lid, place a small pencil or pen-handle under it, grasp the eyelashes and pull the lid gently down and out, rolling it over the rod. Foreign bodies in the eye, such as cinders, specks of dirt, etc., may sometimes be removed by holding the eye open and wiping them out with a piece of clean soft linen or a fresh handkerchief. If the patient be restrained from rubbing the eye the tears caused by the irritating object may wash it into the inner corner, from which it can gener- EMERGENCIES. SPECIAL CASES 117 ally be removed. A drop of castor-oil put into the eye Fig. 77.—Examination of lower eyelid Fig. 78.—Putting drops in the eye. soothes an irritation and assists in removing any foreign material which may be causing it. Putting Drops into the Eye (Fig. 78).—Have the 118 WAR NURSING patient lie or sit with the head thrown back in a good light. The nurse should stand so that her hands will not come between the eye and the light. The patient may face the light and the nurse stand behind him. Open the lids carefully with the thumb and forefinger and hold them firmly. Hold the dropper near the eye, but be careful not to touch the eyeball. Put one or more drops near the outer corner or into the lower lid; the movements of the eye will distribute them over the eyeball. More than 2 drops are unnecessary. Droppers used for the eye should be sterile. Irrigation by Syringe (Fig. 79).—Use by preference a syringe made entirely of rubber, so that if the patient Fig. 79.—Method of syringing eye. struggles a hard glass tip may not strike the eyeball. Lay a bit of cotton over the other eye to protect it; also avoid letting solution run from one eye into the other. Turn the patient's head slightly outward, hold a piece of cotton at the outer corner to receive the drainage, and place the nozzle of the syringe near the inner corner, letting the fluid flow outward. The solution should be just com- EMERGENCIES. SPECIAL CASES 119 fortably warm, never hot nor cold. Use enough to remove all discharge; let there be a little force to the stream so that the cleansing may be thorough. After the irrigation, dry the eye outside with a bit of cotton, wiping outward, away from the nose. Irrigation with fountain bag is similar to that with a syringe. The bag should be hung very low, so as to have little force to the stream. More solution will be used, so that it is well to have the patient's head on a Kelly pad or rubber sheet. Precautions in Eye Cases.—For ordinary cases the pre- caution of not letting fluid run from one eye to the other may be sufficient, but in an infection of any gravity the unaffected eye should be tightly sealed; a watch crystal held in place with adhesive or collodion is often used. In all cases, whether infected or not, never use anything for one eye that has touched the other. Xever touch your own eyes while treating an eye case, nor afterward, until you have thoroughly scrubbed and disinfected your hands. THE EAR In ear troubles the nurse needs especially to know what not to do. Never, without the advice of a doctor, put into the ear any fluid except warm water. Never put into the ear any instrument except a tooth- pick or match well covered with cotton. Insert this very carefully and only a short distance. Do not permit patients with ear trouble to blow the nose vigorously. It may force infection further in or send additional infection up through the Eustachian tube. Ear Irrigation (Figs. 80 and 80A).—The ear may be washed out with a bulb or fountain syringe when ordered by a doctor. If a fountain bag or irrigator is used it should be hung very low, on a level with the ear, so that the stream shall have little force. A kidney-shaped basin held just under the ear is a convenient receptacle for catching the drainage. The procedure is best managed with the Fig. 80.—Irrigation of ear with piston syringe. Fig. 80a.—Method of syringing ear with fountain syringe. The lower end of bag should not be above level of auditory canal. 120 EMERGENCIES. SPECIAL CASES 121 patient in a sitting position. Use clear water, at a tem- perature of about 110° F. Direct the stream a trifle upward, not directly at the ear-drum. THE NOSE In the treatment and handling of the nose also there is need for gentleness. Any procedure, if improperly done, may be the cause of more harm than good. Caution all patients against blowing the nose with any force. This habit is the cause of some ear troubles. Nasal Spray.—If the nose is to be sprayed, use the large tip of the atomizer, one which does not go into the nose Fig. 81.—Nasal douche. Method for syringing nose. The syringe is introduced into upper nostril, the solution escaping from opposite nostril or mouth. but just to the rim of the nostril. Tip the atomizer so as to direct the spray back, not up. As you spray, ask the patient to inhale forcibly so as to help in reaching every part of the nasal cavity. 122 WAR NURSING The Nasal Douche (Fig. 81).—For cleansing the nose a glass douche or soft-rubber nasal syringe is used. If the latter be employed very little force should be given to the stream, as there is danger of forcing matter into the Eustachian tube and setting up an inflammation in the middle ear. The patient, lying in bed, may turn his head a little to one side over a low basin while the nurse injects or pours the solution into the nostril which is uppermost, letting it run out of the lower. The head is then turned to the other side and the douching repeated. The solution used, usually a mild antiseptic, should be blood warm. THE THROAT When the medical officer wishes to make a throat examination he usually prefers a reflected light and uses Fig. 82.—Throat examination, showing the mirror being intro- duced, and also the relative position of the patient and examiner and the position of the light (Morrow). a head mirror (Fig. 82). The light should be behind the patient. The nurse may be asked to steady the patient's head. EMERGENCIES. SPECIAL CASES 123 Throat Treatments.