PRINCIPLES of HOME NURSING A TEXT-BOOK FOR COLLEGE STUDENTS BY EMMA LOUISE MOHS, R.N., A.B. Member of the Department of Child Hygiene and Public Health of Northeast State Teachers College, Kirksville, Missouri ILLUSTRATED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1923 Copyright, 1923, by W. B. Saunders Company MADE IN U. 8. A. PRESS OF W. B. 8AUNDER8 COMPANY PHILADELPHIA PREFACE The author has striven to present in the following pages a reliable text for students who are desirous of acquainting themselves with the correct and accepted modes of caring for the sick in the home. This volume has been written with the exclusive idea of reaching the college student, the prospective teacher and parent, with the hope that the context will in turn be interpreted to the younger generation. The author has endeavored to make her statements as elementary and explicit as will conform to scientific accuracy; when necessary to use scientific terms they are explained in the text or defined in the glossary. Where possible, points under discussion have been adequately illustrated. The author has gleaned much valuable information from other books bearing on the subject, acknowledgment of which is made in the bibliography. The sources of some of the material used have been obscured by time, and the author takes this opportunity to acknowldge her indebt- edness for that used, the origin of which has not been recognized. She also wishes to express her grati- tude to Mrs. Jo Walker Humphrey who gave so generously of her time and advice in the reading of the manuscript, and to Miss Constance Stubblefield for a number of the free-hand drawings. Her heartfelt thanks are extended to her former instructor, Miss Amy Elizabeth Pope, for valuable suggestions and help. Emma Louise Mohs. Kirksville, Missouri, April, 1923. 11 CONTENTS PART I CHAPTER I Page Introduction 17 The Nurse, 19-The Sickroom, 20. CHAPTER II Sickroom Appliances and Their Substitutes in the Home 22 Syringes, 22-Heat Appliances, 25-Bedpans, 29- Drinking Cups, 32-Sputum Cups, 34-Thermometers, 36-Hypodermic Syringe, 37. CHAPTER III The Art of Bedmaking 39 Stripping a Bed, 39-To Make an Empty Bed, 40-To Make One with a Patient in it, 47-Changing the Mat- tress under the Patient, 49. CHAPTER IV The Care and Comfort of the Patient 50 Personal Attentions, 50-Ventilation, 50-Cleanliness, 53-Care of the Mouth, 55--Care of the Nails, 56-Care of the Hair, 57--Preparations for the Night, 58-Chang- ing a Patient's Gown, 59-Pressure Sores, 60-How to Give and Remove the Bedpan, 61-Restraining Patients, 62-Moving a Patient to a Couch, 63-Lifting a Patient from the Bed to a Chair, 64-To Prop Patient up in Bed, 65-Carrying, Lifting, and Moving Patients (Pope), 65. CHAPTER V Hydrotherapy 67 The Skin, 67-Physiological Effect of Heat and Cold on the Body, 68-The Cleansing Bath in Bed, 71-Cold Baths and Packs, 72-Hot Baths and Packs, 74-The Vapor Bath, 78-The Continuous Bath, 79. 13 14 CONTENTS CHAPTER VI Page Physical Signs and Symptoms 80 Charting, 80--Objective Symptoms, 83-Subjective Symptoms, 83. CHAPTER VII Temperature, Pulse, and Respiration 87 Thermal Phenomenon, 87-Temperature, 90-The Ther- mometer, 91-Pulse, 91--Blood Pressure, 93-Respira- tion, 95. CHAPTER VIII Home Treatments and Medication 97 Enemata, 97--Positions, 98-Douches, 102-Counter- irritants, 103-Poultices, 104--Fomentations, 106- Vesicants, 108-Caustics, 109-Medication, 110-Pre- cautions, 113-Weights and Measures, 116-Drugs in Common Use, 117. CHAPTER IX Feeding the Sick 118 Diets, 119-Milk, 120-Suggestions, 120-The Tray, 122-Food Requirements, 122-Classifications of Foods, 124-Nutrition, 126-Rectal Feeding, 136-The Nutri- tive Processes, 136. PART II CHAPTER X Emergencies and First Aid 139 First Things to do, 139-Medical Emergencies, 140-The Sylvester and the Schaefer Methods of Artificial Respira- tion, 145-Poisoning, 147-Surgical Emergencies, 148. CHAPTER XI A Lesson in Bandaging 160 Kinds and Purpose of Bandages, 160-Knots, 167. CONTENTS 15 CHAPTER XII Page Making Dressings 169 The Applicator, 169-The Cotton Sponge, 170--The Flat Sponge, 170-The Gauze Wipe, 170-The Vulva Pad, 171. PART III MATERNITY NURSING CHAPTER XIII Reproduction 173 The Female Reproductive Organs, 174-Male Reproduc- tive Organs, 177-Pregnancy, 179-Infant Mortality, 182-The Venereal Diseases vs. Pregnancy, 183-Prenatal Considerations, 185-Preparations for Confinement, 191 -Parturition, 192-Complications, 195-Post Natal Care, 198. CHAPTER XIV The Care of the Baby 199 The Premature Baby, 199-Care of the Baby, 202- Outdoor Life, 206-Growth, 207-Teething, 209- Habits, 209-Feeding, 210-Baby Ailments, 210. CHAPTER XV The Bottle Fed Baby . . 212 Marketed Milk, 212-Preparation of Artificial Food, 216-The Bowel Movements, 220. PART IV CHAPTER XVI Bacteriology 223 The Protozoa, 224--The Fungi, 225-Bacteria, 227- Toxins, 231-Bacteria in Water, 232-The Self Purifica- tion of Water, 233-Bacteria in the Air, 234-Bacteria in Milk, 234-The Destruction of Bacteria, 235-Physical Agents, 236-Chemical Agents, Antiseptics and Disin- fectants in General Use, 239-Cultures and Specimens, 243-Surgical Operations in Home, 245. 16 CONTENTS CHAPTER XVII Page The Communicable Diseases 249 Portals of Entry, 249-Protective Forces, 250-Phagocy- tosis, 250-Modes of Transmission, 253-Immunization, 254-Restrictive and Preventive Measures, 254- Quarantine, 255-Fumigation, 256-The Exanthemata, 258-Other Communicable Diseases, 263-Infectious Skin Diseases, 275. Bibliography 279 Glossary 281 Index 293 PRINCIPLES OF HOME NURSING PART I CHAPTER I INTRODUCTION Women as mothers of the race become natural nurses; therefore efforts to extend to them a working knowledge of the simple technic of nursing and the elements of hygiene should be made by the domestic science and hygiene departments of every college and university. It is right that all young women should know not only the proper care and management of a sickroom, but the purpose for doing certain things in certain accepted ways; often through erroneous judgment and ignorant handling, seemingly slight maladies develop into serious ones. As the mind of the college woman has become more or less analytic because of her previous school work, she wants to know the reasons for the approved modes of nursing procedures; hence this book is offered primarily with the hope of giving instruction from the deductive and the scientific, rather than from the "grandmother," point of view. Good nursing implies more than a slavish obedience to the doctor's orders. It often means taking charge of the whole situation for the sake of the loved one. It means that the home nurse must play mother to the children, 17 18 PRINCIPLES OF HOME NURSING cook to the father, and caretaker of the house and yard. She should in a tactful way control the reins of the household and see that everything runs smoothly; that worry and excitement are dispelled; that noises are reduced; that friction with the servants and among the children is avoided; and that curious neighbors are tactfully kept out of the sickroom. The nurse who is most loved has a cheerful disposition, is kind and thought- ful of others, and is willing to humor all harmless whims of the patient. Whispering either within or immediately without the sickroom must be prohibited. Patients as a rule are very sensitive to whispered or imperfectly heard remarks, and becomes as a result suspicious, melancholy, or even cross. Necessary conversations should be carried on in a low tone of voice yet not with the idea of excluding the patient. One of the first principles of nursing ethics is to hold inviolate any confidences proffered, or any knowledge gained from the wanderings of a delirious mind, and never to make this knowledge the subject of gossip with other people. The nurse should keep her own personal griefs in the background; she cannot expect to build up endurance in a patient until she herself has learned self-control. The home nurse's five senses should be well developed. Her eye should observe every change of color or of expression in the patient; she should look for signs of distress or weakness in the facial lines and in the position of the patient; her nose should never become used to foul air or to disagreeable odors; she should find a reason for shaking the pillows or for giving nourishment at a moment of mental stress or depression; she should antici- pate a drink or mouthwash before there is a demand for it; she should never rock in the sick-room, nor knock against the bed nor lean or sit on it. She should not ply her patient with annoying questions such as "are you feeling any better now," "shall I bring you something 19 to drink," "are you sure your feet are warm enough?" and so forth, ad nauseum. Flowers with a strong fragrance are taboo in the sick- room, and all flowers should be removed before night. The sick naturally fall into three groups: those who must die; those who are to recover; and the chronic and the aged. Home nursing consists largely in the care of the aged and the chronic invalid. Many old people feel that their work is done, and that they have become a burden to others and have nothing more to live for. A desire for health must be stimulated until natural responses become normal again. Objec- tions to fresh air and to baths must be tactfully over- come. The feather-bed, so universally condemned, must sometimes be endured when clung to desperately. The Nurse.-The home nurse should wear wash dresses that fit neatly and are designed for comfort and freedom. As personal cleanliness is essential for the proper functioning of the skin, the daily bath should not be neglected, no matter what are the demands on her time. Her clothing must be kept scrupulously clean and changed frequently enough to eliminate the neces- sity for perfumes and scented toilet powders so offensive to sensitive patients. Her shoes must be of good quality, with the soles wide and heavy enough for protection to her feet, yet light enough for easy locomotion. It is needless to say that the heels should be low and made of rubber. The feet are more abused than any part of the body, and as nursing implies much standing, the pedal extremities deserve to be comfortably shod. Her Hands.-A nurse should not only keep her hands and nails clean, but she should avoid roughness and chapping, which become sources of irritation to the patient, and often leave the road open for infection. Rest and Recreation.-Too much stress cannot be laid on her need for rest and recreation. A sleepy nurse is not a good one, nor even a safe one; recreation keeps her mind alert. She must be conscientious and have the INTRODUCTION 20 PRINCIPLES OF HOME NURSING interest of her patient at heart, of course; but she cannot afford to neglect Mother Nature's laws. Many a home nurse has collapsed at the very moment when needed most after subjection to long anxious tedious hours of bedside nursing. Walking furnishes the best outdoor exercise. If the nurse feels herself too closely tied to her duties, she can at least take a hard run around the house several times a day. Location of the Sickroom.-The ideal location for a sickroom is at the top of the house away from the noises, and next to the bathroom. If to a corner room with a window on two sides permitting cross ventilation be added a southern exposure, no more ideal situation for a sickroom can be imagined, as fresh air and sunlight are two important factors in the care of the sick. If however, the home is without a bathroom or if the home nurse must supervise both the kitchen and the sickroom, the choice of location is limited. In case of a protracted illness, simple decorations are best, and heavy draperies and useless ornaments can be dispensed with, since they catch dust and add to the labors of the nurse. They can be removed gradually to avoid any annoyance or commotion. Specially prized furnishings or ornaments ought by all means to be taken out, especially if regret will be felt over any injury. In furnace heated houses where the air is liable to become dry, a pan or jardiniere of water set on the radiator or register will usually supply the desired moisture. It is the duty of the home nurse to keep tidy her patient's room; and since she is the most frequent user of the bathroom, she should adopt the cleaning of it as one of her duties. Her work must be done quietly yet thoroughly. Oiled mops, or brooms wrapped in damp cloths, and dust cloths are to be used, not brooms and dusters; these merely scatter the dust to settle elsewhere. The Bed.-The ideal bed is one made of enameled iron thirty to thirty-six inches wide, six feet four inches INTRODUCTION 21 long, and twenty-four to thirty inches high. In homes the beds, being of ordinary height, should be elevated by placing a block under each post as illustrated. When a bed is too low or too wide, the nurse is obliged to use her back muscles in lifting instead of her leg muscles, thus hastening for herself a state of fatigue. Lifting will never tax her strength if she lifts properly. Fig. 1.-The bed. The bed should not be placed in a corner, but well out in the room so that it will be accessible on at least three sides. If it becomes absolutely necessary to place the bed against the wall, the patient should lie at the foot so that the air in the middle of the room may be breathed. The patient should not be so placed that she will lie in a draft as, for instance, between two opposite windows; nor should she be placed so that the light or a streak of light will shine directly into her eyes. CHAPTER II SICKROOM APPLIANCES AND THEIR SUBSTI- TUTES IN THE HOME In order that the student may become familiar with the correct vocabulary of sickroom appliances, it is advisable at this point to explain the styles and usages of those devices which may be called upon to act in ordinary cases of sickness, and substitutes which may be improvised in emergency. Fig. 2.-Fountain syringe. Fig. 3.-Irrigating can. Irrigating Syringe.-One of the most useful appliances is the syringe. It may be bought in several different types: (1) the ordinary rubber bag to which is attached 22 23 SICKROOM APPLIANCES about five feet of rubber tubing; (2) the combination hot water bag and fountain syringe. The style bought depends upon the means and taste of the purchaser. A rubber syringe used only occasionally and permitted to become dry and hard from disuse soon leaks and is absolutely valueless at the time of an emergency. To offset this contingency, there has been put on the market (3) an irrigating can, which is in general use in hospitals. This can has the advantage of being easily cleaned and made sanitary; it can be put away indefinitely without injury, and can be made to sit flat upon a table instead of requiring a nail in the wall or woodwork to be hung by. A set of three nozzles accompanies each syringe- the douche nozzle, which may be of glass or of hard rubber; the large and small rectal nozzles; and sometimes an ear nozzle. In case of emergency a substitute for the irrigating syringe may be made from the rubber tubing attached to a funnel, and the funnel may be made of cardboard. Hard rubber or piston syringe may be had in any size from two ounces up. The six ounce is about the best size for family use. It is useful in giving oil or nutritive injec- tions, as oil is injurious to soft rubber, and more force can be put behind the fluid to be given. The piston syringe may be put away indefinitely if the piston is well oiled. The Davidson syringe is made of soft rubber with a one-way bulb in the middle. By working the bulb, fluid is first sucked into it and then forced out of the other end. It has been superseded by the fountain syringe. The ear syringe or soft bulb syringe is used to irrigate ears, as the name implies; it may also be used to give injections to very young children in cases of colic. Care must be taken not to force air into the ear or the bowel. Fig. 4.-Hard rubber or pis- ton syringe. 24 PRINCIPLES OF HOME NURSING The stomach pump consists of a funnel attached to a long rubber tube, in which about 34 inches from the end is inserted a one-way bulb. Fig. 5.-The Davidson syringe. F i g . 6.-Ear syringe. (Grif- fith, "Care of the Baby.") The rectal tube is a non-collapsible rubber tube about twenty-seven or thirty inches long, with a half or three- Fig. 7.-Stomach pump. Fig. 8.-Rectal tube. quarter inch bore. It is used extensively for the "high enema," for rectal feeding, and for giving medication by rectum. In cases of tympanites (distention with gas), the tube may be inserted into the rectum and allowed to remain until the flatulence has passed off. In the 25 SICKROOM APPLIANCES absence of a syringe, the tube may be attached to a funnel so that the liquid may be introduced Fig. 9.-Soft-rubber catheter. (A. S. Morrow.) The catheter is a slender semi-soft rubber tube about fourteen inches long with an opening one-half inch from the rounded tip. It is introduced into the bladder through the urethra to draw the urine. Those made of glass are Fig. 10.-Glass female catheter. (Ashton.) about six inches long, and are preferable for female use, as they are easily cleaned and sterilized. Catheters come in various sizes, indicated by number. As catheterization involves such serious sequelae, it should not be performed by the home nurse. A hot-water bottle is a satisfactory investment. Being rubber it has the same disadvantages as the rubber syringe, and may prove worse than useless in time of emer- gency. The little Japanese stoves which burn punk and are very light may be used over a sensitive abdo- men or over an aching ear or tooth. Many substitutes for the hot-water bottle may be found in the home, depending on the ingenuity of the nurse. The metal heater is found in many homes; also, the electric pad. Salt bags and sand 26 PRINCIPLES OF HOME NURSING bags, fruit jars filled with hot water and sealed, hot bricks, or hot irons all make good substitutes. The flat bottomed vinegar jug that can be tied to the foot of the bed makes an excellent foot warmer. It may be filled early in the evening, and because it retains heat for the rest of the night, there is no midnight prowling about in Fig. 11.-Hot-water bottle. Fig. 12.-Electric pad. the kitchen. The jug has the additional advantage of acting as a cradle over the feet. A hot-water bottle loses heat early and thus offers a cold surface just at the time of night when the vitality is lowest. In filling a hot-water bottle the nurse must remember three precautions: (1) Not to fill it too hot for fear of burning the patient; have the temperature between 130°F. and 140°F.; (2) not to fill too full; and (3) to express all the air by laying it on a flat surface before screwing in the cork. Thus the bottle will be lighter in weight and SICKROOM APPLIANCES 27 will retain heat longer by the exclusion of air; it will also remain where placed because flat. In putting the bottle away, it should be thoroughly drained and dried, and the cork screwed in with air in the bottle. This insures the sides against sticking together. Ice-caps are made of rubber goods of varying durability, or of Japanese paper. They are made in several shapes Fig. 13.-Ice-cap. Fig. 14.-Ice-cap. Fig. 15.-Throat ice-cap. designed to fit various parts of the body-the throat, the head, the ear, etc. The plain india-rubber ones give the greatest satisfaction because there is not the possi- bility of seeping and sweating. Ice-caps should be filled one-third to one-half full of finely crushed ice that has been washed with water to remove the sharp edges. Air should be expelled, as from the hot-water 28 PRINCIPLES OF HOME NURSING bottle. Ice-caps should be well dried and powdered inside before being put away, and should contain a small packing of cotton to keep the sides apart. Those made of Japanese paper are cheap, and are serviceable as long as they last, which is sometimes long enough for ordinary purposes. Substitutes may be made of a bathing cap, a pig's bladder, or even from a piece of raincoat, if the edges are well tied and turned back to prevent leaking. An ice- cap in use must always be covered. Ice-coils consist of rub- ber or metal tubes coiled in a circular disk, through which ice water runs by gravity from a container on the table to a receptacle on the floor. They are used over the mastoid process, on the abdomen, or over any inflamed part of the body. Rubber rings should be inflated just enough to raise the patient off the bed. When put away they should be kept inflated, and should not be folded. Rings, made of non- absorbent cotton and wrapped with strips of sheeting or gauze, shaped to fit the body promi- nences, are excellent substitutes. A rubber sheet is a good thing to own, and may be had in all grades. Table oilcloth makes a good substitute, but news- papers have the advantage in that they can be burned and fresh ones supplied often. Newspapers made into pads and covered with clean cloths save the lower sheet, and are not so harsh or hot to lie on as the rubber sheet. Unless a good quality of oilcloth is purchased it soon becomes useless by cracking. Fig. 16.-Ice-coil. Fig. 17.-Rubber ring. SICKROOM APPLIANCES 29 Cloth may be made waterproof by dipping it in the following solution: Dissolve one ounce of sugar of lead in one quart of cool water, and one ounce of alum in one quart of boiling water; stir the two solutions together. Any cloth, dipped in this substance, and hung up to dry, is made waterproof; and will remain so after several washings. This is excellent for baby's diapers or undersheet. It is more sanitary than the rubber diapers so much used now, but should not be placed next to baby's delicate skin. The Bedpan.-The "Perfection" pan is considered the best on the market. It can be had in porcelain or Fig. 18.-The "Perfection" porcelain bed and douche pan. enamel. It is shaped to fit the body and there is no pressure to cause discomfort at the end of the spine. Fig. 19.-Bedpan. Because of the wide opening it is easily emptied and cleansed. It can also be used conveniently for a douche pan. The old-fashioned bedpan with the spout is still in use and may be found in many homes. It too is made of porcelain or of enamel. The objection to this pan is 30 PRINCIPLES OF HOME NURSING that the spout is cleansed with such difficulty. Neither is it comfortable to lie on. A substitute may be made Fig. 20.-Douche pan. from a breadpan with a shingle over one end. If held in place a wash basin may be used effectively. Rubber bedpans may be purchased. They resemble rubber rings with rubber bottoms. They must be kept well aired and sunned to prevent odor. Their advantage lies in that they do not offer harsh surfaces to cause pressure sores. Urinals.-The female urinal has not yet been perfected for general use. Substitutes for the male urinal may be made of fruit jars or large mouthed bottles. A urinal should be graduated so that the amount of urine voided may be recorded. Fig. 21.-Rubber bedpan. Fig. 22.-Female urinal. 31 SICKROOM APPLIANCES Puspans or kidney basins are a convenience often desired in the care of the sick. They can be placed at Fig. 23.-Male urinal. any angle or plane to catch a drainage; they may be used when brushing the teeth or gargling the throat. The soap dish of any wash set makes a good substitute. Fig. 24.-Puspan or kidney basin. Fig. 25.-Back rest cr bed rest. A back rest or bed rest may be purchased or made in any style from the simple wooden frame covered with canvas to one made of steel with woven wire or spring back capable of being placed at any angle. Several pillows must be used to make it comfortable. An ordinary kitchen chair inverted is a suitable substitute. It is very difficult for a patient to maintain her posi- tion on a back rest, and she should be given support by the foot sling, which consists of a folded sheet of the required length fastened at each end of the headboard 32 PRINCIPLES OF HOME NURSING to make a brace for the patient's feet. The sling may be modified by a padded board with ropes at the sides. The bed cradle is a framework upon which the bed- clothing is supported to protect any tender part of the Fig. 26.-Bed cradle. body beneath; and is most frequently used in cases of fracture or of infected appendages. It may be con- structed of strong wire, of iron, of aluminum, or of sec- tions of barrel hoops covered with gauze. Fig. 27.-The "Ideal" drink- ing glass. Fig. 28.-Drinking cup. Drinking cups or glasses may be bought in two styles: the "ideal" glass and the feeding cup. The former is of glass with a lip, and the nurse can readily see just how to hold it for the convenience of the patient. The latter has a spout, and like the old style bedpan is very difficult to keep sweet and sanitary, and is therefore not so desirable. If these appliances are not available, an SICKROOM APPLIANCES 33 ordinary cream pitcher may be used, or if the patient is able to manipulate it, a glass half filled serves the purpose very well. Drinking tubes are glass tubes through which liquids can be sucked by the patient. If a bent one cannot be had, hold the straight one in a flame until the glass becomes soft enough to bend at the desired angle. Straws from the soda fountain are better for cold drinks as they can be destroyed. Minim glasses are used for accurately measuring medicines. No dose should be guessed; when the Fig. 29.-Feeding cup. Fig. 30.-Medicine dropper. doctor orders a medicine to be given by minims, a minim glass should be provided; and if he orders it to be given by drops, a medicine dropper should be used. Many persons erroneously claim that a minim and a drop are the same quantity. Graduates come in pint or quart size, are made of glass with the fig- ures of the scale cut into it; and are useful for measuring milk when pre- paring the baby's food, or for meas- uring any of the patient's excreta. A substitute may be made from a pint jar; paste a strip of paper or adhesive up one side and upon this register the measurements ascer- tained by filling the jar with small accurately measured quantities of water. Sometimes a measuring cup makes a good substitute. Fig. 31.-Graduate. 34 PRINCIPLES OF HOME NURSING Sputum cups should be used to catch all infectious discharges from the nose and throat, and are commonly used in the treatment of tuberculosis. An ordinary tincup lined with newspaper, wrap- ping paper or a paper sack, may be substituted. It is recommended that clean, soft, crepe toilet paper be used to catch the discharges rather than old rags or handker- chiefs. Toilet paper is cheap and easily destroyed. The pasteboard or newspaper lining of sputum cups must be burned, with its contents, and the cup sterilized at least twice a day. A stupe wringer is a very convenient thing in sickness. With it flannels may be wrung out extremely hot and Fig. 32.-Stupe wringer. Fig. 33.-Sputum cup. (An American Text-book of Applied Therapeutics.) dry. It is inexpensively made from two sticks and a piece of ticking 10 X 14. Bandages should be in constant supply in homes where there are small children, and can be rolled at home of old muslin. White materials should never be used for washing windows and other housework unless the supply is abundant, but should be laid aside in neat SICKROOM APPLIANCES 35 clean packages for future use. The sterilized bandage in all sizes can be purchased at the drug stores. Absorbent cotton and gauze may be purchased already sterilized in various sized rolls done up in sealed packages. Adhesive or surgeon's plaster can be bought at the drug store in any quantity desired from a strip a half inch wide and one yard long to a roll half a yard wide and ten yards long. Adhesive is useful in many ways, Fig. 34.-Rubber bandage. Fig. 35.-Adhe- sive or surgeon's plaster. its customary usage being for holding dressings in place and for strapping. It may be used next to the skin for strapping a chest, a varicose vein, a sprained ankle, a lame knee; but should never be used directly over a wound except in the case of an incision, when strips of it are placed across the wound to hold the edges together. Tongue depressors may be of metal or the regularly prepared wooden ones, which when bought in quantities for school use are useful and cheap. The handle of a clean spoon may be used. When taking a depressor out of the container, always pick it up by the middle so as not to contaminate either end before putting it into the mouth. Applicators are used for swabs for throat, teeth, ears, cervix, and for iodin brushes. They may be of the highest surgical instrument type, or of hardwood eight inches long and about one-eighth of an inch in diameter. 36 PRINCIPLES OF HOME NURSING Cotton wrapped loosely and firmly attached to one end constitutes a "swab." The Clinical Thermometer.-The clinical thermometer is used for taking the temperature of the body. It Fig. 36.-Applicators. consists of the stem upon which are engraved the scale markings and of a bulb filled with mercury. The mercury expands when heated, and rises into the column of the stem. It is called "self- registering" because the mer- cury does not retreat into the bulb when removed from its environment as is the case with the bath thermometer. The thermometer, depending upon the style, will register from 108°-110°F. Thescaleis divided into degrees, and each degree into tenths. Between 98° and 99° there is usually a red arrow to mark the average normal temperature, 98.6°F. It is never necessary to reset the mercury below 95°F., for a patient who cannot raise even that temperature is in a critical condition. There is a new style of thermometer on the market, so constructed that a spiral spring within the case will cause a resetting with very little effort. Fig. 37.-Clinical thermom- eters. SICKROOM APPLIANCES 37 The bath thermometer is useful for ascertaining the temperature of water for baths and irrigations. The readings must be had before removing the thermometer from the water because the mercury will instantly retreat to the temperature of the atmosphere. It is not self-registering. A wall thermometer should be in every home. The hypodermic syringe may be made of metal with a solid metal plunger, of glass and metal with a rubber Fig. 38.-Bath thermometer. Fig. 39.--All metal hypodermic syringe. (A. S. Morrow.) plunger, or of glass with a glass plunger. The first and last ones may be made sterile by boiling. The hollow needle screws on the fore end. Fig. 40.-Ordinary glass and metal hypodermic syringe. (A. S. Morrow.) A bedside serving table may be improvised in the home from a board supported on each side with pillows or books, or from a folding sewing table with one pair of legs folded under and the other standing on the floor. A bedside commode may be had in either the chair or box form, and may be improvised in the home from a chair with a hole cut in the bottom, or from an ordinary packing box placed over a jar or chamber. 38 PRINCIPLES OF HOME NURSING Fig. 41.-Bedside serving table. Fig. 42.-Bedside serving table. Fig. 43.-Bedside com- mode. CHAPTER III THE ART OF BEDMAKING An enameled iron bed is preferable to a wooden one, and a single bed to a double one. It is almost impossi- ble for the nurse to avoid using her back muscles when working over a patient who is lying in the middle of a double bed. The best mattress is one made of hair or of felt. The use of the feather bed in the sickroom should be con- demned, as it packs in lumps, absorbs moisture and odors, retains heat, and is difficult to make under a patient. A nurse is sometimes called upon to use very delicate tact to persuade some of her patients to adopt the more sanitary and practical mattress. Every mattress should be protected from above by a quilted pad, and from below by a piece of heavy ticking or sheeting over the springs, and so placed that it can be readily removed and sent to the laundry. Papers on the springs are practically useless, as they become easily disarranged, and sooner or later crumble and shed dis- figuring pieces on the floor. Mattress bags are bungle- some, and are usually made too large, thereby being a source of wrinkles. Stripping a Bed.-Place two chairs back to back about two feet below the foot of the bed to allow space for walking between them and the bed, and place the pillows upon the seats of them. Next fold the spread in its original creases, and hang it over the backs of the chairs so it will not be crushed. Loosen all the bedding by inserting the hand under the mattress and pulling out the lower sheet all around. Do this without lifting the mattress off the springs. Fold each sheet and 39 40 PRINCIPLES OF HOME NURSING blanket smoothly, twice, from head to foot and if they are to be used again, place them on the backs of the chairs; but if not, lay them aside for the laundry. Some- times the upper sheet can be substituted for the draw- sheet, thus only one clean sheet need be used. Wipe the rubber sheet with a cloth dampened in a disinfectant solution and place it smoothly over a bar of the bed. After all the bedding has been removed, dust the mattress with a whiskbroom, turn it from head to foot, and set it on its two ends to air for about twenty minutes. Fig. 44.-Bedmaking. First step. Covering the head. To Make an Empty Bed.-There will be needed for this purpose the undersheet, the drawsheet and rubber sheet, the top sheet, two blankets, the spread, and the pillow cases. The undersheet must be put on without a wrinkle, and its smoothness and tautness are indications of the skill of the nurse. Straighten out the mattress, place upon it the quilted pad with all edges and corners square and true, and open the sheet a fold at a time. Never flip a sheet in the air, as this stirs up the dust and scatters germs. THE ART OF BEDMAKING 41 Fig. 45.-Bedmaking. Mitering the corner. Fig. 46.-Bedmaking. Mitering the corner. 42 PRINCIPLES OF HOME NURSING Lay the sheet on straight, sighting the middle fold between the middle posts of the head and foot boards, and let its hem extend at least twelve inches beyond the mattress at the head. Tuck this in so that the mattress will be covered from above by about eight inches of sheet. Miter the corner. To do this lift the sheet between the fingers and thumb, so that the hem runs parallel to the bars of the bed and the selvage perpendicular to them. Tuck in that part of the sheet which extends below the Fig. 47.-Bedmaking. The lower sheet in place. mattress, and let the sheet drop naturally at an angle of about 45°. Starting at the angle, push the sheet under the full length of the mattress, slipping it in without disturbing the mattress. It should reach about half way under the mattress so that the weight of the patient's body will help to hold it in place. In order to save herself steps, the nurse should at this point put on the rubber and draw- sheets before going to the opposite side of the bed; but as any art, including that of bedmaking, is to be learned in 43 THE ART OF BEDMAKING gradual stages, this routine may be postponed until she becomes more proficient. Go to the opposite side and make a mitered corner at the head exactly like the first one, with the exception that from this side the sheet should be drawn extremely tight. To do this, place one hand upon the mattress, gather the sheet in the other and gently push until the mattress is tightly fitted into the sheet; then proceed to make the miter. Hold this miter in place with the elbow of the arm nearest the head of the bed, gather the sheet in the hand of that same arm, push the mattress with the other hand, and tuck the sheet under the mattress, taking care that there are no wrinkles in the pad underneath. Proceed in this manner to fit the mattress into the sheet down the entire side. At the foot, the miters can be made across the end or at the side if the sheet is long enough, according to the taste of the nurse. Next put on the rubber and drawsheets, observing that no wrinkles are hidden away to cause discomfort Fig. 48.-Bedmaking. Showing the rubber sheet in place. 44 PRINCIPLES OF HOME NURSING later. If the rubber sheet is not wide enough to tuck well under the mattress, sew strips of muslin along the two sides. Do not pin it to the mattress. The rubber sheet will wear longer if wrinkles are kept out. The drawsheet, so named because it can be drawn from side to side to give a new cool spot for the patient to lie on, should extend from a trifle under the pillow to the Fig. 49.-Bedmaking. Showing the drawsheet. patient's knees, or below, with the fold if there be one at the top. Place the top sheet with the hem right side down even with the upper line of the mattress. Slip it in at the foot, and miter the corners at the two sides. Put on one blanket with its top line eight inches from the head of the mattress, and miter it at the side of the foot in the same manner as the top sheet. Place on the next blanket in the same way, with the exception that the corners of this one are to be mitered across the foot instead of at the sides. This gives a more THE ART OF BEDMAKING 45 square appearance to the bed, and permits one blanket to be removed without disturbing the other. Put on the spread with its top edge even with the mattress and the top sheet. Miter the corners at the foot and let the spread hang at a graceful angle, taking care that both angles slant to the same degree. Fig. 50.-Bedmaking. The top sheet. At the head, turn the spread back about half way down the bed, turn the blanket over this, cover the blanket with the excess of spread, replace to its original position, and fold the top sheet down over it. This insures the permanency of the covers; delirious and restless patients sometimes so disturb the covers that if not held together in this manner, the blankets become exposed and are a source of irritation to the face. Always shake the pillows outdoors after they have been aired, so that the hot damp feathers will be aired before being shaken into the interior. 46 PRINCIPLES OF HOME NURSING In putting on the pillow case, do not hold the pillow with the teeth or under the chin; nor shake the pillow into the case; but lay the case upon the bed or on a table, grasp the two corners of the pillow and gently insert it into the case by running the hand down the inside. You are putting the case on the pillow, not the pillow into the case. Smooth and flatten the pillows, and place Fig. 51.-Bedmaking. The completed bed. Showing putting on case. them upon the bed in the manner prescribed by taste or usage, preferably with the open end away from the door. If the case is larger than the pillow, turn the superfluous portion down at the top when the bed is not occupied, and up at the bottom when it is. In the latter case, if the excess were turned at the top, the weight of the patient's head would loosen it and make it appear untidy. To add to the square appearance of the bed, the nurse may then crease the edges of the mattress between her two hands to make the corners true. The bed is now ready for occupancy. THE ART OF BEDMAKING 47 Making a Bed with a Patient in It.-If the patient is able to turn or be turned, she can be of great assistance to the nurse; if, however, she is helpless, it is advised that the nurse have an assistant. Trying to work unaided with a helpless patient is foolhardy. Ordinarily, sheets are changed from side to side; but with a helpless Fig. 52.-Turning a patient. patient, especially if the nurse is obliged to work alone, they can be more conveniently changed from top to bottom by pulling them under the patient from head to foot. First remove the upper covers as follows: Loosen them at the foot; then carefully fold the spread and lay it across the backs of the two chairs; upon that lay the folded top blanket; slip the top sheet from underneath the remaining blanket, which should be tucked under- neath the shoulders to hold it firm, leaving it as a covering for the patient. In case the patient cannot be turned on her side, she must be lifted to one side of the bed while the other is 48 PRINCIPLES OF HOME NURSING being made. To do this alone, pass one arm under the patient's head, across her back anchoring your middle finger firmly in her opposite armpit and supporting her head in the crook of the elbow; slip the other hand under her waist; then gently lift her head and shoulders toward you. Next pass one hand under her waist and the other under her thighs, and pull the hips over. Lastly pull the feet over. When the nurse has help, the assis- tant stands on the same side of the bed with the nurse, passing one hand under the sacral region and the other under the knees and lifts the hips while the nurse lifts the head, both lifting in unison. Always pull a patient towards you, do not push her away from you. Loosen the sheets all around beginning on the side on which the patient is lying. On the opposite side, roll the drawsheet to the middle of the bed next to the patient's body, making every move count, and do not punch the patient. Wipe the rubber sheet, lay it across the patient's body, and roll the lower sheet towards the middle. Place the clean lower sheet (rolled or fanned) on the bed with the roll along the halfway line, leaving enough at the top to cover the mattress; miter the corner and slip the sheet under the mattress along the side. Lay the rubber sheet in place, and put on the drawsheet with half of it rolled or fanned next the patient's body, and fasten it under the mattress. This then makes a large lump over which the patient must be either rolled or carefully lifted. After she has been placed on the clean side, go to the opposite side, remove the soiled sheets, draw the clean ones through and tuck each in separately and tightly under the mattress. Be careful not to soil the clean sheet on the one being removed. It is not always necessary to change the lower sheet, in which case the drawsheet can be easily slipped under the patient as she rolls or is lifted from side to side. When the patient is turned on her side, be sure that her back is well supported, and that she is in a comfortable position. THE ART OF BEDMAKING 49 Changing the Mattress under the Patient.-It some- times will add to the comfort of a patient to change or turn the mattress under her. To do this, move her to the edge of the mattress as already described, pull the mattress far enough oft the bed to expose half the springs. Place several pillows or blankets on the springs, and place the patient on this. Remove the mattress, turn it from top to bottom so the patient will not feel that it is falling on her, or replace it by the new one upon which the clean sheets have been placed in their proper order. Draw or lift the patient on to the clean mattress and pull it in place. If it is not necessary to replace the sheets by clean ones, they can be wrapped around the patient's body before she is lifted to the springs. This operation must not be attempted by one person alone. The nurse must have sufficient help to avoid injuring the patient or straining herself. If the patient is helpless, she can be lifted high enough off the bed, the lifters taking place on the same side as described, for the mattresses to be exchanged under her. CHAPTER IV THE CARE AND COMFORT OF THE PATIENT Personal Attentions.-Relieving a patient of mental and physical discomforts is as much a part of nursing as is the giving of medicines. Invalids often become like little children, and need guidance and encouragement at every step. Little things that in health are scarcely noticed may become sources of anxiety in illness, some- times to the extent of retarding recovery. The nurse should endeavor to form habits that will not add to the vexation of the patient. The following suggestions are offered: Before beginning any treatment, be sure that you have everything necessary at hand; try to remember your patient's likes and dislikes; notice if her visitor or if a light annoys her; always do her bidding as quickly and as neatly as possible; never gossip; do not discuss the patient's condition, or in fact anyone's malady, with the patient; do not allow a weak patient to hold a glass or cup while drinking; do not permit her to change her position without assistance; do not let her lie on her side without a support to her back. Concern over a patient's physical comfort includes the following considerations: VENTILATION Definition: Ventilation is "the continuous introduc- tion of pure air into a room or building, thoroughly mixing it with the contained air, and the simultaneous extraction of a like quantity of impure air." 1 1 Bergey, Principles of Hygiene. Saunders Co. 50 THE CARE AND COMFORT OF THE PATIENT 51 Constructive and destructive changes take place in a person sick as well as in normal health; and in an attack of fever, there is a greater metabolism. Therefore plenty of clean fresh air must be continuously supplied for the maintenance of the tissues and cells of the body. A nurse should be as careful about the purity of the air that her patient breathes as she is about the food she eats. Regardless of the fact that the air is being constantly vitiated by the great quantities of impurities poured into it from the lungs of all animals and from decaying vege- table and animal matter, its composition is subject to very little change. The several reasons for this con- stancy may be listed as: (1) Diffusion, or the tendency for gases to penetrate in all directions; this phenomenon may be observed when a bottle of perfume is left uncorked in a room, and the odor permeates to all parts. (2) The movement of the air in breezes and winds. (3) Condensed moisture in the shape of rains, snows, or dew, which carry the impurities down by gravity. (4) Convection, in which the air over a warmed area moves upward, and is replaced by the cold air from below. (5) The oxygen cycle as conducted by plant and animal life, this being the chief agent in the purification of the air. In order to manufacture the green coloring matter of leaves and stems called chlorophyll, plants combine in the sunlight or bright daylight, the carbon dioxide from the air with the sap from the soil. The chemical reaction results in the liberation of oxygen. The cycle is there- fore continuous-the animal inhales oxygen and exhales carbon dioxide, and the plant utilizes carbon dioxide and discards oxygen. Cut flowers absorb oxygen, on the other hand, and give off carbon dioxide as soon as they begin to fade, and are consequently a source of danger in the sickroom. The same forces that prevail outdoors persist in indoor ventilation. Diffusion is seen in the penetration of an odor-the burning of toast being particularly annoying; convection is noticed near the radiator or stove; and 52 PRINCIPLES OF HOME NURSING winds in the shape of drafts can be produced by opening opposite windows. Impurities are thrown into the air of dwellings from the respiration and perspiration of the occupants, and from fires and lights. The odor of a badly ventilated room may have several sources: perspira- tion, teeth, breath; slops, garbage pails, toilets, defective plumbing; the bedpan if not immediately covered or thoroughly cleansed; the bed clothing that has been removed but permitted to remain in the room; or the patient herself if not bathed sufficiently often. Breath- ing vitiated air of an overcrowded room may result in headache, nausea, syncope (fainting); loss of vitality, depression; and if exposure is continuous, anemia. The amount of air space required for each person is 1000 cubic feet, or a space occupied by a room 9 X 12 X 10, the air of which should be changed three times each hour. In natural ventilation, we make use of the five methods enumerated above; in artificial ventilation we employ certain devices such as fans and blowers, which are chiefly used in theaters and restaurants. The open fireplace is a natural ventilator. In the winter when a fire has been built in it, the warmed air is forced up through the chimney thereby sucking fresh air into the room; in the summertime, a draft may be started by placing a burning lamp in it. There are usually objections in winter to flooding the sickroom by opening the windows and doors. Among the devices suggested is that of inserting a board under the lower sash. This produces the natural entrance of fresh air at the junction of the lower and upper sashes, and gives the incoming air an upward tendency. A table leaf may be fastened to the jamb in such a way that the air is admitted indirectly; an improvised screen may be made of a sheet or blanket hung along the side of the bed from head to foot, or from window to chair; if the patient is very sensitive to air, she may be protected by an umbrella over which has been draped a sheet; or the sick- THE CARE AND COMFORT OF THE PATIENT 53 room may be ventilated from another room or the hall; if a wooden bed is being zused, it might be so placed in front of the window that the head board acts as a screen and at the same time a deflector. Fig. 53.-Ventilation with, a board. As a rule, the best temperature ranges between 66°-70°F. in the daytime, and 60°-65°F. at night. CLEANLINESS Because bacteria are carried on particles of dust, vapor, or sprays from the mouth, it is absolutely neces- 54 PRINCIPLES OF HOME NURSING sary for the nurse to maintain strict cleanliness in the sickroom. For that reason all secretions and excretions from the patient must be immediately destroyed or disin- fected. Anything becoming soiled from the excreta of a patient suffering from an infectious disease of the ali- mentary canal must be immediately removed and cleaned. The tiniest spot of a typhoid bowel movement contains enough germs to infect a whole family. Flies, bedbugs, roaches, lice, and mosquitoes become vehicles for bacteria, and must therefore be shut out of the sickroom. Flies carry germs not only on their feet but in their alimentary tracts as well. Whenever a fly desires to eat, he must first dissolve the food by regurgitat- ing upon it. If he is disturbed at his meal, another fly will eat it. Consequently if one fly is infected all flies in his vicinity are bound to be. Hence, flies must be kept out. Dust and dirt afford lodging places for bacteria and prevent their subsequent disinfection. Whenever a bacteria laden substance becomes dry it pulvarizes and the particles together with the germs are blown here and there by the winds and drafts; through the force of gravity they descend again to the floor, or collect on the furniture and draperies. By far the greatest number of bacteria found indoors are carried there on our shoes. Outside, bacterial life is destroyed by the sun's rays; but inside, where sunlight cannot penetrate, bacteria laden dust becomes a source of danger. Experiments made in hospital wards proved that the number of living bac- teria in 600 cubic inches of air ranged from 0 to 13 about midnight when quiet prevailed; that germs were found to be more abundant in the air in the morning when the general ward routine was taking place; and that the number was nearly doubled after sweeping; while experiments made in homes showed that the number was increased nearly 40 times after sweeping. The number of bacteria indoors depends upon the manner in which cleaning is done. Dusting and sweep- 55 THE CARE AND COMFORT OF THE PATIENT ing must be carefully done with a oiled cloth and mop or covered broom; or the floors might be sprinkled with salt, wet tea leaves, or wet paper cut into bits. Sweep with short strokes, and from the sides of the room toward a place where the dust can be gathered easily. Never sweep from one room into another, especially if the disease you are nursing is transmissible. Never sweep before a meal. CARE OF THE MOUTH A patient's mouth should have as good attention as it has during health; namely, a brushing after each meal and at bedtime. If however, the patient is seriously ill, the mouth must have special care to keep it moist and clean. Microbes enter the mouth, are harbored in the coating, or fur, on the tongue, and are protected and fed by the sordes, an accumulation of food, bacteria, and saliva, on the teeth. A clean mouth means fewer microbes. During a fever the rapid evaporation of moisture may result in a dry, cracked, and bleeding mucous membrane. Complications that arise from lack of oral hygiene causing acute suffering are inflammation of the parotid gland, called parotitis; inflammation of the middle ear which arises from bacterial activity in the Eustachian tube, called otitis media; relapses in typhoid fever are often due to reinfection from an unclean mouth. When a patient is too ill to clean her own teeth, the nurse must do it for her, using either the brush or a swab. A brush can be efficiently used for all but uncon- scious patients; it removes the sordes better. At first it may seem awkward to use a tooth brush on someone else, but with a little practice the nurse will prefer it by far over the swab. In fevers-especially after the ingestion of milk or its products-the mouth should be well cleansed both day and night; but if plenty of water is consumed and the mouth is kept moist during the day, once during the night may be sufficient. Water 56 PRINCIPLES OF HOME NURSING should be offered frequently although the patient claims she is not thirsty. If the mouth is very dry, let the patient chew gum to stimulate the flow of saliva. To use the applicator: Wrap a thin pledget of cotton over the end of a wooden applicator, (see pp. 36 and 169), and dip it into the mouthwash, and with it carefully cleanse between the teeth, around the gums, inside the cheeks, and over the tongue, using fresh cotton often; do not dip a used applicator in the mouthwash; break off the end, or get a new one. A toothpick or match may be substituted. If the mouth is dry, use a lubricant such as liquid albolene. Since glycerine is a hygroscopic and its use results in an increased dryness, it should not be employed. Permit the patient, if strong enough to raise her head, to rinse her mouth and gargle her throat. Burn the bits of cotton used. Mouthwashes in common use are: Diluted listerine; equal parts of boric acid and liquid albolene; Dobell's solution; tincture of myrrh, etc. CARE OF THE NAILS Nurses are apt to fail in their responsibility to patients as far as the nails are concerned. They seem to think that their duty ends with the cleansing of the digits. If they could realize the discomfort of rubbing a long toenail against the sheet, or of awkwardly scratching oneself; if they could realize that convalescent patients, not having other occupations, amuse themselves by examining their hands, and their nails in particular, and with what gratitude a patient views a well manicured hand; if they could realize that there might arise occasion for embarrassment when the doctor examined the nails of a neglected hand; they would be more liberal with the use of the scissors and file. After the bath is a good time for this service, because the hands and feet have been immersed in water. It is recommended, however, that a special time be set for manicuring. Have ready a basin of warm water, towels, a nail brush, an orange- THE CARE AND COMFORT OF THE PATIENT 57 wood stick, a nail file, and if a high polish is desired the buffer, powders, and pastes. Place a towel on the bed, the basin over it; soak and scrub the fingertips, and dry. Then with the file trim the nails round in shape, and with the orange stick cleanse underneath and around them, gently pushing back the cuticle until the halfmoon is prominent. Then polish. The toe nails should be cut straight across, and their care may approximate that of the hands. CARE OF THE HAIR Only in terminal cases is it permissible to neglect the hair of a patient. The hair of women patients is most conveniently kept in two braids, one behind each ear. It should be brushed and combed every day. If tangles have been formed, the task of unsnarling them may be very exhausting to the patient, and she may even desire to have her hair cut; but this must not be done without the consent of her relatives. By gently running the fingers through the hair, the snarls can be gradually removed. Begin combing at the end, holding the hair tightly in the left hand and the comb between the thumb and the two first fingers of the right to supply a spring for the contact and to eliminate pain. The ends must be straightened before the hair on top can be combed. A careful home nurse will not tol- erate tangled hair. Sometimes a little oint- ment rubbed into the hair will help; but never use alcohol, as it pro- duces a lasting and disagreeable odor. Massage applied daily will keep the scalp pliable and prevent the hair falling. Pediculi or vermin in the hair requires special atten- Fig. 54.-How to hold a comb. 58 PRINCIPLES OF HOME NURSING tion. Bathe the scalp in equal parts of coaloil and sweet- oil, wrap the head in a triangular bandage or towel, and let it remain on for two hours; then kill the nits-which are the eggs, and look like dandruff fastened tightly to the hair shafts-by dipping the hair in hot vinegar. Repeat the process until the pediculi and nits have dis- appeared. A fine toothed comb is often recommended. To Wash the Hair of a Bed Patient.