—If the throat is to be sprayed have the patient say "ah" with the mouth open, so as to make the throat round and permit one to see it. Use the long, curved atomizer tip, placing it as far back as pos- sible, but do not rest it on the tongue. Direct the spray first to one side of the throat, then to the other, then toward the center. If necessary use a tongue depressor, so that you may see the throat well, and be sure that you spray to the back of the throat, not merely the mouth and tongue. Gargling.—Many patients do not know how to gargle properly, and the solution hardly touches even the pillars of the throat. Try having the patient hold the nose while gargling, and see if the liquid will not go a little further back. A spray is usually more effective than a gargle. A hot gargle gives a more pronounced effect than a cold one. Irrigation of the throat is much used. Fill a fountain bag or irrigating can with at least two quarts of the pre- scribed solution, usually hot soda, hot saline, or plain hot water. The tip used is ordinarily a straight glass point. Protect the patient's clothing and have him hold his head over a large basin. Direct the stream so that it reaches and cleanses every part of the back of the throat. The patient can usually do this himself after the object of the treatment is explained to him. Fractures of the Jaw.—These are extremely difficult and important cases. The auxiliary may be allowed to feed them or to do irrigations of the mouth. All procedures should be carried out with great exactness. Extreme gentleness is necessary, but it must be combined with absolute thoroughness. The mouth must be kept clean, yet irrigations must be done so as net to cause pain nor to disturb the healing tissues. Due regard must be had to the possibility of choking the patient with the irrigation. If a jaw case begins to bleed freely the nurse must make pressure upon the carotid artery (it can readily be found by its strong pulsation) and send another patient at once for help. She must not go herself. These cases require infinite patience and a cheery dis- position, as they are long and discouraging. CHAPTER XV Spongy tissue ANATOMY AND PHYSIOLOGY In order to be able to care for the human body it is necessary to know its construction and working. The bones constitute the skeleton or frame- work upon which the body is built. There are about 200 bones. Some of them, as those of the head and chest, are chiefly for the pro- tection of vital parts, others are chiefly for support and the attach- ment of the muscles which move the body. Bones are composed of two distinct sorts of tissue—the exterior is of compact tissue, hard and dense; the interior is of cancellous tissue, spongy, containing blood-vessels. In a few bones, as the femur (thigh bone) and the humerus (upper arm bone), the center is a. hollow canal filled with marrow—fat and blood- vessels (Fig. 83). Outside the bone and firmly adherent to it is the peri- 124 Compact tissue Marrow Spongy tissue Fig. 83.—Longitudinal section of a long bone (Morrow). ANATOMY AND PHYSIOLOGY 125 Fig. 84.—The human skeleton. 126 WAR NURSING osteum, a tough, hard, bluish-white membrane containing blood-vessels. It is absolutely essential to the life and growth of bone. The chief bones of the body are as follows: The Head (Fig. 85).—Eight cranial bones; these are fitted closely together; the joints, called sutures, break the force of blows and shorten a fracture which may occur. vertex Fig. 85.—Side view of the skull (Sobotta). The spheric shape, better than any other, distributes the force of blows. The thickest part of the skull is the temporal bone—around the ear. There are twelve bones of the face. These protect the eyes and nose, afford insertion for the teeth, etc. The lower jaw (inferior maxilla) is the only bone of the head that is movable. ANATOMY AND PHYSIOLOGY 127 The hyoid bone, that of the tongue, is not joined to any other bone, but is imbedded in the thick, fleshy root of the tongue. lumbar vertebras Fig. 86.—The spinal column (Church and Peterson). The spinal column (Fig. 86) is made up of twenty-four vertebrce (singular, vertebra), of which seven are cervical (of the neck), twelve dorsal (of the back), and five lumbar 128 WAR NURSING (of the loins or small of back); the sacrum (five vertebrae fused together), and the coccyx (three rudimentary ver- tebrae fused). The lumbar vertebrae are the largest and heaviest, the dorsal next in size. There are three parts to a vertebra (Fig. 87); the body or supporting part; the canal, through which runs the spinal cord; and the processes for the attachment of muscles. The spine is not straight. It has three principal curves, Fig. 87.—A type of vertebra (Leidy): 1, Body; 2, pedicle; :>, lamina; 4, spinal foramen; 5, spinous process; 6, transverse process; 7, articular process. one out at the shoulders, one in at the center of the back, one out at the lumbar region. The skull rests on the top of the first cervical vertebra, which has no body, but is merely a ring which permits free movement. There are twenty-four ribs (Fig. 88), twelve on each side. They are all attached to the spine at the back. The upper seven pairs are joined in front directly to the sternum (breast bone); the next three pairs are connected by long cartilages to the ribs above them, and so indirectly to the breast bone; the two lower pairs are "floating"— i. e., attached only to the spine. The sternum is a flat bone consisting of three parts, ANATOMY AND PHYSIOLOGY 129 the lower being of cartilage or gristle (the ensiform car- tilage) . The clavicle (collar bone) and the scapula (shoulder- blade) are considered as belonging to the arm, since they are essential to its movements. The clavicle is joined to the sternum at its inner end and to a process (pointed end) of the scapula at the shoulder or outer end. It is a round bone, shaped like an italic/ (/), which gives it spring and elasticity to resist blows. The scapula is a flat, triangular bone with a high ridge or "spine" running across it. It protects the ribs under- neath. It is attached to other bones only at the shoulder, where its two processes or points form a sort of cavity into which the head of the humerus (arm bone) fits. The scap- ula is very movable, and for this reason is rarely broken. The humerus has a head, a short neck, and a shaft. The 9 130 WAR NURSING A Coracoid proce_ of Scapula Acromion process^_^^-x of Scapula—j^,^ yead 0fHumerus Fig. 90.—Movements of the ulna and radius. head is rounded and fits into the cavity formed by the processes of the scapula, making a ball-and-socket joint ANATOMY AND PHYSIOLOGY 131 which is very movable. (In shoulder dislocations this head slips out of the socket.) The shaft is somewhat tri- angular in shape. The lower end of the humerus is large and rough for the elbow articulation (joint). The ulna and radius are the bones of the forearm. The ulna has a long, curved-on-the-flat process (the olecranon) which forms the point of the elbow. Its shaft is triangular. The radius has a rounded, freely moving head, which actually rolls around the ulna, permitting the free turn- ing of the hand and wrist. Fig. 91.—Right carpal bones, dorsal surface: S, Scaphoid; L, semilunar; C, cuneiform; P, pisiform; U, unciform; 7, os magnum; IT, trapezoid; T, trapezium (Leidy). The carpus (wrist) contains eight small bones, irregular in shape, arranged in two rows (Fig. 91). The metacarpal bones, those of the palm of the hand, are five. The phalanges1 (finger bones) number fourteen, three in each finger, two in the thumb. Their ends form the knuckles. The two innominata (hip bones) are large and very ir- regular. Each has three parts—the ilium, the broad, flat 1 Singular, phalanx. 132 WAR NURSING wing which forms the hip prominence; the ischium, the lower portion, upon which one sits; and the pubes or front portion. The two pubic bones join, having a pad of car- tilage between them. The ilia or wings fit on to each side of the sacrum at the back, the sacro-iliac joint. At the junction of the three parts is a cavity called the acetabulum, Symphysis pubis Fig. 92.—The pelvis (Morrow). into which the head of the femur fits. This is a ball-and- socket joint (Fig. 93). The femur, or thigh bone (Fig. 93) has a head, a long neck, a protuberance called the great trochanter, and a shaft. At the lower end are two protuberances called condyles. It is the largest bone in the body. The tibia and fibula are the bones of the leg. The tibia or shin-bone is the larger; its shaft is triangular. The fibula is very slender and serves chiefly as a reinforce- ment. It does not enter into the knee-joint and only secondarily into the ankle-joint. The patella (knee-cap) is a flattish bone, roughly tri- angular in shape, placed over the knee-joint to protect it. It is inserted between the layers of a large tendon. ANATOMY AND PHYSIOLOGY 133 The ankle tjpnes (tarsus) are seven. They make up the whole of the back half of the foot. The upper bone, which Condyles Fig. 93.—The femur, or thigh bone (Morrow). with the tibia and fibula form the ankle-joint, is the astragalus; the heel bone is the os calcis. These bones, with the five metatarsals, form the arch of the foot; the 134 WAR NURSING ,/?7 Blake splint, 106 Blanket screen, 17 Bleeding, arterial, 150 venous, 150 Blood, amount in the body, 150 coagulation of, 146 composition of, 144 corpuscles, 146 Blood course through the heart, 148 Blood-vessels, 144 Bolsters, 21, 22 Bones, arm, 129-131 names and description, 126 number, 124 of chest, 128 of head, 126 of leg, 132, 133 of pelvis, 132 of spine, 127 structure of, 124 uses, 124 Brachial artery, 149 Brain, 158 Breathing, abdominal, 152 thoracic, 152 Bruises, 85 Bulb syringe, 45 Burning for destroying germs, 68 Burns, treatment, 115 with ambrine, 96, 97 Callus, 89 Capelline bandage, 77 Capillaries, 144, 150 Carbolic acid burns, 115 Care about medicines, 51 after operation, 96 in ear troubles, 119 in eye cases, 116, 119 in treating nose, 121 of clothing, 30 of dead, 63 of hands, 18, 19 of hypodermic, 53 of instruments used in dress- ings, 94 of linen, 19 of mackintoshes, 18 personal, of night nurse, 62 INDEX Care of plumbing, 18 of sinks, 18 of thermometers, 50 of utensils, 18 Carpus, 131 Carotid artery, 149 Carrel method of treating wounds, S8 tubes, 87 Casts, plaster, 101, 102 Catheterization, 157 Cavities of body, 135 Cerebellum, 158 Cerebrospinal nervous system, 157 nerves, 159 Cerebrum, 158 Chair, getting patient into, 37 Changing bed, 25 pillow, 26 Charts, temperature, 50, 51 Checking hemorrhage, 109 Chest bandage, triangular, 71 Chilblains, 19 Chills, 59 Circular air cushion, 28 Circulation, lymphatic, 150 of blood, 144 Clavicle, 129 Cleaning instruments, 94 method of, 15 utensils, 18 Cleanliness, definition, 15 importance, 15 Clinical thermometer, 50 Clothing, care of, 30 removal of, 30 Cocci, 64 Cold applications, 43 compresses, 44 Collapse, 112 Collar bone, 129 Colon, 156 Color of lips, 57 of skin, 58 Commanding officer, 12 Comminuted fracture, 98 Communicable diseases, 65 Complicated fracture, 99 Compound fractures, 87, 99 Compress, cold, 44 Contused wounds, 86 Convoy bed, 23 Convulsions, 59, 112 Cord, spinal, 158 Corpuscles, blood-, 146 Cotton, absorbent, 82 non-absorbent, 82 wool, 82 Cough, 57 Counting pulse, 49 respiration, 51 Cradle, bed, 28 Cranial nerves, 159 Cranium, 135 Cystitis, 157 Dead, care of, 63 Deltoid muscle, 139 Depressed fracture, 99 Diaphragm, 142 Diet, 45 liquid, 46 ordinary, 46 regular, 46 special, 46 Digestive organs, 152, 153 Disagreeable medicines, 52 Discipline, 13 Disinfecting solutions, 55 Dislocations, 98, 131 Douche, nasal, 122 Drainage-tubes, 84 Drains, 84 166 INDEX Draw sheet, adjustment of, 22 changing, 25 Dressing carriage, 92, 93 Dressings, combination, 84 done by nurse, 94 emergency, 82 hot, 42 materials for, 82 opening packages of, 91 protective, 83 removal of, 90 surgical, 82, 89-95 use of forceps in, 95 Droplet infection, 66 Drops in the eye, 117, 118 Drugs, pain-dispelling, 54 precautions with, 51 Dry heat, 40 Extension apparatus, 103, 104 of muscles, 139 Extensor muscles, 140 Eyes, appearance of, 57 drops in, 117, 118 foreign body in, 116 handling, 116 irrigation of, 118, 119 precautions about, 119 Face, bones of, 126 muscles of, 137 Facial expression, 57 Fainting, treatment, 113 Fastening bandage, 78 Feeding patient, 47 Femoral artery, 148 Femur, 132 Ferments, 154 Fibrin, 144 Fibula, 132 Figure-of-8 