-Have ready a small pitcher of soap solution, a large pitcher each of hot and cold water, a foot tub or bucket, towels, and a rubber sheet long enough to cover the pillow and to extend into the tub or bucket on the floor or chair. Move the patient to one side of the bed with the head as near the edge as possible. Roll a small blanket into one end of the rubber sheet and fold into the shape of a horseshoe under the head in such a fashion that the body will be protected, and drop the free end like a trough into the receptacle provided for the waste water. Pin a bath towel around her neck. Rub the soap solution into the hair, massage the scalp well, and pour over the head the rinse water until all the soap has been washed away. Lastly pour a little cold water over the head and apply vigorous friction. Squeeze the water from the hair, wipe the patient's face and remove all wet clothing. Wrap the hair in a towel and wring dry. If possible move her bed so that the hair may be spread out in the sunshine. The process of drying may be hastened by fanning. When dry, comb, and make the patient comfortable. PREPARATIONS FOR THE NIGHT Let the patient use the bedpan or urinal, wash and dry her face, neck, and hand, and let her brush her teeth. Rub her back and hips with alcohol and powder. Remove the pillows, shake, and replace, them. Brush the crumbs from the nightgown and the bed. Arrange the gown, and be sure that the patient is com- fortable. As the spread is primarily intended to protect the blanket underneath, it should be left in place, unless THE CARE AND COMFORT OF THE PATIENT 59 removal is ordained by the custom of the household, in which case cover the blanket with a sheet. To produce sleep, reduce noises to a minimum, see that the patient is comfortable, give some food such as hot milk to draw the blood from the brain, apply heat to the feet, or give a hot foot bath followed by local or general massage. The taking of narcotics should be discouraged in all but exceptional cases, and should be given only under the doctor's supervision. Narcotics usually reduce func- tional activity especially that of the heart, and they lead to the formation of bad habits. Sudden changes take place more frequently at night than in the daytime; the nurse should so familiarize her- self with the pulse action that a change is immediately detected. As night advances an extra blanket should be put over a sleeping patient, since her resistance to cold is being lowered, and this can be done without disturbing her. CHANGING A PATIENT'S GOWN In hospitals short gowns open down the back are pro- vided, and are easily changed. But the home nurse will not ordinarily find such a style in the home, unless the patient is willing to don light colored dressing jackets or middy blouses. The slipover gown is the universally popular one. If the patient is very ill, the nurse is advised to split the gown up the back to the shoulders; it can be readily sewed up again after the patient's recovery. It is comparatively easy to slip over the head, and can be divided under her so that wrinkles and lumps are avoided, while at the same time the shoulders and back are well covered. The soiled gown and the clean one can be exchanged in one movement, as follows: Pull the gown up to the patient's shoulders in the back and around the neck in front. Flex the patient's elbow and remove the sleeve from one arm. Place the clean gown so that the sleeve of it corresponds with one being taken off. Put on the new sleeve, and grasp both gowns 60 PRINCIPLES OF HOME NURSING between the necks, withdrawing one and putting on the other over the head. Now remove the sleeve from the other arm and put the clean one on. Readjust the bed clothing, and straighten out the gown. If the patient can assist, the changing of a gown should be no task at all; but if she is helpless the gown had better be opened in the back as described. Whenever a patient has a helpless arm, the gown should be removed from the sound arm first, and the clean gown started on the injured arm first. PRESSURE SORES A bedsore is gangrene or death of a tissue. The predisposing causes are anything that interferes with the circulation of a part, such as continued pressure in prolonged fever, emaciation, obesity, paralysis, or old age; moisture or crumbs in the bed; lack of cleanliness; wrinkles in the gown or sheets; bruising on the bedpan; or too infrequent change of position. The skin becomes soft and breaks very easily in unconscious and delirious patients who have involuntary discharges from the bowels and bladder. Location.-The bony prominences thinly covered with flesh, as the back of the head or the ears; elbows or heels; shoulder blades; or the end of the spine, are the locations usually attacked, particularly the last one named. As it is easier to prevent than to cure, prophylactic measures consist in keeping the bed dry and clean, and free from crumbs and wrinkles; and in relieving pressure where bedsores threaten. In prolonged illness close guard should be kept on the skin over the whole body, for even tiny scratches are dangerous; patients who are too weak or helpless to change positions should be turned frequently. Alum dissolved in alcohol applied with deep massage will harden the skin; a rubber ring should be inflated only enough to lift the body from the bed, else if too hard it will be uncomfortable and may itself become the source of sores. The nurse caring for a THE CARE AND COMFORT OF THE PATIENT 61 patient is responsible for the development of a bedsore. She should always report to the doctor immediately when a bedsore is threatening; and the treatment should be entirely under his direction as a bedsore is a surgical wound and requires expert treatment. Treatment.-With the first break in the skin much can be done by covering the spot completely with flexible collodion; in the absence of this substance the white of egg answers the purpose very well. Do not use adhesive straps as a break in the skin may develop at the points of attachment; apply all dressings with a binder, or when small, in the shape of a cocoon, a thin pledget of cotton covered and made firm with collodion. Frequently a slough will form, which must be removed before healing can begin. A slough is dead tissue within living flesh. When it becomes decomposed and malodorous it is called gangrene. HOW TO GIVE AND REMOVE THE BEDPAN This procedure can be demonstrated at the same time that the lifting and moving of a patient is studied. A cold pan must never be given a patient; it can be warmed by pouring hot water over it. Take to the bed the pan warmed and well dried, toilet paper, and two news- papers. Place the pan on the bed or on a chair nearby, flex the patient's knees, thus placing her feet firmly upon the bed. Put your hand nearest the head of the bed under her buttocks, raise her, insert a newspaper under her and slip the pan into position. Put the other news- paper over the pan in such a way that the odor does not permeate the bedding. When the pan is to be removed, raise the patient as for placing the pan, remove it, and let her rest upon the paper underneath her, cover the pan with the other paper, turn the patient on her side, and use the toilet paper. Afterwards the parts can be washed with warm water and soap. In case of typhoid, it is a good plan to wash with toilet paper moistened in bichloride solution or lysol which can then be disinfected 62 PRINCIPLES OF HOME NURSING and disposed of with the defecation. If the newspapers used are soiled they must be burned. A bedpan should never be emptied until its contents has been carefully examined, and should always be cleaned absolutely clean. The odor in the room from the defecation may be overcome by burning a piece of ordi- nary wrapping cord, letting it smolder until all is consumed. RESTRAINING PATIENTS Restraint should not be applied until necessary and no more nor longer than necessary, for often the slightest opposition will terrify the patient and impede progress. Mild delirium is often aggra- vated by restraint. One method that may be employed without hesitancy on a mildly delirious patient is to tie her two braids around the post in the headboard; this is merely a reminder to her not to get out of bed, and holds her head upon the pillow while other- wise giving her plenty of freedom. The respiration must not be impeded by any restraint over the chest. The shoulders may be held down by a sheet rolled diagonally passed under the back, over the shoulders, via. the axillae, crossed under the pillow, and tied at the head. An insane or actively delirious patient must never be left alone, and the pulse must be closely watched. The circulation of the arms and legs may be impeded if confined too tightly or too long. Fig. 55.-a, Clove-hitch, method of folding, b, Clove- hitch adjusted on patient. THE CARE AND COMFORT OF THE PATIENT 63 A strip of gauze or muslin looped into the clove hitch may be substituted for the handcuffs in use in hospitals and sanitaria. Two loops are made in a strip as illus- trated, brought together and placed over the hand or foot. No amount of struggling will loosen this loop, but it should not be allowed to become too tight. Some- times boards placed along the sides of the bed like the sides of a crib will suffice to keep a patient in bed. TO HOLD A CHILD FOR EYE, NOSE, OR THROAT EXAMINATION Place the child on your lap with its back toward you and with its legs pinioned between yours. Pass your right arm between his back and arms above the elbows, and hold his left arm firmly with your right hand. Your other hand is then free to press the child's head against your shoulder in a position convenient for the doctor. Amuse the child until you get a good hold on him so he will not become frightened by sudden constraint. MOVING A PATIENT TO A COUCH OR TO ANOTHER BED Place the bed or couch so that its head is on a line with the foot of the patient's bed. Draw the patient to one side. Two persons at least are needed to lift a patient unless she be very slight. The lifting should be done as described in a previous paragraph (p. 48), one per- son carrying the head and shoulders, and the other the hips and thighs. Each should get her hold well estab- lished, so that when the word of command is given, the patient is gently raised and carried, the alternate or broken step being used; have the road between the two beds clear, and see that there are no trailing garments to stumble over. 64 PRINCIPLES OF HOME NURSING LIFTING A PATIENT FROM THE BED TO A CHAIR If the patient is sitting up for the first time after a long illness, she will need assistance. Make the chair comfortable with pillows and a blanket put on diagonally; and dress the patient in her kimona and slippers. If she is weak or is too heavy to carry, place the chair at the foot of the bed facing the head so that no unneces- sary movements need be made. Let her lean over to grasp the arms of the chair, lift her gently by taking her under the arms, and swing her into the chair. Wrap her in the blanket, and find a stool for her feet. Like all exercise, sitting up must be increased slowly; so for the first time, the patient should be limited to a half- hour's recreation, and her condition carefully noted for any signs of infirmity. The return to bed will be the reverse of the getting up, with the exception that because the chair is lower than the bed, the lifting will be harder. Fig. 56.-How to carry a patient. THE CARE AND COMFORT OF THE PATIENT 65 Have ready the backrest, several pillows, and the patient's wrap. Raise her, put on her wrap, supporting her well in the meantime with one arm while arranging TO PROP A PATIENT UP IN BED Fig. 57.-Showing a patient propped up in bed. the rest and the pillows. Place the pillows on the backrest so that when she leans back she will be comfort- able. Place an extra pillow under the small of her back, one under her head, and one under her knees to keep her from slipping down in bed. The foot sling will be found to be very convenient. (See page 31.) CARRYING, LIFTING AND MOVING PATIENTS (From Pope, Procedures of Nursing. Putnam) Important Points to Consider 1. Before lifting a patient from the bed draw her to the edge in order to minimize the necessary degree of stooping. 66 PRINCIPLES OF HOME NURSING 2. When stooping is unavoidable, bend the knees and hips and keep the shoulders thrown back; do not bend the back, especially when you have a weight on your arms. 3. When lifting or carrying a patient do not let her put her arms around your neck, but have her put them across your chest and back (under your arm nearest her) and clasp her hand on your far shoulder. More weight is thus thrown on your shoulder and less upon your back; the shoulders are not easily strained by a weight and the back is. 4. Before lifting a conscious patient tell her to hold herself as stiffly as possible while you are lifting and carrying her. 5. Before moving a patient be sure that there is nothing (e.g. the bedclothes) to impede her movements. 6. If a patient is to be carried, before lifting her see that there is no obstruction between you and your goal. 7. When two or more persons are lifting or carrying a patient, they must lift in unison, and in order that they may do so one must take the command. 8. When two or more persons are carrying a patient in their arms they should step in unison, but not with the same foot; i.e. when one steps with the right foot her neighbor should step with the left. 9. When a patient is weak, especially when she sits up for the first time after a serious illness, she may feel faint and should therefore be supported while the pillows are being arranged. 10. A weak patient should be well supported while sitting up and the pillows should be so adjusted that they will provide a rest for her arms and fit into the curve at the neck and that at the waistline. Also, means should be taken to prevent her slipping down in bed. CHAPTER V HYDROTHERAPY The skin is composed of two layers, the outer thin layer, which may be seen when a blister raises it, called the epidermis; and the deeper layer called the dermis, or true skin. The cells of the exterior layer are dry and flat, and are constantly being pushed toward the surface by new ones from beneath, and shed into the clothing. This process of shedding is known as desquamation. It is aided by the friction of the clothing against the skin, and by bathing. There are two systems of glands in the skin, the per- spiratory glands and the sebaceous, or oil-producing, glands. The secretions from these glands contain organic waste that is deposited upon the skin and by decomposing becomes malodorous. People who lie quietly in bed are denied the natural friction of the clothing, and therefore require more frequent bathing to remove the dead skin and waste deposits. The patient in the home should have at least one cleansing bath a day. In thermataxis, however, the doctor may order more frequent ones. The ideal time for a bath is about one hour after breakfast; at least one hour should elapse after eating. Food taken into the stomach sets up a stimulation of the blood vessels of the alimentary canal for the process of assimilation; if at the same time the capillaries of the skin are dilated by a bath, the blood is diverted from the digestive organs, arousing sometimes symptoms of headache, nausea, or vomiting. 67 68 PRINCIPLES OF HOME NURSING Cold may be applied to the body in the form of ice- bags, iced compresses, ice-coils, the cold bath, or the cold pack. Clinical observation has established the following effects of cold when brought in contact with the skin: 1. The superficial capillaries contract to prevent loss of heat, driving the blood into the interior and checking the perspiration; 2. Reflex action on the nervous centers brings about a change in respiration and heartbeat: the breath is momentarily suspended in a gasp, and the pulse rate is accelerated: 3. The skin feels cold to the touch and becomes roughened, a condition known as "gooseflesh;" 4. There may or may not be a blueness of lips and nails; 5. There comes a sense of chilliness accompanied by shivering-the result of increased muscular contractions; 6. Because of the increased metabolism in the muscles (5), and the accumulation of blood in the great arteries (1), there is a temporary rise of the temperature of the internal organs; 7. The Reaction.-As soon as the cold is removed, a reaction, which may be stimulated by vigorous friction, takes place; that is, a counter condition to the one just described prevails: the capillaries are distended with blood, the skin becomes warm and glowing, and the muscles increase in tone. The cooled blood of the skin is carried to the interior to be exchanged for the hot blood of the viscera (internal organs); this results in an increased diaphoresis (sweating) and radiation, and a lowered temperature. The pulse returns to normal, the respiration becomes deeper, and the eye is brighter. A cold bath because of its adverse reaction should not be given to a small child nor to an old person; to a fat, rheumatic, alcoholic, or extremely nervous individual; to anyone with a subnormal temperature; to anyone suffer- PHYSIOLOGIC EFFECT OF COLD ON THE BODY HYDROTHERAPY 69 ing from nervous or heat exhaustion; to anyone con- valescing from a prolonged or exhausting illness; nor to a chronic invalid. Always see that the room is warm. Cool or cold water applied to the warm skin absorbs heat from it, then transmits it into the air by evaporation. Evaporation does not take place so readily in a cold room, the object of the bath being thereby defeated. Give friction prior to, during, and after a cold bath to keep the blood in the skin, and to prevent chilling. Keep a hot-water bottle at the feet; give a hot drink afterwards; and cover the patient with a blanket. In fevers, cold baths may con- tinue 20-30 minutes; in all other cases the duration is but 10 minutes. Unless the temperature is very high- 104°F. and over-or remains obstinate, its reduction is of slight importance. The purpose of a cold bath is to relieve other conditions, such as restlessness, insomnia; or to invigorate the heart action, etc. The secondary effect should be a slowly diminishing temperature from day to day. PHYSIOLOGIC EFFECT OF HEAT ON THE BODY The application of heat is recommended in the form of hot-water bottles, baths, or packs; and is indicated in shock, subnormal temperature, convulsions, or in nervous or heat exhaustion. A bath of a temperature above that of the skin constitutes a warm bath. Moderately warm baths have a soothing effect and induce sleep, thereby becoming what is called the "sedative" bath. When the body is surrounded by a medium warmer than itself: 1. Loss of heat by evaporation, perspiration, and radiation is prevented; a warm medium does not absorb heat from a cooler body; 2. There results a distention of the capillaries of the skin with a flow of blood to the surface; 3. There is a tendency for the acceleration of the respiration and pulse; it is therefore necessary that the patient's pulse be guarded the whole time in the bath. 70 PRINCIPLES OF HOME NURSING 4. The Reaction.-The reactions obtained are a marked diaphoresis, a great loss of heat by radiation, a consequent lowering of body temperature due to evapora- tion and a cooling skin, and loss of muscle tone. The calming effect on the respiration is decidedly pronounced. Hot baths and packs are given as a means to induce perspiration and increase the elimination of the waste matter through the skin. This relieves the diseased kidney of work and gives it an opportunity to recuperate. A hot bath or pack should not be prolonged over 15-20 minutes. The patient should be closely watched for changes, but swooning must not be suggested by verbal apprehension. A drink of cold water given during the bath and during the period of reaction is recommended. A cold cloth or icebag should be kept on the head to equal- ize the circulation. If the application of heat is prolonged or if too intense, the blood is withdrawn too greatly from the viscera, the tone of the entire vascular system is lowered, the muscles and skin take on a soft sodden appearance, and the nerve centers become depressed resulting in vertigo, headache, and other damaging symptoms; the heart muscles may become so relaxed that death ensues; the internal temperature is positively raised by prolonged hot baths, which limit the dissipation of heat. The danger of the hot bath lies in its action on the skin, which is made softer and more able to throw off in vapor the increased perspiration. If a person enters a cool bedroom with his skin in this sensitive condition, there follows a rapid chilling of the skin and a corresponding contraction of the superficial blood vessels, and his malady is intensified rather than relieved. METHODS OF GIVING BATHS AND PACKS Baths, depending upon the effect desired, may be cleansing, stimulating, refreshing, or sedative. Baths are designated by degrees of temperature as follows: 71 HYDROTHERAPY Cold 40- 65°F. Cool 65- 80°F. Tepid 80- 90°F. Warm 90-100°F. Hot 100-110°F. The Cleansing Bath in Bed.-Have ready a bath blanket to be placed under the patient unless she is too weak to be moved; one for a covering; a wash cloth, soap, sufficient towels; clean gown and bedding; a chair or table protected by a rubber sheet or newspaper; alcohol or talcum powder; a pitcher of warm water; a receptacle to receive the waste water; and a wash basin or foot tub. The enamel wash basin is found to give best satisfaction as it is light in weight and not easily broken; while wash- ing the hands and feet it can be easily lifted and adjusted on the bed with one hand leaving the other free. Have the temperature of the room warm. Place the blankets and remove the upper clothing following direc- tions given for changing sheets and bedding in Chapter III. Draw the patient to one side of the bed, and remove her gown as described. Pour water of the desired tem- perature into the basin on the chair or table, place a towel across the patient's chest, and wash and dry her face, neck, and ears. As baths are given with difficulty under cover, it is perfectly permissible to expose one part of the body at a time. Expose an arm, place it upon a bath towel, and proceed to wash it, using soap, and rinsing well. Wash well in the axilla. Dry, rub and pat with warmed alcohol or powder. Cover the arm, set the basin on the bed over a towel and place the patient's hand in it. Patients derive extreme satisfaction from immersion of the hands and feet in water. Dry the hand and place it under the blanket. Proceed in like manner with the other arm and hand. Replace the water in the basin by a fresh supply from the pitcher and expose the chest and abdomen, taking care to keep both arms covered. Protect the blanket by 72 PRINCIPLES OF HOME NURSING surrounding it with bath towels. Cleanse the chest and abdomen and rub dry; bathe with alcohol or powder; and cover. Expose one leg up to the hip, flex the knee, and surround it by towels. Bathe, wipe dry, and rub and pat with warmed alcohol or powder. Immerse the foot, wash and dry, particularly between the toes. Replenish the water in the basin; turn the patient towards you on her side; and bathe and dry her back. Look for evidences of bedsores. Give a thorough but gentle massage to the back, hips, and buttocks. If the patient is unable to finish her bath by washing the external genitals, the nurse must do it for her. This part of the bath must not be neglected. (See page 194.) Replace the gown or put on a clean one, and rearrange the bed and the room. A cleansing bath should never be prolonged over 20-30 minutes. A nurse must not linger over the bath, and must not vex the patient by too much conversation. A nurse has herself to blame if her patient appears exhausted after an ordinary cleansing bath. COLD BATHS AND PACKS The Cold Sponge Bath.-Have ready a large rubber sheet, a perineal cloth (see T-bandage, page 161), a sea sponge or large wash cloth, a basin of cold water, and a basin of ice to be added as the temperature of the water is raised, towels, ice-bag for the head, and hot-water bottle for the feet. Insert the rubber covered by a sheet under the patient, and roll its sides to form a trough. Put the perineal binder in place, remove the patient's gown, and expose the entire body; it is through the evaporation from the entire skin that the temperature is reduced, if that is the primary result desired. The greater the surface that is exposed to the air the better. If the patient objects, place a large towel or small sheet across her body. Place the ice-cap or cold compresses to the head, and warm bottle to the feet. Apply a light friction, and proceed to sponge the body a part at a time, using long 73 HYDROTHERAPY slow strokes down the trunk and appendages accom- panied by light friction. Stroke the body upward that the friction against the hairs will causes an irritation to the end nerves of the skin. Squeeze plenty of cool water over the patient mopping it up from time to time from the rubber sheet or permitting the surrounding towels to absorb it. Keep the arms away from the body and sponge often along the inner surfaces of the arms and chest, and the inner parts of the thighs. Sometimes a cold compress may be kept to advantage in each axilla, over the chest, over the abdomen, or on the upper parts of the extremities. Let the patient lie exposed to the air for a few minutes; then dry her by patting, and remove the wet things; replace the gown, cover her with a sheet or blanket, and rearrange the room. Fever patients do not require more covering than a sheet. Cold wet packs are given only to those who from previous treatment are known to react right. For this you will need water of a temperature between 70° and 80°F., a large rubber sheet, a blanket, an icecap for the head and a hot-water bottle for the feet. Remove the gown and put on the perineal binder. Place the rubber sheet covered with the blanket under the patient, and cover her with one end of it; wring the sheets out of the water, pass one under the patient tucking the ends under the arms and between the legs; and place the other over her. Keep the sheets moist by sprinkling water over them, preferably from a whisk- broom, and give friction over the sheets. The ice-cap is to be placed to the head and the hot-water bottle to the feet. The duration of this bath is one-half to one hour. If the object is to produce perspiration by the exclusion of air, the blanket and rubber must be tucked around the patient snugly after the cold sheets have been applied, care being taken to wrap the shoulders well. If the patient shows a disposition to chill or shiver, the pack must be discontinued and the doctor notified. 74 PRINCIPLES OF HOME NURSING Usually the chilling will subside as soon as the tem- perature of the sheet reaches that of the body; the heat generated within will stimulate perspiration. The wet pack is removed after 30 minutes and the patient wrapped in a dry warm blanket for 20-30 minutes; then she is given a cleansing bath to remove the traces of perspiration; the gown is replaced and the bedding readjusted. After a cold pack the patient should become calm and should sleep soundly. HOT BATHS AND PACKS Hot foot baths are given to relieve congestion either in the feet themselves or in some distal part of the body; as for instance, pain in the head or in the pelvis. In severe sprains, some doctors prefer to plunge the foot in hot water, gradually raising the temperature; others prefer to reduce the inflammation by the application of cold packs, followed by massage and a rubber bandage. Mustard is often added to the hot foot bath in the proportions of one tablespoonful to each gallon of water. Mix the mustard to a paste with cold water, then gradually add it to the hot water. The feet are put in the tub, but the water must not be hotter than can be comfortably born; envelope the legs and the tub in a blanket. From time to time add hot water to raise the temperature of the bath, but do it carefully to avoid burns. The foot bath is limited to 15-20 minutes. A gentle rubbing of the feet and legs should follow, and the extremities wrapped in a warmed blanket. A foot bath can be conveniently given to a bed patient following the directions just given, by setting the foot tub in the bed and holding it against tipping. Sitz baths are generally ordered to relieve congestion and pain in the rectum or the genito-urinary tract, but are most frequently given for menstrual disorders. Mustard is sometimes used. Use a tub large enough for the patient to sit in comfortably when her feet are HYDROTHERAPY 75 on the floor. Envelope her and the tub in a blanket, let her sit in the tub so that the trunk up to the waist line will be submerged. As in the foot bath, add every few minutes a little hot water to increase the tempera- ture; avoid scalding by holding your hand between the patient and the hot water. The bath should terminate in 20-30 minutes. Friction should be applied to the end of the spine, the hips, and the thighs, and cold compresses should be kept on the head. The patient is then dried and put in a warmed bed. If the bath is prolonged there will result too much relaxation of the abdominal muscles, giving an entirely undesired reaction. In pelvic disorders the muscles must be strengthened, not weakened. Baths for Convulsions.-Baths are commonly given to children in convulsions, hot packs being more con- veniently given to adults. Test the water with the elbow if no bath thermometer is at hand, (the water should be warm); lower the child into the tub with- out disturbing it more than to remove its outer clothing and shoes, support the head and shoulders, and place cold compresses to the head. The clothing can be taken off while the child is in the bath. As soon as the con- vulsion has ceased, remove the child, dry, and keep it quiet. The bath should not extend over 20 minutes. Hot wet packs are given to adults in convulsions; for kidney complications such as Bright's disease and nephritis; for retention or suppression of urine; or for congestion in any part of the body, notably in the lungs. To attain the desired results the technic must be faith- fully and skillfully executed. Have the room in which the hot pack is to be given quite warm but well ventilated. Have ready a cotton blanket to be wrung out of very hot water and a strong sheet; a dry woolen blanket; a large rubber sheet or oilcloth; a perineal binder; at least three hot-water bottles or their substitutes; an ice-cap or iced cloths for the head. To prevent cerebral 76 PRINCIPLES OF HOME NURSING complications, the cold should be applied before the pack is begun. Following the directions already given, remove the coverings, insert the rubber sheet covered by the dry blanket rubber side up under the patient; put on the perineal binder, disrobe the patient, and anoint her whole body with oil or lanolin to prevent too great a relaxation of the skin muscles. Turn her on her side, and cover her until the pack is prepared. Roll or fan the cotton blanket from the sides to the middle, and roll it in the strong sheet. Immerse it in water that is hotter than can be borne by the patient, because it soon cools. Let your assistant grasp the other end of the strong sheet, and each twist in opposite directions until it is as dry as it can possibly be wrung. Unroll half of the blanket and apply it to half of the patient's body beginning at the spine; insert the blanket between the arm and the trunk, and between the limbs; turn the patient; envelope the other half of the patient in the other half of the blanket, being careful that the spine is covered. Cover each part with the dry blanket as you proceed to prevent dissipation of the heat. Work quickly but methodically. When finished, your patient will be completely enveloped in the rubber as illustrated. Success depends on the absolute exclusion of air. Place the hot-water bottles outside the rubber sheet, where they will be convenient for refilling, one at the feet, the others at the sides. Be careful that they are not hot enough to produce steam in the blanket; burns are very difficult to treat. Give sips of cold water to promote the activity of the perspiratory glands. Note the character of the pulse at the temporal artery, and keep close vigilance over it the whole time. A patient in a hot pack must never be left alone. Allow the patient to remain in the wet pack for 10-20 minutes, being careful that no cold air is admitted under the covers. Remove the hot-water bottles; then the wet blanket under cover of the dry one. Removing the wet blanket HYDROTHERAPY 77 without admitting air requires practice and skill. Start at the neck; slip the hand under the dry blanket; pull the wet one from underneath the patient along the half of her body, then from the other half; finally take it away, leaving the patient enveloped in the dry blanket. Because the patient lies on only a part of the blanket it should come away without much effort. As the skin is soft and the blanket rough, the nurse is warned Fig. 58.-The pack. against using force, for the least break in the skin may develop into a bedsore. After 20-30 minutes in the dry wrapping, a warm cleansing bath should be given to remove the waste matter collected on the skin, followed by an alcohol rub to close the pores. A patient to whom hot packs are given should wear outing flannel gowns to avoid too rapid an evaporation from the skin, and must be kept carefully out of drafts. A hot pack requires the undivided attention of the nurse for at least two hours. She must attend to the introduction of heat into the room, to heating the water in which to dip the blanket, to the pack itself, and after- 78 PRINCIPLES OF HOME NURSING wards to the cleansing bath. The nurse should have an assistant, especially if the patient be unconscious, help- less, or heavy in weight. The vapor or Russian bath may be conveniently improvised by placing two bed cradles (see page 32) over the patient to support the blanket and rubber sheet; the enclosure should be made air tight by pinning the blanket to the mattress. The patient should be nude, and her head, which should be outside the tent, kept cool. Through a small opening at the foot of the canopy a tube can be inserted through which vapor is injected under the covers from a boiling kettle. After 30 minutes, the patient is given a sponge bath as after the hot pack. The same rou- tine as to cold applications to the head and sips of cold water applies to all hot baths given for thera- peutic purposes. The hot air or Turkish bath may be improvised with the same parapher- nalia as above with the exception that dry heat instead of steam is deliv- ered under the tent. At first the heat should range between 120-130°F. and later gradually increased to 200°F. Sometimes electric lights are employed to furnish the heat desired, and must be so hung in the cabinet that there will be no danger from fire. Various colored electric lights are used in the treatment of various diseases. Salt rubs and salt water baths are ordered for their tonic effect. For the former, bathtowels are wrung out of strong brine and dried. The nude body is rubbed vigorously with these towels until the skin glows. For Fig. 59.-Bath cabinet. 79 HYDROTHERAPY the bath, sea salt is added to the water in the proportions of ten pounds of sea salt crystals to a tubful of water. The friction of the coarse salt on the skin reddens it and gives an exhilarating effect. The continuous bath is used in skin lesions as from extensive burns or suppurating wounds; it is employed in nephritis; and in insanity to quiet wild ravings; it may be used for prolonged insomnia to good advantage. As the skin becomes soft and soggy, the nurse should guard against bedsores; yet even with the greatest cau- tion they are almost unavoidable. The patient with her head supported on a rubber ring, is immersed in warm water which is kept uniform by the addition of a steady stream of hot water. The water is completely changed every day, when the patient is lifted upon a bed carefully wrapped in warmed blankets, or is suspended from a hammock within the tub. Before she is returned to the tub, she is given a cleansing bath, and her whole body is anointed to avoid the softening of the tissues. Every precaution must be taken to avoid chilling. The continuous bath is used for a single limb, or a part of one, for which an ordinary foot tub may be utilized. CHAPTER VI PHYSICAL SIGNS AND SYMPTOMS If we "eat well, sleep well, and do not suffer pain or discomfort," we can feel reasonably sure that we are in normal health; and in order to preserve that health, we must heed the signals offered by Nature. The first signals, except for sudden pain, are loss of appetite and other gastro-intestinal disturbances, a dull ache in head, back, or "bones," a lack of interest in ordinary activities, a chill, a rise of temperature, a sore throat, etc. The first things to do, especially in the first stages of a cold or of tonsillitis, are to take a cathartic and a hot bath, and to go to bed for a good sweat. The detection of symptoms in the onset of a disease is the natural forte of the home nurse, and by practice, she can become apt in the use of her power of observation. She should not, however, make a display of her knowl- edge, or assume too much responsibility beyond identify- ing the symptoms and honestly stating them when called upon to do so. Charting.-The nurse should keep an accurate and tidy bedside record of the case, following the chart illustrated. The headings are Hour, Temperature, Pulse, Respira- tion, Sleep, Excreta, Nourishment, Treatment, and Remarks. Under the column "Remarks," the nurse should report any manifestations that appear unusual, and any other information she wishes to convey to the doctor. She should neither overstate nor conceal anything. On this chart should appear the doctor's orders for the day. It is suggested that these orders be written across the page just at the time of the doctor's call. If he does not write them himself, the nurse should 80 PHYSICAL SIGNS AND SYMPTOMS 81 DATE HR. T. P. R. tiRjfre DEFW S^F MEDICATION NOURISHMENT REMARKS Dece inker *1 rocs. Pahent has headache; Aches all Over bedv Art. oo 100.6 IT IT J™ E|>Som Sal's Jit Broth 5SL S^eot restless hijbt. 7:oo I I hr Coco a- yiftt Stool -Somewhat Constipated. ?:oo 10 I. 79 18 Cleansing Bath 10:30 Doc tor$ Ver . * .. , ffluid bal Order Diet lets ever} ibis, | L.ti. ||:oo (CoU 5«rTcmk I01E 12:00 101.6 loo 20 I 5 J Bowel movement watery, copious. EM. Z:oo J™ 30 m 2 tablets Tatiant is <\«ite Thirsty 3.00 IOt.0 10 8 Z¥ 30 m. Cold s^,Qnse bath. Toise rab1^- 3:3o Costard yic No Coughing $00 101a 30 nr snort ha|>, restless &00 IE 2 tablets Covgh is troublesome. Bowel movements waterx fa 00 102 2 103 za I Tenesmos Present. Cold bath. 7:oo 101. t cocoa ysir. ■ Patient dozed orcater kirt of 8:00 3o m x tablets O f V afternoon. Awaked Coughing. 9:00 101-3 100 22 I® hnilk yxtir Ex|i«ctoranon. Alcohol rub and VrebaraTions for the1 Dec emb er 15 we dnes' 18} night. Covgh improved.. AM. 2:00 100. 9o 20 9- hrs. 2 tablets In i IK Patient »S YevSV'rin<i-^eat 6:00 99. 80 2.0 0- hrS. 2 tablets Broth yxr S\e|>t roundly all hiybt. Hv*iSrX- Sui 1 .r^ I R hn f £bsom »Salts Vu UztaV\ets J Tdtient iin|> roved. DIAGNOSIS 1tiVutnta PATIENT Tnrs.V/m.nnoore CLINICAL CHART nurse miss Louise. tnotUcr PHYSICIAN DC George Ihood} 82 PRINCIPLES OF HOME NURSING do it, so that she will have definite evidence that she understands them. Medicines should not only be charted, but their results noted, as follows: if a laxative or cathartic is ordered, the exact number of defecations and the description of them should appear on the record; whenever stimulants are given, the effect on the pulse should be noted; if narcotics are required the profundity and length of sleep produced should be recorded. At the end of each twenty-four hours, each column except the Figs. 60, 61.-Stethoscopes. temperature, pulse, and respiration, should be sum- marized, so that the doctor may ascertain at a glance the condition of his patient. The amount of nourish- ment, especially if the diet is liquid, should be indicated, and the number and amount of excreta. Even the last column can be summarized in such phrases as "The patient slept well all night;" "was restless the greater part of the night;" "had a very comfortable day;" "seems much improved today." It will be good training for the student to make up a 24-hour chart following the symptoms and treatment of a real or imaginary malady. PHYSICAL SIGNS AND SYMPTOMS 83 Diagnoses are made by symptoms and physical signs. Symptoms which are discussed later, are conditions observed on the patient. Physical signs are those that are discovered by the physician by means of: 1. Inspection, or visual observation, which will reveal swellings, discolorations, and deformities; 2. Auscultation, listening with the stethoscope or naked ear; rales and murmurs are discoverable by auscultation; 3. Palpation, feeling with the hands; palpation detects tenderness, enlarged abdomen, dropsy; 4. Percussion, obtaining sounds from the parts beneath by "thumping," to show the resonance of the lungs, or to get the outline of an organ; 5. Clinical analysis, when the urine, defecation, blood, and vomitus are put through certain laboratory tests. SYMPTOMS Because the doctor depends for his diagnoses largely upon the symptoms displayed by the patient, and because a prompt realization of any change may save life, it is important for nurses to develop skill in the observa- tion of symptoms, and the acuity of describing them. The symptoms observable by inspection are therefore the particular business of the nurse. Symptoms are classed as (1) subjective, or those which are volunteered by the patient, and are not apparent to the observer; and (2) objective, or those which are apparent to the observer. The most important sub- jective symptoms are pain in various parts of the body, loss of appetite, loss of any of the five senses, nausea, chilliness, dizziness, numbness, etc. The objec- tive symptoms, which the home nurse should train herself to observe, are listed below: Voice.-Is it the nasal voice of rhinitis, the throaty sound of tonsillitis or diphtheria, the weak chesty sound of lung infection? 84 PRINCIPLES OF HOME NURSING Cry.-Is the cry the shriek of temper, the low wailing moan of inanition, the loud cry of hunger, or the inter- mittent scream of colic? Skin.-There may be the jaundice of biliary derange- ment, the waxiness of Bright's disease, the bluish tint of lips and nails of syncope or of heart depression; the pallor of hemorrhage or of shock; the white transparent skin and mucous membrane of anemia; the flushed face of fever; the hectic flush of tuberculosis. Is the skin hot and dry, warm and moist, or cold and clammy; is there marked diaphoresis; is there itching, or a rash? Eyes.-Note if the eyes are yellow or bloodshot, if the lids are swollen, red, and watery; if the look is staring, restless, or excited; note the condition of the pupils, if they are contracted, dilated, or unequally dilated; if there is photophobia. Puffiness around the eyes may indicate kidney disorders or a state of great fatigue. Expression.--Does it betray the excited restlessness of a mental disturbance? Is the delirium violent, or is it of the low muttering type? If stupor is present, is it profound? Is there insomnia? Breath.-The odor of the breath may be fetid or sweet; or it may have the odor of urine or of death upon it. Mouth breathing may indicate a tempor- ary or a permanent obstruction of the nose, due to an acute coryza or to chronic hypertrophy of the adenoid tissue. Gums, Teeth, and Tongue.-When cleansing the mouth, note the condition of the oral cavity; do the gums bleed easily, are the lips dry or cracked? Is the tongue clean or coated; is there tremor of the tongue ? Is there any discharge from the nose? Vomitus may contain food; or it may be only the watery secretion from the stomach; or it may show the presence of bile, giving it a green color and a bitter taste. Expectoration.-"Prune juice" sputum occurs in pneumonia; purulent sputum may contain pus from an abscess; the coin-like sputum is noticeable in tuberculosis. PHYSICAL SIGNS AND SYMPTOMS 85 Cough.-Is it the shallow, painful cough of pneumonia; the peculiar crowing of croup; the whoop of whooping cough; the constant dry hack of tuberculosis? Is the cough worse by day or by night; is there pain or expectoration? If so, describe it. Digestion.-Is there loss of appetite, regurgitation of food, vomiting, nausea? Respiration.-Is there dyspnea, apnea? Sleep.-The nurse must record the number of hours of sleep, and whether it is quiet, restless, or disturbed. Position in Bed.-Does the patient lie with both knees flexed, or only one; more persistently on one side; with the head elevated by 7-8 pillows; or is she restless and uncomfortable? Convulsions result from various causes referring to the nervous system, to the impairment of the kidneys, or to lead poisoning; or they may appear in the pregnant woman, when the condition is called eclampsia. Describe accurately the time of occurrence, the character of the contractions, and which part was first attacked. Rigors, or chills, frequently indicate the onset of the exanthemata; of serious complications; they may accom- pany local infection; or they may be due to nervous excitement. Report their severity and continuance, whether or not they are followed by a rise of temperature, and just how great. Dropsy is a symptom and not a disease, and is the symptom of several diseases with special reference to heart, kidney, or liver disturbances. Note if pitting is present on pressure. Excreta from the bowels and bladder deserve close attention. Is there constipation or diarrhea; tenesmus or tympanites; blood, mucus, curds, particles of food in the defecation ? Clay-colored stools indicate derange- ment in the function of the gall bladder and its ducts. Flatulence is gas due to fermentation in the alimentary canal, and if allowed to accumulate produces tympanites, or distention of the abdomen. 86 PRINCIPLES OF HOME NURSING Is the urine of the normal straw color and of the right amount? Remember there should be for the adult pints of urine daily. Is there distention of the bladder; retention, suppression, or incontinence of urine? Retention.-Urine is secreted but is retained in the bladder due to constriction of the urethra; it is relieved by the use of the catheter. (See page 196.) Suppression.-Urine is not being normally secreted by the kidneys, and consequently the poisonous urea is not being thrown out of the body. This symptom is indicative of nephritis. Incontinence is the inability to retain urine in the bladder; it may be due to an overdistention of the bladder with a constant dripping of urine. Catheterization is withdrawing urine from the bladder by the use of a special instrument called the catheter. (See page 25.) This process should be performed under the strictest surgical cleanliness, and only on the orders of the doctor, and is seldom a duty of the home nurse. A soft rubber catheter is the safer. The glass one must not be used during labor or convulsions, or on delirious patients. CHAPTER VII TEMPERATURE, PULSE, AND RESPIRATION TEMPERATURE Temperature is defined as the degree of heat of a body as measured by a thermometer. Just as heat is produced and liberated when coal is burned, so is it produced in the body by the oxidation of the food prod- ucts which are carried from the alimentary canal by the blood to the muscles, glands, and organs. The tempera- ture of a healthy individual fluctuates very little. The constancy of the temperature of the human body whether asleep or awake, in summer or in winter, in a diver's suit under the sea or in an aeroplane in the air is remark- able. In winter when we shiver with the cold, and in the summer when we swelter from the heat, the ther- mometer registers the same. Were it not for this power to maintain a balance between heat production and heat transmission, man's activities, both mental and physical, would cease in the winter; neither could he as fearlessly sail to the frigid zones as he does. Birds and mammals are known as warm-blooded animals because they possess this heat controlling mechanism; those animals which take their temperature from the surrounding medium are called cold-blooded. The duck swimming on the pond will be warm today and tomorrow, while the fish swimming in the water will be warm today and cold tomorrow depending on the weather. Temperature is spoken of as being "constant;" it is not absolutely so. It varies slightly because of activity or of rest; of youth or of age; is at its highest level in 87 88 PRINCIPLES OF HOME NURSING the afternoon, and lowest at dawn when the vitality is lowest. Excessive exercise, an attack of indigestion, or constipation may upset the equilibrium. The tempera- ture varies in certain organs of the body; that of the muscles fluctuates between 99° and 104°F.; that of the liver often runs as high as 106°F.; that of the blood in the right auricle is higher than that of the left; that of the skin shows the greatest variation-the ears or toes may be broken off if sufficiently frozen. We are informed by the physicist that heat is trans- ferred from a warmer to a colder object by means of the physical agencies of conduction, convection, and radiation; thus, warmth travels from atom to atom of a cool body placed on or next to a warm one; warmed air, or warmed fluid confined in a pipe, has the tendency to rise; and bodies widely separated are warmed by the air into which a hotter body has been transferring heat. A stove warms the cooking utensils upon it, the water in the coil, and the dishes in the cupboard on the opposite wall. Conduction, convection, and radiation are demonstrated side by side in the human body: (1) by means of exercise the muscles warm up, heat is conducted from cell to cell until the whole body is warmed; (2) the warmed blood of the interior has a tendency to flow toward the cooler skin surface, and conversely; (3) by means of evaporation and perspiration, heat is radiated from the surface of the body. The blood is the equalizer of the body tempera- ture; the warmer blood flowing from the viscera and the muscles is mixed in the heart and the great veins with the cooler blood from the skin. When the atmospheric temperature rises, as in summer, the quantity of blood in the skin is increased and the sweat glands become active. When the external temperature is lowered there is a greater demand for more clothing, warm foods, and muscular activity. There comes with a lowering of the external temperature a contraction of the cutaneous vessels and a subsequent flux of blood into the interior; consequently there is less TEMPERATURE, PULSE, AND RESPIRATION 89 blood at the surface to become cooled. If the external temperature falls still lower, there results a chill, accom- panied by shivering. These muscular contractions- shivering-are themselves another mode of exercise, and a sense of warmth is created by the increased oxidation. The "danger zone"-when most colds are contracted- occurs when the atmospheric temperature is lowered so gradually that the body is chilled before any discomfort is experienced; whereas, if the change were made sud- denly, there would be an instant internal demand for a rectification. In other words, until the external temper- ature falls below 60°F., the body relies upon its own heat regulation, and no attempt is made to produce more heat until the damage has been done, after which time an effort for warmth is made by the muscular reflex of shivering. The average normal temperature of the human adult is 98.6°F., but a range of temperature between 98° and 99°F. is considered perfectly normal; anything higher than this is fever, and anything lower is subnormal. A table showing the degrees of fever is submitted below: Fahrenheit Hyperpyrexia 106 and over High fever 103-106 Moderate fever 101-103 Subfebrile 99-101 Normal 98- 99 Subnormal 97- 96 Collapse 96- 95 Algid collapse (death) below 95 Unless high fever is due to an external cause such as sunstroke, or is prolonged into an exhausting stage, no effort should be made for its reduction. Cool baths may be given for their soothing and tone-producing effects. In the past, fever used to be combated with antipyretics (anti, against; pyrexia, fever); but nowadays fever is con- sidered one of Nature's ways of fighting disease; the invading germs and the toxic substances produced by them are more readily destroyed in a hotter than normal environment. 90 PRINCIPLES OF HOME NURSING Fever is terminated by crisis or by lysis; a sudden drop-a fall of 4-5 degrees in as many hours-followed by a gradual return to normal functioning is known as crisis; a gradual descent of temperature, tak- ing several days to reach normal, is known as lysis. Crisis occurs in pneumonia; lysis in typhoid fever. The temperature is taken customarily by mouth, rectum, or axilla. In these places the large blood vessels come nearer the surface so that approximately the temperature of the blood is taken. Do not take a temperature by mouth within five minutes after the patient has ingested something hot or cold; of a delirious or unconscious patient; of one who is coughing or otherwise having difficulty with the respiration; or of a child too young to understand. Before using the thermometer, shake down the mercury to 95°F. To do this hold the thermometer, bulb end down, firmly between the thumb and fingers-not as you hold a pencil in writing, but as you hold a fork when eating. Never touch the bulb; this is an unsanitary thing to do. Do not knock the bulb or let the thermometer slip from the hand, for thermometers are very fragile. Give a quick sharp downward jerk of the wrist, without much shoulder or elbow action. Always wipe the thermometer before putting it in the patient's mouth, and wash and disinfect it afterwards. When not in use, keep it either in its case or in a glass of some disinfectant solution. After resetting to 95°F. place the thermometer under the tongue, and have patient to close the lips tightly for two minutes to insure a correct reading, even though a half-minute thermometer is being used. Fig. 62.- Clinical ther- mometer. TEMPERATURE, PULSE, AND RESPIRATION 91 The thermometer is divided into degrees, and each degree is subdivided into tenths. The temperature can be recorded in tenths, or in fifths if desired, but the use of the tenths is less confusing, and takes less time to write; thus, 986 rather than 98%. Rectal Temperature.-Lubricate the bulb with vaseline or lard, when taking a tem- perature by rectum; oil is not so good, as it runs off the smooth glass surface. Insert the thermometer and leave for three to five minutes. If there is an impaction, the feces must be removed first, as decomposing- matter has a higher temperature than living tissues. Do not take the temperature within ten minutes after an enema. Turn an infant on his side or face down on your knee to take his temperature by rectum, and restrain his arms and legs. Insert the thermometer care- fully so as not to bruise the anus. It is needless to say that a thermometer once used for a rectal temperature should be kept for that purpose alone. Axillary Temperature.-Wipe the armpit dry when taking an axillary temperature, place the bulb in the axilla, and press the arm tightly to the side for five to ten min- utes. Axillary temperature is slightly lower than that of the mouth or rectum. THE PULSE Fig. 63.- Rectal ther- mometer. The pulse is the momentary distention and relaxation of the arteries caused by the con- traction of the heart as the blood is forced into the cir- culation. It furnishes a valuable index to the heart's action. The period of cardiac contraction is called the systole; and the period of rest, when the ventricles are filling with blood, is called the diastole. 92 PRINCIPLES OF HOME NURSING The pulsation of an artery can be felt and counted wherever it passes near the surface over a bony structure: (1) the radial, at the wrist just below the ball of the thumb; (2) the temporal, in front of each ear on a line with the eyes; (3) the facial, over the lower jawbone on a line with the mouth; (4) the femoral, over the pelvic bones; (5) the dorsalis pedis, on the instep. To take the pulse, place your index and middle fingers over the artery; count the beats for one minute. Your thumb has an arterial pulse-beat all its own which might be confused with that of the patient if thumb palpation is practiced. When taking the radial pulse, place your patient's hand in a comfortable position, either across her chest or on a table, and do not apply enough pressure to obliterate the pulse. The number of pulsebeats in a given time is the rate. The average rate per minute is 60- 70 in men 65- 80 in women 72- 90 in children over 7 years 80-120 in children under 7 years 110-130 in infants 130-160 at birth. Variations depending on age, sex, size, food, or exercise may exist even in health. Whenever a nurse feels a pulse she receives valuable informating concerning the heart action and the condi- tion of the vessels. The pulse is often more indicative of a patient's condition than is the temperature. Adjec- tives used for describing the kind of pulse are "frequent" or "infrequent;" "regular" or "irregular;" "soft," "weak," "thready," "flickering;" "full," "bounding," "rapid;" etc. The pulse may be (1) irregular in force or in rhythm; (2) intermittent, either regularly or irregularly; (3) dicrotic. In the intermittent pulse, the dropping of a beat may be due only to the want of a proper distention of the artery, but should always be noted, as this is sometimes a very serious symptom often referring to the TEMPERATURE, PULSE, AND RESPIRATION 93 heart. The intermissions may come at regular or at irregular intervals. The dicrotic pulse is apparently a double beat, and should be counted as one beat. It often follows prolonged and exhausting fevers. The instrument capable of determining the various elements of the pulse and depicting them on paper is called the sphygmograph. Deviations on either side of the standard set by this apparatus are considered to be pathological. The blood pressure within an artery signifies the stress exerted by the blood on the vessel walls, and depends Fig. 64.