bandage, 75 Fire, what to do in case of, 114 Flaxseed poultice, 42 Flexion of limb, 138 Flexor muscles, 140 Fomentations, 41, 42 Foot bath in bed, 32 Forceps for dressings, 95 Foreign body in eye, 116 Four-tailed bandage, 79, 80 Fracture bed, 23 cases, nursing of, 105 comminuted, 98 complicated, 99 compound, 87, 99 apparatus for, 105 depressed, 99 extension in, 100, 103, 104 greenstick, 99 impacted, 99 of jaw, 123 Ear, handling, 119 irrigation, 119 Economy in supplies, 20 of bandages, 7N of labor, 20 Elevation for hemorrhage, 109, 111 Emergencies, 108 Emergency dressings, 82 Enema, simple, 44 Entertaining patients, 14 Epileptic fits, 113 Equivalent weights and meas- ures, 54, 55 Eruption on skin, 58 Ether bed, 24 Etiquette, 13 Examination of throat, 122 Excretion, 157 Excretory organs, 156 Expectoration, 58 Expiration, 152 Expression, facial, 57 INDEX 167 Fracture, results of, 100 setting of, 100 simple, 98 x-ray in, 99 Fuel in war zone, 17 Gall-bladder, 155 Ganglia, sympathetic, 160 Gargling, 123 Gastric juice, 154 Gauze, absorbent, 82 drains, 84 General appearance, 56 condition, 58 Germicides, 66 Germs, 64 Getting patient ready for night, 39 Gifts to patients, 14 Giving rub, 38 medicine, 51, 52 Glands, lymphatic, 150 Gluteal muscles, 140, 141 Greenstick fracture, 99 Hair, washing, 32 Handling patients, 33 Hand scrubbing, 67, 68 Hands, small wounds of, 115 Hawley bed, 104 Head bandage, capelline, 77 triangular, 72 bones of, 126 mirror, use of, 122 Healing of bones, 89 of wounds, 87, 89 Hearing, points concerning, 57 Heart, course of blood through, 149 muscle, 143 size and location of, 149 structure, 147, 148 Heart valves, 148 Heat, bodily, 49 dry, application of, 40 moist, 41 Hemorrhage after operation, 96 defined, 108 fatal, 150 from lungs, 112 from mouth, nose, or throat, 112 from stomach, 112 modes of checking, 109, 110 pulse in, 112 signs, 109 stimulation in, 112 Hopper-top window, 16 Hospitals, auxiliary, 11 military, 11 war, varieties of, 11 Hot dressings, 42 water bottles, 40 Humerus, 129 Hypodermic injection, 52 syringe, care of, 53 Ice bag, 43 Ileocecal valve, 155 Ilium, 131 Impacted fracture, 99 Incised wounds, 85 Infection, 65 carried by lymphatics, 151 droplet, 66 modes, 65 of wounds, 66 Injection, hypodermic, 52 rectal, 44 Injured limbs, handling of, 30 Injuries to bones, 98 Innominate bones, 131 Insertion of muscles, 137 Inspiration, 152 168 Instruments, care of, 95 sterilization of, 94 Intestinal hemorrhage, 111 Intestines, structure and func- tions, 155 Involuntary muscles, 142, 143 Iodin, method of application, 43 Irrigation of ear, 119, 120 of eye, 118, 119 of mouth in jaw cases, 123 of throat, 123 Jaw bandage, 79 fractures, 123 Joints, 135 construction of, 136 injuries to, 136 Kidneys, 157 Mackintoshes, care of, 18 Many-tailed bandage, 79 Material for surgical dressings, 82 Matron, 12 Meals, serving, 45, 47 Measures, 54, 55 Mechanical cleansing, 67 Medical officers, 13 Medicines, disagreeable, 52 giving of, 51, 52 mistakes in, 115 personal, 54 Medulla oblongata, 158 Meninges, 159 Metacarpal bones, 131 Metatarsal bones, 133 Metric system, 54, 55 Microbes, 64 Military hospitals, 11 rank,13 Mistakes in medicine, 115 Modes of infection, 65 Moist heat, 41 Morning report, 62 work, 62 Motor nerves, 160 Muscles, attachment of, 137 chief, 139 gluteal, 141 involuntary, 142, 143 masseter, 139 number of, 139 of abdomen, 142 of back, 141 pectoral, 140 Mustard leaves, 43 poultice, 43 Nasal douche, 122 spray, 121 Nerve-fibers, 160 Nerves, cranial, 159 motor, 160 pneumogastric, 159 INI Lacerated wounds, 86 Lacteals, 151 Leaves, mustard, 43 Lifting patient in bed, 33 from stretcher to bed, 35 Ligaments, 136 Lights, night, 60 Linen, stained, treatment of, 19 Linseed poultice, 42 Lint, 82 Liquid diet, 46 Liver, 155 Lungs, 146, 152 hemorrhage from, 112 Lymph, 150 Lymphatic circulation, 150, 151 glands, 150 Lymphatics carrying infection, 152 INDEX 169 Nerves, sensory, 160 spinal, 160 Nervous system, cerebrospinal, 157 sympathetic, 160 Night lights, 60 nurse, personal care, 62 nursing, 60 orderly, 61 preparing patient for, 39 reports, 61 rounds, 60 Normal pulse, 4S respiration, 51 temperature, 49 Nose, care in handling, 121 Number of bones, 124 of muscles, 139 Nurse, rank of, 12 Nursing in fracture cases, 105, 106,107 Oakcm, S2 Observation of symptoms, 56 Occupation for patients, 14 Officers, commanding, 12 medical, 13 Opening sterile dressings, 91 Operation, care after, 96 hemorrhage after, 96 preparation for, 95 Orderlies, 13, 14, 61 Ordinary diet, 46 Origin of a muscle, 137 Os calcis, 133 Pain, 58 Pancreas, 154 Paralysis, 143, 160 Patella, 132, 134 Pectoral muscles, 140 Pepsin, 154 Periosteum, 124 Phalanges, 131, 135 Picking at bedclothes, 59 Pillows, adjustment of, 27 changing, 26 of empty bed, 23 protection of, 28 Placing bed-pan, 45 Plaster, adhesive, 83 casts, putting on, 101, 102 removal of, 103 Pleura, 152 Pleurisy, 152 Plumbing, care of, 17, 18 Position in bed, 58 Poultices, 42 Preparation for operation, 95 Pressure in case of hemorrhage, 109, 110, 111, 123 Prevention of bed-sores, 29 Protecting bed, 22 pillows, 28 Protective dressings, 83 Pulmonary arteries and veins, 148 Pulse in hemorrhage, 112 intermittent, 49 irregular, 48 quality, 48 rate, 48 Punctured wounds, 86 Pus, 66 Pylorus, 154 Quadriceps maximus, 141 Quality of pulse, 48 of respiration, 51 Radial artery, 149 Radius, 130 Rank, military, 13 of nurses, 12 Rash on skin, 58 170 INDEX Rate of pulse, 48 Rations, army, 46 Receiving sheet, 24 Rectal injection, 44 temperature, 50 Rectum, 156 Regular diet, 46 Relation of patient to nurse, 11 Removing adhesive plaster, 83 bandages, 78 bed-pan, 45 dressing, 90 plaster cast, 103 Repair of tissues, 87, 88 Report, morning, 62 night, 61 Respiration, artificial, 113, 114 counting, 51 quality, 51 Respiratory system, 152 Restlessness, extreme, 59 Reversing a bandage, 74 Ribs, 128 Roller bandage, method of mak- ing, 73 rules for application, 73, 74 Rounds, night, 60 Rubbing back, 39 patient, 38 Rules for bandaging, 73, 74 for using adhesive, 83 Sacro-iliac joint, 132 Salivary glands, 153, 154 Salutes to nurses, 12 Sand-bags, 103 Scapula, 129 Scars and