-Rogers' sphygmomanometer. (A. S. Morrow.) on the (1) peripheral resistance, (2) the force of the heart, and (3) the quantity of the blood. Roughly, the degree of pressure which the blood exerts may be determined by compressing the radial pulse. If the pulse is easily obliterated the pressure is low; when, even after much force has been required, the pulsation is felt below the point of pressure, that blood pressure is high. The difference between the pressure in the veins and the arteries may be seen more strikingly when cut. Blood spurts from an artery in pulsating jets, while it flows from a vein in a steady stream. Pressure is greater in the larger trunks. In the veins of the lower extremities it is considerable^ which explains the varicose veins that develop in the pregnant woman. 94 PRINCIPLES OF HOME NURSING The sphygmomanometer is the apparatus used for the accurate measurement of blood pressure. It consists of a leather cuff over an elastic bag, a manometer, and an air bulb. The cuff is strapped around the patient's arm above the elbow, and the bag inflated by squeezing the bulb until the radial pulsation has been obliterated. The measure is indicated by the manometer. The maxi- mum reading is that of the systolic pressure, the period of contraction. By releasing the pressure in the cuff on the arm to allow the pulse to increase in strength, the diastolic pressure, the period of rest when the ven- tricles are filling with blood, may be obtained from the oscillations of the mercury in the manometer. Systolic pressure represents the force of the left ventricle; and the diastolic, the tone of the arteries. The normal blood pressure is estimated roughly as follows: For a man under twenty years of age it should be one hundred millimeters plus his age, and for every two years added to this age, one millimeter is added to the pressure. In women the pressure may run from seven to ten millimeters lower. After the arteries have lost their elasticity in old age, or in youth due to disease, the arterial walls become thick- ened, and their tissues hardened so that they may be felt underneath the fingers like whipcords. This condi- tion is known as arteriosclerosis, and its presence should be particularly noted by the nurse. Chronic nephritis, heart and cerebral complications, high protein diet, drug poisoning, and arteriosclerosis are among the common causes of high pressure; shock, hemorrhage, disturbed digestion as vomiting or diarrhea, or exhausting diseases like tuberculosis or any fever may cause low pressure. Fig. 65.-The Brown sphyg- momanometer. 95 TEMPERATURE, PULSE, AND RESPIRATION The purpose of respiration is two-fold: (1) the oxy- genation of the blood and the removal of carbon dioxide in the lungs; and (2) the maintenance of combustion within the tissues. The former process is termed external, and takes place in the lungs; the latter, internal or true res- piration, which takes place in every cell of the body. A one-celled animal takes its oxygen from and dis- charges its carbon dioxide into the water in which it lives; an analogous process takes place in every cell of the body-oxygen is absorbed from and carbon dioxide discharged into the lymph in which the cell is bathed. This constitutes internal respiration. In external respiration, inspiration is succeeded by expiration, due to the alternate rise and fall of the chest, so that air is inhaled into and exhaled from the lungs. Mechanics of Respiration.-During inspiration the diaphragm, the floor of the thorax, contracts and becomes flattened, the ribs straighten upon the spinal column to increase the antero-posterior diameter, a vacuum is produced in the air-cells of the lungs and air is sucked in. In normal breathing, the muscles used are the dia- phragm, the external and internal intercostals, and the long and short elevators of the ribs. In expiration, the lungs and thorax are relaxed to their original position, compelling expulsion of air. Normal respiration is pas- sive, but may be made active by coughing, sneezing, or crying. Respiration may be voluntary or involun- tary; it can be controlled, however, by the will only to a definite limit. The respiratory impulses arise in the brain center and are transmitted via the nerves to the muscles enumerated above, the rhythm being uncon- scious and regular. As the blood flows through the capillaries of the lungs, it exchanges some of its carbon dioxide for oxygen from the air-cells, because of the physical tendency for gases to become uniform, giving to the blood its new bright red color. The increased oxidation that occurs in fever and in strenuous exercise THE RESPIRATION 96 PRINCIPLES OF HOME NURSING produces an excess of carbon dioxide; in order to rid the body of the carbon dioxide, more oxygen must be taken in, hence there is an accelerated respiration. Rate of Respiration.-For a normal adult, the average rate of respiration is 18 per minute; but it is more rapid in children and infants, and is slower in men than in women. The ratio between the rates of pulse and respira- tion is very nearly constant, being about four beats to every inspiration, even during violent exercise and in fever. Respirations as low as 8 per minute or above 38 are considered pathological indications. Since respiration may also be voluntary, the chest movements should be counted without the patient being aware of it; therefore, count the respiration after having taken the pulse retaining the finger still at the artery. The two movements-inspiration and expiration -are to be counted as one. Respiration may also be counted while the patient is asleep, which of course will give a slower rate; or the nurse may stand at the head of the bed to observe. Note if the respirations are deep or shallow; thoracic or abdominal; dyspneic, apneic, or stertorous. Dyspnea is difficult and labored breathing, as seen in asthma and heart disease, sometimes being accompanied by cyanosis. Apnea is a temporary cessation of breathing. It is commonly seen in Cheyne-Stokes respiration, which may occur in perfect health in children or in the aged during sound slumber; or in persons suffering from kidney or heart complications, when it becomes a serious symp- tom. It is characterized by a gradual increase in the rate until it ends in a gasp, followed by a gradual decrease and a short cessation; then this rhythm is resumed. In stertorous breathing, there is a deep snoring sound on inspiration, and usually a puffing out of the lips and cheeks on expiration. This respiration is noticeably present in apoplexy. CHAPTER VIII HOME TREATMENTS AND MEDICATION ENEMATA Definition.-An enema (plural enemata) is an injec- tion of fluid into the bowels for therapeutic purposes. Enemata are given for purga- tive, stimulative, and nutritive purposes; for the expuls on of worms, the checking of diar- rhea, the relief of pain, and for flatulence. They may con- tain salt, turpentine, asafetida, medicine, or may be made of starch. But they should never be given by the home nurse without special orders and directions from the doctor. In any morbid state when there is lack of normal exer- cise, the sluggishness of the bowels must be overcome; when a laxative is too slow or too severe, or when it is neces- sary to have a thorough and immediate evacuation of the lower bowel, an enema becomes the natural expedient. Success depends upon the observation of certain details, including the position of the patient, the temperature of the liquid, and the retention of the enema. The fountain syringe or irri- gating can have bv far the advantage over the David- Fig. 66.-The intestinal canal (Leidy): 1, Stomach; 2, duodenum; 3, jejunum; 4, ileum; 5, cecum; 6, vermiform appendix; 7, ascending colon; 8, transverse colon; 9, descend- ing colon; 10, sigmoid flexure; 11, rectum. 97 98 PRINCIPLES OF HOME NURSING son syringe found in so many homes. A rectal tube and a funnel may be used, but precautions must be taken against admitting air into the bowel by keeping a con- tinuous flow of fluid in the funnel and tube. Have ready the syringe and the liquid, the bedpan or commode, vaseline, newspapers, and toilet paper. Fig. 67.-Knee-chest or genupectoral position. (Dorland.) Fig. 68.-Sims position, posterior view. (Dorland.) Fig. 69.-Dorsal recumbent position. (Dorland.) Replace the upper bedding by the bath blanket; protect the bed with a rubber sheet or newspapers; and let the patient assume the position best suited for her comfort as described below: 1. The knee-chest position, which must never be assumed by the patient without the doctor's permission. HOME TREATMENTS AND MEDICATION 99 The patient lies on her face and chest, with her face turned to one side, and raises on her knees to elevate her hips. This position permits gravity to assist the flow, and as there is little or no localized distention in the rectum, there will be less pain, and the patient can retain more fluid and retain it longer. 2. The patient lies on her right side with her knee flexed close to the body to relax the abdominal muscles. As the water enters the descending colon on the left, it will instantly flow through the transverse colon down the ascending colon on the right side, thus avoiding localized distention and pain. 3. Some authorities insist that the patient lie on the left side (Sims) until the enema has been given, then, if she is able, turn her to the right side. As this necessi- tates too much action, and as the liquid remains accumu- lated in the rectum too long, the first two methods are recommended for the best result. 4. The dorsal recumbent, in which the patient lies on her back with her knees flexed; this position is indicated when giving the continuous enema. Procedure.-Release the clamp until the fluid runs from the tube warm, close the tube by pinching it, lubri- cate the tip, and slowly and carefully insert it into the rectum. Sometimes a "high" enema is ordered, for which a soft-rubber rectal tube or large catheter is attached to the nozzle to carry the fluid beyond the sigmoid flexure. X-ray pictures show, however, that the rectal tube does not go beyond the sigmoid, but coils upon itself. Hold or hang the syringe about one foot higher than the patient's buttocks, avoid using force, and do not hurry. If forcibly and rapidly injected, the desire for evacuation is always intensified. Whenever the patient feels pain, pinch the tubing and wait until the spasm passes, which may be a matter of only a few seconds; then proceed until all the fluid has been introduced. Encourage the patient to retain a laxative enema for at 100 PRINCIPLES OF HOME NURSING least twenty minutes, and if she can do so for an hour so much the better; a free movement may result. Material assistance is given by holding a folded towel at the anus. If turpentine has been used, the anus and buttocks must be carefully washed after evacuation. The continuous use of enemata may set up an irritation of the anus, which is relieved by cold compresses; heat adds to the congestion. The Soapsuds Enema.-This is the laxative enema most generally used; sometimes glycerin or oil is added. To make, pour very hot water over ivory or castile soap to dissolve it, (never use laundry or toilet soap), then care- fully add enough cold water to bring it to the desired tepid temperature. Do not stir up a froth, as it is the soapy water and not the froth that passes through the tubing. The virtue of the soapsuds enema lies in the production of peristalsis due to the distention of the rectum by the fluid and the irritation of the mucous membrane by the soap itself. The temperature of the enema should be lukewarm, and the quantity for adults two to four pints, and for children one to two pints. Oil Enemata.-Since oil flows too uncertainly through tubing, besides being injurious to the rubber, it should be given with a piston syringe, a certain amount of pressure being thereby obtained. (See page 23.) Oil is to be injected very slowly, retained long enough (at least an hour) to surround and mix freely with the fecal matter, and may be retained over night. It is usual to follow an oil enema by a soapsuds enema after the prescribed interval. Six ounces of warm sweet oil is the recognized amount for adults. There is no special virtue in olive oil over sweet oil. Salt enemata are given for stimulation after shock, to relieve thirst, and to add water to the system after a hemorrhage, and should be retained indefinitely. Salt is used in the proportions of one teaspoonful of table salt to a pint of water. (See page 243.) Proceed as directed for an ordinary enema, with the exception that HOME TREATMENTS AND MEDICATION 101 the patient lies in the dorsal recumbant position with her knees supported, a rectal tube is used, and the liquid given very slowly, drop by drop. Only a pint should be given at a time as too much will likely be expelled. The rubber tube should be sterilized by boiling, and inserted as high as it will go, which is about six to eight inches. If given for stimulation, it should be given as hot as can be borne, at least 108°F.; and because of the slow introduction, some device for maintaining the temperature should be employed, such as placing a hot- water bottle over the tubing. Strong coffee enemata are given in cases of shock, collapse, or opium poisoning. Make coffee as for table purposes but very strong, strain, and give slowly. Emollient Enemata.-Starch enemata are given in cases of acute diarrhea, especially if there is much tenesmus (ineffectual straining). Make starch as for laundry pur- pose by dissolving the dry starch in cold water, adding it to boiling water, and boiling it three to four minutes; add sufficient cool water to lower the temperature to 103°F., and to make the mixture as thick as cream. Strain for lumps. Use a Davidson or piston syringe to supply the necessary force to get the starch through the tubing. Sometimes laudinum is added. This enema must be retained. Starch is not an astringent, but it checks diarrhea by coagulating in the bowel. A strict bread-and-meat diet is recommended to furnish the bulk. Milk should not be given in any form as it curds, and only aggravates the trouble. An astringent enema may be given in the shape of tea that has been boiled to extract the tannin, but of course must not be given without the doctor's orders. Sedative enemata are given for sleeplessness, chloral and bromide being the drugs most generally used. Cat- nip tea given in small quantities and expelled immedi- ately can be given without fear. Catnip tea may also be drunk at bedtime. The patient must be ready for sleep before the sedative enema is given. 102 PRINCIPLES OF HOME NURSING To relieve pain in the anus due to hemorrhoids, give, with doctor's sanction, small quantities of cold water by injection, permitting the patient to expel it immediately. The cold water running over the congested region will help to reduce the inflammation. Rectal feeding is resorted to in cases of persistent vomiting or inability to take or retain food on the stom- ach. These cases have a very serious aspect, and life may depend upon the skill and sincerity of the nurse. A purgative enema should be given once a day, prefer- ably in the morning, to remove the unabsorbed and decomposing material of the previous day's adminis- trations. The nutritive enema is given about once in six hours, is injected slowly, is introduced as high as possible, and the rectal tube is withdrawn afterwards very slowly. Peptonized or predigested lukewarm milk and eggs are the most frequently used foods, four ounces or about eight tablespoonfuls being the usual amount retained. To Check Excessive Vomiting.-Keep the head low; keep the patient quiet and on her back with her knees flexed and supported; discontinue all foods; place an ice cap over the stomach; give cracked ice to be swallowed whole, or give sips of hot water or weak tea; try, with the doctor's permission, giving several glasses of warm water to wash out the contents of the stomach. To Check Hiccoughing.-Apply steady intermittent pressure at each side of the neck; it is here that the phrenic nerve, which supplies the diaphragm, comes near the surface. Have the patient drink a full glass of water without inhaling, or hold her breath as long as possible. DOUCHES Vaginal douches should never be given or taken without the sanction of the physician. As Nature takes care of the cleansing process, douching after menstruation is unnecessary, and may terminate in actual harm. If a woman has any excessive discharge, (leucorrhea, HOME TREATMENTS AND MEDICATION 103 "whites") she should see her doctor and follow his directions implicitly. To give, place the patient on the douche pan, support- ing her back in the dorsal region with a small pillow, thus raising her hips. Have ready the fountain syringe or irrigating can with the fluid of the temperature 110°F. Before inserting the douche tip, irrigate the vulva. Never hang the syringe higher than two feet above the patient, so that a flooding of the parts may be continuous and slow. Do not put the nozzle into the syringe when through. Boil the nozzle after each use and keep it in a disinfectant solution. Ear douches are given for various reasons, chief among which is the hardening of the cerumen, or wax. A clean fountain syringe, soft rubber or bulb syringe, or a piston syringe may be used. Place a towel over the shoulder, hold a kidney basin under the ear, straighten the canal by pulling upward and backward on the pinna, and douche slowly and carefully having the fluid of a temperature between 105-108°F. The canal should not be obstructed by the nozzle, but the fluid be permitted a free exit to avoid distention and further injury. If dizziness is complained of, the doctor should be notified before another douche is given. Wipe the auditory canal with an applicator, and if a discharge is present, plug the canal loosely with cotton. For pain in the ear it is recommended to swab the throat or to have the pharynx inspected for enlarged adenoids, as often the pain in the ear is due to an infection of the Eustachian tube. Obstruction of the Eustachian tube by adenoids sometimes terminates in permanent deafness. C OUNTERIRRIT ANTS A counterirritant is a therapeutic agent which when applied to the surface of the body produces an irritation of the sensory nerve endings in the periphery, and by reflecting to other parts relieves congestion, inflam- mation, or pain; it is applied directly over the seat of pain 104 PRINCIPLES OF HOME NURSING or inflammation, or at a distal point from it. Counter- irritants may be general, as the therapeutic bath; or local, as (1) rubefacients, or reddeners; (2) vesicants, or blisterers; or (3) caustics. Rubefacients commonly used are dry and moist heat, mustard, iodin, turpentine, plasters, and liniments. Dry heat may be applied in the form of hot flannels, hot-water bottles, or electric pads, and must be light in weight and not too hot lest the patient be burned; bricks retain heat long, but are clumsy. The hot flat- iron may be drawn back and forth over the affected part, like a shoulder or back, that has been previously covered with a flannel or towel, until relief is experienced. Moist heat is more penetrating and relaxing to the blood vessels, and is used in the shape of tub baths, poultices, linaments, fomentations, and stupes. A poultice is a mixture of any mild semi-solid substance that will retain heat, and hot water. Milk when used in the old-fashioned "bread and milk poultice" encourages the growth of bacteria when warm and should not be used; bread does not retain the heat long and is therefore not a good substance. Before applying the poultice, cleanse the seat of application and dry with alcohol. Spread poultices one-half inch thick on muslin which is larger by two inches all around than the required size, fold the margins over the poultice substance, and cover with gauze or cheesecloth. Carry the poultice to the bedside between two hot plates or folded in a towel; apply as hot as can be borne, with the gauze side next to the skin; lift it several times during the act of application to admit air between the poultice and the body; and cover with flannel, rubber, or paper to prevent the dissipation of heat. Create a tolerance in the skin by gradually increasing the heat of each poultice. Poul- tices must be changed frequently enough-at least every half hour-to keep the surface of the skin hot; otherwise they do more harm than good. Never allow a poultice to grow cold on the body. Prepare the fresh HOME TREATMENTS AND MEDICATION 105 one and have it ready to apply before removing the old one. When the treatment is discontinued, wash the region to remove all stains, dry well with alcohol, anoint with oil or vaseline, and protect from the air. Flaxseed (linseed) poultice is the old favorite, and has no equal; because of its content of oil it can be used at a high temperature without fear of blistering. To make, into about two pints of boiling water, sprinkle enough ground flaxseed, stirring constantly, to make the mixture the consistency of mush, just stiff enough to drop off the spoon; beat to make it light; and spread as directed. Hard boiling is not necessary as it makes the poultice tough and heavy. Sometimes a little mustard is added to the flaxseed poultice. Before leaving the kitchen, see that the pan in which the poultice was made is filled with cold water to facilitate its washing later. Starch Poultices.-Starch is made thick as for laundry purposes, and is applied directly to the skin to relieve itching in skin diseases. Mustard Poultices.-Because of its contained volatile oil, mustard is the recognized peerless counterirritant. Its potency lies in the evaporation of the oil; and as hot water lessens the strength of the oil, mustard must not be mixed with water hotter than 100°F. To make, mix flour and dry mustard in the proportions of one to eight for children and one to four for adults, add sufficient tepid or cold water to make a smooth paste that will not flow, spread on muslin one-eighth inch thick as directed, and apply. Observe the skin carefully every few minutes. Any meal, including flaxseed, may be used instead of flour. A mustard draft made with the white of egg, with or without flour, is the most efficient of all. Stir enough ground mustard into the white of an egg to make it of the right consistency and apply in the form of a poultice. Mustard leaves are the ordinary paper plasters purchasable at the drug store, and require only to be dipped in tepid water to make them ready for use. They are popular chiefly because of their convenience 106 PRINCIPLES OF HOME NURSING and speedy action. Place a leaf mustard side down upon the prepared skin,, cover, and leave ten to twenty minutes, or until the skin is rubescent. Should a blister form, dress it like any burn but do not open it. Liniments are usually rubbed in with the hand, and as rubbing is the greater part of the treatment, massage should be continued for five or ten minutes. Liniments cause a slight irritation to the cuticle nerve endings. Plasters.-Capsicum-and-belladonna plasters are often used to relieve pain. They may be applied to the back, shoulder, neck, or side. Their efficacy lies in the drugs used, in the irritation to the skin actuated by the suction of the holes in the plaster, and later to their forcible removal. If pulling the plasters off is contraindicated by the delicacy of the skin, they can be removed with gasoline, alcohol, or benzine. lodin.-The tincture of iodin when painted on the skin provokes a continuous irritation because it pene- trates to the deeper tissues. The skin must be per- fectly dry and clean before applying. It is best smeared with a cotton applicator which can then be discarded. One coat should be permitted to dry before another is put on, and the resulting stain should not be too dark a brown. lodin can be removed, if too much irritation is produced, with ammonia, alcohol, or oil. Stupes and Fomentations.-Stupes consist of two pieces of flannel cloth about eighteen inches square wrung out of hot water and applied alternately to the part to be treated. Fomentations consist of compresses made of lint or absorbent cotton and are usually applied to the eyes. Stupes applied to the abdomen increase peristalsis and relieve pain and flatulence. The flannel must be wrung very dry and very hot. This process can be facilitated by using a stupe wringer (see page 34) or in its absence, a towel, twisting the ends in opposite directions. Carry the stupe and wringer, covered, to the bedside; stupes cool rapidly when exposed to the air. Apply slowly as with the poultice to avoid scalding, and to accustom the HOME TREATMENTS AND MEDICATION 107 skin gradually to the heat. Cover with some impervious material like a dry flannel, paper, or oilcloth to retain the heat. Flannel stupes are changed every ten minutes a new one being ready before the old one is removed. The bed must be well protected while applying moist dress- ings. It is better to apply hot stupes for an hour changing every ten minutes, than all day chang- ing only every hour. Turpentine does not mix with water, and to avoid blistering, should be applied directly to the skin mixed with twice its bulk of oil or melted lard, over which the usual hot stupes are applied, reanointing with the turpentine every sixth or eighth time. Fomentations for the Eyes.- Make compresses of absorbent cotton or lint about two inches in diameter, a separate one for each eye. Compresses for the eyes must be very light in weight. Squeeze them with the fingers out of water that is being kept hot over a gas stove or alcohol lamp. Compresses must be changed every minute or two removing them only when fresh ones are ready, continuously, or for a half hour intermittently, during the day. If a compress is soiled with a discharge, it should be discarded. Cold compresses for the eyes are made of pledgets of absorbent cotton kept cold on a cake of ice, a separate compress being used for each eye, and discarded if soiled from pus. Iced compresses must be changed every minute or two; for if left on until they become warm, they partake the nature of a poultice, when they do more harm than good. Fig. 70.-Using a stupe wringer. 108 PRINCIPLES OF HOME NURSING In case of ophthalmia neonatorum the compresses must be conscientiously changed and kept very cold to check further suppuration. The nurse must be careful to disinfect her hands often, because this is a very infectious disease, and never to rub her own eyes. Neither must she without first disinfecting her hands, use her handker- chief, then rub her eyes with it. Cold compresses to be applied to other parts of the body are made of old linen (cotton will do, but is not so desirable) of the required size and shape wrung out of cold water and applied, the part being enveloped in flannel to exclude the air. The cold water by coming in contact with the warm skin is vaporized, rendering the skin more sensitive to cold air which must therefore be carefully excluded. A compress so applied must be renewed every hour, but not unless it has become thoroughly warmed. Cold applied to the skin contracts the cutaneous vessels, with a compensatory dilatation of the deeper vessels. Throat compresses are applied for tonsillitis, diphtheria, and other pharyngeal congestion, and when improperly applied, the object is defeated. Take a piece of old linen large enough to reach from ear to ear, wring out of cold water, apply, and cover with a flannel that is fastened on top of the head, in which slits are cut for the ears. The dry covering prevents too rapid evaporation. Cold baths are discussed in the chapter on hydrotherapy. Ice-caps are used as counterirritants over various parts of the body-the head, neck, ear,-and should always be kept covered with a towel or specially made case, to absorb the moisture formed on the cap when in contact with the warm skin, and to prevent too great a chilling of the skin. Ice-coils may also be so used. (See pages 27 and 88.) VESICANTS Vesicants are used to draw blisters. Mustard when allowed to remain on a spot too long becomes a vesicant. HOME TREATMENTS AND MEDICATION 109 Cantharides, the most commonly used vesicant, con- sists of the powdered bodies of the Spanish fly, a beetle found in Southern Europe. It can be purchased at the drug store suspended in collodion or in the shape of a plaster. The application of a fly blister is not in the province of the home nurse, and she must therefore use special caution in following the physician's directions. The skin should be prepared as for a minor operation, and oiled. The plaster is usually cut to cover an area of one to two inches, and is lightly held in place by a loose bandage, and left on for four to ten hours. The amount and character of the urine during the twenty-four hours following the application of a cantharides should be specially noted because of its violently irritating effect on the kidneys. After the bleb has formed, remove the plaster carefully, and wash the part with oil. Unless orders are to the contrary, the blister should not be opened. If however, the doctor prefers a puncture, sterile scissors and sterile sponges should be used, and the puncture made at the lowest margin of the blister, to avoid infection. CAUSTICS Caustics may be applied directly in the form of actual fire or heated metal. The silver nitrate or lunar caustic sticks used to touch up a canker sore in the mouth or for burning away the granulations, "proud flesh," in wounds is familiar to all. Sometimes the glowing end of a match is utilized. Actual Cautery.-Cauterization is applied in hospitals directly to the skin with an instrument called an electro- or thermo-cautery, which resembles a pyrograph in appearance and in operation. It is used in cases of bites by rabid animals or poisonous snakes; in nose and throat treatment; also in lumbago and rheumatism. As this instrument is an expensive one, a word of caution may not come amiss here relative to its care. The platinum tips are very delicate and should not be dipped in water 110 PRINCIPLES OF HOME NURSING while hot nor injured by careless handling, and the instrument should be carefully put away in its box, each part in the compartment intended for it. MEDICATION Because of the trust placed in her, it is necessary for a home nurse to understand the effects of the medicines in common use, to know the maximum and the minimum doses, and the symptoms of overdosing. Medicines are culled from all three kingdoms, vege- table, animal, and mineral, and are administered in the solid, the liquid, and the gaseous forms, but most popu- larly in solutions, powders, tablets, capsules and pills. They are absorbed from: 1. The digestive tract, and may be administered by mouth or by rectum. Solutions given by mouth act more readily and are absorbed more quickly, and are commonly given in this form. Those medicines used to stimulate the appetite or the flow of the gastric juices are given before meals; those which are acid, or are irri- tating, such as iron, are given after meals when the stomach is full. Laxatives that act quickly like salts are given in the morning usually before breakfast, and those that act slowly like cascara or castor oil at bedtime. Hypnotics are given only when absolutely necessary, and then not until after all preparations have been made for rest and sleep. Medication is given by rectum in enemata or in sup- positories. A suppository is a cone made of cocoa butter in which the medicine is suspended. When inserted into the rectum, it melts very readily, and the drug is released and absorbed. A glycerin suppository is used to cause hasty evacuation of the bowels; and an opiate to relieve hemorrhoids. 2. From the respiratory tract, and are given as inhala- tions. The absorption by the respiratory tract is swift because of the large area of blood exposed; substances 111 HOME TREATMENTS AND MEDICATION are gaseous-oxygen, ether, chloroform; or vaporous- steam. Inhalations are given for their healing effect upon the lungs when indicated by colds, asthma, pneumonia, croup; for systemic stimulation by inhalations of cam- phor or ammonia; and for general anesthesia when chloroform or ether is used. These drugs may either be inhaled from a handkerchief, a mask, an atomizer, or from the steam of boiling water confined by a cone. A tent improvised of a screen or umbrella covered with a blanket to absorb the moisture, over the head of the bed, under which is forced medicated steam from a tea- kettle or other contrivance, is often used in cases of croup. 3. From the tissues, and are given by hypodermic injection. (See page 37.) Hypodermic or Subcutaneous Injections.-Drugs are given subcutaneously when it is impracticable to give them by mouth, or when immediate results are desired. Those given by hypodermic are heart stimulants, such as strychnia, digitalis, nitroglycerin; narcotics, such as morphine; and depressants such as apomorphine. Medication meant for subcutaneous injection is usually put up in tablets in a concentrated form. These tablets are to be dissolved in warm sterile distilled water, pref- erably by dropping them into the neck of the previously prepared hypodermic syringe. Distilled water is not necessarily sterile, for it may become contaminated in the process of distillation, and unless boiled it may be the source of abscesses. As the home nurse is seldom called upon to give a hypodermic injection, details on the subject are unnecessary further than to state that injec- tions are given into the fleshy outside parts of the arms or legs; should never be given over a bony structure, or into the region of a visible vein; and that the hypodermic and needle must be sterilized by boiling or by drawing up into it, at least six times, 70 per cent alcohol. 4. From the skin by inunctions rubbed in. This treatment is rarely used except in the treatment of 112 PRINCIPLES OF HOME NURSING syphilis, and in extreme emaciation when olive or cod- liver oil is used. 5. Directly from the circulation, when medicines are given directly into the veins. Intravenous injections are given only in extreme cases, and in the administration of neosalvarsan in syphilis. Medicines are given by mouth in the shape of pills and capsules to conceal the taste. The bulk of a pill might be increased if hard to swallow by wrapping it in soft bread or disguising it in fruit or jelly. Seidlitz powders come in pairs in blue and white papers, the contents of each to be dissolved in a half glass of lukewarm water (too cold will be difficult to drink), and poured together just before the patient is ready to drink it. It must be drunk while effervescing. Oils may be disguised in various ways. Castor oil may be boiled in milk and offered to children with crackers as soup. Grape, orange, lemon juices, root beer, are favorite vehicles. Recommendations are made to place the vehicle in the bottom of a glass, pour in the oil, and cover it with more of the vehicle, but the author has never seen this take the shape of the ideal capsule or sandwich described. Oil had best be well beaten into the vehicle used. Let the patient bite into a lemon or a piece of lemon or orange rind before drinking the oil. "Drops" are put into the eye usually with a medicine dropper. Ask the patient to look up, pull down the lower lid, and drop into the cul-de-sac between the lid Fig. 71.-Castor oil in glass ready for administration. (De Lee.) HOME TREATMENTS AND MEDICATION 113 and the eyeball. The dropper must not touch the eye nor the lashes if it is to be used on another person. If the eye is to be flushed with a copious amount of fluid, the solution can be dripped from a saturated cotton sponge into the eye following the procedure just de- scribed, catching the overflow on another piece of sterile cotton held at the angle of the nose. Foreign bodies, such as cinders and bugs, are removed by everting the upper lid, and wiping out the offending particle with the corner of a clean handkerchief or sterile gauze. To evert the lid. (See page 157.) Sometimes it requires all the ingenuity a nurse possesses to give medicine to a child. After cajolery and bribery have failed, she may have to resort to force. Often, however, the struggling and consequent exhaust- ion may do more harm than good. So the doctor must be consulted. When using restraint, wrap the child well in a sheet to confine his arms and legs, hold his nose until he opens his mouth for a breath, then, still holding the nose, insert the spoon into his mouth, gently press down on the back of the tongue, and hold it there until he swallows. If the spoon is removed too soon, he may find it possible to expectorate the medicine. PRECAUTIONS TO BE REMEMBERED IN THE ADMINIS- TRATION OF MEDICINE Many homes devote a shelf of pantry or cupboard to a collection of all kinds of medicines that "might be useful some day," some being relics of deathbed use; some- times they are not labeled, and chances for mistakes are great. At the termination of a case whether by death or recovery, all medicines used particularly for that case should be destroyed; symptoms are different in every case, therefore the medication will be different in any subsequent cases. It is well to have a medicine cabinet in which are kept a few staple drugs for emergency. But as pharmacies are within close range, and as medi- 114 PRINCIPLES OF HOME NURSING cines deteriorate, it is best not to keep much of a supply on hands. The following precautions are worth noting: 1. Mistakes are oftener made through carelessness than through ignorance. 2. Always dilute fluid medicine sufficiently to reduce the concentration, but not enough to prolong the agony of drinking it. Salts should be given with as little water as possible so not to reduce its hygroscopic power. 3. Always see that bottles and boxes are labelled. 4. Never measure or give a drug in the dark or by a dim light. 5. Medicines should be shaken in the bottle before measuring the dose. Sometimes the important ingre- dient is in the sediment, sometimes it floats on the top, and either too much or too little of it would be given. 6. Be sure that you understand the directions; other- wise it is best to skip a dose while you communicate with the doctor. 7. Read the label three times:-before picking up the bottle, before pouring the dose, and before returning the bottle to the shelf. 8. Remove the cork in the crook of the little finger of the right hand and hold it there until replaced in the bottle. This obviates the possibility of contaminating or losing the cork. 9. Never guess at a dose. There is an element of danger in every drug given. 10. Measure exactly by minims when ordered so, or by drops. Spoons are unreliable; it is best to use a regular graduated measuring glass. A drop too much may prove dangerous. The size of a drop varies with the density of the fluid-a minim is always the same. 11. Hold the measuring glass on the level with the eye when pouring the medicine. 12. Avoid defacing the label by holding the bottle label-side up when pouring. 13. Always wipe the lip of the bottle with a clean cloth. HOME TREATMENTS AND MEDICATION 115 14. Cork all bottles carefully after measuring the dose, for some medicines are volatile, and if not corked, might lose some important ingredient. 15. Keep a separate glass for malodorous medicines like cod-liver oil or asafetida. 16. Have the patient prepared for rest before giving a narcotic, and never give one unless the need is urgent. 17. Place pills under the tongue and flush down by a large drink of water. Powders may be given dry on the tongue or dissolved in water or milk. 18. Capsules, pills, and powders are to be given from a spoon and not from the fingers. 19. Be sure that you understand how to measure fractional doses if ordered. The half of Ho is not Ho- If you wish to give Ho grain of strychnia, and the solution that you have on hand measures Ho grain to every ten drops, how many drops would you give? If you wish to give Ho grain of strychnia, and the solution you have measures Ho grains to the ten drops, how much should you give? 20. How would you measure one-half a drop? 21. To calculate a child's dose from the adult dose: Make a fraction, the numerator of which will be the child's age, and the denominator of which will be the child's age plus 12. Divide the adult dose by this fraction; thus, if the child is six years old: 7.- , = 77 of the adult dose. In order that the student may become familiar with terms, signs, and abbreviations commonly used by the doctors, several tables are submitted below: Signs Minim njj Drop gtt, gutta One-half ss, semissis Dram 3 Ounce 5 Pint O 116 PRINCIPLES OF HOME NURSING Apothecaries Fluid Measures 60 minims = 1 dram 8 drams = 1 ounce 480 minims = 1 ounce 16 ounces = 1 pint Household Measures 1 teaspoonful = 1 dram 1 tablespoonful = y2 ounce 1 wineglassful = 2 ounces 1 teacupful = 4-5 ounces 1 tumblerful = 8-10 ounces Abbreviations-time for giving medicine R, receipe, take ad lib, ad libitum, as you please p.r.n. pro re nata, as occasion arises A.C. ante cibum, before meals P.C. post cibum, after meals A.M. ante meridian, in the morning P.M. post meridian, in the evening N. nocte, at night b.i.d. bis in dies, twice a day t.i.d. tres in dies, three times a day 2 X d. twice a day 3 X d. three times a day q.h. quaque hora, every hour q.2h. secunda quaque hora, every 2 hours q.3h. tertia quaque hora, every 3 hours Names Used to Describe the Physiological Effects of Drugs Analgesics relieve pain Anesthetics cause local or general insensibility Anodynes relieve local pain Anthelmintics expell worms Antipyretics reduce fever Antiseptics prevent growth of bacteria Astringents contract tissue, and lessen secretions and hemorrhage Carminatives relieve flatulence Cathartics (purgatives) cause frequent bowel movements Diaphoretics increase perspiration HOME TREATMENTS AND MEDICATION 117 Disinfectants (germicides) destroy microorganisms Diuretics increase secretion of urine Emetics cause vomiting Emollients soothe and soften Expectorants stimulate expectoration Hemostatics (styptics) arrest hemorrhage Hypnotics (narcotics) produce sleep Laxatives cause defecation Sedatives quiet the nerves Stomachics stimulate the appetite Drugs in Common Use Name Composition Dose Aspirin Acetyl-salicylic acid gr. 5-15 Calomel Mild chloride of mer- cury gr. 1-4 Dobell's Solution. . Sod. bicarb, phenol, borax, glycerin. Gargle Dover's Powders... Opium, ipecacuanha, sugar of milk gr. 5-10 Elixir iron, quinine, and strychnine Iron, quinine, strych- nine 51-2 Fowler's Solution Arsenic in 510. -1-10 Ipecac, Syrup Ipecacuanha 5 Li-2 Laudanum Tincture of opium TO 5-20 adult Paragoric Camphoric tr. opium 5 ss-1 adult Phenol Carbolic acid External use only Seidlitz Powders. . . White-Tartaric acid Blue-Sod. bicarb, and Sod. and Pot. Tartrate. 1 white and 1 blue. CHAPTER IX FEEDING THE SICK Food is sometimes more important than medicine. Only as the body is able to assimilate its nourishment can the diseased cells of the organs and the tissues be replaced by healthy ones, and recovery follow; it is there- fore best that the appetite of the sick be stimulated by the products of the kitchen rather than by tonics. The intelligent preparation of diet in the treatment of disease has become to be one of the fine arts, and skill in cooking for and feeding the sick is an accomplishment of which every girl should be proud. To be able to co-operate more intelligently with the doctor, the home nurse should have at least a superficial knowledge of the composition of foods and of their uses in the body. The average nurse might become somewhat bewildered if she were obliged to calculate the food requirements of her patient in terms of Calories of carbohydrates, fats, proteins, mineral salts, vitamins, and water; but her work need not be so formidable, as only a familiarity with the composition and relative values of different foods will be needed in the preparation of ordinary dietaries. In choosing food for the sick, two important factors must be considered, (1) that the digestive juices are diminished in quantity, and (2) that peristalsis is weakened. As fats are more concentrated fuel food and are more difficult to digest, and as sugars ferment easily and cause digestive disturbances, they should be used sparingly in the diet of the sick; hence, starch is an apparently safe source of energy, and can be used freely in invalid cookery. 118 FEEDING THE SICK 119 Waste matter has a tendency to accumulate in the body, even though only fluids are ingested. These waste products act as poisons in the system, especially if because of a lack of exercise there is intestinal sluggishness. Even though the digestion is apparently normal, it is un- safe to add to the burden of the organs that throw off the waste matter by giving foods that are difficult to digest. It was formerly thought that if much food were given a fever patient, her temperature would be increased in consequence of the increased oxidation; but nowadays, food which can be properly assimilated is given freely, to prevent the consumption of the tissue itself, which happens when food is withheld. Consequently, in protracted fevers, 2,000 to 3,000 Calories must be sup- plied, depending on the condition of the patient. Fluids that are highly nourishing and easily digested are given frequently and in small quantities. The nurse should not offer animal broths as they contain no food value other than the fat content. Foods chiefly relied on are milk and its more valuable and palatable compounds, fruit juices if not given more than three times during the twenty-four hours, and raw eggs. A patient who is conscious and trustworthy may be given a small piece of broiled round steak from which she is to chew the juices and discard the pulp. The steak should be tough, else particles of it will unwittingly be swallowed. The act of chewing helps to stimulate the digestive juices. In feeding the sick, four kinds of diets are recognized outside the restricted dietaries prescribed in diseases due to improper metabolism, among which are diabetes, dysentery, constipation: 1. Fluid or Liquid Diet.-Milk, junket, ice cream, strained milktoast, cocoa, milk shake, peptonized milk, milk coffee, malted milk, oyster stew, tomato and celery soup, rice and barley water, strained oatmeal gruel, albumen water, animal broths in which the yolks of eggs are well beaten, gelatin with the white of egg and fruit juices, beef juice chewed from round steak. 120 PRINCIPLES OF HOME NURSING 2. Semisolid or Soft Diet.-All liquids; soft eggs, either boiled, coddled, poached, or shirred; custards, cereals, toast, puddings, rice, prune whip, citrous fruits, cottage cheese, baked potato. Do not give milk with acid fruits, and do not give fruits more than twice during the twenty-four hours. 3. Light or Convalescent Diet.-Anything enumerated above; short fibered meats, such as chicken, broiled or boiled; fish; scraped raw beef; vegetables like asparagus, fresh tomatoes, slaw, greens, squash; fruits; sponge or angel food cake. Do not give pastries or spices, nor anything fried. 4. Regular or Full Diet.-Consists of anything the patient desires that is not indigestible. Avoid boiled cabbage, turnips, and dried beans. Care of Milk in the Home.-Since milk forms the basis of so many dishes in invalid feeding, the proper care of the milk in the home should not be overlooked. Suggestions.-Ask the members of your patient's family, never the patient herself, what her preferences are in the way of food; sometimes when her appetite is languishing a little delicacy of which she is particularly fond daintily served and brought to the bedside as a surprise will give keen enjoyment. The preparation of special dishes should never be entrusted to the cook; ordinarily, maids do not want to "bother" with any special cooking or service; and it is very annoying to have an expensive meal spoiled by careless preparation. All hot foods should be served immediately on hot dishes, and not set back in the oven or on the stove to get hard and dry; and cold foods should be served cold, not luke-warm. Meals should be served punctually. Always cover dishes containing foods in transit to the bedside. Before serving, wash the patient's face and hands, and ventilate the bedroom to freshen the air. FEEDING THE SICK 121 If she is permitted to sit up, mealtime is the time for this exercise. When her appetite is poor, give only one dish at a time, and give small portions. Fastidious people often lose Figs. 72, 73.-The tray. appetite at sight of too much food at once; so if possible serve in courses. If your patient is on a strict fluid diet, and appear- ances indicate that the period is to be an extended one, do not upset her stomach by varying the food much. Give a variety from day to day, but keep the food on each particular day of about the same type. 122 PRINCIPLES OF HOME NURSING Do not offer a hot broth and a cold milk dish at the same meal if these two things constitute the whole meal. The Tray.-The attractiveness of the tray comes next in importance to the preparation of the food. Use the prettiest dishes in the house, but avoid elaborate decora- tions or clashing colors. Do not overcrowd the tray with dishes or food. Artistic touches in the way of a tiny sprig of parsley to garnish the meat, or a freshly cut flower on the tray, will make it more attractive, thereby adding to the patient's pleasure. Fill the cup for the hot drink with very hot water prior to its use. Provide a pot or covered pitcher to contain the hot drink. A tray with cocoa or coffee spilled in the saucer or on the napkin is uninviting. Do not forget the glass of water or the salt and pepper shakers. Helpless patients should be served with great care and delicacy. Fill the glass or cup only half full so the contents will not be spilled down the neck. Do not give the food too fast nor too hot. For liquids, straws or glass tubes are more easily managed than the feeding cup. The glass tubes must be washed, and boiled at least once a day, and oftener if the patient has an infectious disease of the alimentary canal. Functions of Food.-Food has three important func- tions to perform in the body, namely: (1) to form body tissues for growth; (2) to repair their waste; and (3) to give heat and energy. As coal burned gives a certain mensurable fuel value, so food digested in the human body may also be measured by the "heat units" of energy it produces. As a matter of convenience the word "Calorie" is used to designate this definite amount of heat produced by foods. A Calorie represents the amount of heat required to raise the temperature of one pint of water four degrees Fahren- heit. A piece of coal weighing one-half ounce, sixteen English walnuts, one cup of orange juice, five medium sized carrots, one and one-half pounds of lettuce will, when burned, each produce 100 Calories of heat. It FEEDING THE SICK 123 may be of interest to the student to compare the relative food values of the accompanying list: APPROXIMATE AMOUNTS OF FOOD TO YIELD 100 CALORIES1 Milk % cup Cream J4 cup Butter, olive oil 1 tablespoon Bread 1 slice 1 inch thick Uneeda biscuit 4 (1 orange or apple Fresh fruits 1 1 banana [2 peaches or pears Eggs 1 large Meat, cooked, lean 2 ounces Bacon, crisp 4 thin slices Nuts, shelled % ounce Potatoes 1 medium Sweet chocolate % ounce Most foods contain so much water that it is difficult to make comparisons between their food values; sugar, dry starch, oil, and lard are more nearly free from water than any other foods. It takes 0.4 ounce of oil, 0.9 ounce of sugar, or 0.9 ounce of starch to produce 100 Calories of heat, or 2^ times as much sugar or starch as oil. Every movement of the body, walking, sitting, stand- ing, exercising, calls for a certain expenditure of energy and this for a certain amount of fuel. The expenditure in sickness is as great as in normal health, and in fevers it is more, and if not supplied will be taken from the body tissue itself. The additional expenditure in fevers is due to the morbid action of bacteria, making the energy output greater. The following table taken from Rose "Feeding the Family" (courtesy of The Macmillan Company) gives some idea of the energy output in health. 1 Modified from Rose "Feeding the Family." Courtesy of The Macmillan Company. 124 PRINCIPLES OF HOME NURSING Kind of Activity Calories per Pound per Hour Sleeping M Sitting % Standing % Light exercise i Moderate exercise 1K to Active exercise 1% to 2 Thus to be specific, the requirements for one day of a teacher weighing 130 pounds will be calculated as follows: Kind of Activity Calories for Twenty-four Hours Sleeping 8 hours (8 X X 130) . 520 Sitting 6 hours at desk : . . . . 468 Standing 4 hours . 390 Walking 3 hours . 390 Moderate exercise 3 hours . 520 total 2288 Calories Classification of Foods.-Six important foodstuffs are essential for the upkeep of the body, and if any of them are lacking in the diet for any length of time, serious disturbance in health may result. Foodstuffs are classified as follows: 1. Proteins, or'tissue building foods, represented by milk, eggs, meat, cheese, etc. 2. Carbohydrates, or heat and force producing foods, represented by sugar, potatoes, rice, and most vegetables, etc. 3. Fats, or heat and energy producing foods, represented by oils, butter, nuts, etc. 4. Water is essential for the suspension of the food products within the body until absorbed by the cells. 5. Mineral salts, although not required for energy are essential for the maintenance of osmotic pressure. 6. Vitamins, an accessory substance, but nevertheless important for the stability of the health curve. Proteins.-All foods contain the chemical elements, carbon, hydrogen, and oxygen, in varying amounts, the two latter often in the proportion of water. Proteins, however, are different from the other classes FEEDING THE SICK 125 of foodstuffs in that they contain nitrogen in addition to the above named elements. Because of the nitrogen, protein is an essential food, and no diet is adequate without it. It performs certain functions within the body which cannot be done by fats or carbohydrates; namely, that of forming new cells and of repairing old ones. Growing children and convalescents have need for an abundance of protein. Carbohydrates.-The carbohydrates constitute a very large group of foods, but contain no nitrogen or sulphur; the cells of the leaves and stems of plants combine the carbon dioxide of the air and the water of the soil to manufacture sugar, which is transported in the form of sap from one part of the plant to another. The superflu- ous sugar is converted into starch and stored as small granules in the cells. The presence of sugar in apples, sugar beets, maple trees, and of starch in potatoes and rice are examples of the manufacture and transportation of sugar and starch. Fats are familiar to us in such forms as butter, lard, olive oil, and the fats of meats. Like carbohydrates, fats contain carbon, hydrogen, and oxygen, and no nitrogen. Fat is used for the production of energy; and in the form of a cushion about the body helps to regulate the body temperature by preventing too rapid a radiation through its wall. The Esquimo consumes quantities of blubber for heat and energy. Mineral salts are necessary for body structure. Iron enters into the composition of the red corpuscles, calcium in the formation of bones and teeth, sulphur and phosphorus are needed by the cell, and the precipitants are needed for osmotic pressure. A large serving of spinach will supply one-third of a day's iron requirement. Vitamins are essential, although only in small quanti- ties, not alone for growth but for life itself; health is safeguarded by using foods containing them. As the results of experiments, three types of vitamins have been distinguished: "Fat soluble A," a substance soluble in 126 PRINCIPLES OF HOME NURSING fat, is found in eggs, cream, butter, animal fats; in greens, cabbage, lettuce, asparagus; but is absent in vegetable oils and in potatoes. Adults who continue eating monotonous meals develop a condition known as xeroph- thalmia, characterized by an inflammation and a yellow- ish discoloration of the eyes which terminates in total blindness unless dietary defects are corrected. "Water soluble B," a substance soluble in water, appears in nearly all foods except polished rice, white flour, starch, sugars, and fats. Because it is soluble in water, the water in which vegetables are boiled should be utilized in soups and gravies to avoid discarding the vitamins. This vitamin is protective against the defi- ciency disease called beri-beri. Ordinary cooking and preserving of foods unless made alkaline by soda, does not destroy these two vitamins; but drying or heating to a high temperature does. "Water soluble C," a substance soluble in water, is found in fresh fruits and vegetables, but not at all in sugar or butter. It is active against scurvy. Fresh fruit juices or fresh raw milk should be included in the diet of every infant to insure it against scurvy. Infan- tile scurvy may result from the use of boiled or old milk, as heating and aging of milk destroys this vitamin. NUTRITION In a book of this kind it is impossible to go into any great detail on the subject of nutrition, and but a cursory outline must suffice. To cover the whole subject would entail the study of the preparation of food for absorption, its distribution and storage, and its final utilization by the tissues. As one of the prerequisites to the study of Home Nurs- ing implies an elementary knowledge of physiology, it will not be necessary to go deep into the anatomy of the human alimentary tract. It is advised, however, that reference be made to a general physiology while study- ing this part of the course. FEEDING THE SICK 127 If the accompanying illustration will be studied, it will be seen that the successive parts of the canal that are concerned in digestion are the mouth, pharynx, esophagus, stomach, small and large intestine, and Nose- Parotid gland Submaxil- lary and sublingual glands Trachea Pharynx Vein Liver Thoracic duct Gall-bladder Esophagus Stomach Spleen Pancreas Duodenum Lacteals Large intestine Small intestine Fig. 74.-General scheme of the digestive tract, with the chief glands opening into it. (Raymond.) Vermiform appendix Anus rectum. The accessory organs are the spleen, liver, gall-bladder, and pancreas. The structure of the mouth should be sufficiently familiar for us to omit this part of the discussion. The pharynx or throat is the common passage to the digestive and respiratory systems. The esophagus is a flattened tube running down the center of the thorax, beginning with the pharynx, passing behind the trachea or wind- pipe, behind the heart, and through the diaphragm into the stomach. The stomach is the receptacle for food, 128 PRINCIPLES OF HOME NURSING and opens into the small intestine, thence into the large intestine or colon. The colon terminates in the rectum, which leads to the anal outlet. The great length of the canal from mouth to anus, augmented by the coiling of the intestines in the abdomen, is for the purpose of fur- nishing more surface for the absorption of foods. Before food is eaten and made to yield its energy within the body, it must undergo certain changes which make it more palatable and digestible. The ripening of fruits and vegetables, the dressing and curing of meats, the making of flour, the cooking of the foods, are all examples of this preparation. After the food has been ingested it must undergo further changes before it is ready for assimilation--changes that are due both to mechanical and chemical processes. The mechanical process takes place in the acts of mastication, insalivation, swallowing, peristalsis, and defecation. Chemical diges- tion is due to enzymes or ferments contained in the saliva, gastric juice, pancreatic juice, and intestinal juices. Substances which, by chemical means without themselves undergoing any permanent change, split foodstuffs into fragments that will be absorbed through the intestinal walls are called enzymes, or ferments. Mastication and Insalivation.-In the mouth, the mechanical process consists of the grinding and breaking of the food by the teeth. While this mechanical opera- tion goes on, saliva flows freely from the salivary glands, and food is thrust about in the mouth by the tongue so that it becomes well lubricated for swallowing. Chemi- cally, starch is converted to dextrin by the salivary en- zyme called ptyalin. Saliva has no action on fats, but it prepares proteins for the action of the gastric juice. The average human being does not hold his food long enough in his mouth to allow much chemical transforma- tion, which is therefore continued in the stomach. Until babies have reached their eighth month, ptyalin in the saliva is undeveloped, and starches in the shape of crackers, must.not be given them. 129 FEEDING THE SICK The food is transferred to the stomach by a series of stages called swallowing. By the combined action of the mouth muscles, food is thrust into the esophagus where it advances to the stomach more or less slowly (about five seconds) by a succession of contractions and relaxations of the esophagus behind the bolus. This movement is called peristalsis and continues all along the alimentary canal during digestion. Its function consists not so much in the grinding process, as in the mixing of the food with the digestive juices and in exposing it to the absorbing cells. Liquids may be propelled instantly into the stomach. The stomach is a large muscular pouch into which opens two tubes, one the esophagus through the cardiac, and the other the intestine through the pyloric, openings. It has two regions, though not anatomically divided, the functions of which are so different that an analogy may be made between it and the crop and gizzard of a fowl. The fundus, the first part, relaxes as the meal progresses, then exerts a steady pressure upon its con- tents. Here there is no grinding as is generally supposed. In the antrum, the last part, the contractions occur at regular intervals and in successive waves, and push small portions of the contents, now called chyme, through the pylorus into the duodenum. Hunger pangs are due to the contractions in the fundus of the empty stomach; appetite is a mental state referring either to memory or to anticipation. There can be hunger without appetite and appetite without hunger. Digestion in the Stomach.-The chemical action of the saliva on starch begun in the mouth continues in the stomach, and the well cooked starches are transformed to dextrines and sugars, thereby lessening the work yet to be done in the intestine. The glands of the stomach become very active during and after each meal and produce quantities of a clear liquid, which in the fundus is strongly acid due to the hydrochloric acid, and in the antrum neutral or alkaline due to the pepsin and rennin. 130 PRINCIPLES OF HOME NURSING Anger and anxiety may prevent the secretion of gastric juice; hence it is suggested that patients have congenial thoughts at mealtime. Hot clear soups excite the gastric juice, and should therefore be given as a first course. The hydrochloric acid of the gastric juice, is necessary to provide an acid medium for the pepsin, and to stimulate the pancreatic secretion. Most of the germs that are swallowed with the food are destroyed or weakened by the hydrochloric acid. Microbes of dysentery, typhoid fever and cholera, cause disease if ingested in large enough quantities, or if the resistance of the body is low. Infected water is more dangerous than infected food because water alone induces only a slight flow of gastric juice. The gastric juice has no effect on carbohydrates, nor on pure fats other than that of breaking down the connective tissue to free the oils contained. That is why fried foods and toast soaked in melted butter are indigestible. Emulsions like cream are acted upon to a certain extent; but the chief activity here is centered upon protein digestion; those proteins not acted upon in the stomach, however, are rapidly digested by the pan- creatic juice in the intestine. Hence, a person without a stomach can digest proteins. The enzyme of the gastric juice is known as pepsin and an acid medium is essential to its activity; hence the hydrochloric acid. Intestinal Digestion.-Pancreatic juice and bile simultaneously enter the duodenum just below the pylorus and are activated by the acidity of the chyme delivered to the intestine. These juices play a large part in digestion, containing as they do the enzymes that are the most important in the whole digestive tract. The pancreatic juice, which is a copious secretion-a pint at least a day-contains three enzymes, a special one for each of the three classes of foodstuffs-the carbohydrates, fats, and proteins. (1) Diastase or pancreatic amylase resembles ptyalin in that it resumes the digestion of the starches interrupted in the stomach; FEEDING THE SICK 131 (2) lipase, or steapsin, an enzyme which changes fats into fatty acids and glycerine; and (3) trypsin, the protein splitting enzyme which finishes the action begun by pepsin. Trypsin acts not only upon protein that has undergone a partial digestion, but is capable of all stages in the hydrolysis of proteins,-forming as it were, a natural follow-up system. The Bile.-Continuous secretion of bile goes on in the liver, and it is accumulated and stored in the gall-bladder until needed in intestinal digestion. It does not deserve to be classed as a digestive juice because it has no enzyme and acts only as an ally to the pancreatic juice. It contains useless waste matter known as pigment which gives bile and the feces their color. Gall-stones are the result of deposits of these pigments in a solid form. In jaundice, bile is prevented from entering the intestine, the pigments find their way to the skin and to the sclera of the eye, and are greatly increased in the urine, giving it a characteristic brownish green color; but it is absent from the feces which become in color and appearance very much like clay. The intestinal juice, secreted by millions of glands in the small intestines, is abundant, has considerable share in digestion, and acts upon both carbohydrates and proteins. Its chief activity is breaking down the complex sugars-cane, malt, and milk sugars-through enzymes adapted for each of them into dextrose which can then be readily assimilated by the body cells. The protein enzyme, erepsin, of the digestive juice has power to act only on the peptones (the hydrolyzed proteins), so that when deprived of the pancreatic juice, a person is still able to digest protein-pepsin beginning the operation and erepsin finishing it. The contents of the small intestine, the chyme, is of the same consistency throughout the canal except for a reduction of bulk; but after it is pushed into the colon, where water is absorbed, the resi- due consists mainly of animal tissue and cellulose-the "roughage" so strongly advocated. 132 PRINCIPLES OF HOME NURSING The Colon.-The large intestine, the colon, where the contents are attacked by the putrefying and fermenting bacteria, is made up of four parts: the ascending, the transverse, the descending colons, and the rectum, with an S-shaped kink, the sigmoid flexure, between the descending colon and the rectum. Extraction of water chiefly takes place in the ascending colon. The more solid material, passing through the transverse and the descending colons, reaches the sigmoid flexure where it is stored until considerable quantity has been collected, when a strong contraction moves it into the rectum. There is then a desire for defecation; and if postponed, the rectum may relax and a state known as constipation prevails. Summary.-The stomach stores the food, and gradu- ally furnishes the intestines with a smooth and creamy substance called chyme, which two to three hours after ingestion contains the peptones hydrolyzed from protein, TABULAR SUMMARY OF THE CHEMICAL PROCESSES OF DIGES- TION1 Foods Enzymes Organs se- creting Place of action Final or end products of digestion Pepsin Stomach Stomach Proteoses, peptones, Proteins. . . . Trypsin Pancreas Intestine peptids, amino-acids Erepsin Intestine Intestine Ptyalin Salivary Mouth Dextrines, maltose Starch glands Fundus Amylopsin Pancreas Intestine Cane sugar. . Inverting Enz. Intestine Intestine Glucose + fructose Milk sugar. . Inverting Enz. Intestine Intestine Glucose + galactose Maltose Inverting Enz. Intestine Intestine Glucose Glycerin Fat. .. Lipase Pancreas Intestine Fatty acids Soaps i From Hough & Sedgwick, The Human Mechanism, Ginn & Company. 133 FEEDING THE SICK the sugar and dextrine derived from the starch, and some glycerine and fatty acids from the fats. When chyme enters the intestine its mechanical reduction has been completed, but its chemical preparation for absorp- tion has only begun and continues throughout the intes- tine. Indigestion or dyspepsia may be the result of one of three abnormalities: the food may not be thoroughly ripened, cooked, or masticated; the stomach walls may have lost tone and the mechanical process hindered; or there may be a reduction in the amount or quality of the gastric juices. About four to five hours after a meal, the stomach will be practically empty; the chyme will be undergoing digestion and absorption in every coil of the intestine as peristalsis continues; and part of it may be pushing its way into the large intestine. ABSORPTION Contrary to common belief the stomach is not the chief organ of absorption. There is some absorption of water, sugar, and peptones from the stomach, but water taken on an empty stomach seems to pass freely through the pyloric opening; alcohol is absorbed with great rapidity, and that is why "wine goes to the head." There are three coats of the intestine-two muscular and a glandular mucous membrane. The fibers of the outer muscular coat run in a longitudinal direction; those of the inner muscular coat are transverse, or circular. Through contraction and relaxation of these muscles, food is pushed along. This process is known as peristal- sis. The crawling of a worm is a splendid illustration of peristalsis. As the circular muscles contract, the longitudinal ones are relaxed and the worm stretches in length; as the longitudinal muscles contract, the cir- cular ones are relaxed and the worm shortens and pulls himself along his journey. The mucous membrane coat inside the canal is rich in blood vessels and nerves; this lining is not smooth like that of the mouth-its roughness being due to depressions, the glands that secrete the 134 PRINCIPLES OF HOME NURSING juices, and to finger-like projections, the villi; the entire surface has the appearance of velvet. The Villi.-The outer cover- ing of an individual villus con- sists of a layer of columnar cells that, as they stand side by side, act as filters by admit- ting the food elements directly through their protoplasm. In- side a villus, extending up its center, is a small branch of the lymphatic system surrounded by a network of capillaries. Within the spaces surrounding this core flows the lymph, or serum, from the blood. As we have learned from the study of chemistry, there is a tend- ency for two unlike solutions separated by a permeable mem- brane to become equalized by the process of osmosis. Food- stuffs are made diffusible by the mechanical and chemical digestion, as just described; and as this diffusible material flows on one side of the columnar cells of the villi and the lymph of the blood on the other, there takes place a free exchange of the elements between the food products within the intes- tine and the lymph within each villus. Those elements derived from carbohydrates and proteins are absorbed from the lymph within the villi into the capillaries. The capillaries are collected into larger and Fig. 75.-This is a con- ventionalized drawing to show the essentials in the structure of a villus. The lining cells of the intestine are shown as in section. Within is seen a tangle of capillaries, and at the very core of the villus a lymphatic (L). The loose tissue, which in reality exists inside the villus, has been ignored for the sake of simplicity. (Stiles.) 135 FEEDING THE SICK larger vessels until they form the portal vein which conducts to the liver. Those elements derived from fats are taken up by the lymphatic vessels extending into the centers of the villi, carried by what is known as the thoracic duct which lies close to the backbone, and finally emptied into the vena cava near the heart; they are then mixed with the blood and distributed to every tissue of the body. Salts such as the precipitants of calcium, sulphate, phosphate, citrate, and tartrate, are not absorbed by the intestine; therefore as they remain in solution, a large quantity of water is retained in the intestine and is then defecated in frequent watery bowel movements. This constitutes the virtue of saline cathartics. The Portal Circulation.-The blood of the systemic circulation flows from the left ventricle of the heart through the arteries and capillaries over the whole body, and returns by the veins to the right auricle. The portal circulation is a departure from this order. The blood supply of the digestive tract is not returned directly to the great veins thence to the heart; it is distributed first to the villi, where it collects food ele- ments, and is then gathered into the portal vein and transported to the liver, as has just been said. There it is redistributed into capillaries to every cell of the liver where the final digestive processes take place. The product of the foodstuffs is changed within the liver to glycogen. It is stored as such, and is gradually doled out to the system; that which is supplied in excess of the liver's needs, is returned to the blood, gathered by the capillaries of the liver into the hepatic vein, and dumped into the inferior vena cava just below the diaphragm, thence into the general circulation. From the general circulation the muscles extract the food needed for their energy and store it in the shape of glycogen for future needs. The reduction of glycogen in the liver goes on very slowly but is hastened by muscular activity and by fever. During periods of fasting, the glycogen of the 136 PRINCIPLES OF HOME NURSING liver is changed back to sugar more rapidly than normal and is returned to the general circulation to be extracted by the tissues. The sugar content of the blood remains practically constant except when an abundance of sugar has been ingested, or in the pathological condition known as diabetes, when the sugar is removed from the blood by the kidneys and excreted with the urine, a condition called glycosuria. Rectal Feedings.-As previously stated, in certain cases of sickness it becomes necessary to give food by rectum, although this mode of feeding has fewer advo- cates than formerly. Ordinarily the colon takes little or no part in the action of digestion, but may be called upon in extreme cases to absorb small amounts. Stimu- lants and water are readily absorbed, and water may be given freely to allay thirst. Foodstuffs such as eggs and milk, preferably predigested, may be given by rectum in small quantities, but sugar except in very small amounts is barred. In the way of offering assistance to the student in the study of this very difficult subject, the following outline on the nutritive processes has been submitted, and it is suggested that it be made a definite part of the course: THE NUTRITIVE PROCESSES 1. Ingestion (a) Mastication (6) Insalivation (c) Swallowing 2. Digestion (a) Storing of food in the fundus of the stomach (6) Mixing it with the gastric juices (c) Grinding it in the antrum to form chyme 3. Absorption (a) Peristalsis brings food in contact with the villi (6) The villi, through which absorption takes place FEEDING THE SICK 137 4. Distribution (a) Products of proteins and carbohydrates to liver through portal vein; stored there; and redistributed to the blood as needed (6) Fats reduced to chyle taken up by the lacteals; transported by the thoracic duct to the vena cava, thence to the heart; carried by the blood to the tissues 5. Resorption (a) Osmosis, between the cells and the lymph surrounding them, of the food required and the carbon dioxide cast off 6. Metabolism (work of the cell) (a) Catabolism, the breaking down of the food in the cell (6) Anabolism, conversion of food into pro- toplasm 7. Excretion (casting oft of waste material from the body) (a) Mucous secretions (through glands) (b) Perspiration (through skin) (c) Urine (through kidneys) 1. Blood carries water to the kidneys 2. Kidneys extract the water and salts, including excess sugar 3. Water is carried through the ureters to the bladder 4. Discarded from the bladder through the urethra (d) Feces (through intestines) 8. Defecation (of unused material) (a) The colon 1. Ascending (water is absorbed here) 2. Transverse 3. Descending (a) Sigmoid flexure 4. Rectum with the anus at the end PART II CHAPTER X EMERGENCIES AND FIRST AID Often the home nurse happens to be the only one in a crowd collected by an accident that has sufficient knowl- edge to assume any responsibility; but she must remem- ber above all things not to go beyond the limits of simple first aid. If the injury sustained is a minor one, she may do all that is essential pending medical attention. She should not, however, shoulder the responsibility of diagnosing any cases, setting any bones, or prescribing any medicines. She must act quickly; yet by the example of her quiet assuring manner she should control the situation, steady the bystanders and turn them to some use. Anyone attempting to do first aid should have an elementary knowledge of anatomy and physiology, at least enough to enable her to locate the bones most liable to fracture and the points for pressure in case of hemorrhage. An unconscious person is dependent for care upon the per- sons who are first on the scene. It is therefore impera- tive that those who proffer first aid know what not to do as well as what to do. First Things to Do.-Send for a physician, writing if possible a message in which the injury is fully described so that he may know what to bring; be calm; keep the crowd back to give the patient plenty of air; loosen his collar and other tight clothing; note the color of his face, the quality and rate of his pulse; note whether or not he is breathing; note the condition of the skin-whether 139 140 PRINCIPLES OF HOME NURSING hot, cold, or moist; see if the pupils are dilated, con- tracted, or unequal; look for wounds and a possible hem- orrhage. Apply dressings as soon as all signs of foreign matter has been removed, if clean dry cotton or guaze can be had. Dressings should be surgically clean, can be purchased ready for use at the drug store, and should be rigidly protected from contamination. Hemorrhage if present, should be controlled at once; and if the patient is suffering from shock he should be revived. In case of fracture see that no further injury is done-a simple fracture may become a compound one through rough or ignorant handling. If a wound is located under the clothing cut the garment along the seams; in case of a burn, cut the adhering clothing close to the wound but do not jerk it off. If it is necessary to remove the patient to a place of safety or comfort, handle him gently and cor- rectly in the manner previously described. (See page 65.) Emergencies are divided into two groups, medical and surgical. Medical emergencies are those that are characterized by unconsciousness, which may be resul- tant from epilepsy, hysteria, syncope; alcoholism, apoplexy; sunstroke, drowning, poisoning. Surgical emergencies are wounds, fractures, dislocations, sprains; frost-bites and exposure to intense cold, burns, scalds; hemorrhage, shock; foreign bodies in ear, eyes, nose, throat. MEDICAL EMERGENCIES Unconsciousness is a temporary loss of senses, due to a brain disturbance of some sort, such as trauma, drug poisoning, or pressure on the brain tissue. It may be profound or slight. Syncope, or fainting, is due to a temporary flux of blood from the brain, and may be occasioned by emotion, heat, vitiated atmosphere, pain, hemorrhage. A person about to faint becomes suddenly weak, sees black spots before the eyes, and experiences difficulty of breath- ing. He becomes pale of face and lip, his pulse is weak EMERGENCIES AND FIRST AID 141 and frequent, and he sinks back in his chair or slips unconscious to the floor. The attack may be diverted by improving the air or by lowering the head between the knees to permit a gravitation of blood to the brain. Treatment.-A person who has fainted should be laid in the recumbent position with the head low. Fresh air is of primary importance. Whiffs of smelling salts, camphor, or ammonia; washing the face with cold water and fanning; are all good things to do. After the return to consciousness give the patient a half teaspoonful of aromatic spirits of ammonia very much diluted, or raise him at the waist several times off the flat surface-a modified artificial respiration. Convulsions in adults may be due to epilepsy, hysteria, or to toxic condition of the system. Epilepsy is a hereditary trait if it appears in a child under twenty years of age regardless of the claims of parents that lay the blame to a fall or cranial injury, a fright, or a strain. When it appears in adults it is usually due to trauma, syphilis, or alcoholism. Symptoms.-Usually there is a warning, called aura, in the form of brief dizziness, which may or may not be accompanied by the peculiar cry of epilepsy. The con- vulsion begins in hand, foot, oi' face, and travels over the whole body in a few minutes; the tongue is sometimes pushed between the teeth and bitten, when the froth of the mouth becomes tinged with blood. The patient gradually enters a stage of coma, the convulsions cease, breathing becomes easier but is still stertorous, and the patient may fall asleep, when he should not be disturbed. Mental deficiency usually presents itself sooner or later as the convulsions increase in frequency and severity. Treatment.-Allow the patient to remain where he falls; do not attempt to confine his movements; place a rolled handkerchief or towel, but nothing hard enough to break the teeth, across the teeth inside the mouth to protect the tongue; and prevent other injuries. Do not arouse 142 PRINCIPLES OF HOME NURSING him, but cover him and move him later to a place of safety. The dangers of epileptic seizures are more often due to fatal falls or burns than from the attacks them- selves. Bromide is administered to lessen the severity of the attacks when the patient is under medical care. Hysteria is seen chiefly among women, and used to be considered correlative with menstrual disorders. There is an absence of the clinical signs that accompany the organic diseases; there is never a loss of intelligence, and the exciting cause may be melancholy, morbid desire for sympathy, shock, grief, or too much self-analysis. Treatment consists in the recognition and removal of the cause, in ignoring the attacks, and in a change of climate and mode of living. The difference between epileptic and hysterical fits may be readily recognized by a study of the following tabulations: Epilepsy Hysteria Consciousness Sudden loss of, patient falling where attacked May be partial, patient never falls to hurt self Memory . Blank Clear Tongue . Often bitten and scarred Never Pupils . Dilated Normal Duration . Few minutes Prolonged Restoration . Fairly rapid Capricious Alcoholism may be acute or chronic. The diagnosis of ordinary drunkenness is easily made when the habits of the patient are known; but when a person is found in a comotose state, the symptoms because of their similarity to those of apoplexy may be somewhat confusing. The odor of liquor on the breath is not always a trustworthy sign, as he may have taken it feeling the need of a stimu- lant, or some bystander may have given it. Cases of mistaken diagnosis, when a man is thrown into a cell to "sleep it off," have often terminated disastrously. Apoplexy, or a stroke, is due to a break in a blood vessel of the brain causing a pressure upon the brain EMERGENCIES AND FIRST AID 143 tissue. It occurs in persons between the ages of forty and sixty, often in men in whom arteriosclerosis, and con- sequently high blood pressure, is present. Arteries are more apt to rupture in the brain because they are not supported by the tissues as they are in other parts of the body. Trauma, strain, or certain diseases like chronic nephritis, syphilis, or softening of the brain, are predisposing causes. Premonitory symptoms such as headache, palpitation, disturbed digestion may precede an attack. Active symptoms are sudden pain in the head, dizziness, and abrupt unconsciousness; the face is flushed and bloated, the mouth may be drawn to one side; the pupils are fixed and dilated, sometimes unequal; the pulse is full and slow; the respiration stertorous with puffing of cheeks; the head and eyes may be turned away' from the paralyzed side. Hemiplegia, paralysis of the face, arm, or leg of one side due to a lesion of the opposite side of the brain, may be present. In a fatal termination coma increases, the respiration becomes irregular, bordering on Cheyne-Stokes, and the tempera- ture falls to subnormal. If the prognosis is favorable, the patient may regain consciousness within a few hours or at least a day or two. The blood oozing upon the brain tissue destroys it, thereby activating an inflamma- tion; later the serum may be absorbed, the clot is either encapsulated or slowly absorbed, and recovery takes place. The first aid treatment of any brain lesion whether from internal or external cause is the same. One diagnos- tic symptom must be instantly recognized by the home nurse, and that is the color of the face; if it is pale, always lower the head, but if it is flushed, especially if accom- panied by stertorous respiration, raise the head high. Give plenty of fresh air, loosen all tight clothing, and move the patient as little as possible; raise the head and apply an icecap to the side of the lesion and heat to the feet. Never under any circumstances give alcohol or any stimulant. 144 PRINCIPLES OF HOME NURSING Sunstroke and heat exhaustion are produced by exposure to the direct rays of the sun or by prolonged exposure to excessive heat. The difference between the two is important because of the difference in treatment. In severe sunstroke the patient may die almost instantly. The heat interfers with the thermal mechanism of the body and causes internal congestion and a rise of tem- perature often to 110°F. The skin is hot and red, the pulse full, the respiration labored, the pupils contracted, the eyes bloodshot, and the patient enters a state of stupor. Treatment.--Attempts to reduce the temperature should be made without a moment's loss by placing the patient in cold water, adding ice and rubbing the body with ice, and by applying ice to the head. The water- hose may be the first available means of giving the bath. Persist in this treatment until the temperature drops; the patient should then be treated as for shock. Patients once recovered from sunstroke should move to a colder climate. Heat exhaustion, on the other hand, may result because of undue bodily weariness or lack of muscle tone at the time of exposure to continued heat. The surface of the body is cold and clammy, with cold extremities, the pulse is weak and rapid, and the respiration shallow. Vomiting may be present, accompanied by a feeling of great prostration. There may or may not be a complete loss of consciousness or there may be hysterical weeping or laughter. Death may be due to heart failure. Treatment.-Heat, friction, stimulants, and fresh air are indicated, with hot-water bottles to the feet, and cold clothes to the head which should be lowered. Coffee is a good stimulant to give. For vomiting give an enema of normal salt solution. (See page 100.) Suffocation.-Life is maintained by the inspiration of fresh air and the expiration of used air, and when this process is hindered, there results a state of suffocation. Suffocation is caused by drowning, strangling, obstruc- 145 EMERGENCIES AND FIRST AID tion of the air passages, and by the inhalation of certain gases. As most cases are treated by artificial respiration students should have some knowledge of the two sys- tems in common use. The Sylvester Method of Artificial Respiration.-Lay the patient on his back with his shoulder blades raised on a pillow or folded coat. Loosen all tight clothing; draw forward his tongue, covered with a dry cloth, to prevent its falling back into the throat and obstructing the air passages; and have an assistant hold it there. Stand at his head, grasp his arms above the wrists and draw them outward and upward over his head, keeping them stretched for two seconds; then gradually lower them permitting the hands to cross just above the dia- phragm, and apply slight pressure there to expell the air. Then raise the arms again. These movements are to be repeated at the rate of fourteen to sixteen per minute, and may be regulated in the absence of a time- piece, by counting slowly or by following the rythm of your own respiration, raising the arms at each inspira- tion and lowering them at each expiration. Artificial respiration should be continued until there is a certainty that restoration is not possible, even if for three hours or intermittently for days. Circulation is stimulated by friction to the extremities which should be applied by another assistant. When the respiration has been fully established and the general condition appears normal, the patient should be put to bed with plenty of fresh air, warmly covered and given hot drinks. The Schafer Method of Artificial Respiration.-1This method is called the prone method. It has the advan- tage over the Sylvester method because it is easier to operate and can be done by one person because the tongue does not need attention. Loosen the tight clothing, lay the patient face downward with a pad under his chest, and with his arms extended forward, and his nose to one side so breathing is not obstructed. Kneel astride his body at the thighs facing his head; 146 PRINCIPLES OF HOME NURSING place your hands one on each side of his backbone in the region of the short ribs. Lean forward, throwing your weight against the lower part of the patient's chest in such a manner that the abdominal viscera will be forced against the diaphragm; this decreases the size of the chest and the air is forced out. Then swing backward to remove the pressure, retaining your Fig. 76.-The Sylvester method of artificial respiration, a, First movement, inspiration, b, second movement, expiration. (Saunders, "Pocket Medical Formulary.") hands in the same position; the chest walls expand and inspiration is encouraged. These movements are repeated at the rate of fourteen to sixteen per minute, swinging forward for each expiration and backward for each inspiration. If suffocation is due to drowning, the water must first be allowed to run out of the lungs. Lay the patient after loosening his clothing upon his face, then lift him high through the middle. This throws his head lower 147 EMERGENCIES AND FIRST AID than his lungs, and the water will run out by gravity. Poisoning.-Each poison produces its own peculiar symptoms; some produce vomiting, diarrhea, and pros- tration; others cause convulsions or stupor. In case Fig. 77.-The Schafer method, a, Inspiration; pressure off. b, Expiration; pressure on. (From Estes, "Surgery of Accidents," in Keen's "Surgery," Vol. VI.) of suspected poison, always smell the breath; examine the mouth and lips for acid burns; and observe if any of it were spilled on clothing or floor. In case there is complete absence of definite evidences, a general pro- cedure may be followed that applies to all poisons; namely, give milk, the white of egg, and strong tea, as 148 PRINCIPLES OF HOME NURSING they do no harm, dilute the poison, and may prove to be the antidote wanted; next get the poison out of the stomach as soon as possible. In the absence of a stomach pump, produce vomiting by running the finger down the throat, or by giving repeated glasses of lukewarm salt or mustard water, or give an emetic-the syrup of ipecac, one teaspoonful, being the drug indicated. Ptomaine Poisoning.-Ptomaine forms in protein foods that have been kept long in warm weather, and is found in such foods as fish or old icecream. Symptoms are sudden vomiting and dysentery, excruciating pain in the abdomen and the head, and sudden collapse. Symptoms may appear immediately or not for hours after the food has been eaten. Encourage vomiting by giving plenty of lukewarm water or an emetic, and empty the bowels by enema. After recovery give castor oil, and keep patient quiet until completely restored. In true ptomaine there is extreme prostration, which may last for days. Ivy poisoning (poison oak, poison creeper, etc.) is a spreading skin eruption caused by coming in contact with the flower or the pollen of the three leafed creeping ivy; it is characterized by redness, blistering, itching, and burning. Treatment.-Apply some cooling antiseptic solution such as soda bicarbonate or Epsom salts; the spreading is often prevented by painting with collodion or the white of egg. SURGICAL EMERGENCIES Wounds of Different Kinds.-A wound, or trauma, is a "break in the continuity of the tissues." Wounds are classed according to the character of the injury as lacer- ated, contused, incised, or punctured. A lacerated wound is one made by a blunt tearing object which bruises the flesh. Such wounds as dogbites are classed as lacerated. EMERGENCIES AND FIRST AID 149 A contused wound is a bruise, the bruising or crushing of the tissues being resultant from the blow of a blunt object such as a fist or a rock; the discoloration is due to an exudation of blood under the skin from the ruptured superficial blood vessels. A "black eye" is a contusion. An incised wound is a clean cut made by a sharp knife-like instrument, and may be complicated by the severing of a blood vessel or a tendon if deep enough. A punctured wound is made by a sharp pointed instru- ment like a dagger or a nail; a gunshot wound belongs to this class. Punctured wounds because so deep and small in bore are liable to tetanus infection. Wounds that are infected by pathogenic germs are called septic; those not infected are aseptic or clean. Wounds heal by first intention, or primary union; or by second intention, or granulations. As soon as a wound is made a blood clot is formed, followed by a congestion of the tissues which encourages the rapid reproduction of new cells and the growth of new tissue. Whenever the sides of an asceptic wound are brought together, as when sutured, healing takes place quickly by first inten- tion, and the scar is slight. Whenever there is a gaping of the wound due to inflammation, suppuration, or lack of surgical care, the cavity must be filled in from below by granulations, and healing is said to be by second inten- tion, and the scar is sometimes unsightly. Sometimes, however, the granulations, popularly known as " proud flesh" grow so rapidly that they must be destroyed by caustics or by the knife, to stimulate normal healing. Fractures.-A fracture is a break in a bone caused by violence; it is a frequent emergency. The following named types are the ones most commonly found: 1. A simple fracture is a break in the bone when the skin is left intact, and is therefore not open to infection. 2. A compound fracture is one in which the skin and flesh are lacerated, the bone sometimes protruding from the wound. A compound fracture is also a complicated one. 150 PRINCIPLES OF HOME NURSING 3. A multiple fracture is one in which the bone is broken in several places. 4. A comminuted fracture consists of a splintering of the bone; it may be simple or compound. 5. An impacted fracture is one in which the ends of the bone are forcibly driven into each other at the time of the injury, usually occurring in the long bones. 6. A greenstick fracture is a bending or partial breaking of soft bones, and occurs in the long bones of children. 7. Two fractures difficult to treat are Colles', a fracture of the lower end of the radius, and Pott's, of the lower end of the tibia. It is absolutely necessary that reduc- tion of these fractures be made correctly to prevent per- manent deformity of wrist or ankle. Symptoms of fracture are pain, loss of function, crepitus -a crackling sound produced by the friction of the two ends of the bone-deformity, swelling, and discoloration. The x-ray diagnosis should confirm all others; and it should confirm the proper setting of the bone. Treatment.--No one but a surgeon should attempt to reduce a fracture because injudicious handling of a part may involve further injury. The laity have the fal- lacious idea that a fracture must be approximated immedi- ately, but even a wait of a day or two is better than rebreaking it to set it again. Therefore a fractured limb should be handled as little as possible, and then only to place it in a temporary splint for support. If there is a wound (a complicated fracture) the clothing should be cut away to apply the dressings. Never grip a fractured limb from above; place the two hands underneath, one on each side of the point of injury, and lift gently and uniformly. Ihe limb may be placed on a pillow, a padded board, a cane, or one leg may be bandaged to the other, and elevated to keep down the swelling. Repair of fractures is similar to that of wounds with the exception that bone is formed instead of flesh, the first deposit being a temporary callus or cartilege which develops later into bony tissue. The failure of bone to EMERGENCIES AND FIRST AID 151 unite is due to imperfect surgery, infection, improper after-care, or malnutrition of the patient. Dislocations.-A dislocation is a displacement of a joint out of its socket, and is accompanied by a twisting of the tendons and ligaments and injury to surrounding tissues. Like fractures, dislocations may be simple or compound depending upon the attendant rupture of the flesh; and if a fracture or serious wound exists simultane- ously, the dislocation is said to be complicated. A compound dislocation is very serious, for if an infection should attack the wound there might result permanent crippling of the joint. Symptoms are intense pain, deformity, and loss of function. Treatment.-The nurse can do very little besides applying cold to prevent swelling. Heat produces a congestion of blood to the part and an increase of pain, and should not be used. Reduction of a dislocation means replacement of the joint to its socket, which is brought about by making extension on the limb. The part is then properly bandaged and supported by splints. If disarticulated, there may result a permanent deform- ity and immobility, due to the growth of new tissue in the socket. The reduction of a fracture can usually be delayed, but that of a dislocation becomes impossible after congestion has set in. It is therefore imperative that swelling be kept down. Dislocation of the jaw is easily reduced by placing your thumbs, protected with a towel, upon the lower molars far back and applying a firm downward and backward pressure until the jaw snaps into place. A finger dislocation is reduced by pulling upon it steadily in a straight line. A sprain is a wrenching of a joint, which is automatic- ally reduced, and is attended by a twisting of the liga- ments and tendons. Symptoms.-There is severe pain, immobility, and swelling. To keep down the swelling the limb must be elevated and cold and gentle massage applied, followed 152 PRINCIPLES OF HOME NURSING in a few hours by graduated exercise. A sprained ankle should be strapped and the patient urged to make moder- ate use of the foot. Treatment.-Beyond the application of cold or heat and elevation, the home nurse can do nothing, because she is not qualified to distinguish between a fracture, a dislocation, and a sprain. Shock is prostration due to loss of vitality following some severe physical or mental strain. It is always occasioned by some event. If the symptoms of shock appear in a case of prolonged illness, the patient's state is said to be due to collapse. Symptoms are extreme pallor, relaxed pupils, cold clammy skin, and cold extremities; rapid weak pulse, and shallow sighing respiration; subnormal temperature, and complete muscular relaxation. The patient may or may not be conscious. Whenever vomiting occurs it is a sign of returning vitality. Treatment consists in immediate reduction of symp- toms by the application of heat and stimulants, lowering the head, and giving plenty of air. Following all surgical operations and all accidents, especially burns, shock should be anticipated and the pulse and general condition watched closely. Hemorrhage is the loss of blood from a blood-vessel. Hemorrhage, because of its sudden fatality, should be immediately recognized and promptly controlled. Hemor- rhage may come from an artery, a vein, a capillary, or from all three at once. The blood from an artery comes out in strong spurts corresponding to the pulse beat, and is bright red; that from a vein may show some pulsation but is usually steady, and is a darker red in color, easily distinguishable from the arterial color. Hemorrhage may be external, subcutaneous (extravasa- tion), or internal. Internal hemorrhage may be concealed or revealed. In concealed hemorrhage an intelli- gent recognition of symptoms will save life. Symptoms are a sudden change in the character of the pulse, EMERGENCIES AND FIRST AID 153 becoming feeble and rapid; pallor and faintness; sighing respiration with a struggle for air; cyanosis, or blueness of skin may first be noticed at the lips and under the nails; there is usually restlessness, a bright excited anxious look in the eye. Syncope may be looked upon as a favorable symptom, and any operation or treatment may be contin- ued while patient is in this state unless collapse sets in. Treatment consists in checking the hemorrhage by applying direct or indirect pressure, elevation, heat or cold, or the joint may be forcibly flexed with a padding underneath it; or by the use of astringents such as vinegar, ergot, or adrenelin. For hemorrhage from the lungs, place the patient in the upright position, and apply cold to the chest. Hemorrhage is controlled by natural and by artificial means-natural by clotting of the blood and a diminished force of the heart; artificial means are position, pressure, and surgical or medical hemostatics. Direct pressure is applied immediately over the seat of injury; indirect, over the artery controlling the area of the wound, or by a tourniquet. Tourniquets are applied between the wound and the heart, unless the wound be in the head when direct pressure is used. A tourniquet should not be left on longer than forty minutes, otherwise slough- ing or gangrene may result; a tourniquet must be released gradually to prevent displacing the clot. In emergency a tourniquet can be improvised of a handker- chief tied in a knot around the limb with a pad over the artery, and twisted with a stick to the desired tenseness; or of a part of a rubber tubing, tightly wound around the limb. If hot water is used it must be between 114° and 120°F. Any temperature below this merely encourages hemorrhage. Cold should be applied in ice bags, as cold water has a tendency to prevent coagulation. After the hemorrhage has ceased, attention should be directed toward the general improvement of the patient. If it had been necessary to elevate the foot of the bed, let it down gradually, a few inches each day. 154 PRINCIPLES OF HOME NURSING Epistaxis, or nosebleed, is sometimes occasioned by a too vigorous blowing of the nose. If slight, cold com- presses can be applied to the bridge of the nose and the back of the neck until it ceases. Hot applications to the face and neck are also efficacious. Pressure on the upper lip is recommended. If the hemorrhage is severe, the nostril may be plugged with strips of sterile gauze (never cotton) until medical assistance can be had. Hemophilia is a hereditary trait usually occurring in the males and transmitted by the females of the family afflicted. It is characterized by a persistent bleeding from the slightest wound, and the person may bleed to death from a tooth extraction. Postpartum hemorrhage, or a hemorrhage after child- birth, is due to the failure of the uterus to contract sufficiently or to remain contracted after the birth of the placenta; or it may be caused by the retention of a part of the placenta. If prompt action is not at hand life may be lost in a few minutes. The symptoms are marked, and develop abruptly. The uterus instead of being the hard contracted mass low in the pelvis is felt high up through the abdominal wall soft and flabby. Treatment consists in forcing the uterus to contract. The nurse should grasp the uterus through the abdominal wall, and knead it with considerable pressure but gently until it is reduced, or until the surgeon arrives. He will usually want plenty of hot (114°-120°F.) water, or cold sterile water, and gauze for packing. After the hemor- rhage has subsided, a pad should be placed over the pelvis and a binder pinned snugly over the abdomen. Bums and Scalds.-The symptoms and treatment of burns and scalds are the same, and they are therefore considered under the same head. Burns are caused by dry heat in direct contact with the tissues; and scalds, by moist heat in the shape of steam or boiling liquid. Three intensities are recognized, depending upon the depth of the injury: first degree, a superficial reddening EMERGENCIES AND FIRST AID 155 of the epidermis; second degree, the derma is destroyed enough to raise a blister; third degree, the subcutaneous tissue is destroyed. With the first two there is more pain than with the third. The magnitude of a burn is a more important consideration than its depth unless important nerves or vessels are involved. A superficial burn covering a large part of the body is more serious than a small deep one. If two-thirds of the skin is destroyed death may be expected, even in an injury of the first degree. Shock must always be looked for no matter what the degree of the burn. If a person's clothes should catch fire, let him lie down and roll, even though it is necessary to use force. Wrap him in a blanket, a rug, or some other heavy, but clean, material, and smother the flames by slapping or rolling him, being careful not to let him inhale the smoke and not to bruise the already injured tissues. Afterwards cut away his clothing taking care not to pull any of that which adheres to the wounds, exposing only a small portion at a time and dressing that promptly to exclude the air. Exposure to the air intensifies the pain. Treatment.-The surface may be dusted freely with bicarbonate of soda, but never with flour, as it forms a dough hard to remove later. Never place cotton next to the wound as the fluid which exudes from a burn combines with the cotton and forms a hard mass that sticks and retards healing. If blisters arise and break, dress them with sterile oil. Salad oil or lard will do. Carron oil (equal parts of limewater and sweet oil) is commonly used. A process for covering the surface of the burn with liquid paraffin is highly recommended. Do not open any blisters, for with every open wound there is a chance for infection which is always dangerous. If there is much shock treat for that immediately by immersing the patient in moderately cool water either of bicarbonate of soda or boric acid. Continuous warm baths are used where deep tissues are destroyed and sloughing is present. 156 PRINCIPLES OF HOME NURSING Complications that arise in burns and scalds are sloughing, gangrene, or erysipelas; nephritis, pneumonia, or intestinal disturbances. Sudden attacks of rigor, vomiting, rise of temperature, or convulsions are all suspicious symptoms. Burns from Chemical Acids or Alkalines.-Immedi- ately flush the surface with water so that all trace of the drug is removed then dress with an antidote, if that is to be had. As a usual thing, an acid counteracts an alkali, and conversely; so that weak vinegar, weak ammonia, or a solution of bicarbonate of soda is always safe. A carbolic acid burn is counteracted almost instantly by alcohol, but oil must be avoided as it helps in the absorp- tion of the acid. If lime gets into the eye a copious flushing of the eye with water followed by weak vinegar is indicated. Sunburns are treated the same as any other burn-by covering with bicarbonate of soda and later with an oil dressing. Frost-bites and Freezing.-A frost-bite is the partial destruction of tissue due to exposure to extreme cold. It may occur on the ears, toes, or fingers. Cold has a tendency to contract the blood vessels at the periphery thus cutting off the circulation of the part, and sloughing or gangrene may result, or amputation be necessary. The part injured has a very white appearance and may be so hard that it breaks off when touched. The patient should not be placed in a warm room, but on the con- trary, the part frozen should be rubbed briskly with snow or ice cold compresses applied until the normal color has been restored. A drowsiness, bordering on coma, may steal over him from which he may not recover. The temperature of the room should be gradually raised, and those parts that are sloughing should be wrapped in cotton until shed. Foreign Bodies in the Eye.-Foreign bodies in the eye may lodge in the conjunctiva of either lid, or may become imbedded in the sclera or cornea, or may even penetrate EMERGENCIES AND FIRST AID 157 into the interior of the eyeball, when of course the condition becomes critical. A lightly imbedded object is often washed out by the tears, or it may be dislodged by blowing the nose to increase lacrimation. To remove an object from under the lid, seat the patient in a good light, advise him to look up, and pull down the lower lid. The object can be easily seen in the conjunc- tival sac, if there. If not, evert the upper lid over a match or pencil. To do this tell the patient to look down; grasp the lashes of the upper lid between the Figs. 78, 79.-Everting the upper eyelid. thumb and forefinger of the left hand, lift the lid down- ward and away from the eyeball, then place a match or pencil across the lid, insisting that the patient continue to look downward; then by a dexterous movement turn the lid inside out over the match. Hold the lid in this posi- tion with the left hand and wipe out the fragment with the corner of a clean handkerchief held in the right. After the object has been removed, turn the lid back gently and hold the finger over it for a minute to prevent blinking, and apply a warm or cold compress to relieve inflammation. Never attempt to remove an embedded body. Surgical aid must be sought. 158 PRINCIPLES OF HOME NURSING Foreign Bodies in the Nose.-Children sometimes poke things into the nose. If the object is a bean great care must be taken in attempting to remove it; beans begin to swell as soon as they are put in a moist medium. Most objects can be removed by blowing vigorously through the obstructed nostril or by tickling the nostril with a feather to cause sneezing. If the object is not far into the nose, it may be held from the outside while removing it with a hairpin or clean bent wire; if not large enough to rupture the passage, it may be pushed into the pharynx and spit out. Follow with a warm boracic acid douche. Foreign Bodies in the Ear.-Children sometimes intro- duce such foreign bodies as buttons, beans, peas, into the ear. Insects sometimes enter the ear and become very annoying. They are readily removed by a few drops of warm oil. Other objects may be douched out. As vege- table substances swell as soon as moistened, the services of a doctor should be had. Never poke at the ear. It may result in driving the object farther in to injure the eardrum. Foreign Bodies in the Throat.-Foreign bodies such as coins, fishbones, pins, fruit stones, or nutshells may lodge in the throat, either obstructing the esophagus, in which case the victim has difficulty in swallowing; or the trachea, when there is difficulty in breathing. Harmless objects may be forced down by a drink of water or by bread; a sharp or pointed object like a pin should be followed immediately and for several days by a copious diet of bread and meat to form a mass around it, and the defecations carefully noted until the object has been passed. A mild laxative may then be given, but never before. If the object lodges in the larynx there will be a violent fit of coughing until it is expelled, or it may gradu- ally work its way into the lung to become a source of permanent inflammation and infection. It may, if large enough, close the air passage; and the patient becomes blue in the face, struggles frantically for air, and EMERGENCIES AND FIRST AID 159 is suffocated unless medical assistance is had at once. If choking is present, a sharp slap between the shoulders, or a pumping of the arm to lift the ribs may be of assistance. A child may be held by its feet; and an adult told to lean over the back of a chair and to lower the head. Many objects can be simply removed by hooking them in the index finger. Sometimes it is necessary to produce vomiting. Dog Bites.