scar tissue, 89 Screen, improvised, 17 Scrubbing hands, 67, 68 Scultetus bandage, 79 Sensory nerves, 160 Sepsis, 66 Septicemia, 66, 152 Serving meals, 45 Serum, blood-, 144 antitetanic, 86 Setting of fractured bones, 100 Sheets, changing, 25, 26 Shock, 161 Sinks, care and cleaning, 18 Skin, eruption on, 58 observation of, 58 Sleep, 59 induction of, 61 Sling for arm, 69, 71 Slipping in bed, 38 Solar plexus, 160 Soleus muscle, 141 Solutions, method of making, 55 Special diet, 46 Sphincter muscles, 142 Spica bandage, 75 Spinal column, 127 cord, 158 nerves, 160 puncture, 159 Spiral bandage, 74 Spirilla, 65 Spirit of nursing, 11 Spleen, 146 Splint, Blake, 106 Splints, use of, 101 Sponges, surgical, 84 Sprains, 98 Spray, nasal, 121 Stained linen, treatment of, 19 Staphylococcus, 65 Statement of symptoms, 56 Steam sterilization, 67 Sterilization, 67, 84 by boiling, 67 by disinfecting solutions, 67, 84 by dry heat, 67 INDEX 171 Sterilization by flaming, 67 Sternomastoid muscle, 138, 139 Sternum, 128 Stimulation in hemorrhage, 112 Stomach, 153 Streptococcus, 65 Stretcher, transferring patients from bed to, 35 Structure of bones, 124 Support in sitting position, 35 Surgical dressings, 85, S9 wounds, 85 Sympathetic nervous system, 160 Symptoms, classification of, 56 observation of, 56 of hemorrhage, 109 Syringe, bulb, 45 hypodermic, 53 Syringing ear, 119, 120 eye, 118 T-bandage, 80, 81 Taking pulse, 49 Technic in the use of ambrine for burns, 97 Temperature, bodily, 49 charts, 50, 51 normal, 49 rectal, 50 variation in, 50 Tendons, 137 Tetanus, 65 Thermometer, care of, 50 clinical, 50 Thoracic breathing, 152 Thorax, 135 Throat, examination of, 57, 122 irrigation of, 123 Through-and-through wounds, 86 Tibia, 132 Tongue, appearance of, 57 Tourniquet, 109 Tourniquet, application of, 110, 111 Transferring patient from stretch- er to bed, 36 Treatment of sprains, 98 of throat, 123 Triangular bandage, method of making, 70 for arm, 69, 71 for chest, 71 for foot, 72 for hand, 70 for head, 72 for knee, 72 Triceps muscle, 140 Tubes, drainage-, 84 Turning patient in bed, 33 Twitching, muscular, 59 Typhoid, hemorrhage in, 111 Undressing patient, 30 Ureters, 157 Urethra, 157 Urinary organs, 157 Utensils, care and cleaning of, 18 Valve, ileocecal, 155 Valves of heart, 148 of veins, 149, 150 Variation in pulse, 48 in temperature, 50 Veins, 144, 145, 149, 150 Vena cava, 149 Ventilation, 16 Ventricles of the heart, 148 Vertebra?, number and location of, 127 structure of, 128 Vital signs, 48 Voice, observation of, 57 172 INDEX War hospitals, 11 Ward cleaning, 15 discipline, 13 heating, 17 ventilation, 16 Washing hair of patient, 32 Weights, tables of, 54 Women orderlies, 14 Wound infection, 66 Wounded arm, lifting, 33 leg, lifting, 33 handling, 33 Wounds, bullet, 86 contused, 86 Wounds, healing of, 87 hemorrhage from, 111 incised, 85 kinds of, 85 lacerated, 86 of the blood-vessels, 150 punctured, 86 small, importance of, 115 surgical, 85 through-and-through, 86 z-Ray in bullet wounds, 86 in fractures, 99 . Books for Nurses PUBLISHED BY W. B. SAUNDERS COMPANY West Washington Square Philadelphia London : 9, Henrietta Street, Covent Garden Sanders' Nursing new <«> edition This new edition is undoubtedly the most com- plete and practical work on nursing ever pub- lished. Miss Sander's already superior work has been amplified and the methods simplified to bring it down to the newest ideas in nursing. There is none other so full of good, practical information detailed in a clean-cut, definite way. Modern Methods in Nursing. By Georgiana J. Sanders, formerly Superintendent of Nurses at Massachusetts Gen- eral Hospital. 12mo of 900 pages, with 217 illustrations. Cloth, $2.50 net. Published August. 1916 Dunton's Occupation Therapy EMPHASIZING BASIC PRINCIPLES Dr. Dunton gives those forms likely to be of most service to the nurse in private practice. You get chapters on puzzles, reading, physical exercises, card games, string, paper, wood, plastic and metal work, weaving, picture puzzles, basketry, chair caning, bookbinding, gardening, nature study, drawing, painting, pyrography, needle- work, photography, and music. Occupation Therapy for Nurses. By William Rush Dunton, Jr., M. D., Assistant Physician at Sheppard and Enoch Pratt Hospitals, Towson, Md. i2mo of 240 page;, illustrated. Cloth, $1.50 net. October, 1915 This Catalogue Revised to August. 1917 Stoney's Nursing NEW (5th) EDITION Of this work the American Journal of Nursing says: "It is the fullest and most complete and may well be recommended as being of great general usefulness. The bes' chapter is the one on observation of symptoms which is very thorough." There are directions how to improvise everything. Practical Points in Nursing. By Emily M. A. Stoney. Revised by Lucy Cornelia Catlin, R. N., Youngstown Hospital, Ohio. 12mo, 511 pages, illustrated. Cloth, $1.75 net. Published August, 1916 Stoney's Materia Medica new od) edition Stoney's Materia Medica was written by a head nurse who knows just what the nurse needs. American Mediciyie says it contains "all the information in regards to drugs that a nurse should possess." Materia Medica for Nurses. By Emily M. A. Stoney, formerly Super- intendent of the Training School for Nurses in the Carney Hospital, South Boston, Mass. 300 pages. Cloth, $1.50 net. April, 1906 JUST ISSUED NEW (4th) EDITION Stoney's Surgical Technic The first part deals with bacteriology, including antitoxins; the second with all the latest developments in surgical technic. The National Hospital Record says: "Pregnant with just the information nurses constantly need." Bacteriology and Surgical Technic for Nurses. By Emily M. A. Stoney. 342 pages, illustrated. Cloth, SI.75 net. October, 1916 Goodnow's First-Year Nursing 2d edition Miss Goodnow's work deals entirely with the practical side of first-year nursing work. It is the application of text-book knowledge. It tells the nurse how to do those things she is called upon to do in her first year in the training school—the actual ward work. First-Year Nursing. By Minnie Goodnow, R. N., formerly Super- intendent of the Women's Hospital, Denver. 12mo of 354 pages, illustrated. Cloth, $1.50 net. Published February, 1916 Aikens' Hospital Management This is just the work for hospital superintendents, training- school principals, physicians, and all who are actively inter- ested in hospital administration. The Medical Record says: "Tells in concise form exactly what a hospital should do and how it should be run, from the scrubwoman up to its financing." Hospital Management. Arranged and edited by Charlotte A. Aikens, formerly Director of .Sibley Memorial Hospital, Washing- ton, D. C. 4S8 pages, illustrated. Cloth, $3.00 net. April, 1911 Aikens' Primary Studies NEW (3d) edttion Trained Nurse and Hospital Review says: " It is safe to say that any pupil who has mastered even the major portion of this work would be one of the best prepared first year pupils who ever stood for examination." Primary Studies for Nurses. By Charlotte A. Aikens, formerly Director of Sibley Memorial Hospital, Washington, D. C. 12mo of 472 pages, illustrated. Cloth, $1.75 net. Published June, 1915 Aikens' Training-School Methods and the Head Nurse This work not only tells how to teach, but also what should be taught the nurse and how much. The Medical Record says: " This book is original, breezy and healthy." Hospital Training-School Methods and the Head Nurse. By Char- lotte A. Aikens, formerly Director of Sibley Memorial Hospital, Washington, D. C. 267 pages. Cloth, $1.50 net. October, 1907 Aikens' Clinical Studies NEW (3d) EDITION This work for second and third year students is written on the same lines as the author's successful work for primary stu- dents. Dietetic and Hygienic Gazette says there " is a large amount of practical information in this book." Clinical Studies for Nurses. By Charlotte A. Aikens, formerly Director of Sibley Memorial Hospital, Washington, D. C. i2mo of 569 pages, illustrated Cloth, $2.00 net. Published August, 1916 3 Bolduan & Grund's Bacteriology 2d ed.t.on The authors have laid particular emphasis on the immediate application of bacteriology to the art of nursing. It is an applied bacteriology in the truest sense. A study of all the ordinary modes of transmission of infection are included. Applied Bacteriology for Nurses. By Charles F. Bolduan, M.D., Director Bureau of Public Health Education, and Marie Grund, M. D , Bacteriologist, Department of Health, City of New York 188 pages, illustrated. Cloth, $1.50 net. Published November, 1916 Fiske's The Body anew idea Trained Nurse and Hospital Review says "it is concise, well- written and well illustrated, and should meet with favor in schools for nurses and with the graduate nurse." Structure and Functions of the Body. By Annette Fiske, A. M.. Graduate of the Waltham Training School for Nurses, Massa- chusetts. i2mo of 221 pages, illustrated.Cloth. $1.25 net. May. 1911 Beck's Reference Handbook new (3d> ed.t.on Phis book contains all the information that a nurse requires to carry out any directions given by the physician. The Montreal Medical Journal says it is "cleverly systematized anc shows close observation of the sickroom and hospital regime.1 A Reference Handbook for Nurses. By Amanda K. Beck, Graduate of the Illinois Training School for Nurses, Chicago, 111. 32tuo of 244 pages. Bound in flexible leather, $1.25 net. February, 1913 Roberts' Bacteriology & Pathology "EZ™ This new work is practical in the strictest sense. Written specially for nurses, it confines itself to information that the nurse should know. All unessential matter is excluded. The style is concise and to the point, yet clear and plain. The text is illustrated throughout. Bacteriology and Pathology for Nurses. By Jay G. Robe-ts, Ph. <;., M. D., Oskaloosa, Iowa. 206 pages, illus. $1.50 uet. August, 1916 4 DeLee's Obstetrics for Nurses E8XSS Dr. DeLee's book really considers two subjects—obstetrics for nurses and actual obstetric nursing. Trained Nurse and Hospital Review says the "book abounds with practical suggestions, and they are given with such clearness that they cannot fail to leave their impress." Obstetrics for Nurses. By Joseph B. DeI,ee, M. D., Professor of Obstetrics at the Northwestern University Medical School, Chicago. limo volume of 508 pages, illustrated. Cloth, $2.50 net. July, 1913 Davis' Obstetric & Gynecologic Nursing JUST OUT—NEW (5th) EDITION The Traified Nurse and Hospital Review says: " This is one of the most practical and useful books ever presented to the nursing profession." The text is illustrated. Obstetric and Gynecologic Nursing. By Edward P. Davis, M. D., Professor of Obstetrics in the Jefferson Medical College, Philadel- phia. 480 pages, illustrated. Cloth, $2.00 net. Published May, 1917 Macfarlane's Gynecology for Nurses NEW (2d) EDITION Dr. A. M. Seabrook, Woman's Hospital of Philadelphia, says: "It is a most admirable little book, covering in a concise but attractive way the subject from the nurse's standpoint." A Reference Handbook of Gynecology for Nurses. By Catharine Macfarlane, M. D., Gynecologist to the Woman's Hospital of Phila- delphia. 32010 of 156 pages, with 70 illustrations. Flexible leather, $1.25 net Published May. 1913 Asher's Chemistry and Toxicology Dr. Asher's one aim was to emphasize throughout his book !he application of chemical and toxicologic knowledge in the study and practice of nursing. He has admirably succeeded. i2mo of 190 pages. By Philip Asher, Ph. G, M. D., Dean and Pro- fessor of Chemistry, New Orleans College of Pharmacy. Cloth, $1.25 net. Published October, 1914 5 Aikens' Home Nurse's Handbook "EZto* The point about this work is this: It tells you, and shows you just how to do those little things entirely omitted from other nursing books, or at best only incidentally treated. The chapters on "Home Treatments" and "Every-Day Care of the Baby," stand out as particularly practical. Home Nurse's Handbook. By Charlotte A. Aikens, formerly Di- rector of the Sibley Memorial Hospital, Washington, D. C. i2mo of 303 pages, illustrated. Cloth, $1.5" net. Published March, 1917 Eye, Ear, Nose, and Throat Nursing This book is written from beginning to end for the nurse. You get antiseptics, sterilization, nurse's duties, etc. You