-A wound made by the bite of a healthy dog may be treated as any ordinary lacerated wound by swabbing it with iodin and applying a dressing. If there is reason to suspect rabies, the dog should be con- fined for at least two weeks, within which time symptoms will develop fast. Often in the excitement of the moment the dog is killed, and important evidence is destroyed. If the dog develops hydrophobia, the one bitten should undergo the Pasteur treatment, which consists of a series of inoculations. The incubation period of rabies is from ten days to three weeks, sometimes longer, there- fore there is plenty of time for observations before the inoculations are begun. A sudden change in the dog's disposition, with an apparent dislocation of the jaw accompanied by drooling of saliva should be regarded with suspicion, especially if there is a paralysis of the hind legs. CHAPTER XI A LESSON IN BANDAGING In order to do first aid work adequately and efficiently, a home nurse should become versatile in the art of bandaging. Only by long practice can she acquire the skill and manual dexterity needed for putting on a bandage so that it may not only fulfill its function, but will be a thing of beauty as well. If too tightly applied, it will interfere with the circulation; if too loosely, the dressings or splint will slip; and if uncomfortable, it will inhibit recovery. Bandages are applied for five purposes, namely: 1. To give support to injured members; 2. To apply pressure in case of hemorrhage; 3. To hold dressings and splints in place; 4. To prevent motion in case of fracture; 5. To protect against infection. Various materials, depending upon the particular purpose for which the bandage is intended, may be employed, such as gauze, muslin, crinoline, flannel, or rubber. In the home or in emergencies, dressings can be suitably improvised from clean old linens; often a bandage that has been taken off may be washed, rolled, and reused. It is not recommended, however, that dressings be improvised except in great emergency, as the surgically prepared dressings are always safest. The gauze or cheesecloth bandage is more pliable, is less bulky, and fits more snugly about a part, and is therefore more generally used. The muslin, although not so adjustable, has more strength and is therefore advan- tageously used to bind dressings and splints, and when 160 A LESSON IN BANDAGING 161 extra pressure is desired. Crinoline combined with plaster of Paris is used for making casts. Flannel and rubber bandages are applied to reduce swelling, to restrain varicose veins, and to control hemorrhage; the former, also used to give warmth to rheumatic joints, should be cut on the bias so that the elasticity will insure a firmer pressure. Various kinds of bandages are recognized, the triangu- lar and the roller bandages being the ones generally used. The former is made of a square piece of material of the required size, usually one yard, folded or cut across diagonally. Where quick action is needed, it has the advantage over the roller band- age in being more speedily applied in a variety of ways. It may be put on any part of the body; it may act as a sling to support the hand, the elbow, or the collar bone; it can be applied to foot, hand, or head; to stump, shoulder, or hip. The four-tailed bandage is used for the back, top, or front of the head, for the jaw, and the knee. The T-bandage, as the name implies, is made in the shape of the letter T, and is used to keep perineal dressings in place. If the perpendicular piece is made wide, it becomes the perineal binder. (See page 72.) A straight binder for the chest may be made of a strip of muslin cut along the lines sketched in the illustration. It is to be pinned over each shoulder and tightly down the front with safety pins that are put in lengthwise to the body, not crosswise. The straight binder is used also in the padded form in cases of lung congestion. Fig. 80.-Head and arm bandages. 162 PRINCIPLES OF HOME NURSING Fig. 81.-Hand bandage. Fig. 82.-Four-tailed bandage. A LESSON IN BANDAGING 163 Muslin roller bandages are made by tearing strips of muslin of the desired width in lengths of eight to ten yards, removing all ravellings, and rolling very tightly. They are usually rolled on a special bandage roller. If rolled by hand, the first foot or so should be folded upon Fig. 83.-T-Bandage. itself for several turns to get a start and rolled on a hard flat surface until large enough to be held without slipping between the thumb and forefinger of the left hand; then it should be smoothly and evenly rotated, making con- Fig. 84.-Chest binder. siderable pressure with the right hand. The gauze bandage must be cut wider than the muslin because cheesecloth stretches and is liable to become stringy. A thread should be pulled in the material to serve as a guide in cutting the gauze straight. 164 PRINCIPLES OF HOME NURSING Widths of Bandages used are as follows: Finger inch Head or arm 2^ inch Leg 3-4 inches Trunk 6-8 inches To Bandage.-Place the patient in a comfortable posi- tion and support the part to be bandaged either with the hand or on a specially constructed rest. Stand in front of the patient, and bandage away from yourself. Hold the bandage in the right hand with the roll side up and unwrap it from left to right keeping the roll close to the member. First fix the bandage with one or two turns over the same area to prevent slipping; then proceed, having each turn overlap the previous one by two-thirds of its width, and make the bandage absolutely smooth over the body prominences. Maintain a uniform pres- sure through the course; respect the patient's comfort; avoid excessive tightness, yet allow for a subsequent loosening due to the patient's movements. Bandage a limb from the extremity towards the trunk, finish on the outside but not over the wound, and fasten with needle and thread, a small safety-pin (never a common pin), adhesive tape, or by tearing or cutting back a piece and tying it around the member. Tips of fingers and toes must be left exposed for observation; if they become cold or blue the bandage must be loosened for it interferes with the circulation. If upon the removal of a bandage there be present any ridges corresponding to the folds or turns of the bandage taken off, indications are that it had been applied too tightly. When removing a band- age, always gather the material in one hand as it is unwound, and pass it from hand to hand; never pull a bandage off letting part of it drag. Roller bandages are applied in four ways: The re- current, the simple spiral, the reverse spiral, and ihe figure- eight. The recurrent bandage is applied to the ends of A LESSON IN BANDAGING 165 fingers or over a stump, is laid first on one side then the other and bound down by a spiral. In the simple spiral, the bandage is wound round and round in a circular direction each turn overlapping the Fig. 85.-Recurrent and spiral bandage. previous one by two-thirds of its width over a member, which, in order to be covered smoothly, must be of an equal diameter from top to bottom. The spiral is there- fore limited to the finger, the upper arm, and the trunk. The reverse spiral accommodates itself much more readily to the shape of a limb. After fixing it by several turns, hold it at an oblique angle to the axis of the member being bandaged with the thumb of the left hand, and fold it sharply upon itself making a bias fold at the top. Each reverse is made exactly above the pre- ceding one and in line with all, but not over a bony surface where discomfort from the unequal pressure is liable. The figure-eight bandage is used over joints and wherever an angle is to be covered, and consists of a series of loops made above and below a middle point. Because of its great firmness, it is used to hold splints and dressings. As the elbow, knee, and heel bandages are applied in the same way, the descrip- tion of one will suffice. Fig. 86.-The re- verse spiral. 166 PRINCIPLES OF HOME NURSING To Apply an Elbow Bandage.-Direct the patient to hold his arm at an obtuse angle in a position that can be comfortably maintained, and support the hand. Fix the bandage on the forearm by several circular turns, carry it twice or thrice over the sharp angle of the elbow, then apply first above, then below the middle Fig. 87.-The elbow bandage. Fig. 88.- Spica of the thumb. Fig. 89.-The ankle band- age. point, which is the elbow joint, crossing in front each time over the flexor surface so that each turn is made farther from the elbow. It has when completed very much the appearance of a stovepipe elbow. A LESSON IN BANDAGING 167 A figure-eight applied to the thumb, hip, or shoulder is called a spica, and is a modification of the figure-eight. The Spica of the Thumb.-If necessary cover the tip of the thumb by several turns over it along its full Fig. 90.-Method of tying granny-knot. (International Text-book of Surgery.) Fig. 91.-Method of tying square or reef-knot. (International Text-book of Surgery.) length, apply the spiral bandage up to the first joint just as you do in case of the finger bandage. At the first joint, carry the bandage round the top of the hand, around the wrist, un- der the ball of the thumb, and over the thumb; then around it, and over the hand again, repeating these turns until the joint is fully covered. In order to familiar- ize themselves with the different kinds of bandages, students should have the opportunity to put on to the satisfaction of the instructor at least the following bandages: The spiral on the finger, the spica on the thumb, the reverse on the forearm, the figure-eight on the elbow, and the figure-eight over the ankle. Fig. 92.-Method of tying surgeon's knot. (International Text-book of Surgery.) KNOTS The granny knot is the one ordinarily used in tying two strings together. It is also called the round or hard 168 PRINCIPLES OF HOME NURSING knot, will usually slip, is not easily untied, and causes pressure over a wound or under a splint. The surgeon's knot, also called the reef knot, square knot, or flat knot, is used to hold parts without slipping, and because it is flat and soft it will not cause discomfort. CHAPTER XII MAKING DRESSINGS It is recommended that the student be given an opportunity to make some of each type of dressing described below. As all surgical dressings are made from Fig. 93.-The applicator. modifications of these, the home nurse should have at least this elementary knowledge. Before making dress- ings, the hands should be carefully washed and all work done over a clean surface, such as a towel or wrap- ping paper. Dressings should be bundled into muslin squares and dis- tinctly labeled preparatory to steril- ization. (See pp. 237 and 238.) THE APPLICATOR Tear off from the roll of cotton a very small thin piece, about X inch. Hold it between the forefinger and thumb of the left hand; place the applicator upon the margin and roll, attaching the cotton firmly to the applicator, but leaving a soft fluffy tuft at the end. Fig. 94.-The cotton sponge. 169 170 PRINCIPLES OF HOME NURSING THE COTTON SPONGE Tear off a piece of cotton about two inches in diameter, gather up the circumference, and twist into a puff. THE FLAT GAUZE SPONGE Crease a piece of gauze eight inches square into four equal parts with the back of a knife. Lay it flat on the Fig. 95.-The flat gauze sponge. table, fold down the top two inches; fold each side margin over the center crease to form an oblong 3X6 inches; fold back the lower two-thirds of this oblong and tuck the excess two inches in at the top. This should make a square sponge 3X3 inches with all ravellings safely concealed. THE GAUZE WIPE Use a piece of gauze eight inches square; the wipe can be made of smaller squares, and need not be exactly true. Fold one corner down diagonally not quite through the middle. Hold it in the left hand between the forefinger and the thumb, and the third and fourth fingers. With the right hand gather up the remaining three corners and twist hard; fold this roll back upon MAKING DRESSINGS 171 itself, and tuck it into the opening between the first and second fingers. This makes a bunchy sponge that can be easily separated from its fellows after sterilization. Fig. 96.-The gauze wipe. THE VULVA PAD Cut strips of gauze 12 X 8 inches. In the center of each strip, place a thick piece of absorbent cotton 8X4 inches, and turn the excess margins of the gauze to cover the cotton. This makes a long narrow pad which is used over the female external genitals. PART III MATERNITY NURSING CHAPTER XIII REPRODUCTION Procreation, manifested by all stages of development from the simplest process of cell division to the highest form of sexual development, is the ultimate aim of each plant and animal. If it were not for this special act of rejuvenation, life would cease at the death of the individual. The function of reproduction in the higher organisms is confined to certain cells so massed and constructed that they become the special organs of perpetuation. Sexual reproduction, (see page 224), consists in the fusion of an ovum with a spermatozoid to produce an embryo which develops into an adult of the same species. Puberty.-Since our immediate concern is with human reproduction, a study of human sex organs is now in order. Physiological and psychical changes take place in both sexes at puberty, the period between the ages of twelve and seventeen. There develops a change in form, angularity giving way to grace in the girl, the muscles becoming hard and tense in the boy; a change of voice, manifested in the lowering of the male tones, and the melodizing of the female pitch; the emotions are easily played upon; and there comes a desire to please and attract the opposite sex. The change in the sex organs themselves is indicated by the advent of the menstrual flow in the girl, and the discharge of seminal fluid, called emissions, in the boy. 173 174 PRINCIPLES ON HOME NURSING FEMALE REPRODUCTIVE ORGANS The uterus is a pear shaped organ about the size of the fist situated in the middle of the pelvis between the bladder and the rectum. It is held in place by the broad and the round ligaments. It is formed of thick muscular walls which permit of great expansion, its cavity being very small holding only about one ounce of water. Its lower extremity, the cervix, opens into the vagina, the passageway through which the infertile ova (eggs) escape. Ovulation.-The ovaries are small almond shaped masses of tissue situated in the pelvic cavity one on each side of the uterus, and are anchored to the uterus by the broad ligament. In old age the ovaries shrink some- times to the size of a bean. Here after puberty the unripe ova {sing. ovum) come to maturity one or two at a time, and are expelled about every twenty-eight days coincident with the menses. This process is known as ovulation. The ovum is the largest cell in the body, and is just visible to the eye as it breaks away from the ovary. It is spherical in shape and its nucleus is the seat of the "germinal spot" which controls the hereditary characteristics. Whether the menstrual flow is governed by the ripening and expulsion of an ovum, or whether ovulation and menstruation function independently is still a matter of doubt. True it is that at birth each girl baby has her full allotment of ova, estimated at 30,000 to 200,000, and that one or two is discarded each month during her normal reproductive life. Students are reminded that this feature may be seen in the hen, in whose "egg basket" are found thousands of egg yolks ever diminish- ing in size until they become so minute that they cannot be seen. An ovum is discharged into the pelvic cavity, whence it is drawn into one of the fallopian tubes. The fallo- pian tubes are open ducts leading from the upper portion of the uterus to an area in the immediate neighborhood 175 REPRODUCTION of each ovary. They end in shreds of tissue called fimbria, which are covered with cilia whose continuous motion sets up a current toward the tube. The ovum is caught in this current being thereby sucked into the tube and propelled toward the uterus, the organ provided for the development of the embryo. It remains in the tube four to eight days where it awaits fertilization; and is finally discharged through the vaginal outlet at the time of menstruation. Fallopian tube Fimbria ■•Ovary Uterus Broad ligament Round ligament Cervix V agina Fig. 97.-The female generative organs. Menstruation.-This phenomenon, a monthly sangui- neus discharge from the uterus, recurs every three to four weeks, is attended by local manifestation such as pelvic congestion and pain, lassitude, nervousness, and continues in more or less regular cycles until middle life when a state known as menopause, or "change of life," obtains. The power for blood making is greater in the female than in the male, and when pregnancy does not occur, this superfluous blood is unessential to the body and must be discarded; hence the menstrual flow. Just before each appearance of the flow the lining of the uterus becomes congested, swollen, and red; then, attended by some sloughing of the lining, the capillaries 176 PRINCIPLES OF HOME NURSING rupture and exude blood into the uterus. The conges- tion subsides after three to seven days, the menstrual flow gradually decreases in amount and fades in color. There follows a rest period of a few days; then prepara- tions for the next menses begin. Menstruation is thought to be influenced by ovulation, the monthly changes in the uterus being preparatory for the reception of the fertilized ovum. In perfect health, there should be no menstrual- dis- Uterus Rectum Bladder Cervix Pubic bone Vagina Meatus • Anus Labia Fig. 98.-The female generative organs, lateral section. orders, and girls should be able to carry on ordinary occupations without interruptions. Excessive exercise like hiking and dancing should not be indulged in at this time. Dysmenorrhea (pain) indicates a hindrance to the flow, either because the uterus is deflected or because the os uteri (uterine orifice) does not dilate sufficiently to permit egress of the discharge. Organic and functional disturbances should be taken to a physician. Since muscles are strengthened by use, the uterine muscles may be made stronger by consistent exercise. First, the bowels must be trained to regular evacua- tions, and regularity of habit persisted in. Then each REPRODUCTION 177 morning or evening when the body is unconfined by tight clothing the following exercise may be taken: push out the abdominal wall as for a bowel evacuation, then gradually draw it in, repeating the exercise several times; it is not a respiratory exercise, but on the contrary can best be performed while holding the breath. It is purely a muscular movement, and is designed to strengthen the abdominal muscles and incidentally those of the uterus. A cessation of the flow does not mean that tubercu- losis will necessarily follow. In anemia, malnutrition, and tuberculosis, the flow is sometimes withheld for the purpose of building up the tissues being depleted by pathogenic conditions. Some women are so constituted that the periodicity occurs normally every few months. A change in the mode of living, as going from an active to a sedentary life, moving from the country to the city, or vice versa, may interrupt the regularity. A short or long flow, a scant or full flow, unless continued to a point of exhaustion should not cause alarm. There are several types of cycles-the 21-, the 27-, the 28-, and the 30-day cycle; a six-week cycle is perfectly nor- mal as long as the woman keeps healthy. MALE REPRODUCTIVE ORGANS The testes occupy a position in the male generative tract analogous to that of the ovaries in the female, and are suspended from the perineum behind the penis in a double pouch called the scrotum. From puberty to old age spermatozoa (sing. spermatozoid) are produced in these organs in prodigious quantities, which find then- way through minute tortuous passages to the seminal vesi- cles on the under side of the bladder where they are stored until evacuated. A periodicity of five to six weeks is noticeable in the seminal emissions due, no doubt, to the formation of new sperm. The spermato- zoid is the aggressive element, and is therefore constructed for motion with an ovoid head, a short neck, 178 PRINCIPLES OF HOME NURSING and a flagellated tail. It is stripped of all that is not essential for procreation, the nourishment of the new individual being contributed by the ovum. During coitus the semen containing the sperm is forced out through the urethra, the outlet to the bladder which extends the length of the penis, and is placed at the very portal of the womb. Some of the spermatozoa Bladder Spermatic duct Penis Seminal vesicle Urethra Epididy- mis , Testis Fig. 99.-The male generative organs. force their way through the uterus to the fallopian tube where an ovum may be encountered; some pass through the fallopian tube on one side into the pelvic cavity and enter the fallopian tube on the other side, where the ripened ovum may be met; the rest die and are discarded with the normal vaginal secretions. They are a long- lived cell, being capable of surviving many unfavorable REPRODUCTION 179 conditions; they have been known to live three weeks in the fallopian tube when no ovum was ready for fertilization. Fertilization.-Only one sperm can impregnate an ovum, the cell wall of which instantly thickens to pro- tect itself against the intrusion of any more. The head and middle pieces of the sperm, which contain the pro- creative powers and the hereditary traits, pierce the wall of the ovum (the tail being lost) and make their way directly to the nucleus with which they fuse. This is known as fertilization, fecundation, impregnation, incarnation, and is the beginning of life. The woman is now pregnant. The new individual is alive, and its characteristics have been stamped upon it, half of its traits being contributed by the father and half by the mother. Twins.-It may happen that following coitus two ova are impregnated, or due to heredity or some mechan- ical disturbance such as a fall during the first stage of cell division, two individuals are formed from the same fertilized cell. In the first instance the children may be of different sexes and have very dissimilar char- acteristics and features, and are known as "ordinary" twins; in the second, the twins born are "identical;" that is, they are of the same sex, and are said to be alike even to their finger prints. An experiment to produce identical twins may be performed on the frog egg during the first cleavage. Run a blunt hatpin carefully around the line of cleavage and gently sever the two halves of the egg along this line. There will develop two tadpoles instead of one, which, however, will be much smaller and more delicate than the others of the same jelly-nest. Development of the Ovum.-The fecundated ovum, now called a zygote, begins its journey of four to eight days down the fallopian tube to the uterus which has been prepared for its reception. For a week after fecun- PREGNANCY 180 PRINCIPLES OF HOME NURSING elation, the fertilized ovum is called a zygote, then an embryo; after four to five months, it is known as a fetus; after expulsion at full time until the navel heals, the new-born babe; and until it is a year old, an infant. Fertilization is promptly followed by the cleavage of the egg cell into two cells, then four, eight, sixteen, and so on until the cells thus made, at first appearing to be alike, unite to form tissues, organs, systems, and tracts, each with its own function. Before the zygote has arrived in the uterus it has formed its amnion and its chorion; the amnion and the chori.on are the two layers within the placenta, or "afterbirth," that form the sac, "bag of waters" in which the embryo eventually floats. The zygote attaches itself to the mucous membrane in the upper region of the uterus, and remains there as a para- site for a matter of twenty-four hours, or until the circu- latory system of the placenta has been fairly well estab- lished. During this period the mother has not yet become conscious of her pregnancy. The placenta enlarges until it ultimately takes up the whole of the uterine cavity, completely obliterating it by the fourth month. The amniotic fluid in which the embryo floats and from which it drinks its nourishment is secreted in the sac. The two arteries and the vein of the navel cord are inserted about the middle of the placenta and spread out in capillaries upon it. The out side coat of the placenta consists of villi-like projec- tions which dovetail with those of the uterine lining through which food material and oxygen are delivered from the maternal blood to the fetus by osmosis. The blood of the child floats inside the villi, that of the mother outside, so that the circulation of the mother and child are absolutely distinct; the two bloods never mix. As there is no direct connection between the mother and child except by the osmosis of the elements, "maternal impressions" and "markings" are impossible. The child is from the first an independent being, soon establishing its own circulatory system, and performing 181 REPRODUCTION all the functions of life-circulation, digestion, assimila- tion, and excretion. Growth in the uterus is very rapid. By the end of the fourth week the embryo is about a half inch long so curved that its head and tail lie close together, and with buds extending for limbs; at the end of three months it is three and one-half inches long, its hands, feet, eyes, and mouth are well formed. Functions of the Amniotic Fluid.-(1) It is the nourish- ment which the fetus drinks; (2) it is a shock-absorber permitting the fetus freedom of movement and protect- ing it from external injury; (3) it lessens the pain to the mother of the child's movements; and (4) during labor it dilates the passages and flushes the vagina. Functions of the Placenta.-(1) It is the respiratory organ of the fetus; (2) it acts as the excretory organ of the fetus; (3) it assimilates food for the fetus; and (4) it stores up glycogen for the fetus. Time of Conception.-The time that conception takes place is still a matter of conjecture, and the exact date of labor only to be guessed. Some authorities claim that the ovum which activated the last menses was the one fertilized, others that the most favorable time for conception is just after the menses has ceased to flow, and still others that impregnation occurs most frequently about sixteen days after menstruation begins. Ordina- rily, the length of pregnancy is counted as nine months or ten moons, usually 280 days from the first day of the last menstruation. The simplest way to reckon the probable date of birth is to count back 85 days from the beginning of the last menses. Sometimes the date of probable confinement is calculated from the date of quickening, or "life," four and one-half months from this date will give the approximate date of labor. Signs of Pregnancy.-(1) Menstruation is usually suspended during pregnancy; (2) there may or may not be nausea and vomiting, "morning sickness;" (3) fre- quent micturition (desire to urinate) is complained of; 182 PRINCIPLES OF HOME NURSING (4) there may be constipation; (5) the mammary glands enlarge and become sensitive, and the nipples deepen in color; (6) between the third and fourth month fetal movements, "quickening," are felt; (7) the fetal heart beat may be heard through the abdominal wall; (8) the uterus and abdomen become distended; (9) and labor begins after a term of 260-280 days. INFANT MORTALITY To bring to mind the importance of prenatal care, a few citations on infant and maternal mortality may not come amiss at this point. During the seventeen months that the United States was engaged in the World War, some 50,000 men made the supreme sacrifice; during that same period, 33,000 women died in the States from causes due to pregnancy, over half of whom should have been saved. Out of 1,000 babies born into the United States every year eleven die before they complete the first year, making a total average wastage of 250,000 babies each year. About two-fifths of these die within the first three weeks after birth, indicating a lack of proper prenatal care and instruction. Statistics show that the average income runs below the wage needed for decent living and proper nourishment. Free access to the physician, surgeon, dentist, and hospital should be given those women who have not the means for private service. The way, however, is gradually being opened by the prenatal clinics, child welfare stations, maternity hospitals, and public health nurses throughout the whole country. The following list of publications is included in this text-book because they are books that should be read by every student: PUBLICATIONS Grace Ellis, The Origin of Life, Grand Rapids, Michigan. Cady, The Way Life Begins. Maeterlink, The Life of a Bee. REPRODUCTION 183 Saleeby, Parenthood and Race Culture. Goddard, The Kallikak Family. Dugdale, The Jukes. Jewett, The Next Generation. Downing, The Third and Fourth Generation. Davenport, Heredity in Relation to Eugenics. Havelock Ellis, The Task of Social Hygiene. Wile, Ira, Sex Education. Cabot, A Laymans Handbook of Medicine. The human venereal diseases are three in number. Each is propagated by its own specific organism; there is then no possible chance of one "running into the other." They are extremely contagious, being transmitted by direct venereal contact, with an occasional chance for conveyance by clothing, towels, toilet seats, etc. An individual may contract all three of them, or only one. They are chancroid, gonorrhea, and syphilis. Chancroid is characterized by itching and by multiple local soft sores which may or may not break down into purulent ulcers. It causes no further disturbance than that manifested by local discomfort. The secretions from the ulcers are contagious, being spread, however, only by direct contact. Chancroid is a disease of uncleanliness, and soon responds to a soap and water treatment. Because of the similarity in names, it must not be confused with chancre, the first lesion of syphilis. Gonorrhea.-The gonococcus attacks the genital mucous membrane, and excites local pain, congestion, irritation, and purulent discharges; it may lie dormant in the genital tract for a period of seven years or more. Its presence is recognized by the male within the first twenty-four hours because of the intense pain and swelling of the penis; but it may become chronic in the female before she is aware of its presence, thinking the discharge to be leukorrhea. The cervix which is covered with mucous membrane but is nerveless, else childbirth would be unbearable, is the first member involved; here there is no sensation. The toxic element, now prolific, THE VENEREAL DISEASES AS CONTRACEPTICS 184 PRINCIPLES OF HOME NURSING travels swiftly through the uterus, the lining of which is resistant, to the fallopian tubes and the ovaries, the resultant inflammation finally leading to the agony of the operating table. Statistics show that three-fourths of the abdominal operations performed on women are due to this one cause alone. A man who marries after he has contracted gonorrhea, even though he considers himself cured, is taking chances on ruining his bride. Gonorrhea causes sterility in both sexes, as the micro- organism produces diseased tissue; one cannot conceive of an unsound germ cell becoming productive. It is the cause of ophthalmia in the newborn, and of 20-30 per cent of our blindness. Syphilis.-It has been said that the race is deterior- ating because of " syphilization and civilization." Syphilis is propagated by the spirocheta pallida, a spiral maggot which infests every tissue of the body. It is transmitted by actual contact but can be contracted through the kiss, the drinking cup, or the towel if still moist from the secretions from a lesion. There are three stages of this disease, designated as such because of the manifestation of definite symptoms: 1. The primary stage appears within two to six weeks after infection, is marked by the chancre, a hard painless usually single lesion visible at the seat of infection, which destroys the tissues within a radius of about an inch. 2. The secondary stage appears between the third and twelfth weeks, is characterized by pains in the legs and back, an eruption which may simulate any of the exan- themata, a temporary falling of the hair in spots, sores and mucous patches in the mouth, and laryngitis. The patient may have all or none of these symptoms; they are often negligible in women in whom the chancre sometimes appears on the unexposed surface of the vagina, and who come to the stage of degeneration before being conscious of any taint. During these two stages syphilis is very infectious; even the tears are said to contain the infectious principle. REPRODUCTION 185 3. The tertiary stage, running from five to twenty years after inoculation, is generally considered non-infectious, but is the stage of degeneration in which no tissue or organ is spared. It leads to locomotor ataxia, paralysis under the age of forty-five, insanity, irresponsibility, heart disease, and sudden death; life is shortened by twenty years. Congenital Syphilis.-It is the unborn child that pays. If the father is in the first or second stage he transmits the disease to the mother, thence to his child. If he has reached the non-infectious period, he transmits it neither to mother nor child, and may if the mother is healthy become the father of robust children. The syphilitic mother, on the contrary, always transmits the infection to her offspring. Her family tree is blasted forever. Miscarriage is one of the most persistent manifestations. The pregnant woman will miscarry without apparent cause for six or eight times, each fetus being a' little stronger than the previous one, until a full time babe is born either still or so feeble it cannot survive. At last she may bear a child that shows no symptoms until puberty, when blindness, mental deficiency, and other lesions are ushered in. Restrictions.-These are reportable diseases, and per- sons attacked should be placed under strict quarantine. United States Public Health Service clinics are being established throughout the country in the hope that this scourge may be controlled within a generation or two. These clinics have the power to arrest and examine any man or woman who is reported as spreading these infections. Free pamphlets may be had by writing the United States Public Health Service at Washington. PRENATAL CARE Changes Due to Pregnancy.-From the very first, changes take place in the uterus, which soon transform the figure of the mother. The uterus increases in size, is lifted out of the pelvic cavity into the abdominal cav- 186 PRINCIPLES OF HOME NURSING ity, and is raised above the bladder pushing the intestines backward. The mother begins to stand with the lumbar region pushed inward in order to keep up with the ever changing center of equilibrium. Due to increased pressure on the veins below the diaphragm varicose veins are liable to develop in various parts of the body, chiefly in the legs. For relief the mother is advised not to stand much, when sitting to elevate the feet, and to dis- card all tight clothing especially the round garter. Relief may be had from bandaging the legs with a bias strip of flannel three inches wide and eight yards long. Cramps in the legs are due to pressure on the nerves in the pelvis, and may be relieved by rubbing them vigor- ously or by emersing the feet in warm water. Due to constipation and straining at stool hemorrhoids (piles) are likely to develop. If the bowels do not act readily, a mild laxative like licorice powders may be taken; laxative fruits such as prunes, apples, and oranges, and fresh vegetables should take the chief place in the diet. Eructations due to gastric disturbances, and so- called Uheartburn" due to an abnormal secretion of acid fluid in the stomach, may become annoying. These latter symptoms are overcome by cutting down the amount of fat in the diet; by increasing the alkaline foods; or as is highly recommended by drinking lemonade. Pressure of the enlarged womb against the diaphragm may cause dyspnea; and pressure against the kidneys may disturb the function of these organs so that eclampsia or uremic poisoning results. For this reason it is wise for every pregnant woman to get at once in touch with her physician. As the uterus rises, the abdominal walls grow thinner and thinner until the skin seems about to burst; in fact, confluent, sometimes radiating, irregularly formed lines break the skin of the abdomen, thighs, and breasts during the later stages of pregnancy. They may be pre- vented by rubbing the parts thoroughly and regularly in a circular direction with oil or cocoabutter. REPRODUCTION 187 A woman should enjoy as good health during preg- nancy as she normally does. Often, however, she finds herself the victim of various aches and pains. Many little ills are ascribed to her "condition," but unless sug- gested by too much self-concentration or maudlin sym- pathy from others, she should see her doctor and not allow herself to be tortured. Teeth.--Notably among her pains will be found tooth- ache and neuralgia. Because of the utilization of the lime by the bone-forming tissues of the embryo, the teeth of the mother are more susceptible to decay during pregnancy. It is therefore recommended that she visit her dentist as soon as she is cognizant of her condition. Prophylaxis should be more diligently practiced; the teeth should be brushed after each meal, and especially after each emesis. Lime water, milk of magnesia, or baking soda dissolved in water will aid in reducing the acidity of the mouth. Nausea and Vomiting.-"Morning sickness," from which a large number of pregnant women suffer, may be relieved by hygienic and dietary care. Usually eating six light meals a day, and not rising until breakfast has been fairly well digested will ward off attacks. If continued to a distressing degree, the mother should consult her doctor. Diet.-Any food customarily eaten if it is consistent with health may be continued during pregnancy; but that which seems to cause the slightest distress should at once be declined. Tea, coffee, and alcoholic drinks should not be used. Because it is necessary for the mother to excrete for two she should adhere as much as possible to a light laxative but nutritious diet consisting largely of fruits, both fresh and dried, vegetables, coarse foods like oatmeal, cornmeal, and graham bread; molas- ses has a laxative effect; meats should be eaten only once a day; cabbage and baked beans should be omitted from the diet. It is better for the expectant mother to eat several small wholesome yet non-stimulating meals frequently 188 PRINCIPLES OF HOME NURSING during the day, and especially is it recommended to consume a light lunch at bedtime. Her diet should include plenty of milk, sweet or butter. As the waste products of the body are suspended in fluid, at least two or three quarts of water, or eight glasses, a day are required. The accumulation of waste in the body is largely responsible for the many minor ills complained of, and may lead to the more serious ones. It is a mistaken idea that the prospective mother needs an unusual amount of food from the very beginning "as she must eat for two;" an increase in food is not neces- sary before the fifth month. As the child doubles its weight during the last eight weeks, ample food must be supplied in late pregnancy. The right food, and the avoidance of sudden rising in the morning, will do much to relieve the morning sickness experienced in early pregnancy. Bowels.-Constipation is the invariable complaint, and is the result of the increased pressure upon the bowels. The mother should establish a regular hour for going to the toilet; the use of enemas and laxatives should be avoided, and should be used only under the doctor's direction, as they not only fail to relieve the cause, but increase the trouble by reducing the normal muscular response of the intestines. If the laxative diet does not have a beneficial effect, senna prepared as follows may help: pour one quart of boiling water over one ounce of senna leaves, and let stand for two hours; strain over one pound of clean prunes, and soak all night; in the morning boil till tender, and sweeten to taste. Eat four to eight prunes at night increasing or decreasing the number as occasion demands. A paste made of senna leaves, prunes, figs, and raisins is palatable and efficient. Urine.-As the burden of the kidneys has been increased it is important that they be continously flushed by increasing the drinking water. The work of the kidneys is somewhat relieved by the increased func- tioning of the skin, and by the regularity of the bowel REPRODUCTION 189 movement. A specimen of urine must be submitted to the doctor at least once a month for laboratory tests, and during the last month every week. The appearance of the urine does not indicate any clue to what the laboratory test might discover. The twenty-four-hour quantity should be measured; if it runs under three pints, the patient must drink more water and must at once consult her physician. The skin is another excretory organ that deserves special attention. It is important for the pregnant woman to bathe frequently, for the sweat and oil glands are increasing in activity, and if the pores of the skin become clogged, the waste products ordinarily thrown off will be retained in the body and additional work be thrown on the kidneys. If retained, serious complica- tions might arise. The bath can take the shape of a shower, sponge, or tub bath, and should be neither too hot nor cold, depending upon the individual comfort. Vaginal douches are not to be taken except under medical direction. Clothing.-In the summer light weight and cool clothing should be worn; in winter clothing corresponding to the temperature that will maintain the body warmth. Union suits are best as they eliminate the band around the waist. It is not necessary for a woman to feel ashamed of her figure; the most comfortable and becom- ing maternity dresses which hang from the shoulders can be had, so that there is nothing to drag or pull or bind. Maternity corsets of approved models with supporters at the sides do not make a pressure downward and are a support to the abdomen. A band so con- structed that the weight of the abdomen is borne may be worn instead. Round garters impede the circulation of the lower extremities and are liable to produce varicose veins, and should therefore be discarded. Shoes.-Due to the extra weight and strain on her feet the expectant mother must supply herself with comfortable well fitting shoes, with low heels to avoid 190 PRINCIPLES OF HOME NURSING turning the ankle and falling, and to equalize the pressure upon the pelvic organs. Swelling feet and legs are common during the later months, and are worse toward evening. Exercise.-At least two hours in outdoor exercise should be taken by the pregnant woman, the vigor with which pursued depending upon her previous habits and upon her present strength. No exercise should be taken to the point of exhaustion. Violent exercise, lifting and overwork should be avoided. Walking, light gardening, driving, may all be endulged in, but not horseback riding or hard travel over rough roads. Lying outdoors in a hammock and reading is greatly recommended. She should take frequent periods of rest-at least five minutes in every hour. Breasts.-As the nipples and the breasts are under- going changes in preparation for birth, they require some special attention. Every expectant mother should have a natural desire to nurse the coming child, and should make the required preparation for it. When handling the breasts the hands must be clean, and all dressings applied to the nipples should be sterile to prevent infection. Nursing sometimes is destructive to the tissues of the nipples, therefore the mother should either harden them with alcohol and alum, or soften them with oil against the time of lactation. About eight weeks before the probable date of confinement, the physician should be consulted for any special treatment. Mental Condition of the Mother.-The expectant mother should be protected as far as possible from undue excitement or worry. She is prone to become despon- dent and irritable and those about her must show infinite patience. She should avoid for the sake of the child such neighbors and friends that have a depressing effect on her, neither should she read morbid literature; all chances for the "blues" should be guarded against. A quiet and peaceful life is better for the nervous systems of both mother and child. 191 REPRODUCTION Any unusual symptoms such as headache, swelling of the feet and legs, diminished urine, dizziness, dimmed vision, should be reported instantly. PREPARATIONS FOR CONFINEMENT Supplies and Dressings.-Everything that is to come in contact with the external genitalia must be as rigidly sterile as for any operative case; therefore all supplies and dressings should be carefully prepared and laid away in protected packages until needed. The following list will cover most of the things necessary, if labor is to take place at home: 1 abdominal binder, a roller towel sometimes answering the purpose; 1 rubber sheet, wide enough to cover the middle of the bed; 1 pound of absorbent cotton in half pound packages; 1 pound of sterile gauze in smaller packages; 1 tube of vaseline; Boracic acid, both in powder and solution; Nightgowns, bedding, towels, etc.; 1 new fountain syringe, and a douche or bed pan; 6 large and 6 small newspaper pads made of 24 to 30 sheets of newspaper covered with soft old muslin, and pressed with a hot iron for five minutes. Layette.-The preparation of the layette is usually intensely fascinating to the prospective mother; but she should not forget while she is spending hours on delicate embroidery and laces that the good disposition of the child frequently depends upon her own mental and nervous state during pregnancy, and these upon her particular attention to personal hygiene. The following named articles of wearing apparel are the indispensible ones, and may be made as elaborate as the mother has fancy and strength for: Three sizes of safety-pins; Squares of gauze or old linen, six inches square; Soap, castile is preferred; 192 PRINCIPLES OF HOME NURSING Talcum powder; 1 pint of sweet oil; Soft baby brush and comb; Diapers, bird's eye or double faced outing flannel, washed before being used, about two dozen; 2-4 unhemmed flannel bands 6-8 inches wide and 18-20 long; 4-8 white cotton slips, or outing slips; Bootees or stockings, wraps and cap, flannel petticoats; 3 wool shirts open down the front. PARTURITION Parturition (labor) is the expulsion of the fetus through the vagina into the outside world; other descriptive terms commonly used are accouchement, childbirth, confinement, delivery, travail. The expulsion of the embryo before the third month is known as abortion; between the third and seventh month, as miscarriage; between the seventh and ninth month, as premature labor; and at term, full-time birth. The course of labor is divided into three stages: (1) the stage of dilatation-the pains become more and more regular and frequent, the os uteri and the vaginal walls soften and dilate sufficiently for the passage of the infant; (2) the stage of expulsion-the "bag of waters" bursts, the pains become expulsive in character, the head (in a normal delivery) descends gradually into the vagina, and after a mighty effort the child's body is born; (3) the stage of placenta or afterbirth-about ten to thirty minutes after the delivery of the child the placenta is expelled, and the uterus begins to contract towards normalcy. Preparation of the Patient.-After giving the patient a cleansing bath, put on her gown, comb her hair in two braids, give her a simple soapsuds enema to empty the lower bowel, and disinfect the external genitalia, some physicians requiring them to be shaved. Notify the 193 REPRODUCTION doctor, note on the chart the exact time of the first pains, and prepare the room for action. Make the bed as described in Chapter III, place over the drawsheet four of the prepared newspaper pads or water proofed squares, and tie to the foot of the bed a sheet twisted diagonally for the patient to pull on during the expulsive stage. See that there is plenty of both hot and cold sterile water. Prepare a bowl of disinfectant solution for the doctor's hands, and put on the table at the bedside the following articles: the sterile sheets, towels, and dressings; the glass or cup in which the cord or tape was boiled; the basins; the boracic acid solution prepared for baby's eyes; the warmed sweet oil; and the doctors instru- ments, which must be boiled. Line the blanket designed to receive the baby with a soft diaper and hang it where it will be warmed; in the absence of a bassinet, face a chair against a warm wall and put a pillow on it. In the meantime, permit the mother, warmly clad, to walk about as she pleases, urging her to rest between the pains. As soon as the "bag of waters," ruptures, she should be put to bed, and sterile leg dressings and sheets adjusted. The second stage has begun. As soon as the child's head is born, wipe its eyes and face with sterile cotton, being careful to use a separate piece for each eye and to wipe from the nose outward; then wrap cotton about the fore-finger, dip it in the boracic acid solution, and cleanse the mouth of the mucus collected in it. After the child has been born, either before or after the cord has been severed, drop a 2 per cent silver nitrate solution which the doctor will provide in each eye and neutralize with normal salt solution, to guard against any possible infection. This procedure has been made legal in many States. Blindness is caused by ophthalmia neonatorum, a purulent discharge due to gonorrhea. This inflammation is not the result of "taking the child to the light too soon." If at any time while the child is under the home nurse's care, the eyes appear red, swollen, and purulent, the doctor's 194 PRINCIPLES OF HOME NURSING attention must be called to it at once, as a few hours of delay may involve eyesight. An infant should cry out as soon as born; if it does not, special treatment is required and is performed by the doctor. When the cord ceases to pulsate it is ligated in two places close to the child's body and is severed with the scissors between the ligations. The child can now be anointed with the oil, wrapped in the warmed blanket, and laid in its crib. The newspaper pad under the mother which has become soiled by the gush of blood and mucus that accompanied birth should now be carefully removed letting the mother rest on the clean dry one underneath; place convenient the pan for the reception of the afterbirth. As soon as the placenta is expelled remove the second pad under the mother which leaves her on the third clean one; cover her with a warm blanket, and give her a hot drink; cleanse the vulva and the surround- ing regions by pouring over her a disinfectant solution while she lies on the bedpan, and place a sterile vulva pad over the genitalia; pin the binder tightly about her abdomen. Set the room to rights, darken it, and permit her to repose - the reward so justly earned. Burn the soiled pads and the placenta. The Lying-in Period.-What is now known as the lying-in period has begun, during which the organs are restored to their normal conditions. It continues until the cessation of the lochia. The lochia is the vaginal discharge of a week or two following childbirth. It is at first pure blood, then it gradually wanes in amount and color until about the eighth or ninth day it is pale pink or almost white. Any abnormal odor or color should be instantly reported to the doctor. The vulva pads should be changed whenever soiled, at first every two or three hours, and the geni- talia flushed with a disinfectant solution, as described. Because of the danger from puerperal fever, " child bed fever," nothing but sterile dressings should come in contact with the vulva. REPRODUCTION 195 Involution is the return of the uterus after delivery to its natural size and shape. It does not quite regain normalcy, however, for at least three months; therefore special care not to overwork must be taken by the mother. It sinks down into the pelvic cavity until it resumes its original position. "After-pains" are the result of the muscular contractions of the uterus, and are increased in intensity in the mother who has borne more than one child. The function of nursing hastens the process of involution, which is consequently delayed in the non- nursing woman. If after-pains are severe enough to disturb the mother's rest, confer with the physician. Lacerations.-If the head is born too quickly as in sudden birth before the arrival of the doctor, or if the vaginal walls have not been dilated sufficiently, there results a tear in the tissues, occasionally the whole perineum down to the anus being involved, when the condition becomes serious. Often the cervix is torn, which if neglected leads to considerable discomfort for the mother and may result in miscarriage of subsequent pregnancies. Unless the patient is in a precarious condi- tion a laceration should be mended immediately after parturition to save a later and more serious operation. Postpartum hemorrhage is due to the probable reten- tion of blood clots or part of the placenta, the inability of the uterus to contract, or to the relaxation of the uterus. (See page 154.) When this emergency arises the nurse should act quickly, for a moment's delay may mean death; she should knead the abdomen vigorously until the uterus so contracts that it may be felt as a small lump in the pelvis. Ergot, because of its contractile effect on the arteries, is the drug indicated. The doctor may find it necessary to pack the uterus with long strips of gauze. The operation must be performed under the most vigilently sterile conditions, even if haste is the first essential. COMPLICATIONS 196 PRINCIPLES OF HOME NURSING Septicemia, "childbed fever," is an infection due to lack of cleanliness. Retention of Urine.-Due to the swollen tissues, the urethra sometimes is so paralyzed that the patient finds it impossible to void urine. Unless she is suffering, a period of twelve hours of retention is not an alarming symptom. After that time, however, efforts to produce micturition should be made by applying alternately heat and cold either dry or moist over the region of the bladder; by placing the patient over the bedpan in which there is hot water; by pouring warm water over the vulva; by letting her hear running water either from the faucet or from one receptacle to another; by applying gentle but steady pressure over the bladder; or by giving an enema; a teaspoonful of baking soda given either dry on the tongue or in a glass of water may be tried; some women are so sensitive that they cannot relax as long as another person is in the room; some doctors permit the patient to sit up to void, this being less dangerous than the catheter, and being the natural position will often aid the flow of lochia; the patient must be well supported in the sitting position. The catheter must not be used except as a last expedient, and then only under the doctor's direc- tions since its use is fraught with so much danger. The patient must drink quantities of water to avoid a repetition, and she must be urged to void urine every eight hours afterwards. Trouble of this sort happens usually but once in the new mother. Breasts.-Colostrum is the name given to the thin watery laxative fluid first secreted in the mother's breasts after delivery. As the baby needs this laxative element to help him get rid of his first bowel movements which are black and tarry in nature, he must be put to the breast and encouraged to nurse as soon after delivery as is convenient. Meconium is the name given to these first bowel movements, and they should be caught in squares of muslin or in soft paper placed inside the diaper REPRODUCTION 197 and then destroyed; soft crepe paper is recommended, for it can be thrown into the toilet. Early nursing has three effects: it draws out the nipple; it excites the secretion of milk; it favors involution. Lactation means the period in which milk is secreted in the breasts, or the period during which the child nurses; it ends with the weaning of the child. Weaning is not indicated at the return of the menses, but is imperative with a new pregnancy, as the strain would be too great on the mother. Sometimes, occurring usually after two to four days, the breasts become so engorged and heavy, and they become so extremely sensitive, that a binder is necessary. This should be applied so that pressure is made from below and from the outside, pulling the breasts toward the center. Two strips of strong muslin three to six inches wide pinned diagonally across the chest and back over the shoulders with a padding of non-absorbing cotton in each axilla have been found to do good service; but too great a pressure will have the effect of checking the secretion, and therefore requires care and skill in the application. The breasts should not be manipulated nor handled more than necessary, as this increases the activity of the glands; nor should the lumps be massaged away or the breast pump be used unless so directed by the doctor. Liquids should be restricted for a while, and salines administered. The nipples should be kept clean and dry, using boric acid solution. If they are cracked and painful it may be necessary to use a shield for a few days. Regularity in nursing should be one of the first habits established in the new-born. This regularity will be a factor in keeping the baby well and will minimize the work of the mother, besides assuring her of definite periods of rest and recreation. Baby habits formed during the first ten days are the ones easiest to form and hardest to change, and must therefore be made right. The intervals of feeding at first need be only six hours, but later when the milk comes, the child should be put 198 PRINCIPLES OF HOME NURSING to the breast every three or four hours, depending upon the supply and demand, or as the doctor regulates it. If the child does not appear to derive enough nourish- ment, the quantity nursed may be measured by weighing him before and after nursing, then subtracting. Wet diapers must not be changed during this experiment. Even though the amount is insufficient, the mother must be encouraged to suckle the infant, as even the smallest amount during the first three months is of great benefit to the child. Mother's Diet.-It is plain that the child's comfort depends upon the disposition, habits, and diet of the mother during the period of lactation. The ill effects of constipation are transferred to the child through the medium of the milk; the mother who nurses her child while in a nervous, overheated, worried, or angry state of mind may disturb the digestion of the nursing babe. Whatever upsets the mother has the tendency to produce unfavor- able effects on the child. Therefore the diet should be restricted to the foods most nourishing and most easily digested. She should be given quantities of fluids to stimulate the secretion of milk, and her meals should always include a glass of milk. Her diet of the first twenty-four hours should be liquid, gradually increasing it to a light diet so that it may be a generous one by the end of the second week. It is better to give her light meals five or six times a day than three full or overloading ones. Acid foods, such as citrous fruits or boiled toma- toes, because of their tendency to cause colic in the child, should be avoided; onions, turnips, cabbage, potatoes, beans, which may cause flatulence in the mother, should be avoided for several weeks. The mother should, not return to her gainful occupation or assume full responsi- bility of her household duties under a month or six weeks, when she should be given a final examination by the doctor to see that everything is all right. CHAPTER XIV CARE OF THE BABE The Premature Baby.-The premature infant, or any babe weighing five pounds or less, requires skilful nurs- ing care. An incubator of some sort is absolutely indis- pensible. Many such children lose their lives because of the treacherous attitude that ''it would die anyhow, so why worry?" The splen- did work done by those who specialize in baby incu- bators proves that the frail babe as well as the weak chick deserves the best skill that money can buy. Due to the undeveloped fat tis- sue and the subnormal heat production, these babies have very low vitality. The first essential is to prevent a loss of heat by surround- ing the child with artificial heat. The premature baby should not be wrapped directly in cotton, as the natural moisture from its body combines with the cot- ton making it adhere to the tender skin and clog the pores. After anointing the child with oil, the band, a wool shirt open down the front, and a diaper are all the clothing needed except for the envelop- ing robe or bag as pictured. The robe is easily made, Fig. 100.-Gown for premature baby. (Courtesy of " The Trained Nurse and Hospital Review.") 199 200 PRINCIPLES OF HOME NURSING and can be either quilted or tacked; it is made of cheese cloth padded with non-absorbent cotton. A light weight wool blanket may be substituted, but because of the delicacy of the child's skin, pure wool should not be placed Fig. 101.-The homemade incubator. next to the body. To avoid handling, a pad may be substituted for the diaper. A homemade incubator can be constructed without the need of much skill or labor, out of an ordinary wooden box, as follows: knock or saw out the lower third of one end, and on a level with the upper margin of the hole thus made along the inside drive or screw staples or screw eyes two inches apart. String cord or twine across diagonally from one to another until a floor for the upper portion of the box has been made. Upon this, and along the sides, lay or tack a thick padding of non-absor- bent cotton covered with some soft material and hang a thermometer inside. The child, wrapped in its robe with only the face exposed is placed on the bed thus prepared. Over the whole box is thrown a light weight wool blanket leaving an opening of a few Fig. 102.-The homemade in- cubator. CARE OF THE BABE 201 inches at the head to assist in the circulation of the warmed air from beneath. In the space under the twine trellis place at least three hot water bottles or their sub- stitutes. The bottles should be only partially filled with water of 120°F.; if one is refilled every fifteen or twenty minutes an even temperature of 80-90°F. can be main- tained, although the temperature of the room is 70°F. or below. The room must be kept well ventilated, but of an even temperature to avoid sudden changes. The resis- tive power of delicate babies is very low and as they are susceptible to infection, especially to colds, they should be specially guarded against all possibilities of conta- mination: all visitors should be excluded. These babies do not cry much, but require a frequent change of position. Baths.-The frail infant needs a daily oil rub. The oil keeps the skin soft and pliable, and is just as cleansing as water. The room must be very warm during the bath, and there should be no unnecessary delay in putting the child directly back into its incubator. Feeding.-Mother's milk is an absolute necessity, and must be procured at any cost from another source if the Fig. 103.-Feeder for a frail babe. (Griffith, " Care of the Baby.") mother is unable.to furnish it. That procured must be milk from the breast of a lying-in woman, and it must be drawn with the greatest care and cleanliness, and kept on ice. Because the child is too weak to nurse, it must be fed with a medicine dropper. To avoid injury to the mouth, the rubber end of the dropper should be punc- tured with a hot needle and used for the nipple, and a bulb to express the milk into the baby's mouth be at- tached to the other end. The child should not be taken 202 PRINCIPLES OF HOME NURSING up at feeding time. At first, feed slowly a teaspoonful every two hours, rapidly but cautiously increasing the amount until in twenty-four hours three ounces (six tablespoonfuls) for every pound of body weight is administered; for instance, a child weighing six pounds will take eighteen ounces, or a little over a pint of milk a day. The intervals between feeding are also length- Fig. 104.-Illustrating how to lift a baby. (By Lorado Taft, Courtesy of Infant Welfare Society of Chicago.) ened to every three hours unless the child is so feeble as to contraindicate it. Sterile cool water should be given between each feeding. The bowels must move regularly every day. When strong enough to nurse, put the child to the breast. How to Lift a Baby.-A young baby because of the weakness of its spine should be very tenderly lifted. 203 CARE OF THE BABE To do so, support the head in the crook of your left arm, pass your left arm and hand lengthwise beneath the back and spread your fingers across the body in such a way that the spine and buttocks are supported; pass the right arm along the lower portion of the body, place the right hand over the hips and draw the child towards you, letting it snuggle against your body. Baby's Bath.-After delivery, and while the mother is resting, the home nurse will find it opportune to bathe the baby. The newborn babe's body is covered with a cheesy substance, which is easily removed by the oil but otherwise difficult. It adheres particularly to the skin where folds or creases are formed, as around the neck, under the arms, on the genitals, on the scalp; these parts must be specially anointed. The infant, until the navel has healed, requires only a daily rub with warm oil. Have ready in a warm room, preferably the bathroom, thrown over the back of a chair or a clothes horse, the clothing to be worn, placing the skirt, if one is used, inside the dress so that both garments may be slipped on at the same time; the soft linen towels and wash rags; a basin or a baby tub; a padded table upon which to lay the child; a tray or basket in which are kept the parapher- nalia for baby's comfort as follows: A small jar or sterilized box for absorbent cotton, a bottle of boracic acid solution and a wine glass into which to pour the solution when needed, soap, talcum powder, soft hair brush, safety pins, pieces of muslin six inches square to place in the diaper, and scissors for the manicure. The nurse must wash her hands before proceeding, and see that there is nothing rough about her clothing to wound the baby. The Oil Bath.-Rub the entire body of the child with a pledget of cotton well soaked in warm oil, and then dry it with absorbent cotton taking care that no bits of cotton adhere to the skin; expose only a part of the body at a time. The Sponge Bath.-Sponge with warm water each part of the body senarately, using soap sparingly, and 204 PRINCIPLES OF HOME NURSING dry by patting. The stump of the cord needs no care after the first dressing unless it becomes soiled or wet. The cord severs some time during the second week, and prompt healing should take place. The Tub Bath.-After the cord has dropped and the navel healed, the child may be lowered into the tub for its bath. Warm the room to about 75°F.; the room should not be so warm that there is danger of chilling the child when he is taken to the nursery. Lay him on the pad on the table by the side of the tray and the tub. Undress him, removing everything except the diaper which should be unpinned but left about him, and wrap him in a light bath blanket. The special sense organs may be cleansed before or after the bath; doing it before sometimes makes the child cross and hard to manage; when deferred till afterwards, it is often neglected. The nurse must choose her own line of procedure as will best fit the case. First, wash the head, neck, face, and ears by sponging lightly with the soaped wash cloth, taking care not to get soap into the eyes; rinse and dry; then go over the whole body with the soaped rag, paying special attention to the folds and creases, the palms, and the skin between the fingers and the toes. Test the water in the tub with the elbow if no bath thermometer has been provided just before immersing the child. Lower him gently into the water, carefully supporting his back and head, and rinse off the soap quickly with the free hand. ' Lift him to the blanket and at once wrap him in it, and dry him by patting. Afterwards go over his whole body with a soft dry linen towel or cloth to be sure that all parts are thoroughly dry; dust lightly with powder, not as a substitute for drying, and not sufficient to fill the pores of the skin; dress the baby, putting on first the shirt, diaper and hose; then slip the dress over the-feet, not over the head. A new-born babe should wear bootees or hose. Care of the Special Sense Organs.-The eyes should be flushed with boracic acid solution every morning 205 CARE OF THE BABE until the child is several months old. To do this, hold a pledget of dry sterile cotton on the outside angle of the eye, turn his head in that direction, and from a dripping pledget of cotton let the boracic acid solution fall gently into the eye as the lids are being held apart, catching the overflow in the dry cotton. As the dripping sponge does not come in contact with the eye, it may be used for both eyes, and later for the other organs; but the cotton placed next the eye must be renewed each time. Always wipe the eye from the nose outward. The eyes of a young child should be protected from a strong light, from the wind, and from particles of flying dust. The Nose.-Tear off a piece of the wet sponge and roll one end of it to a sharp tight point, then insert it into a nostril and twist it, using a fresh piece for each nostril; then with a dry piece of cotton, dipped in oil or vaseline, lubricate the nostrils. The Ears.-Make a wedge of the wet sponge as for the nose and twist it in the external canal of the ear, drying with a dry pledget. The use of applicators or hairpins for eyes, ears, or nose is to be discouraged, as there is danger of injury from the quick sudden movements of the child; the pledgets if made right serve the purpose ever so much better. The Mouth.-Twist the remainder of the wet sponge squeezed dry firmly about the forefinger and go over the whole inside surface of the mouth, the gums, inside the cheeks, the roof, and the tongue. This should be done several times a day, care being taken not to injure the mucous membrane. As the saliva of a healthy mouth acts as a cleaning fluid, the washing of the mouth before and after each feeding becomes an unnecessary task and should not be practiced. The genitalia require special attention, but they should be handled as little as possible. Girls are easily kept clean by separating the labia and washing with boracic solution. In boys the prepuce must be retracted and the glans penis cleansed. The doctor's advice should be solicited on this procedure. 206 PRINCIPLES OF HOME NURSING The nursery provided should be one which may be readily exposed to sunshine and fresh air, as these are dominant factors in growth. Dark shades may be provided to exclude the heat in the summer. The decoration of the nursery should be simple and the colors soft; white produces a glare. Only a few persons should be allowed in the room at a time. A large incidence in infant mortality is due to overcrowding the infant, especially if he is obliged to sleep in the room with several Fig. 105.-The "Betterbaby" crib. adults. The nursery must be kept scrupulously clean; it is best to wax the floor, and to use oiled mops and dust cloths. Development of the Normal Baby.-If a baby exhibits a normal appetite, a clear skin with firm flesh, a bright eye, a daily regular bowel movement, a uniform gain in weight, and if he sleeps well without interruptions, he may be said to be thriving and in good health. Outdoor Life.-From the very beginning the child should spend the greater part of his day in the open; he may be laid in his crib or carriage on the porch or in the yard. On very cold days or during dusty storms he had better take his airing in a well ventilated room. During the heat of summer, he should be taken out early in the day, and should be dressed as lightly as possible. 207 CARE OF THE BABE Sleep.-The new-born babe should sleep from eighteen to twenty hours out of the twenty-four, and should be aroused at his regular nursing time if he is asleep. As a normal child ought to sleep through ordinary household noises, talking in whispers and walking on tiptoes when baby sleeps are not good form. His wakeful intervals should lengthen as he grows older and stronger until at six months during the day he takes a nap in the forenoon and one in the afternoon, and at night he sleeps for twelve hours without awakening except for a possible drink of water or change of diaper. He should be undressed and put to bed at six o'clock, and be given the last feeding at ten o'clock. The daytime naps should be gradually shortened until at a year the child needs only the afternoon nap, which habit should be persisted in until he is five or six years old. A child should never take his nap fully dressed; at least the shoes and outer garments should be removed, and he should be put in a darkened, well ventilated room. He must not be allowed to lull himself to sleep by sucking things, such as a passifier, his fingers, thumbs, or dress. If a habit of the latter nature has been formed, mittens should be put on or cuffs applied over the flexor region of the elbows to prevent the bending of the arms; and the passifier should never be offered. Growth.-The average weight of the new-born babe is seven to nine pounds; during the first and second weeks one-tenth of his original weight is lost owing to the insufficient nourishment of the colostrum; this, however, is restored by the end.of the third week; he should double his weight in six months, and treble it in a year. It should not be the mother's ambition to raise a heavy, fat, flabby baby, but, on the contrary, one that is well proportioned with slowly growing bone and muscle. It is better that during the summer he show little or no gain rather than be overfeed him with the foolish hope of increasing his weight. 208 PRINCIPLES OF HOME NURSING Weighing the Baby.-The health curve of a normal adult changes from day to day; so it is that a baby's weight taken daily is not indicative of his growth; a weekly weighing taking place at the same hour is much more dependable. The loss of an ounce over the pre- vious day's record has been the source of much useless anxiety and fretting on the part of the over-zealous mother. To weigh; remove all his clothing, lay him on the pan of the scales which has been covered with a warm diaper or blanket, weigh, and subtract the weight of the cloth used. The hanging scales are not accurate, and as there is danger in letting the baby fall, they should not be used. The exercise of the normal child consists in stretching, in working his legs and arms vigorously, and in attempting to raise his head. If his motions are hampered by too much clothing he is denied this natural exercise. The Cry.-Sometimes a lusty cry is good for the development of the lungs, but the home nurse must learn the difference between the child's Fig. 106.-Scales for weighing an in- fant. (Wilson, "Ob- stetric Nursing.") Lower jaw. Upper jaw. Fig. 107.-The milk or deciduous teeth. (Government Bulletin.) cries, as they are his only mode of expression. The cry of hunger, of thirst; the cry of temper, of pain, of dis- comfort; must all be distinguished. CARE OF THE BABE 209 Teething.-The teeth develop with the embryo, but do not begin to cut through the gums until about the sixth month; the process of teething should proceed naturally and without discomfort, and be completed when the child is two and a half years old, the two lower central incisors generally being the first to appear. There are twenty in all, called the milk or the deciduous teeth. Parents and nurses are cautioned against putting their fingers in the child's mouth to feel the teeth, as bacteria are thereby introduced; neither should he be permitted to bite on hard rubber rings and other things manufac- tured for the purpose in an effort to force the teeth through. Weaning should not be begun in the summer, and should progress slowly and methodically. The process may be begun by the ninth or tenth month depending on the season and on the child's health, and should be concluded by the end of his first year. If a child has been taught from early infancy to drink water out of a cup, weaning should not prove such a task. One feed- ing a day may be omitted to let the child drink his milk or gruel from a cup. When he becomes accustomed to the new routine, another meal may be substituted, thus gradually increasing the number of the meals and decreasing the number of feedings. By the end of the first year, the child should be eating such foods as toast, bacon, soft eggs, some vegetables, and some fruits. Habits.-Reducing the care of the baby to a system relieves the mother of many irritating irregularities and gives her the opportunity to adjust her own work and rest. Properly trained habits should begin at birth, and may prove of benefit to him all through life. The formation of good habits requires infinite patience and considerable time but it will save steps in the long run. The child may be trained as early as in the third month to designate by some sign his desire to use the toilet. The habit early established of having regular evacuation will save the child the discomfort of constipation in adult life. To install such a habit, the nurse is advised 210 PRINCIPLES OF HOME NURSING to set the child over a chamber in her lap. At first it may be necessary to use the soap stick, which is made of a long rounded wedge of some pure soap moistened in water or oil, and held in the rectum for a few minutes. Because of the irritating effect of glycerin to the mucous membrane, glycerin suppositories should not be used; neither should enemas become the rule. Gently massag- ing the abdomen in a circular direction and at the same time urging the child to "grunt" will give him some idea of what you are wanting of him. Fig. 108.-Stomach, of infant at birth (natural size) capacity 1 oz. (Griffith, "Care of Baby.") Feeding.-When one considers the diminutive size of the new-born babe's stomach and realizes that it will hold only one ounce of fluid (two tablespoonfuls) at birth, one should become cautious about feeding an infant. The act of nursing should not be prolonged over fifteen minutes, whether the child is breast or bottle fed, and he should not be allowed to get his food so rapidly that the regularity of his respiration is inter- fered with. Cool boiled water should be given between each feeding. 211 CARE OF THE BABE As a baby can become suddenly and alarmingly ill, the home nurse must be prompt in recognizing the symp- toms exhibited, which are to be observed from the posi- tion of the child, his facial expression, the color of his skin, his manner of nursing and swallowing; often a child holds his hand over the seat of pain; the nurse should recognize at once if he has fever. If the digestion is disturbed, the milk should be reduced and more water given. Of the common disorders, colic deserves mention. The child shrieks out in pain, draws up his legs, his abdomen becomes tense, his skin is usually cold, and he may break out in a cold sweat. The treatment consists in getting rid of the gas, and watching his diet. Keep his feet warm, do not allow him to gorge, give him plenty of warm water, with or without peppermint or soda, rub the abdomen in a circular direction to produce the passage of gas which may be assisted by an enema, a procedure that should not be practiced too frequently. He should not be fed during the attacks although he gives the impression that he is ravenous. If the child is breast fed it is wise to simplify the mother's diet for a few weeks. Hiccough is associated with too rapid feeding or to overfeeding; water usually stops it. Regurgitation usually indicates a too full stomach, and to avoid upsetting the digestion, the amount of milk should be diminished or the time of nursing be limited. Regurgitation may also be due to bathing too soon after nursing. Thrush is seen in the bottle fed baby, consists of small white patches or blisters in the mouth, arousing symp- toms of pain on nursing and difficult swallowing, and is due to lack of proper oral hygiene. Absolute cleanliness with the use of boracic acid solution usually reduces it. Jaundice appears during the first or second week and usually requires no treatment. BABY AILMENTS CHAPTER XV THE BOTTLE FED BABY A baby that is deprived of its natural food is distress- ingly unfortunate. He immediately becomes a perplex- ing problem, as frothing will satisfactorily replace human milk. The wet nurse is hard to find, is often unreliable, and her milk is frequently at a variance with the child's requirements. Goat's milk is highly recommended for infant feeding. The arguments in its favor are that the casein breaks into small clumps, thus more nearly resembling human milk; that the goat is free from tuberculosis, is more easily and cheaply sheltered and foddered than a cow, can be washed and milked less laboriously; and that the original cost is less. Cow's milk has been universally accepted as the sub- stitute for mother's milk; although it can be made to resemble human milk, it is never the same-it was intended for a calf. Breast milk is clean and pure; cow's milk is apt to be unwholesome by the time it reaches the home. The importance of the sanitary production of wholesome milk cannot be overestimated, as it plays such a prominent role in infant life. No artificial milk will suit every baby; therefore the home nurse is cautioned against recommending a sub- stitute because she knew it to work well in another instance. Experimenting with baby mechanism is altogether out of the province of any parent or nurse; expert advice should be sought. Cow's milk is delivered to the public in the following forms: 212 THE BOTTLE FED BABY 213 Certified milk.-Milk that is produced under the very best possible conditions, usually under government or state supervision and control. The barns must be built according to specifications conforming with the sanitary laws, of sanitary materials, the walls washed or white- washed at least twice a year, and the floors twice or oftener a day; the cows are washed before milking, the milker wears clean clothes, has clean hands, uses clean utensils, etc. As a check on certified milk, its bacterial count must be less than 10,000 per cubic centimeter when delivered at the creamery. Pasteurized Milk.-Milk that has undergone a process of cleaning and straining, and is heated to a temperature of 145°F. and sustained at that point for thirty minutes, or to 167°F. for twenty minutes, then rapidly chilled. Pasteurization if improperly conducted gives a false sense of security; sometimes it merely inhibits the growth of bacteria, and when the optimum temperature for reproductiorr is reached, multiplication is resumed all the more rapidly for the hindrance. There is a growing tendency on the part of health boards to require the pasteurization of all milk sold to the public. Sterilized Milk.- Milk that has been boiled, so that all bacteria are killed. As boiling also injures the vita- mins, its value both from a palatable and nourishing standpoint is reduced. Its use should be augmented by fresh fruit juices. Modified Milk.- Milk to which has been added other ingredients such as water, sugar, cream, or lime water, to suit the requirements of the individual for whom intended. Modified milk is often supplied for babies by creameries who cooperate with the doctor in charge in order that a perfect substitute may be furnished. Condensed Milk.-Cow's milk, which has been sweetened with cane sugar to a 40 per cent degree, and evaporated to two-fifths or less of its original bulk. The high content of sugar tends to preserve it against spoiling and freezing, but disease germs may persist in it; 214 PRINCIPLES OF HOME NURSING when opened the can should be emptied at once, the milk kept cold, and used within the week. Because of its increased sugar value, it is not an adequate food for children, and may disturb the digestion; or it may produce a fat, flabby, pale baby, unresistive to disease. For infant feeding this food is only for temporary use and is not safe in the hands of the average woman without competent medical supervision. Evaporated Milk.-Milk made of unsweetened fresh milk evaporated to one-half or three-fifths of its volume, and sterilized in the can. It deteriorates rapidly on being exposed to the air. The separate food constituents are not perceptibly decreased by the process of evapora- tion; the vitamins are thought to be uninjured. Evapor- ated milk when reconstituted with an equal amount of water shows practically the same proportion as the original milk. When fresh milk cannot be obtained the evaporated milk is a more desirable substitute than condensed milk. As in both cases there is the possibility of destroying the antiscorbutic vitamin, which is the most sensitive one, and as the iron is reduced in the modification, these deficiencies should be supplied by supplementing the food with orange juice. Dry milk, milk powder, is manufactured by several factories in this country and is used extensively in the production of ice cream and candy. Desiccated milk has not yet attracted the attention of the housewife to the degree that it deserves. The process, called the Merrel-Gere spray process, consists in subjecting milk in the form of an almost invisible spray to hot air which evaporates the moisture, and the residual solids pass into a state of dry powder. Because of the essential point of procuring a high quality, the very best possible conditions must prevail both in the dairies and the factories; some firms have been maintaining a standard bacterial count as low as 60001 per cubic centimeter, and are able to place it on the market at about the same 1 Klim, Merrel-Soules Corporation, Syracuse, N. Y. THE BOTTLE FED BABY 215 price as fresh milk. The tangible advantages are that the fat globules are broken up, the casein is not coagul- ated and toughened by the heat, the vitamins are not injured, and when mixed with water in the proper proportions, it has lost none of its flavor or food value; in addition, the bacterial count is lower than that of certified milk, the keeping qualities are good, and it is particularly convenient when travelling. Because of its small bulk it can be transported around the world, thereby giving every child the opportunity of having milk that would otherwise have been wasted on the farm. Proprietary Foods.-Patent foods are of two kinds, those that contain dried milk, and those that do not. The manufacturers claim them to be only "milk modifiers," and insist that they be used in conjunction with cow's milk, as they do not constitute complete foods without it. They contain a combination of sugar and starch, very much out of proportion to the other food stuffs; and in comparison to the simple foods bought of the grocer are excessively expensive. These foods have success- Per cent of Water Pro- tein Fat ' Milk Sugai- Added sugar Salts Mothers'1 87. 3 1. 5 4. 0 7. 0 0. 2 Cows'1 87. 0 4. 0 4. 0 4.3 0. 7 Goats'1 87. 5 3. 6 4. 2 4. 0 0. 56 Condensed2 26. 5 8. 5 9. 0 13. 3 Cane sugar 40.9 % 1.8 Evaporated 2 73. 0 7. 5 8. 3 9. 7 1. 5 Powdered (whole milk)3 88. 3 3. 2 3. 3 4. 5 0. 69 Dextrins Maltose "Milk modifiers"4 87. 4 2. 1 1. 1 2.44 6.38 0. 5 87. 7 1.34 0.02 2.68 7.65 0.55 TABLE COMPARING INFANT FOODS 1 Gould and Pyle. 2 Hunziker, Condensed Milk, Lafayette, Ind. 3 Merrel-Soule, "Klim," Syracuse, N. Y. 4 Reduced to scale from Mellin's Food, American Journal of Nursing. 216 PRINCIPLES OF HOME NURSING fully reared many children as is evidenced by their advertisements, which, however, are silent on the subject of the sacrifices. The shameful connivance between the registration courts and the manufacturers of proprietary baby foods is to be censured; mothers still in the lying-in period receive all sorts of glowing advertisements which through odious comparisons seem to decry the natural sustenance. Referring to the accompanying table, the student can make comparisons at a glance between the various milks, and may draw her own conclusions as to the merits of each; it is plain that by diluting the substitute to the right proportion of protein, all the other constituents are diminished, so that the services of the scientist are required to adjust them to the standard of mother's milk. THE PREPARATION OF ARTIFICIAL FOOD The Equipment.-For the preparation of artificial feeding the proper utensils should be provided and should Fig. 109.-Approved styles of nursing bottles. be kept for that purpose alone. The preparation should not be entrusted to anyone other than the mother or the nurse. The necessary equipment includes: THE BOTTLE FED BABY 217 1. A dozen nursing bottles, or at least one for each feed- ing, of the round large-mouthed type to favor cleansing and sterilization. They should be marked in ounces so that the exact amount can be measured in them; Fig. 110.-Varieties of rubber nipples. (Griffith, "Care of the Baby.") 2. A nipple for each feeding, the kind that can be easily turned and brushed. Fig. 111.-a, Measuring cup; b, graduate and (c) thermometer. 3. A mixing pitcher, spoon, graduate, and ther- mometer; 4. Non-absorbent cotton, or oiled paper and rubber bands, to seal the bottles; 218 PRINCIPLES OF HOME NURSING 5. A bottle rack, which can be made at home from wire; 6. A covered kettle large enough to comfortably hold the rack of bottles. The milk should stand in the original receptacle for five hours to allow sufficient cream to rise, the upper half being the baby's portion. The slightest detail connected Fig. 112.-The " Ma- terna'' graduate for scientifically and accur- ately modifying the baby's milk. Fig. 113.-The Chapin dip- per. (McCombs.) with the intelligent preparation of the food becomes a matter of vast importance because milk, being sensitive, is easily contaminated by careless handling. The nurse should wash her hands and thoroughly cleanse the bottle before she removes the cap. The utensils, bottles, and nipples should be boiled for fifteen minutes before being used. Enough feedings should be prepared for the full twenty-four hours-seven bottles for the child under three months, six for the one under six months, and five 219 THE BOTTLE FED BABY for the child up to ten months. The amount of diluent (which of course should be sterile) and the number of feedings decrease as the amount of milk increases with the age and vigor of the child. Lime water in the propor- tions of one in ten should be added, after pasteurization, to counteract the acidity of cow's milk and to break up the curds; a pinch of salt is recom- mended to make up the deficiency created by the modification. The mixing should be done accur- ately and to rule, the right amount poured into each bottle, and each corked with cotton or covered with waxed paper. Lower the rack into the kettle of cold water, set the ket- tle over the fire and heat until the thermometer lowered in one of the bottles registers the degree for pasteurization (a thermometer is indispensible). Then maintain it at this temperature for the right number of minutes, and chill swiftly by carefully running cold water into the kettle. If the milk is not chilled at once, an optimum temperature will be reached in which the dormant bacteria will begin to grow and propagate. The milk should then be placed on ice till required. At feeding time, wash the hands, place the bottle, with the nipple adjusted, in a vessel of water and heat to 100°F., taking care not to overheat. To test the tempera- ture reverse the bottle and without touching the nipple, let a drop or two trickle on the back of the hand. In winter a flannel cover should be provided for the bottle to prevent the dissipation of heat. Ten minutes is the least time, and twenty the greatest, in which a child should nurse. If he gets the milk too quickly, the holes in the nipple are too large, and if he dallies too long, Fig. 114.-Arnold ster- ilizer. 220 PRINCIPLES OF HOME NURSING something of enough importance is wrong to warrant an investigation. The baby ought to be taken up while nursing. Throw away the milk he does not drink, rinse and fill the bottle with cold water, and the next day at the regular time wash and boil for fifteen minutes. At the age of three months, a little starch may be added to the child's diet in the form of barley, rice, or oatmeal water in the place of the sterile water. The sugar should be gradually increased until at eight months he is taking about the normal content of cow's milk, which is three level tablespoonfuls of cane sugar in the twenty-four hours; then it should be decreased until at ten months, or as soon thereafter as conditions warrant it, he is able to drink cow's milk unsweetened and undiluted from a cup. Whether breast fed or bottle fed the child should be drinking out of a cup by the tenth month. Other foods are to be added to his diet as soon as one quart of milk a day proves to be insufficient. How to Prepare Barley Water.-Dissolve two table- spoonfuls of barley meal in cold water to make a paste and add to a quart of cold water. Boil for one hour, stirring constantly and adding enough water from time to time to keep the quantity up to a quart, strain, and put on ice till mixing time. It is not as constipating as rice water, or as laxative as oatmeal water. Rice water is made in the same way, using a table- spoonful of rice to a quart of water. Rice has a soothing- effect on irritated intestines, and is useful in diarrhea. Oatmeal Water.-Take two tablespoonfuls of oatmeal to one quart of boiling water, let simmer for two hours, or cook in a double boiler, keeping the quantity up to a quart, and strain. It is indicated in constipation. These diluents should be made fresh every morning. The bowel movements of the bottle fed baby are fewer in number, lighter in color, and more solid in form than those of the breast fed child. There is often a tendency towards constipation. A loose green evacua- tion with mucus and curds suggests a disturbance of 221 THE BOTTLE FED BABY the digestion, and that the diet requires additional supervision. Diarrhea should not be neglected, or attributed to "teething." In the summer this ailment is a great factor in infant mortality. If diarrhea is present, boil the diapers for fifteen minutes to kill the bacteria, which might otherwise be transmitted to the other children. PART IV CHAPTER XVI BACTERIOLOGY Everywhere on the face of the globe except directly over a hot surface, in the sun, deep in the seas, or below the surface of the earth, may be found myriads of micro-organisms that are both friends and foes to mankind. An organism is a living being, either of the animal or of the plant kingdom; a micro-organism is an organism that can be seen only with the aid of the microscope. Plant and animal micro-organisms are differentiated in two ways: (1) the cell wall of the plant is cellulose, that of the animal is protoplasm; (2) the plant has the ability to manufacture its own protein, the animal must utilize that of another organism-it can manufacture protein only from protein. Examples of the animal micro-organisms, the Pro- tozoa, are the malaria and yellow fever parasites, the ameba, and the paramecium; examples of the lowest forms of plant life are the Fungi-yeasts, molds, and bacteria. Within these single celled micro-organisms are centered all the functions of life-locomotion, respiration, nutri- tion, and reproduction. Each cell is made up of a ball of living substance called protoplasm, is surrounded by a cell wall, and contains a nucleus near or at the center, without which an organism cannot live. Micro-organisms need the following conditions for growth: warmth, usually blood heat; darkness, at least 223 224 PRINCIPLES OF HOME NURSING a shielding from the sun; moisture; food, either animal or plant, dead or living; some live better in an acid medium, others are killed by it; some require oxygen, others thrive best without air. Reproduction.-It is by reproduction that life is continued. There are two methods of reproduction,- the sexual and the asexual, and the method varies with the types and species. The sexual method is employed by both animals and plants, and consists in the union of an ovum from the female and a sperm from the male to produce an embryo which, after definite stages of development, grows into an exact image of the parents. There are five distinct types in the asexual method: (1) Simple division, or binary fission,-the organism divides through the middle at right angles to the long axis and forms two halves each of which becomes a new organism; (2) budding, or gemmation,-minute parts of the parent are pinched off at the periphery and develop into organisms like the parent; (3) sporulation,-the whole parent body surface breaks into a network of reproductive bodies called spores; (4) slipping, or layering, -a part of the plant runs along the ground and takes root here and there, being the method employed by strawberries and violets; (5) by the formation of bulbs. The Protozoa are the animal micro-organisms. Some are so small that they have as yet been undiscovered by the microscope; others grow to be one-quarter of an inch long. Motion is produced by means of cilia; of flagella; and notably in the ameba, by pseudopodia, which are extensions of protoplasms advancing from the body in the direction of motion. Protozoa absorb food through the cell wall by osmosis. Pathogenic Protozoa.-Those that cause malaria, sleeping sickness, and yellow fever develop partly in man and partly in the body of a peculiarly adaptive THE PROTOZOA BACTERIOLOGY 225 insect called the host, which sucks the blood of an infected person. The germ after undergoing sexual growth in the body of the host, is transmitted to a healthy indi- vidual through the bite of the insect. Among the diseases spread by protozoa are amebic dysentery, the protozoa being carried by polluted water; the tropical disease known as sleeping disease, which is spread by the bite of the tsetse fly; malaria, through the bite of the anopheles mosquito; and yellow fever through the bite of the stegomyia mosquito. Because they require the medium of a third party, they cannot be spread from one person to another; therefore, the home nurse should have no fear when caring for any of these cases. THE FUNGI The fungi differ from ordinary plants in that they are colorless; that is, they do not possess chlorophyll, the green coloring matter of leaves; and in that they require organic matter for food. Yeasts.-Yeasts are placed in a distinctive class chiefly because of their mode of reproduction, which is by bud- ding. The yeast cell is usually oval in shape, is micro- scopic but is much larger than the bacterium. Its covering membrane is of cellulose, and its body holds several fat globules and water vacuoles. The phenome- non of fermentation is produced by this plant-sugar is destroyed to produce a gas (carbon dioxide), which passes off in bubbles, and a liquid (alcohol). Fermentation is familiar to us in the rising of bread, the conversion of the sugar of the grape into the alcohol of the wine, and in the souring of milk. The artificial fermentation of milk is called kumiss, which is used freely in the diet of the sick. Yeasts rank high in then- make-up in vitamin content, and are therefore recommended as an adjunct to food. Reproduction takes place by budding; that is the parent cell sends out spherical buds or shoots from its surface, there being a free exchange of protoplasm between parent 226 PRINCIPLES OF HOME NURSING and daughter cell until the latter is gradually separated into an independent being. Yeast is capable of being completely dried without injury and may remain for months in the air, being floated about by the currents of air, when it is known as wild yeast. Commercially, yeast is sold in the com- pressed form when millions of the yeast plant are massed together and mixed with a variable amount of starch. In order to obtain the best results, yeast in this form must be used within a day or two, and must be kept cold, as the plants die quickly, espe- cially in warm moist weather. Yeast is also sold in the dried form in which state the plants may be preserved for months. Molds.-Molds grow best in dark, damp, warm places where there is not a free circulation of air, and are largely a source of putrefaction, especially in fruits. The structure of mold is evident to the naked eye in the form of long slender shoots which penetrate the substance on which they feed. These shoots are known as mycelia (singular, mycelium') and unless disturbed they begin to reproduce by sporulation at a rapid rate, soon reducing the substance from which they derive sustenance to naught. Molds are not unhealthful; in fact, the delicate flavor of some cheese is largely due to mold. It is not necessary to discard anything attacked by this fungi unless it has become putrescent; the moldy surface can be lifted off, leaving the part underneath perfectly wholesome. The malodorous gas produced as a result of their metabolism causes the odor of putrefaction. Molds are divided into two classes, depending on the manner of reproduction, one class utilizing the asexual, and the other the sexual, method. In the former the ends of the mycelia enlarge into spherical bodies called sporangia which burst when ripe and throw out spores in a spray of fine dust. The mold on the banana may be Fig. 115.-Yeast buds. 227 BACTERIOLOGY made to demonstrate this phenomenon most impres- sively. In the sexual method the tips of two mycelia meet, protoplasm being freely exchanged between them until a new cell develops at the point of contact which finally breaks away, finds for itself a new environment, and begins to reproduce by the asexual method-sporula- tion. The air of every household is filled with mold spores, as may be verified by exposing a piece of moist bread for an hour or two to the atmosphere of a room, then laying it in a dark warm place for a few days to develop a crop of mold. Mold attacks human tissue in the form of ringworm. Bacteria.-Bacteria are indifferently called germs, micro-organisms, or microbes, and are smaller, more difficult to study, and have a greater variety of species than the other fungi. In size they range from 2 51 0 0 0 to 5,0 on of an inch. Not all bacteria are foes to health; in fact, only a few are pathogenic {pathos, disease or suffering, and genesis, to produce). Many are useful to mankind, and by means of putrefaction and fermentation tear to pieces and destroy dead organic matter that it can be rebuilt into new forms of life. Such bacteria are those found in the soil, the nitrogen fixation bacteria that exist in the nodules of the roots of the legumes-peas, beans, clover; they are capable of taking nitrogen directly from the air and making it available for the use of the plants. If it were not for the soil bacteria, plant life would not long exist. When the farmer plows his clover under, he is restoring the nitrogen to the soil, and is doing it more cheaply and efficiently than by applying a commercial fertilizer. Manure when spread in the garden or field is speedily attacked by bacteria, and is decomposed to earth, from whence the elements are assimilated by the new crop. Shape.-Although small, bacteria have fairly definite forms, which enable the bacteriologist to distinguish one kind from another, and according to which they are classified under three main types: the coccus or micrococ- 228 PRINCIPLES OF HOME NURSING cus (plural, cocci), ball or slightly oval shaped; the bacillus, (plural, bacilli), cylindrical or straight rod shaped; and the spirillum (plural, spirilla), the curved rod or coil shaped. The bacilli outnumber the other forms by far. Each produces its own kind, a coccus producing a coccus, etc., with never a variation, which proves that one disease may be followed by or accompany another but does not "run into" it. Because of the microscope and the perfection of staining and isolation of germs, bacter- iology takes its position among the exact sciences. The bac- teriologist spreads a minute particle of the substance to be examined on a glass slide, fixes it in a flame, stains it, and places it under the micro- scope for observation. This is called a smear. He may notice that some bacteria have the power of locomotion; that some are incapsulated; and that some contain spores. Motive power is confined to the bacilli and the spirilla, and is produced by the lashing motion of hairlike append- ages called flagella; flagella may be arranged at one end, both ends, or they may encircle the whole surface of the cell. The speed with which a bacterium moves depends upon the temperature and density of the liquid in which it floats, and upon the number and position of its flagella. Incapsulation.-Some bacteria, like those of tubercu- losis, are surrounded by a resistant capsule, which makes them difficult to kill when once they gain a foothold in animal tissue; their destructive work cannot be checked Fig. 116.-The microscope. BACTERIOLOGY 229 until this capsule has been broken down. The panacea against tuberculosis will be something that will break down this capsule without doing injury to the tissues. Spore Formation.-A bacterium sometimes retires into a resting stage, a condition in which the cytoplasm becomes concentrated into a small ro'und or oval highly refractive body surrounded by a tough membrane. In this form it is known as a spore, and has no resemblance to the parent. Spore formation is most common among Fig. 117.--Bacteria. the bacilli, and is probably never seen in the cocci. During this stage bacteria are very resistant, requiring a more prolonged or intense exposure to a disinfectant. Fortunately, very few pathogenic bacteria have this power, anthrax and tetanus being the two best known. When adverse conditions arise (exposure to a weak chemical, drought, cold, or an absence of oxygen in some cases), bacteria withdraw from the active stage, survive in the shape of spores, and immediately upon the resumption of favorable conditions begin to reproduce. 230 PRINCIPLES OF HOME NURSING The warmth of the living body offers the right tempera- ture for the optimum growth of bacteria; within the body bacteria find all the conditions favorable for growth-food, warmth, darkness, and moisture. This stage, spore formation, is not to be confused with the reproductive stage of molds, called sporulation; each bacterium is capable of producing only one spore that becomes only one organism when normal conditions are restored; while in sporulation, millions of spores are formed, each of which becomes an individual like the parent. Bacteria often form enzymes, or ferments, and their function is to break up the food upon which they live without themselves entering into the process so that absorption may be made possible for them. These enzymes, or catalyzers, are prolific in the alimentary canal. Reproduction.--Bacteria multiply by the first and simplest asexual method; that is, by fission-a cell grows to the limits of its adult form, divides through the middle into two distinct individuals, each of which divides and subdivides until a large mass has been formed. They sometimes reproduce as single individuals; adhere in groups of twos, fours, or eights; in long or short chains; or in clumps. Their rate of development is astounding, depending upon the species and the environment. Under favorable conditions a new generation may be produced every twenty minutes. It has been estimated that a single bacterium if left undisturbed would yield approximately 16,000,000 descendants in a single day. Such multiplication, however, is hardly possible under natural conditions owing to the decrease of the food upon which they thrive, to the increase in their own numbers, to the accumulation of waste products from their bodies, and to their natural enemies-sunshine, desiccation, excessive temperature, and rapid tem- perature changes. Food is taken directly through the cell wall by osmosis. Fungi feed upon either vegetable or animal tissue, and BACTERIOLOGY 231 in that respect, and in that they do not manufacture chlorophyll, they are unlike the higher plants which are able to use the minerals and salts from the soil. As all protoplasm is composed of the chemical ele- ments, carbon, hydrogen, oxygen, and nitrogen, and certain salts, these elements must be furnished for growth, which in some instances are extracted from dead matter and in others from living. The bacteria that break up dead organic matter causing putrefaction and decay are classed as saprophytes (sapros, decay, phyton, plant) and are non-pathogenic; those that exist on the tissues of a living host are called parasites, and are pathogenic. Protein decomposition and fat cleavage in the intestines are largely due to the saprophytic bacteria, assisted by the action of the enzymes. The parasites produce the same conditions in the living tissues as saprophites do in the dead. There is still another class of bacteria called pyogens, those which cause suppuration. Toxins.-The metabolic processes going on in the cell bodies of bacteria give rise to poisonous secretions that are toxic to the host, so that when they find lodgment in the animal body they become very destructive to the delicate tissues and set up a morbid condition known as sickness, or intoxication. After the entrance of bacteria into the body, disease may be produced by: (1) The growth and reproduction of germs, a condition known as infection; and (2) by the production of a secretion that is poisonous to the tissues, called intoxication. Bacteria leave the body in the excreta from the bowels and bladder; in the discharges from nose and throat; in pus from wounds; and in the cast-off skin after acute eruptive diseases. Therefore, these sources of reinfection must be destroyed as soon as discarded by the body. To Recapitulate.-Bacteria may be classified by their shape as cocci, bacilli, and spirilli; by their food as sapro- phytes or parasites; and by their potency as non-patho- genic, pathogenic, or pyogenic. 232 PRINCIPLES OF HOME NURSING Pure water contains neither pathogenic bacteria nor organic matter. Impure water contains organic matter, indicating that it has been polluted by animal excreta or refuse; and it may contain pathogenic and putrefactive bacteria. Absolutely pure water is seldom found in nature. Even that of springs and of deep wells contains some micro-organisms, which, however, may be only the normal flora of the water, and need not cause alarm. Hygienists recognize two sources of drinking water- ground water (deep wells) and surface water (ponds, lakes, rivers, and oceans.) All surface water is sure to be contaminated, organisms being carried into it by rains and by seepage. Bacteria are less abundant in standing water than in flowing water, because streams are more subject to contamination along their routes from drainage. Most cities dump their sewage into streams upon which cities and towns further downstream depend for domestic purposes. Many epidemics are traced to drinking water thus polluted. The most common patho- genic bacteria in water are the B. coli, B. ty phosis, and S. cholera asiatica, and they produce what are known as the water-borne diseases. Whenever B. coli exists in any quantity, you may be sure that the water is not wholesome. These bacteria are reproduced in the human and animal intestines, but do not live long after being defecated; hence, if found in considerable numbers, they are being continuously supplied by seepage or contamination, or they are surviving on the organic matter in the water which also means animal contamina- tion. Home nurses cannot control the water supply, but they can ascertain whether or not the water is being contaminated at its source, and can act accordingly by sterilizing it. The health of a community depends upon the purity of its drinking water; therefore morbidity and mortality can be controlled by (1) the actual reduction in the number of bacteria in the water; and (2) by the improve- BACTERIA IN WATER BACTERIOLOGY 233 ment of the vigor and resistance to disease of each individ- ual through public and domestic hygiene. Self Purification of Water.