get an- atomy and physiology, common remedies, how to invert the lids, administer drops, solutions, salves, anesthetics, the various diseases and their management. New (2d) Edition. Nursing in Diseases of the Eye, Ear, Nose and Throat. By the Committee on Nurses of the Manhattan Eye, Ear and Throat Hospital. i2mo of 291 pages, illustrated. Cloth, 51.5" net. Published Sept. 1915 Paul's Materia Medica NEw (2a) ed.t.on In this work you get definitions—what an alkaloid is, an in- fusion, a mixture, an ointment, a solution, a tincture, etc. Then a classification of drugs according to their physiologic action, when to administer drugs, how to administer them, and how much to give. A Text-Book of Materia Medica for Nurses. By C.korbe P. Paul, M.D. 12mo of 282 pages. Cloth, $1.50 net. Published September, 1911 Paul's Fever Nursing NEW(3d) ed.t.on In the first part you get chapters on fever in general, hygiene, diet, methods for reducing the Jever, complications. In the second part each infection is taken up hi detail. In the third part you get antitoxins and vaccines, bacteria, warnings of the full dose of drugs, poison antidotes, enemata, etc. Nursing in the Acute Infectious Fevers. By Gkorgk P. Paul, M. D. 12mo of 275 pages, illustrated. Cloth, $1."" net. October. 1915 McCombs' Diseases of Children for Nurses NEW (3d) EDITION Dr. McCombs' experience in lecturing to nurses has enabled him to emphasize//^/ those points that nurses most need to know. National Hospital Record says: "We have needed a good book on children's diseases and this volume admirably fills the want." The nurse's side has been written by head nurses, very valuable being the work of Miss Jennie Manly. Diseases of Children for Nurses. By Robert S. McCombs, M. D.. Instructor of Nurses at the Children's Hospital of Philadelphia. 12111a of 509 pages, illustrated. Cloth, 52.00 net. Published June, 1916 Wilson's Obstetric Nursing new (3d) edition In Dr. Wilson's work the entire subject is covered from the beginning of pregnancy, its course, signs, labor, its actual accomplishment, the puerperium and care of the infant. American Journal of Obstetrics says: " Every page empasizes the nurse's relation to the case." A Reference Handbook of Obstetric Nursing. By W. Reynolds Wilson, M. D., Visiting Physician to the Philadelphia Lying-in Charity. 355 pages, illus. Flexible leather, $1.25 net. April, 1916 NEW (9th) EDITION American Pocket Dictionary The Trained Nurse and Hospital Review says: "We have had many occasions to refer to this dictionary, and in every instance we have found the desired information." American Pocket Medical Dictionary. Edited by W. A. Newman Dorland, A. M., M. D. Flexible leather, gold edges, 31.25 net; indexed, S1.50 net. April, 1915 THIRD EDITION Lewis' Anatomy and Physiology Nurses Joarnal of Pacitic Coast says "it is not in any sense rudimentary, but comprehensive in its treatment of the sub- jects." The low price makes this book particularly attractive. Anatomy and Physiology for Nurses. By I,eRoy Lv;wis, M.D. 12mo of 326 pages; 150 illustrations. Cloth, $1.75 net. Published September, 1913 Pope's Materia Medica ready soon The important knowledge of the physiologic action of drugs is given here. You learn what symptoms to watch for, and the results of each drug upon the various organs and functions of the body. Vaccines are included. 12mo of 400 pages. By Amy K- Pope, formerly Instructor in the Presbyterian Hospital School. Warnshius' Surgical Nursing ready soon The author gives you here the essential principles of surgical nursing, and reliable fundamental knowledge based on his own personal conclusions and experiences. Secondary matter is excluded, and all primary and pertinent points are set down briefly and concisely. Octavo of 350 pages, with 200 illustrations. By Frederick C Warnshius, M.D., F.A.C.S., Visiting Surgeon, Butterworth Hos- pital, Great Rapids, Michigan. Friedenwald and Ruhrah's Dietetics for rN urses new od) edition This work has been prepared to meet the needs of the nurse, both in training school and after graduation. American four- nal of Nursing says it "is exactly the book for which nurses and others have long and vainly sought." Dietetics for Nurses. By Julius Friedenwald, M. D., Professor of Diseases of the Stomach, and John Ruhrah, M.D., Professor of Diseases of Children, College of Physicians and Surgeons, Baltimore. umo volume of 431 pages. Cloth, $1.50 net. Published September, 1913 Friedenwald & Ruhrah on Diet ed0,™! This work is a fuller treatment of the subject of diet, pre- sented along the same lines as the smaller work. Everything concerning diets, their preparation and use, coloric values, rectal feeding, etc., is here given in the light of the most re- cent researches. Published July, 1913 Diet in Health and Disease. By Julius FRIEDENWALD, M.D., and John Ruhrah, M.D. Octavo volume of 857 pages. Cloth. $4.00 net Pyle's Personal Hygiene SK Dr. Pyle's work discusses the care of the teeth, skin, com- plexion and hair, bathing, clothing, mouth breathing, catch- ing cold; singing, care of the eyes, school hygiene, body posture, ventilation, heating, water supply, house-cleaning, home gymnastics, first-aid measures, etc. A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D.. Wills Eye Hospital, Philadelphia. i2mo, 543 pages of illus. Galbraith's Personal Hygiene and Physical Training for Women new sedition Dr. Galbraith's book tells you how to train the physical pow- ers to their highest degree of efficiency by means of fresh air, tonic baths, proper food and clothing, gymnastic and outdoor exercise. There are chapters on the skin, hair, development of the form, carriage, dancing, walking, running, swimming, rowing, and other outdoor sports. Personal Hygiene and Physical Training for Women. By Anna M. Galbraith, M.D., Fellow New York Academy of Medicine. i2tio of 393 pages, illustrated. Cloth, $2.25 net. Published January. 