-A common fallacy exists that running water will purify itself every seven miles. If it were not for the constant contamination along the route from privies and barns, this might be true; for water has a tendency to rid itself of bacteria in the follow- ing ways: (1) By sedimentation-solid particles being heavier than water fall to the bottom of the stream carry- ing with them any bacteria in their way. At the bottom bacteria meet with such unfavorable conditions that they are unable to sustain life. This is especially true of the pathogenic bacteria; (2) by filtration-as water flows over the sand bed the silt is caught by grains of sand and gravel; (3) by aeration-as water flows along in ripples, all parts of it are exposed to the air; (4) sun- light has a slight disinfectant value against the bacteria near the surface; (5) water plants and algae obstruct the current and catch and hold the micro-organisms; (6) protozoa that live in polluted waters depend upon bacteria for their food and reduce the number considerably; (7) saprophytes break up organic matter, thereby liberating oxygen which is inimical to pathogenic bacteria. In municipal water plants the water is settled in reservoirs for a considerable time before it is delivered to the mains, and those natural factors just explained that prevail in the self-purification of water are active in the reservoirs. In addition, filters, specially constructed, and coagulants are used to hasten the process. Impure waters may be fairly well sterilized for cities by the use of disinfectants. When calcium hypochlorite is added to water, the bacteria are effectively destroyed, the free chlorine disappearing by the time the water reaches its destination. Filters consist of layers of sand of variable grades in a special reservoir through which the water runs and upon which all foreign matter collects. The filter is renovated by removing the top layer of sand at stated intervals. Domestic filters are made of porcelain, and 234 PRINCIPLES OF HOME NURSING are attached to the faucet in the home; they are efficient only when given the required sanitary care. Impure water for domestic use should be boiled, and the flat taste removed by pouring it from one container to another. Water in shallow pans will be sterilized by one hour's exposure to the direct rays of the sun. Bacteria naturally found in the air are not pathogenic and consist mostly of molds and yeasts, those which are resistant to desiccation. After a rain, the air may be nearly free of bacteria. Indoors the air may be contami- nated by perspiration, odors from the body, and respiration. Organisms are not ordinarily expired in quiet breathing, but are thrown off in the vapor expelled in forced breathing, such as sneezing, coughing, or talking; tubercle bacilli have been found twenty feet from a coughing consumptive. As the majority of pathogenic bacteria can exist only where there is moisture, they die as soon as this vapor is evaporated. Diseases whose germs are scattered by the air are called air-borne, and are usually of respiratory origin. Sunlight and desiccation kill most bacteria. Those of tuberculosis, anthrax, and tetanus, however, that are capable of spore formation may live many months, and finally find lodg- ment in the tissues of an unresistive person, and grow. Anthrax germs have been known to be virulent after twenty years. There are more bacteria in cities than in rural districts, in houses than in the open, in places where people con- gregate than where they do not. Night air should have no more terrors than day air; in fact, the air indoors at night is as much night air as that without, so the nurse need have no fear in raising the windows at night. BACTERIA IN THE AIR BACTERIA IN MILK In the udder of the cow, milk is sterile, and only after it has been drawn does it become contaminated, the BACTERIOLOGY 235 following factors being the possible sources: (1) Bacteria and dirt fall into the milk from the body, hair, and tail of the cow at the time of milking; (2) from the unclean hands of the milker; (3) from the air of the barn; it is best if the weather permits to milk outdoors; (4) from unclean utensils. As milk is drawn from the udder in the warm state, it affords a very favorable culture medium. Epi- demics have been traced to milk cans that were rinsed in contaminated water. Milk may be soured by bacteria, or it may become ropy or tinged with color due to the introduction of various bacteria which are not, however, pathogenic. To prevent the growth of bacteria, milk must be immedi- ately chilled and kept so until used by the consumer. Anyone observing the route of milk from the barn of the dairyman to the railroad station where it stands in the hot sun, to the creamery where it is handled by the most unskilled labor, to the consumer, will have reason to suspect the presence of bacteria. Milk affords an ideal environment for pathogenic bacteria when the tempera- ture is favorable, as it furnishes both food and moisture. Contaminated milk is responsible for a considerable portion of infant mortality. Diseases distributed by milk are tuberculosis, scarlet fever, diphtheria, typhoid, and septic sore throat. THE DESTRUCTION OF BACTERIA Heat Incineration Dry heat Moist heat-boiling, streaming steam, steam under pressure. Physical Disinfectants Sunlight Desiccation Cleanliness Solid agents-lime, and chloride of lime. Bichloride of mercury, Carbolic, lysol, creolin, Potassium permanganate, Formalin, milk of lime, alcohol. Coal oil and gasoline-insecticides. Chemical Liquid agents Gaseous agents-Formaldehyde and sulphur. 236 PRINCIPLES OF HOME NURSING Since bacteria are universally distributed, and the progeny of even one bacterium may become millions in twenty-four hours, their destructive power if not checked would become unlimited. Bacteria must not only be reduced in number by a vigilant fight, but in case of contagion, every germ must be destroyed to remove the possibility of a recurrence. Physical Agents.-The various measures employed for checking the growth of bacteria include both chemical and physical agencies. The physical agents used are: (1) Thorough cleanliness; (2) drying, or desiccation; complete exhaustion of moisture will destroy most of the patho- genic germs, although each may show a different resis- tance; tubercle bacilli may retain virulence for months after being completely dried; (3) direct sunlight kills all bacteria except those that are active in the production of chlorophyll, and these employ the sunlight for their purpose; (4) cold is almost useless as a disinfectant; it may delay reproduction, but destroys very few patho- genic bacteria; (5) incineration is the method par excel- lent; (6) heat, in varying temperatures, is the most effective and the most universally used agent for the sterilization of bacteria-those in the active stage being easily de- stroyed by a temperature of 160-170°Fahrenheit, and those in the spore formation stage are killed by boil- ing or by subjection to steam under pressure in the autoclave. Heat may be used in the dry state or in the moist-the former requiring a longer and more intense exposure. Dry heat consists in actually burning in the fire, baking in the oven, or passing through a flame. Moist heat is employed in the shape of boiling water, or of steam either with or without pressure. Moisture is more penetrative and renders the work of destruction in less time. Steam under pressure is the most reliable method. The auto- clave is the surgical device used in hospitals for sterilizing dressings, utensils, and instruments, and consists of an air-tight chamber surrounded by a double jacket of BACTERIOLOGY 237 tremendous strength, into which steam under a given number of pounds pressure is forced for a definite period of time. An improvised home sterilizer may be made from a Fig. 118.-The autoclave. wash boiler into which is suspended a towel or a piece of muslin from handle to handle to form a hammock upon which to lay the dressings done up in squares of muslin and plainly marked as explained on page 169. About two inches of water is boiled vigorously with the lid of 238 PRINCIPLES OF HOME NURSING the boiler kept tightly in place for one hour to produce pressure to the steam. The dressings, without disturb- ing the coverings, are afterwards dried in the sun or are suspended from the grate in a warm oven. Processing in fruit canning is a practical application of steriliza- tion. Because the pathogenic germs seldom go into spore formation stage, a lower temperature than boil- ing is sufficient for disinfection if the exposure is long enough. Fig. 119.-The Rochester steam sterilizer. Chemical Agents.-Certain things cannot be subjected to heat or boiling, and therefore chemical agents are recommended. Each species of bacteria differs in its power of resistance against chemicals as it does against destruction by physical means. The factors to be con- sidered in chemical disinfection are trifold: (1) The actual number of bacteria to be destroyed; (2) the temperature of the agent, whether only high enough for the optimum growth of the bacteria, or higher or lower; (3) the medium in which the bacteria are living; for instance, sputum is difficult to disinfect because in it the bacteria are surrounded by a coating of mucus which is very protective. The paper Cup in which the sputum is caught should be thrown into the fire. The feces of BACTERIOLOGY 239 typhoid, dysentery, and cholera should by all means be burned, or at least thoroughly scalded in large volumes of boiling water. As it is necessary for the home nurse to understand terms used in connection with chemical disinfectants, a few definitions are listed below, and the student is advised to study carefully the differences between them: Disinfectants, germicides, are substances which pro- duce the actual destruction of germs, especially of those that are pathogenic. Antiseptics are substances which arrest activity and check development but do not destroy the bacteria. Insecticides are substances that destroy insects, but not necessarily germs. Deodorants are substances which neutralize offensive odors by one that may be stronger; they may or may not be antiseptics or disinfectants. Burning a string in the room will serve as a deodorant. Sterilization is the process used for the complete destruction of bacteria, with special reference to the use of heat. Sepsis is infection by the pyogenic organisms. Asepsis is freedom from septic matter. Infection is invasion of pathogenic bacteria into the body in such a way that disease results; infection may be local as in infected wounds, or systemic as in the communicable diseases. Disinfection is the process of destroying pathogenic germs. ANTISEPTICS AND DISINFECTANTS IN GENERAL USE As all chemical substances used for disinfection are poisonous, the home nurse is warned to use due precau- tions in handling them. The disinfectants advocated for sickroom use are as follows: Bichloride of mercury, or corrosive sublimate, an extremely poisonous odorless salt comes in white crystals. 240 PRINCIPLES OF HOME NURSING Although highly advocated in surgical use, it is practi- cally useless in many ways, and is not now employed as a matter of routine as it formerly was. It has many dis- advantages, chief among which is its ability to combine with the albumen of secretions, thus forming a protective layer over the bacteria; it is therefore not an ideal dis- infectant. Since it is injurious to woodwork, paint, metal and porcelain, it must not be used for bathroom disinfection. It fixes permanently stains in white cloth, is an irritant to raw surfaces, is sometimes absorbed by the raw tissues producing toxic symptoms, and it occa- sionally excites a skin eruption that persists even after prolonged treatment. It is an excellent insecticide, however, and may be painted in a 5 per cent solution in circles around table legs and cupboards to drive away the ants. Ants will not cross the line. Carbolic acid, or phenol, a coal-tar product which comes in white crystals, has a characteristic odor, and dissolves readily in twenty parts or more of cold water. It is the most valuable and commonly used disinfectant. For ordinary purposes it is used in the strength of one part of the substance to nineteen of water, customarily called a "1 in 20" solution. Stronger than this it is irritating to the skin. It is a corrosive poison, but its evil effects can be instantly overcome by either of its antidotes, alcohol or epsom salts. It shows a contrasting characteristic to bichloride in that it can be used with safety in a dilute form on woodwork or linens. A sheet wrung out of it hung in the doorway of a quarantined room makes an excellent defense against germ-laden dust, and prevents its distribution through the rest of the house. Lysol and creolin are two other coal-tar derivatives that are in common use. In fact, on account of the increased cost of carbolic, lysol has practically superseded it. One teaspoonful of lysol added to one pint of water makes a 1 per cent solution, which is recommended for all surgical purposes. Creolin is used in 5-10 per cent BACTERIOLOGY 241 solution. It is a dark syrup-like liquid, and forms a milky white solution. These two drugs kill ordinary bacteria in three minutes, and spore bearing ones in one hour. Lime, whitewash, milk of lime, is one of the cheapest and best disinfectants known, and is made by mixing one part of unslaked lime in four parts of cold water. Common slaked lime is practically inert as a disinfectant and is of less efficiency than ordinary wood ashes, for the ashes do contain some lye. Lime acts only in the presence of water and must be made fresh every 24 hours, as it absorbs the carbon dioxide from the air and becomes worthless. It is especially efficient for excreta when used in an amount equal in bulk to the excreta, which should stand two hours before final disposal; the vessel or bed- pan should afterwards be disinfected and scrubbed well with soap suds. Chloride of lime, chlorinated lime, is a better disinfectant and deodorant than milk of lime, but it soon becomes stale, and it bleaches and injures fabrics and colors. It is used in the proportions of six ounces to a gallon of water. It may be used dry on moist excreta. Its value depends on the liberation of free chlorine, which is set free in the presence of air and water. Chloride of lime is extensively used as a disin- fectant for privies and wells, for drinking water if it contains much organic matter, for baths and swimming- pools, and for floors and walls. For camping or touring trips, for the disinfection of drinking water, it is recom- mended to carry a mixture of one quart of water and one teaspoonful of chloride of lime; add one teaspoonful of this solution to two gallons of water and let stand fifteen minutes. Formalin is a 40 per cent solution of formaldehyde gas and water, making a clear liquid with a pungent odor. In a 2-10 per cent solution, it is adaptable as a disin- fectant and deodorizer of excreta. It should be thor- oughly mixed with the excreta, and allowed to act for one hour. 242 PRINCIPLES OF HOME NURSING Tincture of iodin in the proportions of 10 per cent iodin to 70 per cent alcohol has no equal as a surface disinfec- tant. It penetrates the epidermis and is considered the best disinfectant to be applied to the skin prior to a surgical operation. In a 3 per cent solution, it is excellent in fresh wounds, although it must be carefully used on exposed tissues, as it is likely to be absorbed and cause systemic symptoms. Alcohol is a disinfectant in a 60-70 per cent, and an antiseptic in a 30-40 per cent, solution. Silver nitrate is used locally on wounds in the shape of lunar caustic to destroy superfluous granulations, and to stimulate healthy ones. It is universally used in a 2 per cent solution as a prophylaxis in the eyes of the new- born babe, many states making this practice obligatory on the part of the practitioner. Silver nitrate is used also in diphtheria. Its commercial preparations for local use are called argyrol and protargyrol. Soaps of all kinds are disinfectants when adequately used either on the hands or the clothing. Soap has the additional virtue of removing the dirt. Sal soda added increases the efficiency. The practice of laundrying with soap and of boiling the clothes are practical forms of the principles of disinfection. The two gaseous disinfectants that have popular approval are formaldehyde and sulphur. For a discus- sion on these two gases, see "Fumigation," pages 257 and 258. GASEOUS DISINFECTANTS ANTISEPTICS All disinfectants in dilute form are antiseptics. Boracic Acid, Boric Acid.-This substance may be bought in a crystalline or powdered form. It is a non- irritating antiseptic, and is most frequently used in a 2 per cent strength for eye, ear, nose, mouth, and bladder irrigations. The saturated solution, 4 per cent, is made by boiling one teaspoonful in one pint of distilled BACTERIOLOGY 243 water. It dissolves readily in hot water. There need be no fear of getting too strong a solution, as the excess over a saturated solution precipitates. The dry powder can be used in any wound. Hydrogen peroxide used to be considered an indis- pensible antiseptic for fresh wounds, but it is now thought to be irritating to the tissues. It is sometimes ordered for gargles, but is contraindicated in certain stages of throat inflammation. Normal salt solution is thus named because it has the same specific gravity as the human blood serum and may be injected into a vein without causing disintegration of the red corpuscles. It is made by boiling one tea- spoonful of salt to one pint of water. It is frequently used in the form of enemas to relieve thirst, to replace fluid in the body after a hemorrhage, and to act as a stimulant in case of shock; and for irrigations. If it is to be used intravenously, it must be very carefully made, and had best be purchased from the druggist. CULTURES AND SPECIMENS Throat Culture.-Often a nurse is required to make a throat culture. Have ready the prepared sterilized test-tube containing the medium and the sterile swab (culture tubes are furnished free of charge by most state boards of health), a tongue depressor, and a flame of either a Bunsen burner or of an alcohol lamp. Place the patient in a good light, hold the tongue down with the depressor, remove the cotton stopper of the test-tube, held in the left hand, in the crook of the little finger of the right so that it will not become contaminated; run the swab over the infected surface, especially over a patch if there be one. Taking care not to touch other parts of the mouth or throat with the swab, smear it over the medium in the test-tube, pass the mouth of the test- tube through the flame, replace the plug, and discard the swab. The swab should always be burned, so that that 244 PRINCIPLES OF HOME NURSING particular source of transmission is destroyed in case the culture proves positive. This culture tube must be labelled, and sent immediately to the laboratory or to the doctor's office. Fig. 120.-The method of making a smear culture. (A. S. Morrow.) To Collect a Specimen of Water or Milk.-The home nurse may be requested to prepare a specimen of water or of milk for laboratory examination. Water.-Sterilize a bottle holding at least six ounces by boiling it, let water run copiously from the pump, then col- lect some in the bottle without contamin- ating the bottle against the pump, and stopper with a piece of sterile cotton. Label, stating definitely the date, hour, location of the well with reference to sources of contamination, and the name and address of the householder, and send immediately to the laboratory. Milk should be poured directly from the receptacle in which it was delivered into the sterile bottle, first shaking Fig. 121.-Alco- hol lamp. 245 BACTERIOLOGY the milk thoroughly, stopper, and label as for the water specimen, and send to the laboratory at once. To Collect a Specimen of Urine.-A doctor often asks for a specimen of urine, and the home nurse should know how to prepare it. Clean and sterilize the bedpan and a bottle holding about eight ounces, cleanse the external genitalia by pouring over them a disinfectant solution. Pour the urine into the bottle, stopper, and label. Unless the doctor specifies the time, the first urine in the day should be saved. If he wishes a "24-hour specimen," proceed as follows: Discard the first urine voided after the request for a specimen was made, then pour all the urine voided after that time into a receptacle large enough to hold the full quantity, and urge the patient to void for the last time exactly at the time on the previous day that the process was begun. Then shake the receptacle, and procure a sample in a six to eight ounce bottle as has already been described. Putrefaction may be pre- vented by adding a few drops of formalin or chloroform. To Collect a Specimen of Sputum.-The sputum should be received in a thoroughly cleansed wide mouthed bottle, the patient expectorating directly into it, and plugged with raw cotton. The expectoration should come from the lungs, and not merely from the throat and mouth; if necessary, a cough can be produced by tickling the throat. The amount is a minor point, as only a minute particle can be examined at a time, and if the specimen is a true lung expectoration, just one ejection is sufficient. SURGICAL OPERATIONS Although surgical operations performed in the home are rare and are usually minor in character, there comes a time when a nurse must assist in the preparations for a major operation, and she should have some knowledge of what will be required and how to prepare it. Prepara- tions, if possible, should be begun prior to the day set 246 PRINCIPLES OF HOME NURSING for the operation. As sterile dressings can be purchased of the druggist or may be furnished by the surgeon, the nurse may be spared the duty of sterilization. If, how- ever, the contrary is the case, she should follow directions given on page 237. In any case, she must have plenty of sheets, and towels on hand; bungalow aprons make good surgical gowns. All utensils to be used must be thoroughly scoured, even though they appear clean, and boiled in a washboiler, or disinfected in a 1-1000 solution of bichloride. An instrument tray may be improvised from a bread pan, unless the doctor furnishes his own receptacle. At least two pails to receive the waste water must be provided; and two five-gallon jars or buckets furnished, one for cold sterile water, the other for hot. The cold sterile water must be boiled and collected the day before the operation, and the receptacle covered with a clean sterile towel. On the day of the operation, the hot water should be collected in the other receptacle. The room in which the operation is to be held, must be other than the patient's room, should be easily heated to a temperature of 80°F., and should have plenty of light, the northern exposure being preferred; it should be convenient to the patient's room and to the bath-room. Remove all furniture and draperies, and other things not required, dust the ceiling and walls, preferably with a vacuum cleaner, and scrub or mop the floor. The view from the outside should be intercepted by a gauze curtain or by coating the pane with whiting. For a minor opera- tion such elaborate preparations need not be made, but they must approximate according to the gravity of the case. Place in the room end to end two kitchen tables, or a substitute, for the operating table; a table for sterile dressings, instruments, and solutions; and a table for the anesthetist. Cover the operating table with a pad, and later with a sterile sheet. Protect the other tables with oil cloth or papers, cover them with pieces of muslin secured to the legs, and just prior to the opera- tion, with sterile cloths or towels. BACTERIOLOGY 247 While these preparations are going on, see that the doctor's orders are being carried out with reference to the patient's medication, diet, bath, encouragement, and comfort. The part to be operated on must be shaved and cleansed several hours previous to the hour set for the operation. Some surgeons prefer a thorough scrubbing of the skin with a brush and soap and water, followed by a moist dressing of some disinfectant; others prefer to paint the skin with tincture of iodin and to cover it with a dry sterile dressing, a second application of iodin to be made after the patient is on the table. The skin must be thoroughly dry for this. The tincture of iodin is preferred today because it permeates to the subcu- taneous tissues; there is no softening of the skin and underlying tissues as is the case when a moist dressing is used; and there is less discomfort for the patient. Disinfecting the Hands.-Each surgeon prefers his own method for this, but the initial step is the same in all cases: he scrubs his hands and forearms with soap and running water for five minutes using a stiff brush; then he cleanses underneath and around his nails with an orange stick or nail file; and immerses his hands in the disinfectant. Sterile rubber gloves are usually worn during an operation. Post Operative Care of the Patient.-As the patient loses heat during, and suffers considerable shock after, the operation, and is unconscious, she should be placed between blankets in a warmed bed, and surrounded by heat; she should be under constant surveillance until consciousness is restored, because the tongue due to the relaxed condition of all the muscles of the body is liable to fall back over the trachea and cut off her air. Every care should be taken not to burn the patient with the heat appliances used; the resistance under an anes- thetic is lowered, and burns occur easily, and are hard to treat. The patient must be kept very quiet on her back, and not permitted to turn without the sanction of 248 PRINCIPLES OF HOME NURSING the attending physician. It is a good plan to lay a towel or folded sheet under the patient's buttocks to enable lifting afterwards. If the patient vomits, turn her head to one side into a basin, and if the operation was a laparotomy, hold your hands one on each side of the wound and apply slight pressure towards the wound to relieve pain and to obviate the possibility of breaking stitches. As soon as she becomes conscious, wash her face with cold water, but do not give her a drink until permission has been given. Look for and report any unusual symptoms. Unless nausea is present, simple food should be given freely after the first bowel movement, to stimulate subsequent peristalsis. CHAPTER XVII THE COMMUNICABLE DISEASES In early history, the origin of disease was attributed to the occupation of the body by a demon; and it was the peculiar office of the medicine-man to drive out this devil by means of charms, compromises, noises, bitter herbs, or by torture applied directly to the body of the afflicted one. Very little progress was made in the scientific treatment of the sick until the nineteenth century when Rudolph Virchow advanced the doctrine that all organic matter was composed of cells, and that life depended upon the process of cell activity. Then followed the germ theory of that brilliant scientist, Louis Pasteur, which forms the basis of all progressive investigations of today. As the human race is afflicted at all times by disease, and as some bacteria cause physical disorders by pro- gressively invading the whole body, and others by remain- ing localized, it is plain that a departure from the state of health depends upon influences other than that of the mere presence of the microbes. The production of disease is therefore determined by (1) the number of bacteria which gain entrance (a few may be overcome by the defensive forces of the body), and (2) whether or not the path of entrance to the body is adapted to their peculiar requirements. Portals of Entry.-Pathogenic bacteria in order to produce disease must gain entrance into the human body, the definite paths being: 1. The broken skin; 2. The mucous membrane of the mouth and the nasal passages, and the conjunctiva of the eye; CONSIDERATIONS AND PROPHYLAXIS 249 250 PRINCIPLES OF HOME NURSING 3. The respiratory tract; 4. The alimentary canal; 5. The genito-urinary system. The Protective Forces of the Body.-As opportunities for invasion into the body are so numerous, we marvel that we are not all ill all of the time. It is therefore evident that the body must possess some means of defense against the potency of bacteria. This power we shall call resistance, the opposite to resistance being suscepti- bility. Degrees of resistance are dependent upon the following factors: 1. The unbroken skin-the germs of sepsis, tetanus, rabies, are inactive unless they gain entrance through a wound; 2. The mucous membrane with its mucus-the mucus has the power to catch and destroy germs to a surprising degree; 3. Immunity-when resistance is especially marked, it is called immunity. Immunity may be natural-the infectious diseases which commonly effect man do not spontaneously attack the animals, and conversely; or it may be acquired-actively through an attack of the disease, or passively by the introduction into the body of protective substances in the shape of antitoxins or vaccines; 4. The phagocytes (white corpuscles) of the blood. Phagocytosis.-As we proceed higher in the scale of the animal kingdom, we find that the function of intra- cellular digestion of crude materials is limited to a definite group of cells. In man this function is performed by the white blood corpuscles, the leucocytes. The presence of foreign material in the body calls for an increase in the numbers of these cells; they attack it, be it living or dead; digest and destroy it; then neutralize any toxins secreted by such destruction or digestion which might otherwise become harmful to the general system. The death of a few leucocytes matters very little. To illustrate the protection offered by the phagocytes THE COMMUNICABLE DISEASES 251 (phagocytosis), the development of a furuncle, or boil, may be appropriately included at this point: The Development of a Boil.-Boils, contrary to general belief, do not arise from "bad blood," but are the result of local infection due to an invasion of bacteria from the outside. As was stated in a previous paragraph, page 67, the skin is composed of two layers, the epidermis and the dermis. The epidermis consists of a layer of protec- tive cells, that, when broken is no longer a defence to the body. The germs on the penetrating instrument lodge in the subcutaneous tissue and there, because of the favorable environment of warmth, moisture, and food, begin to multiply. The moment a foreign body comes in contact with the sensory end-nerves, a message is sent to and from the brain center from and to the local seat of injury; in response there is a dilatation of the capillaries, in consequence of which more blood is sent to the region. With the increase of blood supply comes a greater number of red and white corpuscles. Certain of the leucocytes are called the phagocytes and are the "white soldiers" of the body; they are capable of passing through the capillary walls to attack and devour the invading bacteria. Because of the increasing engorge- ment in the area the part becomes swollen, red, and hot; and because of the added pressure on the nerves, pain becomes intense. A dense mass composed of dead phagocytes and dead bacteria collects. The digestive fluid secreted for the purpose of disintegrating and destroying the bacteria produces a toxin, which if allowed to accumulate and be absorbed by the blood stream in any quantity, sets up a condition popularly known as "blood poisoning." The dense mass "comes to a head," and begins to soften. The boil ruptures along the line of least resistance, which is usually through the skin, discharging pus. The "core" comes out, the tissues surrounding take on a healthy appearance, and there is a return to normal healing. Treatment.-As cold contracts the peripheral vessels. 252 PRINCIPLES OF HOME NURSING thereby decreasing the amount of blood in the region, and at the same time reducing pain by relieving the pressure, ice is the first thing to apply on a rising boil. The ice, by providing an unfavorable environment, if applied early enough, so retards the multiplication of bacteria that the infection is scattered entirely, a result which may be greatly hastened by applying massage in radii away from the seat of infection. As heat dilates the capillaries and draws more blood to the surface, it adds to the redness, swelling, and pain, and should not be used in the first stages; it should, however, be employed when the boil has made good progress and is about to rupture. By applying moist heat the tissues are softened and the rupture is precipitated. A stye is an infection of the hair follicle of an eyelash, and is to be treated in the same manner as a boil. Causes of Disease.-Those factors such as germs, injuries, and poisons, which operate directly upon the body and cause immediate indisposition are known as direct causes; those that set up morbid conditions indi- rectly and are concerned with age, sex, habit, occupation, heredity, season, climate, etc., are spoken of as indirect or predisposing causes. Contagion vs. Infection.-When micro-organisms are conveyed by direct contact into the body, and set up a morbid condition, the process is known as infection. Infection may be local as in a septic wound, or systemic as in the communicable diseases. All diseases due to bacteria are infectious. Contagion is the result of trans- mission either by direct or by indirect contact. All contagious diseases are infectious, but not all infectious diseases are contagious. The two words are at times used interchangeably. In order to avoid confusion, the term "communicable diseases" is applied in this text to the transmissible diseases. Classification of Communicable Diseases with Respect to Extent.-A transmissible disease becomes an epidemic when it attacks many people at the same time; it is a THE COMMUNICABLE DISEASES 253 pandemic when the epidemic has become more or less universal; it is endemic when it is peculiar to a certain locality; and it is sporadic when it springs up spontane- ously and runs its course in an isolated case. Common Causes of Epidemics.-Epidemics are apt to occur in communities in which the members live in crowded unhygienic quarters, ignorance and superstition, malnutrition and overwork, being chief contributing causes. Modes of Transmission.--Diseases are conveyed by carriers, vehicles, and fomites. A "carrier" is a person who is himself immune but who is discharging virulent bacteria and becomes a source of danger to the public. A vehicle is a medium through which contamination is propagated and carried, as water, milk, and food; rabid dogs, flies, mosquitoes, and fleas, which act as intermediary hosts, and inoculate directly into the body or blood by means of a bite; or excreta or discharges from an infected person, carried by a fomite. A fomite is any inanimate object or substance which has been actually handled by the patient, or which has come in contact with the germ and thereby becomes a medium for infection, such as bacteria laden dust, which enters the alimentary canal or respiratory tract. The Stages of Development in the Eruptive Diseases. The eruptive diseases, or the exanthemata, are char- acterized by definite stages, which may be tabulated as follows: 1. Inoculation, exposure to and introduction of the virus into the system; 2. Incubation, period between the entrance of the germ into the body and the development of the first symptoms, usually one to three weeks; 3. Invasion, the appearance of the toxic symptoms; 4. Febrile or active stage, the fever rises and declines, specific symptoms become prominent; 5. Eruption, the rash or eruption appears; 6. Desquamation, the destroyed epidermis peels off. 254 PRINCIPLES OF HOME NURSING IMMUNIZATION-VACCINE AND ANTITOXIN The Difference between Vaccine and Antitoxin.- Vaccines contain either dead or attenuated micro-organ- isms, or the secretions produced by them. Vaccines immunize against smallpox, typhoid fever, rabies, Asiatic cholera, and bubonic plague. Antitoxin consists of the serum of the blood of an animal, usually a horse, which was made resistant by repeated injections of the bacterial toxin. For each particular disease, a special antitoxin called an antibody is manufactured by the body when attacked and it becomes active or immune against the germ of that disease. Diseases combated by serums are diphtheria, pneumonia, streptococcus infection, and tetanus. The usual sites chosen for vaccination are the upper arm or thigh; for the injection of antitoxin, the buttocks, the abdomen, and the back near the scapula. Typhoid vaccine is usually injected into the upper arm, and smallpox vaccine is inoculated directly into the tissues through a scarification (scraping) of the skin. The seat of puncture or inoculation must be cleansed as for a surgical wound. Vaccination against smallpox should be done during the child's first year, when there will be little or no constitutional disturbance; it should be repeated when the child enters school; and should always be done when there is an epidemic. Immunity after vaccination lasts from three to seven years. Restrictions and Preventive Measures.-As every case of transmissible disease is directly or indirectly the source of infection from which other cases may develop, proper precautionary measures consist in the early recognition of symptoms and the immediate notification of suspects to the public health officer. Among the symptoms which should arouse a home nurse's suspicion are colds or coughs when measles or whooping cough are epidemic; a rash at anytime; or tonsillitis or sore throat, the forerun- ners of diphtheria and scarlet fever. Children exhibiting THE COMMUNICABLE DISEASES 255 any such symptoms should be excluded from school until seen by a doctor. It is the duty of the health officer to prescribe measures that will prevent the spread of infection by enforcing quarantine and the existing sanitary laws of the state board of health. These measures consist in keeping the premises absolutely clean and fly proof, in protecting all infected matter from flies, and in keeping flies out of the sickroom; in soaking bedding and wearing apparel used by the patient in a disinfectant for over an hour before it is sent to the laundry; in the disinfection or burning of the excreta and secretions known to contain the germ, especially in districts where excreta are emptied into privies; in protecting foods to be eaten raw like milk and vegetables against contamination; in prohibit- ing the collection of milk bottles from a quarantined house. Quarantine means the isolation of the patient and his attendants, and the strict exclusion of any person other than the physician and health officer unless definitely authorized. It is well to hang two sheets kept wet with a disin- fectant solution in the doorway to catch the bacteria laden dust and to afford entrance and exit between them. Protective clothing for the head, body, and feet should be provided for the doctor, and kept between the sheets. Nothing must be taken from the room without first being disinfected. All unnecessary and useless household goods and articles should be laid aside in the room to be fumigated at the termination of the disease. The patient should be bathed daily unless prohibited by the doctor. After recovery or death, the patient should have a bath and shampoo of 1:5000 bichloride of mercury, be wrapped in an uncontaminated sheet, and taken to another room where she can be considered out of quaran- tine. These precautions apply also to the nurse. The Nurse.-While in the sickroom the nurse should wear a large enveloping apron and a cap that completely 256 PRINCIPLES OF HOME NURSING covers her hair; she should never leave the room without first washing her face and hands with bichloride, and putting on a clean gown and cap which should hang immediately outside the door. She should gargle her throat often, wash and disinfect her hands before meals, and whenever possible, take daily recreation, and eat and sleep in a room other than the sickroom. When swabbing the throat of a diphtheritic she should protect her own eyes and mouth against possible pieces of mem- brane that might be coughed up by the patient. Basins filled with a germicide solution should be kept in readiness at all times. Excreta, including bowel movements, urine, sputum, and discharges, should be burned, scalded, or thoroughly mixed with an equal amount of disinfectant solution, such as milk of lime, carbolic, or lysol, and permitted to stand thirty minutes to one hour before being emptied. There is much argument pro and con fumigation. If it is done at all, it must be done right. To prepare a room for fumigation, open all drawers, and closets, hang clothing, bedding, and rugs over lines stretched across the room, and lay mattresses over chairs so that all sur- faces will be exposed to the action of the disinfectant. After fumigation, throw rugs and mattresses out of the window to be sunned and aired. Books had better be burned because the gaseous disinfectants do not pene- trate the leaves. Bacteria are known to live for years in books. As gases escape through the cracks and keyholes, spaces around doors and windows must be tightly stuffed with paper or rags, or pasted over with strips of paper which can afterwards be washed off. Fireplaces and ventilators must be closed. As a warm, moist atmos- phere is essential for the success of fumigation, the room must be warmed, and the moisture supplied by sprinkling with water or by setting a tub of boiling water FUMIGATION THE COMMUNICABLE DISEASES 257 in the room just before closing it. The nurse is cautioned to protect the floor. Before generating the gas, be ready to leave the room. Then seal the door. After the room has been closed for twelve hours, enter to air it, being careful to hold the breath until fresh air can be inhaled. Then every piece of furniture and woodwork should be thoroughly cleansed with soap and water. The addition of a disinfectant is often advisable. Fig. 122.-Fumigating a room. The most efficient gases are formaldehyde and sulphur, the former being the better germicide, the latter the better insecticide. Germs are instantly killed when exposed directly to formaldehyde vapor, but those bear- ing spores or protected by dust or other matter require longer exposure. Formaldehyde gas can be produced by means of lamps, candles, the chemical reaction of potassium permanga- nate on formalin, or by suspending in the room sheets dampened in 10 per cent formalin. The customary and most satisfactory method is to use one-half pound of potassium permanganate crystals to one pint of 40 258 PRINCIPLES OF HOME NURSING per cent formalin for every 1000 cubic feet, which is a moderate sized room. When poured together the chemi- cal reaction results in the liberation of the formaldehyde gas. The. ingredients should be put in a pail inside a tub containing hot water as a protective measure and to supply the necessary moisture, and the reaction watched from the outside. But they should not be put together until you are ready to leave the room, for vigorous reaction takes place immediately. Sulphur.-Use five pounds for every 1000 cubic feet of space. Put the sulphur in a pan on a brick in a tub of water as the receptacle becomes very hot. It is recom- mended to put the sulphur into several broad shallow vessels to insure a larger area from which the gas is generated. Pour alcohol over the sulphur and light it. Hot coals can be used instead of the alcohol. Comparative Merits.-Formaldehyde gas is not destructive to furnishings or to metal decorations, does not fade colors except a few delicate lavenders and pinks; although its fumes are irritating to the mucous membrane of the eyes and throat it is not poisonous. It is not an insecticide. Sulphur is practically without germicidal powers, but is the best insecticide known, being especially deadly to bedbugs. It is poisonous, will fade colors, and will ruin metals by combining with them. Metals may be protected by a coating of vaselin or paraffin. The Exanthemata.-The five eruptive fevers-measles, German measles, scarlet fever, smallpox, and chicken- pox-in each of which the rash and desquamation presents a characteristic appearance, are classed as exanthemata. The specific germ in each case is unknown. Other exanthemata are erysipelas, dengue, typhus fever, and typhoid fever. The prodromal symptoms in all febrile cases are so similar that they may be grouped together. There are loss of appetite, headache, backache, general aching over the body, malaise, chilliness, sometimes a cough or coryza, and a rise of temperature. THE COMMUNICABLE DISEASES 259 The general nursing care is the same in practically all febrile diseases, and applies also to the contagious diseases, with special reference to the prevention of transmission; namely, fluid or carefully guarded diet, plenty of water to drink, fresh air, a diurnal bath, sponge baths for temperature, and oil rubs during the period of desquamation; quarantine, disinfection, and fumiga- tion are to be attended to consistently. THE EXANTHEMATA Measles, rubeola, is one of the worst scourges to mankind known, prevailing most intensely during the cooler months. It is marked by coryza, fever, eruption, and desquamation. Anyone who is not immune by a previous attack is liable to infection. The infant's chances for recovery are only one in five. Contagion is spread by the epithelium that is discarded with the exfoliation, and by the secretions from the nose and mouth, cast off in the act of sneezing or coughing. The germs are probably conveyed to a susceptible individual on this vapor or upon dust or other fomites which contain the active element. Incubation period is ten to fourteen days. Symptoms.-When an epidemic of measles is about, red and watery eyes with swollen lids accompanied by cold in the head, a cough, and nasal discharges, should be looked upon as suspicious symptoms. Other promi- nent symptoms are chilliness, headache, pains in the back and legs; the tonsils may be swollen and sore; the temperature rises gradually to 102-4°F. and remains up until the rash fades, when it generally falls by crisis. White spots called Koplik spots usually appear on the mucous membrane inside the cheeks prior to the appear- ance of the eruption. The eruption appears about the fourth or fifth day, consists of little red pin-prick spots barely visible above the skin, coming out first on the forehead and face and spreading gradually to the body. The skin feels velvety 260 PRINCIPLES OF HOME NURSING to the touch, but soon becomes splotchy in appearance and dusky red in color. The eruption fades after two to five days, and the desquamation of a powdery epithelium starts and continues for a week or more. The complications most to be feared are those that involve the respiratory tract, chief among which are pneumonia and phthisis. Whooping cough sometimes follows but must not be considered a complication. The nursing care in measles is the same as for ordinary fever, with the additional precautionary care against transmission. The patient must be kept in a darkened well ventilated room. Black measles is a severe type in which the eruption is very dark due to hemorrhages under the skin. German Measles, rubella.-The symptoms of German measles resemble those of measles and scarlatina, but are milder, the fever seldom going above 100°F. The throat is scarlet like that of scarlet fever. The rash is light and appears ordinarily on the first day, sometimes being the first symptom noticed; it fades after the second or third day and is followed by a slight desquamation. There are no special complications, the prognosis usually being favorable. The patient need not be put to bed but must be kept isolated in a well ventilated room. Scarlet fever, scarlatina, is an acute infectious disease occurring in the fall and winter and is often spread in epidemic form by contaminated milk. It is character- ized by a scarlet rash and runs its course in spite of treatment. Sporadic cases spring up now and then. The younger the child attacked the greater is the danger. The toxic element is given oft with the secretions from the nose and throat and chiefly from the skin during desquamation. The specific organism, although un- known, is particularly resistant, and will show virulence after many years. Incubation period is one to ten days. Symptoms.-The onset is rather sudden, beginning with chills, vomiting, and a sore and vividly red throat THE COMMUNICABLE DISEASES 261 and mucous membrane; there is a peculiarly distinctive odor; the temperature rises abruptly, sometimes going to-106°F., and persists for several weeks; the tongue has a characteristic appearance: it is dry and coated, with red edges and swollen papillae, producing what writers describe as the "strawberry tongue." The eruption appears about the second day in the form of scattered red spots which coalesce into a subcutaneous scarlet flush, appearing first on the neck, chest, and back, and spreading directly to the rest of the body; the por- tions about the lips and chin are rarely involved which gives to the face a "made-up" aspect. Desquamation extends over a period of one to seven weeks when the skin peels off in large flakes and strips, bearing some relation to the intensity of the rash; the patient is in a septic state until scaling has entirely ceased. Complications.-Nephritis is always a serious complica- tion, and as it may follow even light cases, a urinalysis should be made every day. The earlier nephritis appears the most difficult it is to treat. The patient should be given large quantities of water. Otitis media is one of the more common and serious complications and is due to the extension of the pharyngeal infection through the Eustachian tube to the middle ear, and is frequently the cause of deafness in children. Any purulent discharge from the nose or ears are infectious and should be treated as such. Cardiac complications may lead to sudden death, even during convalescence. The Nursing Care.-Give large quantities of water, fruit juices, and fluid diet. Sponge for fever, and keep an ice-cap constantly to the head. The care of the mouth and throat is of utmost importance. Strict quarantine must be maintained; the other children should be sent out of the house. Disinfection and fumi- gation should be carefully carried out. All books and toys used by the patient should be burned. Scarlet fever and measles are differentiated by the longer period of invasion and the later appearance of the 262 PRINCIPLES OF HOME NURSING rash in measles; the scarlet throat, the scarlet rash, and the peculiar stripping of the skin during desquamation in scarlatina. Smallpox, variola, is one of the most noxious of the exanthemata, is characterized by a shot-like eruption which passes through the five stages of papule, vesicle, pustule, crust, and cicatrix. It is common to all ages and attacks readily those who have not acquired immunity. It usually prevails in the winter months. The infectious agent is conveyed by the secretions from the nose and throat, and the dustlike scales desquamated from the body that cling to clothing or other fomites. Varioloid is a modified form due to a resistance increased by vaccination or by a previous attack. Black smallpox is a hemorrhagic form and is usually fatal. Incubation is nine to fifteen days. Symptoms.-The common initial symptoms are chills, vomiting, frontal headache, and distressing backache especially of the lumbar region. A combination of these symptoms when smallpox is epidemic should suggest precautionary measures. The peculiar odor which appears from the onset is of diagnostic value. The temperature rises abruptly on the first day to 103-A°F., and there may be delirium. The eyes and face are swollen. The eruption, passing through the five stages enum- erated above, begins about the third or fourth day, when the severe symptoms abate, giving the patient the false assurance that recovery from "the grip" is com- plete and he attends his usual occupation, thereby spreading the disease. After a week the scabs form and fall off, occasionally leaving scars. The complications are nephritis, broncho-pneumonia, abscesses, purulent conjunctivitis. The nursing care consists in shielding the eyes from the light, in giving large quantities of water to drink, in giving cold sponges for fever, in applying 1:5000 solu- THE COMMUNICABLE DISEASES 263 tion of bichloride of mercury to the face, in anointing the body with oil when the crusts form, and in relieving the itching with carbolated vaseline or oil. Isolation with an abundance of fresh air should be enforced until the last crust falls. Disinfection and fumigation should be diligently followed. Chicken-pox, varicella, is an acute infectious disease, particularly contagious to children between two and six years, is marked by a vesicular eruption which appears in crops. This disease is often confused with smallpox, one differential point being that at the time of convales- cence, owing to the different crops, all stages are visible at one time in chicken-pox, while only one stage is seen at a time in smallpox. Incubation period is ten to fifteen days. Symptoms, except in adults, appear suddenly and are usually mild. The eruption appears on the second day of the disease, sometimes first on the face, but ordinarily on the back and chest. The vesicles rarely become pustular, but shrivel and fall off in dark brown crusts seldom leaving a scar. The fever is not high, but persists throughout the course. The prognosis is good, there usually being no complications. One attack does not immunize. The nursing care consists in the usual care given a fever patient, with some precautionary attention. OTHER COMMUNICABLE DISEASES Diphtheria, membranous croup, is an acute infectious disease due to the Klebs-LdfHer bacillus, and is charac- terized by patches of grayish white membrane covering the mucous membrane of the throat. The infectious element may be transferred to any open wound or to the conjunctiva of the eye where it produces toxic symptoms. The disease is attended by intense constitutional symp- toms due to the production of toxic substances by the invading bacteria, and the patient may be overwhelmed in two or three days. The disease may persevere from a 264 PRINCIPLES OF HOME NURSING few days to a week or two, frequently terminating fatally. It generally attacks children between the second and fifth years, but is common to all ages. The germ is long lived; the disease may be transmitted by fomites or by persons (carriers) recovered from the disease even after fifteen months. Throats that appear perfectly healthy may carry the germs. Epidemics have been traced to contaminated milk. The Schick Test- The measure of one's immunity against diphtheria is discoverable by the Schick test. Epidemics should be controlled by making this test on every person exposed. It is much less painful and expen- sive than antitoxin, and is a convenient and reliable clinical test. It consists in injecting a small quantity of diphtheria toxin under the skin. If the subject has in his own body enough antibodies to neutralize the toxin injected, he may be considered immune; but if the area in the vicinity of the injection becomes inflamed, he must be given antitoxin or be placed in isolation for further development. The Schick test has proved of immense practical value in the reduction of epidemics. It discovers the children who are susceptible, and those who carry the germ; and it eliminates the necessity for giving antitoxin to everybody exposed, thus reducing the cost and the risk. The incubation period is five to six days. Symptoms are those of any febrile attack attended with an abruptly rising temperature to 102-4°F. within twenty-four hours; and a sore and swollen throat the mucous membrane of which is covered with grayish white patches that adhere closely to the tissues; when this membrane is stripped off raw bleeding spots are produced which are soon covered by new membrane. The patient may complain of a difficulty in swallowing; upon examina- tion the tonsils and back of the throat may be seen patched with the grayish white membrane, associated with great redness, swelling, and pain, which spreads rapidly, changes to a dirty white, and fades with con- THE COMMUNICABLE DISEASES 265 valescence. All throat infections must be looked upon with suspicion, and measures for isolation and disinfec- tion carried out until a negative reaction can be had. Complications.-Cardiac complications are found to be present in 60 per cent of the cases, sometimes being heralded by a sudden drop in the pulse rate from 110 or 120 to 30 or 40 per minute. Nephritis, sometimes with complete suppression of the urine, is often manifested and may appear early. Paralysis, particularly of the muscles of deglutition, may follow even mild cases, and may not develop until the second or third week of convalescence. The Nursing Care.-Isolation and disinfection should be faithfully executed until two cultures taken twenty- four hours apart are reported negative. The secretions should be destroyed. In case of fatality, the body should be bathed with bichloride, and the funeral conducted privately. Although painful to swallow, large quantities of water and sufficient liquid diet must be insisted upon to keep the patient resistant to the toxic effects of the disease. Throat cultures are of importance in diagno- sis; instructions on this procedure are found on page 243, and the nurse is cautioned to follow directions carefully if requested to prepare a culture. Antitoxin is given as soon as the reaction is reported positive, and is sometimes repeated in twenty-four hours, the initial dose in an ordinary case being 3000-10,000 units, and in a severe case 10,000-12,000 units, when it is repeated in six hours. There is more danger attendant upon too small than too large a dose. During convales- cence cardiac symptoms must be particularly guarded against by keeping the child from any possible overexer- tion either in play or work. Membranous croup and diphtheria are the same disease. Tonsillitis.-The tonsils are small almond shaped masses of tissue situated one on each side of the throat near the base of the tongue. They are covered with 266 PRINCIPLES OF HOME NURSING mucous membrane and contain crypts, or follicles, which are the first sites of attack. They are believed to act as guards against the invasion of bacteria through the mouth; when diseased and weakened by repeated infection, they provide a favorable environment for the growth of micro-organisms, and leads to a tendency to take colds. Acute tonsillitis is an infection of the tonsils and pharynx brought on by exposure to cold and drenchings and inocu- lation with the organism; it is directly communicable from person to person and may be spread in epidemic form, or it may be sporadic. The incubation period is one to seven days. The symptoms are a rapidly rising temperature, which falls by lysis on recovery, an aching body, chilli- ness, a coated tongue, a malodorous breath, pain on swallowing, and loss of appetite. On examination, the tonsils are .found to be enlarged and dotted here and there with yellow cheesy looking patches which, unlike the diphtheritic membrane, can be separated from the tissues without producing erosion. Enlarged tonsils are readily seen by making an inspection of the throat. Differential points between tonsillitis and diphtheria lie chiefly in the difference in the color and appearance of the membrane, which in diphtheria is grayish, almost a dirty white, and uniform; and in tonsillitis it is yellowish white and patchy. The presence of the Klebs-Lbffler bacilli is the positive diagnostic point. The Nursing Care.