1917 Galbraith's Four Epochs of Woman's Life This book covers each epoch fully, in a clean, instructive way, taking up puberty, menstruation, marriage, sexual instinct, sterility, pregnancy, confinement, nursing, the menopause. The Four Epochs of Woman's Life. By Anna M. Galbraith, M. D. With an Introductory Note by John H. Musser, M. D., University of Pennsylvania. i2mo of 288 pages. New (3d) Edition. March, 1917 Griffith's Care of the Baby NEW <6.h) edition Here is a book that tells in simple, straightforward language exactly how to care for the baby in health and disease; how to keep it well and strong; and should it fall sick, how to carry out the physician's instructions and nurse it back to health apraiU. Published June, 1915 The Care of the Baby. By J. P. Crozer Griffith, M.D., Univers- ity of Pennsylvania, umo of 458 pages, illustrated. Cloth, $1.50 net Aikens' Ethics for Nurses ™s.£ToTN™ss This book emphasizes the importance of ethical training. It is a most excellent text-book, particularly well adapted for classroom work. The illustrations and practical problems used in the book are drawn from life. Studies in Ethics for Nurses. By Charlotte A. Aikens, formerly Superintendent of Columbia Hospital, Pittsburg, umo of }i8 pages. Cloth. SI.75 net. Published April, 1916 Goodnow's History of Nursing Miss Goodnow's work gives the main facts of nursing history from the beginning to the present time. It is suited for class- room work or postgraduate reading. Sufficient details and personalities have been added to give color and interest, and to present a picture of the times described. History of Nursing. By Minnie Goodnow, R.N., formerly Super- intendent of the Women's Hospital, Denver. 121110 of 370 pages, illustrated. Cloth, S2.00 net. Published December, 1916 Berry's Orthopedics for Nurses The object of Dr. Berry's book is to supply the nurse with a work that discusses clearly and simply the diagnosis, prog- nosis and treatment of the more common and important ortho- pedic deformities. Many illustrations are included. The work is very practical. Orthopedic Surgery for Nurses. By John McWlLLIAMS Berry, M.D., Clinical Professor of Orthopedics and Rontgenology, Albany Medical College. Cloth, $1.00 net. Published July, 1916 Whiting's Bandaging This new work takes up each bandage in detail, telling you— and showing you by original illustrations—just how each bandage should be applied, each turn made. Dr. Whiting's teaching experience has enabled him to devise means for over- coming common errors in applying bandages. Bandaging. By A. D. Whiting, M.D., Instructor in Surgery at the University of Pennsylvania. i2mo of 151 pages, with 117 Illustra- tions. Cloth, $1.25 net. Published November, 1915 10 Smith's Operating-Room just issued The object is to show you how to assist the surgeon according to the newest operative technic. You get the result of active experience systematized, and in concise form. You get a thor- ough digest of every essential: detailed lists of instruments; glossary of medical terms. Every phase of the subject is covered by ample, practical instruction. The Operating-Room. A Primer for Nurses. By Amy Armour Smith, R.N., formerly Superintendent of Nurses at the Woman's Hospital of the State of New York. 12mo of 295 pages, illustrated. Cloth *1.50 net. Published October, 1916 Bandler's The Expectant Mother just out This is an anatomv, physiology and hygiene covering those points and function's concerned in child-bearing and designed for the use of the nurse and the mother. Every question of interest to the expectant mother is treated. The Expectant Mother. By S. Wyllis Bandler, M. D., Professor of Diseases of Women, New York Post-Graduate Medical School aiui Hospital. Cloth, $125 net. Published October. 1916 Winslow's Prevention of Disease isSSl Here you get a practical guide, giving you briefly the means to avoid the various diseases described. The chapters on diet, exercise, tea, coffee, alcohol, prevention of cancer, etc., are of special interest. There are, besides, chapters on the preven- tion of malaria, colds, constipation, obesity, nervous disorders and tuberculosis. It is a record of twenty-five years' active practice. By keselm Winslow, M.D., formerly Assistant Professor of Com- perative Therapeutics, Harvard University. 12mo of 348 pages, illustrated. Cloth, $1-75 net. Published November. 1916 Brady's Personal Health just out This is different from other health books. It is written by a physician with some fifteen years' experience in writing for the laity It covers the entire range of health questions—care ot mouth and teeth, catching cold, adenoids and tonsils, eye and ear, ventilation, skin, hair and nails, nutrition, nervous ail- ments, etc. Personal Health. A Doctor Book for Discriminating People. By William Brady, M.D., Elmira, N.Y. 12mo of 400 pages. Cloth, $1.50 net. Published September. 1916 11 Hoxie & Laptad's Medicine for Nurses Medicine for Nurses and Housemothers. By George Howard Hoxie, M. D., University of Kansas; and Pearl L. Laptad. 12mo of 351 pages, illustrated. Cloth, $1.50 ne^ Second Edition —April* 1913 Bohm & Painter's Massage Massage. By Max Bohm, M.D., Berlin, Germany. Ed- ited by Chas. F. Painter, M.D., Tufts College. Octavo of 91 pages, 97illustrations. Cloth, $1.75 net. June, 1913 Boyd's State Registration for Nurses State Registration for Nurses. By Louie Croft Boyd, R. N., Graduate Colorado Training School for Nurses. Cloth, $1.25 net. Second Edition—February, 1915 Morrow's Immediate Care of Injured Immediate Care of the Injured. By Albert S. Mor- row, M.D., New York Polyclinic. Octavo of 354 pages, with 242 illustrations. Cloth, $2.50 net. Second Edition—March, 1912 deNancrede's Anatomy eighth edition Essentials of Anatomy. By Charles B. G. deNan- CREDE, M. I)., University of Michigan. 12mo of 400 pages, 180 illustrations. Cloth, $1.25 net. Sept., 1911 Morris' Materia Medica seventh ed.t.on Essentials of Materia Medica, Therapeutics, and Pre- scription Writing. By Henry Morris, M. T). Re- vised by W. A. Bastedo, M. D., Columbia University, New York. 12mo of 300 pages, illustrated. Cloth, $1.25 net. Published March, 1905 Register's Fever Nursing A Text-Book on Practical Fever Nursing. By KdwardC. Register, M.D., North Carolina Medical College. Oc tavoof 350 pages, illustrated. Cloth, $2.50 net. June 1907 12