-The patient should be put to bed, after having been given a physic to open the bowels, and a hot bath and hot drink to stimulate sweating; the home treatment consists in giving a glass of water every half hour and a gargle as often as every fifteen minutes if necessary. Vinegar, cold boiled tea, and salt water, used alternately, are often as effective gargles as the more expensive drugs. Special attention should be paid to general hygiene and diet. Recurrent attacks lead to a chronic condition, when the tonsils become breeding places for disease germs. THE COMMUNICABLE DISEASES 267 Chronic Tonsillitis.-When repeated infection pro- duces a chronic state, the hypertrophy is liable to extend to the adenoid tissue behind the nasal passages, producing that deforming habit of mouth-breathing and, indirectly, a stupid facial expression, impaired hearing, a lowered mentality and vitality, and restless and disturbed sleep with stertorous respirations. The treatment is hygienic and surgical. Although the active symptoms abate with age, the damage to the general system has been permanently perpetrated. Fig. 123.-Effect of adenoid growth. Acute Rhinitis, Coryza, Cold in the Head.-This is an acute infection of the mucous membrane of the nasal and pharyngeal passages attended with a ropy discharge. The diplococcus of coryza has its normal habitat in the nose and throat of many an otherwise healthy individual, and when offered the right encouragement it becomes prolific. Colds are prevalent in the changeable weather of spring and autumn, and outbreaks may spread so rap- idly as to take the nature of epidemics. Attacks are transmitted from person to person until each of the family or the school has been affected. Symptoms are those usual to febrile attacks with chill- ing, headache, sneezing, general aches, slight rise of temperature, the head feels 11 stuffed up," and there is difficulty in breathing through the nose; there may be sore throat and a stiffness of the neck. There develops a profuse watery discharge from the nose which by the third day becomes ropy and tenacious, when the severe symptoms gradually abate. There are seldom any com- 268 PRINCIPLES OF HOME NURSING plications, but a neglected case may lead to a chronic condition. The treatment is the same as for tonsillitis with special reference to diet and hygiene. Chronic recurrences may be treated with vaccine. Women are especially disposed to scatter germs of the infectious diseases by the careless handling of their handkerchiefs. It has become the disgusting habit to carry one in the hand, as though ready for immediate emergency, and it is notunusual to have offered in greeting a hand with one of the dirty things in it. A handker- chief is a part of the private dress, and should be carried in a pocket, and should not be thrown about promiscuously on the dresser, piano, or dining table where its germs can freely contaminate everything with which it comes in contact. If women would be less negligent with their handkerchiefs, coryza and tonsillitis would not spread like wildfire to the children and other members of the family. Influenza, La Grippe, Spanish Flu, is highly infectious, and spreads with remarkable rapidity. Attacks may become so widely epidemic as to take on the nature pf a pandemic. Incubation period is from two to four days. Symptoms.-The onset is generally abrupt, with a slight chill followed by a rise in temperature, intense aches and pains, accompanied by a feeling of prostration, and by coryza, the discharges of which contain the bacilli of infection. Nursing Care.-Old people are especially prone to this infection and should therefore be well guarded against it. The general care is the same as in all other infectious cases. Convalescence requires special man- agement, as the reaction is similar to that of typhoid, and the lassitude and depression are extremely obstinate. Pneumonia is an acute infectious disease characterized by an inflammation of the lungs and excessive toxemia, the effect of which upon the heart often results fatally. THE COMMUNICABLE DISEASES 269 It prevails in March and April after a winter of neglected "trifling" colds. It is usually brought on indirectly by exposure to cold and drenching which lowers the resis- tance, and as the pneumococcus is harbored in most mouths, infection is almost inevitable; this accounts for the presence of pneumonia in old age, and as a complica- tion in many of the prostrating diseases. The incubation period is short, varying from one to seven days. The symptoms begin abruptly, the patient may awaken in the night having a hard chill. There will follow within a few hours a sudden rise of temperature to 104-5°F., with accelerated pulse and respiration, the pulse-respira- tory ratio being somewhat disturbed, and a short dry agonizing cough. The patient may lie on the effected side. The sputum, which at first is frothy, becomes tenacious and blood-tinged assuming the appearance described as "prune juice." The temperature remains up for seven to ten days when a crisis or turning point is reached. The crisis is thought to take place on the odd days particularly on the fifth or the seventh day. The temperature drops to normal or below within twenty- four hours, accompanied by a sense of comfort as com- pared to the previous state of distress, and recovery takes place by resolution. To avoid collapse which sometimes attends the critical stage the patient must be surrounded by heat, stimulated by a hot drink, and kept quiet. The complications are pericarditis, endocarditis, and pleurisy. The Nursing Care.-Fresh air is of primary importance; the windows must be opened, preferably from the top in cold weather, or the patient kept out of doors, when the feet must be kept warm and the bed protected from drafts. Baths for temperature and plenty of nourishing, easily digested food are indicated. Everything must be done to make the patient comfortable and to save him exertion, as any sudden action such as sitting up or 270 PRINCIPLES OF HOME NURSING straining to cough or vomit may result in heart failure. Since the sputum contains the infectious germ, it must be destroyed. The patient should expectorate into a cup or on toilet paper in a paper bag which can be burned. Tuberculosis, phthisis,-an infection caused by the bacillus tubercle which attacks practically all tissues of the body, the usual sites in the child being the joints, bones, and glands, especially those of the neck; and in adult, the lungs. The bacillus may be disseminated by the blood and lymph streams to other parts of the body than those first attacked. Children should be closely observed for symptoms of limping or for peculiar manner- isms of holding the head. Foul air, malnutrition, and fatigue are predisposing factors. No age is exempt, but more casualties occur between the years of eighteen and thirty-five, thus cutting down our youth during the most vital age. There are in the United States over a million persons constantly sick with tuberculosis. Symptoms.-One of the first things complained of is the distressing night sweats and the resultant weakness; there is a dry hacking cough; a loss of appetite and a consequent increasing emaciation; the typical tempera- ture curve-up in the evening and down in the morning- the hectic flush, and the bright eyes are objectives of great diagnostic value. In the acute form, known as "galloping consumption," the symptoms are milder but ever so much more pronounced, and the patient may succumb within a few weeks after the onset. The nursing care consists in enforced isolation if possi- ble, hygienic living, and careful disinfection of the excreta known to contain the contagious principle. The patient should use a sputum cup, the paper containers of which can be burned and the cup boiled daily. The patient should be kept out of doors constantly day and night, and be brought in only for necessary treatment. Plenty of nourishing food, consisting chiefly of milk and eggs, should be offered. Prophylaxis consists in teaching the children in the schools, as prospective adults, not to spit; THE COMMUNICABLE DISEASES 271 not to swap edibles or pencils; and to turn the head, or hold the hand or handkerchief before the mouth, when sneezing or coughing. Typhoid fever, enteric fever, is an infectious disease caused by the bacillus typhosis, characterized by intes- tinal ulcers and general toxic symptoms elaborated by the bacilli. This disease must not be confused with typhus because of the similarity of the names, as they have very dissimilar characteristics, typhus being spread by the body louse. Typhoid is transmitted by anything that is contaminated with the germ, particularly by the three F's-fingers, food, flies-and can only perform its function in the body after being swallowed. Therefore, to put it crudely, the feces of one person must be swal- lowed by another. Milk and vegetables eaten raw are prolific sources of transmission. Until the introduction of vaccination, it has caused more casualties in armies than the ammunition of the enemy. It becomes epi- demic in autumn, but may be sporadic at any time of the year. Its greatest havoc is performed on the youth between fifteen and twenty-five. Each patient and each convalescent is to be regarded as a source of infection for several years after recovery although apparently in perfect health. Incubation period is eight to twenty-four days. Symptoms.--Loss of appetite, headache, epistaxis; pains in the back, legs, and abdomen; extreme lassitude; rose spots on the abdomen; the tongue becomes dry and coated, sometimes covered with a brown crust which cracks; the teeth and lips are covered with sordes, a mixture of food, saliva, and bacteria. There may be constipation or diarrhea, in the latter case the dejecta have the peculiar appearance of pea soup. The tem- perature rises progressively, reaches its acme of 103-4°F. during the second week, where it maintains a steady level for one or two weeks, and declines during the third week by lysis. If the temperature remains high for any considerable time, the case assumes a serious aspect, and 272 PRINCIPLES OF HOME NURSING the patient becomes delirious or comatose. A sudden drop in the temperature or change in the rate or nature of the pulse at any time is an unfavorable sign as it heralds a complication, and the doctor must be notified instantly. Complications.-About one-fourth of the deaths from this disease are due to perforation, in which the ulcer breaks through the intestinal wall, admitting fecal matter into the peritoneum and causing peritonitis. There is usually a sudden sharp pain, which may be the only symptom until the patient collapses. Hemorrhage from the bowels is a serious complication; it occurs during the third week, when any change in the temperature or character of the pulse must be immediately recognized; every evacuation should be examined for signs of blood. The patient's bed should be elevated at the foot, and light ice-bags applied to the abdomen. Otitis media and inflammation of the parotid glands are two complications originating from neglect of the mouth. Bed sores are common. The Nursing Care.-The patient should be isolated in a well ventilated room; and everything that becomes contaminated with the excreta, including the bedding, must be disinfected. After every defecation, the patient's buttocks and anus must be cleansed with a disinfectant solution to prevent spreading the infection. The nurse must be extremely careful about her own hands before handling anything, and especially before her meals. Careful nursing will hasten convalescence more effec- tively than will medicine. The patient should be kept absolutely quiet and not permitted even to turn without assistance, especially after a complication has set in. Proper hydrotherapy is indicated. An ice-cap should be kept to the head continuously. The mouth should have special care to keep the tongue and teeth clean and moist and free from sordes. If the lips and tongue are cracked and bleeding, apply liquid vaseline or oil, not glycerin, give the patient frequent drinks of water, and 273 THE COMMUNICABLE DISEASES urge him to chew gum. The diet is of the utmost importance; the patient should be given 2500 to 3000 Calor- ies in liquids high in protein and carbohydrate content. The diet upon recovery should be steadily and cautiously increased until, a week after the temperature has become normal, meats and some vegetables may be taken without disturbance. Whooping-cough, pertussis, is an acute infectious disease characterized by an inflammation of the mucous membrane of the respiratory passages and a peculiar convulsive cough which ends in a characteristic prolonged crow or whoop. The specific infection is due to the bac- illus pertussis, and is found in the early stages associated with the sputum and probably on the vapor discharged with the cough. Sporadic cases appear, but it runs largely in epidemics as it travels by direct contact. It is more prevalent in cold weather, and often follows or is coincident with epidemics of measles. It assails all persons, but chiefly the child between the first and second dentition periods; it ranks as one of the most deadly among the acute diseases to the child attacked under five. No child with whooping-cough should be permitted to expose another either at school, in a picture theater, or in other places of public congregation. Incubation period is seven to fourteen days. The symptoms begin like an ordinary cold with dis- charging nose, injected eyes, sneezing, slight fever-101° to 102°F.-which subsides as the cough becomes more intense; there follows in series incessant dry bronchial coughs which gradually increase in severity until the child is unable to inhale, becomes cyanosed, and grasps for a support; finally there comes relief in the peculiarly penetrating inspiration, brazen because of the closure of the glottis. Sudden death is not unusual during this stage. Vomiting and epistaxis are frequently induced by the paroxysms. The extent of vomiting may be so great that the child becomes emaciated because he is unable to retain sufficient nourishment; in this state he 274 PRINCIPLES OF HOME NURSING is receptive to the complications and sequelae of this disease. The attacks vary from two or three a day to fifty or more. Convalescence occurs rarely under six weeks. Complications.-The gravity of this malady of child- hood is not generally appreciated, and treatment in this one disease alone is more neglected than in any other. It is a dangerous disease because of its complications, which include pneumonia, convulsions, hemorrhages into the eye, ear, or brain; and it often opens the way for tuberculosis, asthma, and chronic catarrh and bronchitis. The Nursing Care.-Isolation with rest in bed; the child should not be sent to school; fresh air both day and night, in the open air if possible, warm clothing, proper food. The sputum should be disinfected. A tight binder about the chest and abdomen, and inhalations, relieve the severity of the paroxysms. The cough may hang on for months, and if the child remains delicate, a change of climate is recommended. After recovery, the possibility of complications should be carefully kept in mind. Mumps, acute parotitis.-The contagious principle of this disease is unknown. It is characterized by the swelling and inflammation of the salivary glands, usually of the parotid just below and in front of the ear. It becomes epidemic in spring and autumn, is directly communicable from the first symptom until after convalescence, and attacks most frequently the adoles- cent child. The incubation period is two to three weeks. Symptoms.-The first indication is a pain and swelling beneath the ear, which gradually spreads to the area in front of the ear; increased pain upon eating acids or sweets; earache, slight fever-101° to 102°F. Both glands or only one may be involved. The swelling increases until the child has difficulty in opening the mouth, in masticating and in swallowing. Afters even to ten days the symptoms subside and convalescence sets in. Attacks do not immunize. THE COMMUNICABLE DISEASES 275 Complications.-Otitis media and impairment of hear- ing are the common complications. In males there may arise an inflammation of the testes, and in females a slight swelling of the breasts. The Nursing Care.-The child should be kept in bed and isolated until the swelling disappears, with cold or hot compresses to the glands as the doctor dictates. Oral hygiene is of special importance as infection may be carried to the middle ear through the Eustachian tube. COMMON INFECTIOUS SKIN DISEASE Scabies, the itch, is a contagious disease caused by the female itch mite which bores beneath the skin in order to deposit her eggs. The points of attack are principally the skin between the fingers and toes, but it may spread to the body. It is attended with intense itching and burning, together with an eczema which is the result of scratching. This disease is highly contagious, being transmitted by direct contact with the clothing, towels, and bedding; these articles therefore should be disinfected before being sent to the laundry. The Treatment.-An inunction with soap twice a day and frequent change of clothing are indicated. The soap is allowed to dry on the body for a minute or two, then is washed off with hot water. Sulphur ointment is frequently recommended. Relief from itching may be had by applying a 2 per cent solution of carbolic. Ringworm, tinea, is a highly contagious disease of the skin and hair follicles of the body caused by a vege- table parasite, a relative of the mold, which is carried in the clothing and in the scabs of the sores. The most common site of attack is the scalp but it may be found anywhere on the body. It is characterized by red ele- vated circular patches that become scaly. The hair becomes dry and brittle, and is easily pulled out. As the circle enlarges, the patch usually clears up in the center. 276 PRINCIPLES OF HOME NURSING The treatment consists in diurnal baths, perfect hygiene, faithful care, and the inunction of sulphur or mercury. Favus is a severe form of ringworm due to a parasitic fungus which involves large areas of the scalp and results in the permanent loss of hair if neglected. It is marked by crusts, intense itching, and an offensive moldy odor. The treatment consists in softening the crusts by apply- ing warm oil or a poultice, and by anointing with sulphur or mercury. Prophylaxis consists in hygienic care, and disinfection. Because of limited space it will be impossible to describe any more diseases in this text, and a list of the important infectious and non-infectious diseases will follow with the suggestion that if the home nurse is particularly interested in this phase, she will consult the books devoted to this subject alone, where she will find much more satisfactory material. Infectious Diseases Non-infectious Diseases anthrax Asiatic cholera chicken-pox cholera infantum dengue diphtheria dysentery erysipelas gonorrhea influenza leprosy malaria measles meningitis mumps otitis media pneumonia poliomyelitis rabies, hydrophobia apoplexy appendicitis arteriosclerosis asthma Bright's disease bronchitis chorea colic cretinism diabetes epilepsy gall stones gout heart diseases hemorrhoids hysteria jaundice locomotor ataxia marasmus THE COMMUNICABLE DISEASES 277 scarlatina septicemia smallpox syphilis tetanus tonsillitis tuberculosis typhoid fever typhus fever whooping cough yellow fever nephritis neuralgia neurasthenia paralysis rheumatic fever ulcerative stomatitis BIBLIOGRAPHY Maxwell and Pope, Practical Nursing, Putnam. Pope, A. E., Manual of Nursing Procedure, Putnam. Sanders, G. J., Modern Methods in Nursing, Saunders. Isabelle Hampton Robb, Nursing. Browne, Principles of Nursing, Lea and Febiger. Henderson, Practical Nursing. Aikens, Home Nurse's Handbook of Practical Nursing, Saunders. Emerson, Essentials of Medicine, Bobbs Merrill. Cabot, A Laymans Handbook of Medicine. Kirk, Physiology. Hough and Sedgwick, Human Mechanism, Ginn and Company. Stiles, Human Physiology, Saunders. Baruch, Hydrotherapy. Carter, Howe, Nutrition, Lea and Febiger. Stiles, Nutritional Physiology, Saunders. Rose, Feeding the Family. Sherman, Food Products, Macmillan. Lynch, Manual of First Aid, Blakiston. Pyle, Personal Hygiene, Saunders. Eliason, First Aid. Johnson, First Aid Manual. Cady, The Way Life Begins. Ellis, The Origin of Life. Spargo, The Common Sense of the Milk Question, Macmillan. DeLee, Principles of Obstetrics, Saunders. Government Pamphlets. Holt, Care of Children. Griffith, Care of the Baby, Saunders. Hiss and Zinsser, Bacteriology. Keyes, Genito-Urinary Diseases. Herbert Fox, Bacteriology, Lea and Febiger. Conn, Bacteria, Yeasts and Molds. Conn, Agricultural Bacteriology. Rosenau, Personal Hygiene. Osler and McCrae, Principles and Practice of Medicine, Appleton. Dorland, American Illustrated Medical Dictionary, Saunders. 279 GLOSSARY Ablution, the act of washing or cleansing. Abnormal, not normal. Abortion, the expulsion of the fetus prior to the third month. Abrasion, a rubbing or scraping. Absorption, the taking up of fluids or other substances. Acceleration, a quickening, as of the pulse rate or respiration. Ache, a continuous, fixed pain. Acme, crisis or highest point of the disease. Acne, an eruption. Adenitis, inflammation of a gland. Adipose, fatty tissue. After-birth, the placenta. Albumen, the white of eggs. Albumin, the simple protein found in nearly every animal and in many vegetable tissues. Albuminuria, the presence of albumin in the urine. Ameba, a minute one celled animal organism. Amnion, the innermost fetal membrane, forming the bag of waters; the sac that encloses the fetus and forms a sheath for the umbilical cord. Amniotic fluid, the fluid contained in the amnion in which the fetus floats. • Anabolism, any constructive process by which simple substances are converted into more complex compounds; constructive metabolism and assimilation. Anemia, deficiency in the blood. Anesthesia, loss of feeling or sensation. Anesthetist, an expert in administering anesthetics. Anopheles, mosquito that transmits malaria. Antibody, a substance in the blood and tissues of animals rendered immune by inoculation. Antidote, a remedy for counteracting a poison. Antipyretic, relieving fever. Antisepsis, the inhibiting of the growth of bacteria; not neces- sarily destroying them. Antiseptic, a substance that prevents bacterial growth. Antitoxin, therapeutic agent derived from the blood serum of animals that have been subjected to the disease, that neu- tralizes the poisons of the disease. 281 282 PRINCIPLES OF HOME NURSING Anus, the distal end and outlet of the rectum. Apnea, the transient cessations of breathing. Apoplexy, sudden paralysis and coma. Arteriosclerosis, abnormal hardening of an artery. Arthritis, inflammation of a joint. Aseptic, free from infection. Assimilation, the transformation of food into living tissue. Atrophy, a wasting or diminution in the size of a part. Attenuate, to weaken; to render less virulent. Aura, a peculiar sensation that precedes an epileptic attack. Aural, pertaining to the ear. Auscultation, the act of listening for sounds within the body. Autoclave, an apparatus for effecting sterilization by steam under pressure. Bacillus (plu. bacilli), a rod shaped micro-organism. Bacterium (plu. bacteria), any non-animal micro-organism. Beriberi, a disease due to lack of water soluble "B" vitamin in the food. Bile, the gall secreted by the liver. Bolus, a round mass swallowed. Boracic acid, white crystalline powder used as an antiseptic. Bovine, pertaining to cow. Bronchitis, inflammation of the bronchial tubes. Calorie, the amount of heat required to raise the temperature of one pint of water 4°F. calorie, the small calorie, used in chemistry, £qqq of a large Calorie. Cantharides, the blistering or Spanish fly. Capillary, a small blood vessel. Cardiac, pertaining to the heart. Carminative, relieving flatulence. Carrier, an individual who has recovered from an infectious disease, but who still harbors in his body the specific organisms of the disease, and thus acts as a carrier of infection. Casein, the principal protein of milk and the basis of cheese. Castor oil, a thick purgative fixed oil used to stimulate intestinal peristalsis. Catabolism, destructive metabolism. Catalyzer, a substance producing a reaction without itself entering into it. Catarrh, inflammation of the mucous membrane of the air passages of the head and throat. Cathartic, a medicine that quickens and increases the evacuation from the bowels. 283 GLOSSARY Catheter, a surgical instrument for drawing fluids from the cavities of body. Caustic, burning or corrosive; destructive to living tissues. Cell, a minute protoplasmic mass which makes up organized tissue, consisting of a mass of protoplasm containing a nucleus. Cellulose, a carbohydrate forming the skeleton of plant structures. Cervix, the lower and narrow end of the uterus. Chancre, the primary lesion of syphilis. Chancroid, a soft or non syphilitic venereal sore. Cholera, Asiatic, a disease marked by dysentery, cramps and prostration. Cholera infantum, a non contagious diarrhea of young children, often fatal. Chromosome, a body in a cell which carries the hereditary traits. Chyle, the milky fluid taken up by the lacteals. Chyme, the mass of food in the intestine. Cicatrix, a scar. Cilia, minute lash-like processes. Colic, acute abdominal pain. Colon, large intestine. Colostrum, the first fluid secreted by the mammary gland after childbirth. Coma, profound stupor. Congestion, excessive or abnormal accumulation of blood in a part. Conjunctiva, the delicate membrane that lines the eyelids and covers the eyeball in front. Constipation, infrequent or difficult evacuation of the feces. Counterirritation, an irritation which is intended to relieve some other irritation. Cretinism, a disease associated with the thyroid gland. Crisis, the turning point of a disease for good or evil. Crypt, a follicle or pit. Culture, a medium for propagating micro-organisms. Cyanosis, blueness of skin due to insufficient oxygenation of the blood. Decay, the gradual decomposition of dead organic matter. Defecation, the discharge of fecal matter from the bowel. Defective, a person lacking in some physical, mental, or moral quality. Defervescence, the period of disappearance of fever. Deglutition, the act of swallowing. Dentition, the cutting of the teeth. Deodorant, a substance that destroys ill odors. Dermis, the true skin. Desiccation, the act of drying up. Desquamation, the shedding of epithelium. 284 PRINCIPLES OF HOME NURSING Dextrose, grape sugar. Diaphragm, the partition that separates the abdomen from the thorax. Diaphoresis, perspiration. Diuretic, increasing the secretion of urine. Dropsy, an abnormal accumulation of serous fluid in a body cavity. Dysentery, a febril attack marked by large and frequent bowel movements. Dysmenorrhea, painful and difficult menstruation. Dyspnea, difficult or labored breathing. Eczema, an inflammatory skin disease. Edema, swelling due to effusion of watery liquid into the con- nective tissue. Element, in chemistry, a substance which cannot be resolved into different constituents. Embryo, the fetus in its earlier stages of development, before end of third month. Emesis, vomiting. Endemic, a disease which is peculiar to a locality. Endocarditis, inflammation of the endocardium, the lining of the heart. Enema, an injection of liquid into the rectum for therapeutic purposes. Enzyme, a chemical ferment formed within the body. Epidemic, attacking many people in any region at the same time. Epilepsy, a hereditary disease characterized by convulsion. Epistaxis, nose bleed. Epithelium, the covering of the skin and mucous membranes. Erepsin, a ferment of the intestinal mucous membrane which breaks up peptones and dextro-albumins. Ergot, a drug used to check hemorrhage after parturition. Erosion, a kind of ulceration. Etiology, the study or theory of the causation of any disease. Excreta, waste matters. Extravasation, an escape of blood from a vessel into the tissues. Eye-tooth, an upper canine tooth. Fallopian tube, a tube leading from the uterus to an ovary. Febrile, pertaining to fever. Fecal, pertaining to or of the nature of feces, the undigested residue of the food discharged from the bowels. Fecundation, impregnation or fertilization. Fetus, the child in the womb after the end of the third month. Fimbria, a fringe, especially the fringe-like end of the oviduct. Fissure, any cleft or groove, normal or other. GLOSSARY 285 Flagellum, a mobile, whip like process or cilium. Flatulence, distention of the stomach or intestines with gas. Flex, to bend or put in a state of flexion. Flora, flower. Follicle, a very small excretory or secretory sac or gland. Fomentation, treatment by warm moist applications. Fomite, anything that absorbs and transmits a contagium. Fumigation, exposure to disinfecting fumes. Function, the special, normal, or proper action of any part or organ. Furuncle, a boil. Fusion, the act or process of melting or uniting. Gall, the bile. Gangrene, the mortification or non-molecular death of a part. Genitals, the reproductive organs; also genitalia. Germ, a microbe or bacteria. Germ-plasm, the protoplasm of a cell. Germicide, an agent that destroys germs. Gland, an organ that separates any fluid from the body. Glottis, the opening between the vocal cords. Glucose, grape sugar, or dextrose. Glycogen, a carbohydrate stored in the liver and muscles. Glycosuria, the presence of sugar in the urine. Graduate, a measuring glass marked by a series of lines. Heart-burn, a burning sensation in the esophagus. Hectic, irregular fever of phthisis. Hemafecia, blood in the feces. Hemiplegia, paralysis of one side of the body. Hemoglobin, the coloring matter of the red blood corpuscles, con- taining iron. Hemorrhage, a copious escape of blood from the vessels; bleeding. Hemorrhoids, piles. Hemostat, a surgical instrument or medicine for checking hemorrhage. Hepatic, pertaining to the liver. Hermaphrodite, a person who has or appears to have both male and female characters. Hernia, a protrusion of a loop of the intestine through the peritoneum. Herpes, fever blisters. Hormone, a chemic substance produced in an organ, which being carried to an associated organ by the blood stream, excites in the latter organ a functional activity. Host, any animal or plant upon which another organism lives parasitically. 286 PRINCIPLES OF HOME NURSING Hydragogue, a cathartic which causes watery purgation. Hydrolysis, decomposition due to the absorption of water. Hydrotherapy, the use of water in treating disease. Hygiene, the science of health and of its preservation. Oral h. the proper care of the mouth and teeth. Hymen, the membranous fold which covers the external opening of the vagina. Hypertrophy, the morbid enlargement or overgrowth of an organ or part. Hypnotic, a drug that induces sleep. Hypodermic, applied or administered beneath the skin. Idiocy, complete congenital imbecility. Imbecility, feebleness of mind, congenital or acquired. Immunity, security against any particular disease. Acquired i., that which is due to previous attack or inoculation. Natural i., that with which an individual is born. Impregnation, the act of fecundation or of rendering pregnant. Incision, a cut or wound. Incontinence, inability to restrain a natural discharge. Incubation, the period between the implanting of an infectious disease and its manifestation. Infant, a child under one year. Infection, invasion of the tissues by living pathogenic organisms in such a way as to favor their growth and permit their toxins to injure the tissues. Infectious disease, one caused by parasites, such as bacteria, pro- tozoa, or fungi, and it may or may not be contagious. Inflammation, the condition into which tissues enter as a reaction to irritation. Ingestion, the act of taking food, medicines, etc., into the body Inhibit, to restrain. Inoculation, the insertion of a virus into the body in order to com- municate a disease. Inorganic, not of organic origin. Insomnia, inability to sleep. Intercostal, situated between the ribs. Intermittent, having periods of cessation of activity. Intolerance, inability to endure or withstand. Intoxication, poisoning, the state of being poisoned. Involution, the return of the uterus to its normal size after par- turition. Ipecac, ipecacuanha, a drug employed in moderate doses as an emetic, and in small doses as an expectorant and stimulant to the stomach. Iritis, inflammation of the iris, marked by photophobia, contraction of the pupil, and discoloration of the iris. 287 GLOSSARY Irritation, a state of overexcitation and undue sensitiveness. Isolation, the separation of persons having a contagious disease. -itis, a termination denoting inflammation. Jaundice, yellowness of the skin, eyes, and secretions, due to the presence of bile pigments in the blood. Knot, an intertwining of the ends or parts of one or more cords so that they cannot easily be separated, such as clove-hitch, granny, square or reef, surgeons, etc. , Koplik spots, small bluish white spots surrounded by a reddish areola on the mucous membrane of the cheeks during the prodromal stage of measles. Koumiss, kumiss, a fermented alcoholic drink prepared from cows' milk. Labia, the plural of labium, lip or lip shaped organ. Labor, childbirth; the bringing forth of a child. Laceration, a wound made by tearing. Lactase, a pancreatic ferment that splits lactose into glucose and galactose. Lactation, the period of secretion of milk. Lacteal, any one of the intestinal lymphatics that take up chyle. Lactose, milk sugar. Laparotomy, surgical incision through the abdomen. Laryngitis, inflammation of the larynx, the "voice box." Laudanum, the tincture of opium. Laxative, a mild cathartic. Leg, the lower extremity between the knee and the ankle. Legume, the pod or fruit of a leguminous plant, such as peas and beans. Lesion, any hurt, wound, or local degeneration. Leukocyte, any colorless, ameboid cell mass, such as a white blood corpuscle. Levator, any raising or lifting muscle. Levulose, fruit sugar. Ligate, to tie or bind with a ligature. Lightening, the sensation of decreased abdominal distention pro- duced by the descent of the uterus into the pelvic cavity just previous to labor. Lipase, fat splitting ferment occurring in the liver, pancreas, stomach. Lochia, the vaginal discharge during the first week or two after childbirth. Lues, syphilis. Lumen, the transverse section of the clear space within a tube. 288 PRINCIPLES OF HOME NURSING Lymph, a transparent slightly yellow liquid which fills the lym- phatic vessels. Lymphatics, vessels conveying lymph. Lysis, the gradual abatement of the symptoms of a disease. Malaise, a feeling of indisposition. Mal, disease; malodorous, foul odor. Malnutrition, imperfect assimilation and nutrition. Manometer, an instrument for measuring the pressure or tension of liquids or gases. Mastication, the chewing of food. Marasmus, progressive wasting and emaciation. Meconium, the fecal matter discharged by the new-born. Medium, a substance used in the culture of bacteria, called also culture-m. Meningitis, inflammation of the meninges, the covering of the brain. Menses, menstruation, the monthly sanguineous discharge peculiar to women. Metabolism, the changes, constructive and destructive, that take place in the cells composing the tissues of the body (Pope). Micro-, a prefix signifying small. Microbe, micro-organism, any minute animal or plant. Micturition, the passage of urine. Milk, the fluid secreted in the mammary glands. Miscarriage, birth of the fetus before the twenty-eighth week. Morning sickness, nausea and vomiting occurring on arising, one of the characteristic symptoms of pregnancy. Morbidity, the condition of being diseased or morbid; the sick-rate. Mortality, the death-rate. Motility, the ability to move spontaneously. Mucous (adj.), membrane, the membrane that lines the cavities and canals of the body which connect with the open air. Mucus {noun), the viscid watery secretion of the mucous glands. Narcotic, any drug that produces sleep or stupor and relieves pain. Nasopharynx, the part of the throat above the soft palate. Nausea, tendency to vomit. Necrosis, death of a tissue, especially bone. Nephritis, inflammation of the kidney accompanied by albu- minuria. Neurasthenia, nervous prostration. Nitrifying, forming nitrous and nitric acids out of ammonia. Nocturnal, pertaining to the night. Objective, perceptible to the senses. Obstetrics, pertaining to pregnancy and labor. GLOSSARY 289 Olfactory, pertaining to the sense of smell. Ophthalmia, severe inflammation of the eye or of the conjunctiva. Optimum, a condition which is most favorable to activity. Organism, any individual animal or plant. Orifice, the entrance or outlet of any body cavity. Os uteri, mouth of the womb. Osmosis, the passage of fluids and solutions, separated by a mem- brane or other porous septum, through such a partition so as to become mixed or diffused through each other. Otitis media, inflammation of the middle ear. Ovary, female sexual gland in which the ova are formed. Ovulation, the formation and discharge of an unimpregnated ovum from the ovary. Pack, treatment by wrapping a patient in blankets, wet or dry. Palliative, affording relief, but not cure. Panacea, a cure all. Pandemic, a wide spread epidemic. Papilla, any small nipple-shaped elevation. Papule, a small circumscribed, solid elevation of the skin. Parasite, a plant or animal which lives upon or within a living organism. Paratyphoid, a diseased condition resembling typhoid fever. Paresis, general paralysis. Parturition, the act or process of giving birth to a child. Pasteurization, the arrest or checking of fermentation by heating. Pathogenic, producing disease. Pathology, treating with the nature of disease. Pediculosis, lousiness. Pepsin, a ferment found in the gastric juice, capable of digesting proteins by changing them into peptones. Pericarditis, inflammation of the pericardium, the sac which con- tains the heart. Perineum, the space between the anus and the genital organs. Peripheral, pertaining to or situated at or near the periphery, the outside. Peristalsis, the worm like movement by which the alimentary canal propels its contents. Peritoneum, the membrane which lines the abdominal walls. Phagocyte, any cell that destroys micro-organisms or harmful cells. Phenol, carbolic acid. Photophobia, intolerance of light. Phthisis, pulmonary consumption. Pigment, any normal or abnormal coloring matter of the body. Placenta, the afterbirth. Plasma, the fluid portion of the blood and lymph. 290 PRINCIPLES OF HOME NURSING Pledget, a small compress of cotton, lint, or wool. Portal vein, vein leading from the gastro-intestinal tract to the liver. Postpartum, occurring after childbirth. Pregnancy, the condition of being with child; gestation. Premature, an infant born before its proper time, but viable. Pre-natal, before birth. Prognosis, a forecast as to the probable result of an attack of disease. Prodrome, a symptom indicating the onset of a disease. Prophylaxis, the prevention of disease; preventive treatment. Protoplasm, a viscid, granular material which forms the essential constituent of the living cell. Protozoa, a class of unicellular animal organisms, forming the lowest division of the animal kingdom. Pseudopodium, foot-like protrusion. Ptyalin, an unorganized ferment occurring in the saliva. Puerpera, a woman in childbed. Purgative, a cathartic medicine. Purulent, consisting of or containing pus. Pylorus, the duodenal aperture of the stomach. Pyogenic, producing pus. Quarantine, to detain or isolate on account of suspected contagion. Quickening, the first recognizable movements of the fetus in utero. Rabies, incorrectly called hydrophobia. Reaction, opposite action, or counteraction. Rectum, the lower part of the large intestine. Regurgitation, the casting up of undigested food. Retention, the persistent keeping within the body of matters normally excreted. Sac, a bag like organ. Saprophyte, any vegetable organism living upon dead or decaying organic matter. Sepsis, putrefaction. Serum, the clear portion of any animal liquid separated from its more solid elements, as the serum of the blood. Shock, sudden vital depression. Sordes, the dark brown, foul matter which collects on the lips and teeth in low fevers. Spasm, a sudden, involuntary, rigid muscular contraction. Sphincter, a ring like muscle which closes a natural orifice. Splint, a rigid appliance for the fixation of displaced or movable parts. Stegomyia, a mosquito that transmits yellow fever to man. GLOSSARY 291 Sterilization, the act or process of rendering free from all germs. Stertorous, characterized by sonorous breathing. Styptic, astringent. Subcutaneous, situated or occurring beneath the skin. Subjective, perceived only by the affected individual. Subsultus, a twisting movement of the muscles and tendons in typhoid. Sudorific, promoting the flow of sweat. Symptom, any evidence of disease or of the patient's condition. Syncope, fainting. Temperature, the degree of sensible heat or cold. Tenesmus, straining at stool or in urination. Tetanus, lockjaw. Therapeutics, the science and art of healing. Tissue, an aggregation of cells, fibers, and various cell products forming a structural element. Tracheotomy, the formation of an artificial opening into the trachea, often performed in diphtheria. Trauma, a wound or injury. Tremor, involuntary trembling or quivering. Trypsin, the proteolytic ferment of the pancreatic secretion. Tympanic, of or pertaining to the eardrum. Tympanites, distention of the abdomen due to gas or air in the intestine or peritoneal cavity. Ulcer, an open sore other than a wound. Umbilicus, the navel. Ureter, the tube which conveys the urine from the kidney to the bladder. Urethra, the canal which conveys urine from the bladder to the surface. Urinalysis, the chemic analysis of urine. Uterus, the womb. Vascular, pertaining to or supplied with vessels. Vaccination, the act or process of inoculating with a virus. Vacuole, any space or cavity formed in the protoplasm of a cell. Varicose veins, unnaturally swollen vein. Vehicle, any medium through which a disease is propagated. Venous, pertaining to the veins. Vertigo, dizziness. Vesicant, causing blisters. Vesicular, pertaining to or made up of vesicles on the skin. Villus, a minute, club shaped projection from the mucous mem- brane of the intestine. Virulent, exceedingly noxious. 292 PRINCIPLES OF HOMS! NURSING Virus, any animal poison produced by and capable of transmitting a disease. Viscera, the large interior organs of the four great cavities of the body. Viscid, clammy or sticky. Vomiting, the forcible expulsion of the contents of the stomach through the mouth. Vitiated, devitalized. Vulva, external female generative organs. Xerophthalmia, conjunctivitis with dry and lusterless condition of the eyeball. Zygote, the fertilized ovum of a week or less. INDEX Abbreviations, 116 Abdominal binder, 191, 194 Abortion, 192 Absorbent cotton, 35 Absorption of foods, 133-137 of water, 131, 132, 133 Accidents and first-aid, 139-159 Acid, boric, 242 carbolic, 240 Actual cautery, 109 Adenoids, 34, 103, 167 Adhesive plaster, 35 Afterbirth, 180, 194 After-pains, 195 Aged persons, nursing care, 19, 268 Air, bacteria in, 54 impurities in, 51, 234 ventilation, 52, 53 vitiated, effects of, 52 Alcohol and alum for back rubs, 60, 72 as a disinfectant, 242 Alcoholism, 142 Alimentary canal, 127 Amniotic fluid, 180, 181 Amylopsin, 130 Anemia, 84, 177 Anesthesia, 246 Animals, warm and cold blooded, 87 Anopheles, transmission of malaria by, 225 Anthrax, 234 Antibody, 254 Antidote to carbolic, 240 Antipyretic, 89 Antiseptics, 242 Antitoxin, 254 in diphtheria, 265 Ants, destruction of, 240 Apoplexy, 96, 142 Apothecaries' fluid measure, 116 signs, 115 Applicators, 35, 36, 56, 106, 243 Argyrol and protargyrol, 242 Arnold sterilizer, 219 Aromatic spirits of ammonia, 141 Arteriosclerosis, 94, 143 Artificial control of hemorrhage, 153 food, preparation of, 216 respiration, 141, 145, 146, 147 ventilation, 52 Asepsis, 149 Asexual reproduction, 224, 226 Asphyxia, 144-147, 158 in shock after operation, 247 Asthma, dyspnea in, 96 Astringent enemata, 101 Aura in epilepsy, 141 Auscultation, 82, 83 Autoclave, 236, 237 Axillary temperature, 91 Baby, ailments of, 210 bath, 201, 203 care of, 199-223 cry, 208 293 294 INDEX Baby, exercise, 208 feeding, 201, 210 growth, 207 habits, 209 outdoor life, 206 premature, 199, 200 sleep, 207 special sense organs, care of, 204 teething, 209 weaning, 209 weight, 207, 208 Bacillus, Klebs-Loffler, 263 spore of, 229 tubercle, 228, 270 typhoid, 232, 271 Back, care of, 58, 60 rest, 31, 66 Bacteria, 53, 54, 227 classification of, 227, 228, 231 conditions that favor growth, 223, 230 food of, 230, 231 fission of, 230 in air, 234 in dust, 54 in milk, 234 in mouth, nose, secretions, excreta, 231 in water, 232 methods of destroying, 235 motility, 228 pathogenic and non-patho- genic, 227, 231, 232, 249 portals of entry into body, 249 protection against, 250 pyogenic, 231 reproduction of, 224, 230 shape of, 227 size of, 227 smear, culture, staining, 228 transmission of, 253 Bacteria, where found, 223 Bacterial count in milk, 213, 224 Bacteriology, 223-232 Bandages, 160 ankle, 166 elbow, 166 figure-eight, 165 finger, 165 forearm, 165 four-tailed, 162 handkerchief sling, and head, 161 materials used for, 160 plaster of Paris, 161 purposes, 160 recurrent, 165 removing, 164 reverse spiral, 165 roll, how to, 163 roller, 164 rubber, 35, 161 spica of the thumb, 166 spiral, 163 T-, perineal, 72, 161, 162 widths used, 164 Bandaging, rules for, 160-167 Barley water as infant food, 220 Bath, oil, for premature baby, 201 Baths, baby, 201, 203 cleansing, 67, 71 cold, 72, 73 continuous, 79 foot, 74 for convulsions, 75 hot, 74, 75 air and vapor, 78 and cold, physiological effects of, 68, 69, 70, 251, 252 wet packs, 75 INDEX 295 Baths, methods of giving, 71 salt rubs, 72 sedative, 69 Sitz, 74 sponge baths, 71 Bed, 21, 39 Bedmaking, 39-49 bedspread, 39 stripping the bed, 39 with patient in bed, 47 Bedpan, care of, 29 how to give and remove, 61 rubber, 30 Bedside commode, 37, 38 reports, charts, 80, 81 Bedsores, pressure sores, 60 treatment, 61 Beri-beri, 126 Bibliography, 279 Bichloride of mercury, 239 Bile, 131 Binder, abdominal, 191 chest, 161, 163, 197 perineal, 163 Birth, preparations for, 191 Blisters, 109, 155 Blood phagocytes, 250 pressure, 93, 94 Boiling in disinfection and sterilization, 236 Boils, 251 course of, 251 Bolus, 129 Boracic acid, boric acid, 242 Bottle-fed baby, 212-223 Bottles, care of, 218, 220 nursing, 216 Bowels, constipated, 88,101,188 movements of bottle-fed baby, 220 Bread and milk poultice, 104 Breasts, 190, 197 Breath, odor as symptom, 84 Bright's disease, 75 Broths, animal, 119 Budding of yeast cells, 225 Burns and scalds, 154 Calories, 122 in diet, 118, 119, 122, 123 Can, irrigating, 22, 23 Cantharides, fly blister, 109 Carbohydrates, 125 Carbolic acid, 240 burns, 156, 240 Carbon dioxide, 51, 95 Carriers of disease, 253 Carron oil in burns, 155 Carrying, lifting, and moving patients, 66 Castor oil, 110, 112, 148 Casts, 161 Catheter, 25 Catheterization, 86, 196 Catnip tea enemata, 101 Caustics, 109 Cauterization, 109 Certified milk, 213 Chancre, 183, 184 Chancroid, 183 Change of life, 175 Chapin dipper, 218 Chapped hands, 19 Charting, 80, 81, 82 Chemical burns, 156 disinfectants, 238-242 Chewing gum for thirst, 56 Cheyne-Stokes' respiration, 96, 143 Chicken-pox, varicella, 263 Childbed fever, 196 Childbirth, 192 Child's dose, calculated from adult dose, 115 296 INDEX Chills, rigors, 85 Chloride of lime, 241 Chlorophyll, 51, 225, 236 Cholera, Asiatic, 232, 254 Chyle, 137 Chyme, 129 Classifications of foods, 124 Cleanliness of sick room, 53 Clove hitch, modified, 64 Coffee enemata, 101 Cold applications, 107, 108 baths, 72 enemata, 102 for hemorrhage, 153, 154 physiological effect of, 68, 69, 70, 251, 252 wet packs, 73 Colds, coryza, 267 Colic, 211 Colles' fracture, 150 Collodion, new skin, 61 Colon, 97, 132 Colostrum, 196 Comb, how to hold, 57 Commode, 37, 38 Communicable diseases, 252 Complications, due to unclean mouth, 55 in burns and scalds, 156, 265 in measles, 260 in pregnancy, 195 in whooping cough, 274 Compress, 107, 108 Conception, time of, 181 Condensed milk, 213 Conduction, convection, and radiation, 88 Confinement, 192 Congenital syphilis, 185 Constipation, 88, 101, 188 Contagion vs. infection, 252 Continuous bath, 78, 155 Contraceptics, venereal diseases as, 183 Contusion, 149 Convulsions, baths for, 75 in epilepsy, 141 Cord, navel, 194 Corrosive sublimate, 239' Coryza, 267 Cough, 85 Counterirritants, 103 Cow's milk, 212, 213 Cradles, bed, 32 Creolin, 240 Crinolin bandage, 161 Crisis in fever, 90, 269 Croup tent, 111 Cry, baby's, 208 significance of, 84 Cultures, throat, 243, 265 Cups, drinking, 32, 33 sputum, 34 Cycles in menstruation, 177 Danger zone in atmospheric temperature, 89 Delirium as symptom, 84 restraint in, 63 Deodorants, 62, 239 Dermis, 67 Destruction of bacteria, 235- 242, 257, 258 Diarrhea, diet in, 101 enema for, 101 Diastole and systole, 91, 94 Dicrotic pulse, 93 Diets in diarrhea, 101 in fever, 119 in pregnancy, 187 in typhoid, 273 of nursing mother, 198 Digestion, 85, 129, 130 Diphtheria, 256, 263, 266 INDEX 297 Diphtheria, antitoxin in, 254, 265 complications in, 265 Schick test for, 264 Disarticulation of dislocation, 151 Disease "carriers," 252 communicable, 249-276 origin of, 249 portals of entry of, 249 predisposing causes, 252, 253. prevention and restrictions, prodromal symptoms of, 258 254 resistance to, 250 stages in infection, 253 transmission of, 253 Disinfectants, chemical, 238 physical, 236 Dislocations, 151 of finger, 151 of jaw, 151 Doctor's orders, 80 Dog bites, 159 Dorsal recumbent position, 99 Douche pan, 30 Douches, 102, 158 Draw sheet, 44, 48 Dressings, making of, 169 Dried milk, 214 Drinking cups, glasses, tubes, 32, 122 Drops in eye, 112 Dropsy as symptom, 85 Drowning, artificial respiration, 145, 146, 147 Drugs in common use, 117 Dusting and cleaning, 20, 54 Dysmenorrhea, 176 Dyspnea, 96, 186 Ear, care of, in infancy, 205 douche, 103 foreign body in, 158 Earache, 103 Eclampsia, 85, 186 Embryo, 180 Emergencies and first aid, 139- 159 Endemic diseases, 253 Enemata, 97-102 astringent, 101 coffee, 101 cold, 101 nutritive, 102 oil, 100 position of patient, 98, 99 procedure, 99 saline, 100 sedative, 101 starch, 101 Enteric typhoid fever, 271 Enzymes, 128, 230 Epidemics, 235, 252 Epidermis, 67 Epilepsy, 141, 142 Epistaxis, 154 Epsom salts, 135 Equipment for the modification of milk, 216 Erepsin, 131 Ergot in postpartum hemor- rhage, 195 Esophagus, 127 Eustachian tube, 103 Evaporated milk, 214 Exanthemata, eruptive fevers, 85, 184, 258, 259 stages of development, 253 Excreta, 85, 131, 256 Exercise for baby, 203 for dysmenorrhea, 177 Exhaustion, heat, 69, 144 298 INDEX Expectoration, 84, 270 Expression, 84 Extravasation, 152 Eyes, care of, in infant, 204 everting lid of, 157 flushing of, 112 fomentations and compresses, 106, 107 foreign body in, 157 observance of symptoms of, 84 opthalmia neonatorum, 108, 184, 193, 242 Fainting, syncope, 140 Fallopian tubes, 174, 175, 178, 184 Fat soluble vitamin, 126 Fats, 125 Favus, 276 Feces, 85 Fecundation, 179 Feeding, artificial, 216 cups, glasses, and tubes, 32, 33 infant, 197, 201, 210 of helpless patients, 122 ■of premature baby, 201, 202 rectal, 102 the sick, 118-137 Feet and hands of patient, 56, 71 Female reproductive organs, 174 Fermentation, 225 Ferments, 128, 230 Fertilization, 178, 179 Fetal heart beat, 182 Fetus, 180 Fever, 51, 55, 89 baths for, 67, 72, 73, 89 Fever, crisis and lysis, 90 diet in, 119, 123 in tuberculosis, 270 symptoms of, 258 Figure-eight bandage, 165 Filters, 233 Fimbria, 175 Fire, 155 First things to do in emergency, 139 Flagella, 228 Flannel bandage, 161 Flatulence, 85 Flaxseed poultice, 105 Flies, 54, 255 Flowers in sickroom, 19, 51 Fly blister, 109 Fomentations, 106, 107 Fomites, 253 Foods, absorption, 133, 134 caloric value of, 122 classification of, 124 digestion of, 129, 130 functions of, 122 iron content of, 125 vitamins in, 125 Foot, bath, 74 sling, 31, 66 Foreign bodies in eye, ear, nose, throat, 157-159 Formaldehyde, 241, 257 Formalin, 241 Four-tailed bandage, 161, 162 Fractional doses, 115 Fractures, 149, 151 Freezing, 156 Friction in artificial respiration, 146 in cold bath, 68, 69 Frostbites and freezing, 156 Fumigation, 256, 257, 258 Fungi, 223, 225 299 INDEX Funnel and tubing as substitute for syringe, 23 Fur on tongue, 55 Furuncle, boil, 251 Gall-stones, 131 Gangrene in bedsores, 60 in freezing, 156 Gargle, 267 Gastric juices, 130 Gauze bandage, 160, 163 sponge, 170 wipe, 170 Genitalia, care of, after labor, 194 in infancy, 205 Germicides, 236, 238 Germinal spot, 174 Glossary, 281 Glycogen, 135 Glycosuria, 136 Goat's milk, 212 Gonorrhea, 183, 193 Good nursing, 17, 18, 19 Gown, changing of, 59 Graduates, 33, 217 Granny knot, 167 Granulations, 149 Greenstick fracture, 150 Growth of baby, 207 Gums, teeth, tongue, 84 Habits, baby, 197, 209, 210 Hair, care of, 57 in restraint, 63 vermin in, 57, 58 washing, 58 Handkerchief as vehicle for germs, 268 Hands, care of, 19, 56, 57, 213, 247 Healing of wounds, 149 Health officer's duties, 255 Heart failure, 270 Heartburn, 186 Heat as counterirritant, 104 effects on body, 68, 69, 70 exhaustion, 144 sterilization, 236, 237 unit, calorie, 122 Hemiplegia, 143 Hemophilia, 154 Hemorrhage, 152 in typhoid, 272 postpartum, 154, 195 Hemorrhoids, 186 Hepatic vein, 135 Hiccough, hiccup, 211 to check, 102 Host, 225 Hot air baths, 78 Hot-water bottles, 25 precautions in filling, 26, 247 How to lift a baby, 202 Hydrophobia, 159 Hypodermic injections, 111 syringe, 37 Hysteria, 142 Ice-cap, how to fill and care for, 27 Ice-coils, 28 Immunity, 250, 254, 264 Immunization, 254 Impacted fracture, 150 Impregnation, 179 Incapsulation of bacteria, 228 Incision, 149 Incubator, baby, home-made, 200 Indigestion, 133 Infant, 180 mortality, 182 Infection, 231, 251, 252 300 INDEX Inflammation, 74, 251 Influenza, 268 Inhalations, 111 Inoculation, 225, 253 Insects as vehicles for bacteria, 54, 253 Insomnia, 70, 79 Intermittent pulse, 92 Intestinal canal, 97, 127 juices, 131 Intoxication, 231 Intravenous injection, 112 Inunctions, 111 Involution of uterus, 195 lodin, as counterirritant, 106 as disinfectant, 242, 247 brushes, 35 Ipecac, 117, 148 Isolation, 255, 268 Itch, scabies, 275 Ivy poisoning, 148 Japanese stoves, 25 Jaundice, 131, 211 Kidney basin, 31 Kidneys, inflammation of, 143 Knee-chest position, 98 Knots, clove-hitch, modified, 64 granny, 167 square, surgeons, 167 Koplik's spots in measles, 259 Kumiss, 225 Labor, complications in, 195 nursing care, 192-196 preparations for, 191 stages of, 192 Laceration, 148, 195 Lactation, 197 Laxatives, 97, 188 Layette, 191 Leucorrhea, 102 Lice, head, 57 "Life," 181 Lifting a baby, 202 patients, 48, 66, Light diet, 120, 121 Lime, 241 in acidity of mouth, 187 water in infant feeding, 219 Liniments, 106 Linseed poultice, 105 Lipase, 131 Liquid diet, 119 Liver, 135 Location of bed, 21 of sickroom, 20 Lochia, 194 Locomotor ataxia, 185 Lying-in period, 194 Lymphatic, 134 Lysis, 90, 266, 271 Lysol, 240 Making dressings, 169 Malaria, 225 Male reproductive organs, 177 Massage for congestion in boil, 252 of back, 60, 71 scalp, 58 Mastoiditis, 28 Maternal impressions, 180 Mattress, 39 protection of, 39 turning under a patient, 49 Measles, black, 260 complications, 260 German, rubella, 260 rubeola, 259 Mechanics of respiration, 95 Meconium, 196 Medical emergencies, 140-148 INDEX 301 Medication, 110 Medicine chest, 113 dropper, 33 Medicines, 110 absorption of, 110, 111 precautions in giving, 113, 114, 115 Membranous croup, diphtheria, 263 Menopause, 175 Menstruation, 175 hygiene, 176, 177 Metabolism, 137 Microorganisms, 223 Microscope, 228 Micturition, 86, 188, 196 Milk, bacterial count of, 234 certified, pasteurized, con- densed, 213 cow's, goat's, human, 212, 215 dried, powdered, 214 modified, 213, 219 of lime, 241 powder, 214 proprietary, 215 specimen of, 244 Mineral salts in foods, 125 Minim glasses, 33 Miscarriage, 185, 192 Miters in bed-making, 42 Modification of milk, 213, 219 Molds, 226, ringworm, 227, 275, 276 Morning sickness, 181, 187 Mosquitoes, 225 Mother's milk, 215 Mouth, breathing, 84, 267 care of, 55, 205 in typhoid, 272 washes, 56 Moving patients, 66 Mumps, 274 Municipal water plants, 233 Muslin bandage, 160, 163 Mustard as counterirritant, 104 foot bath, 74 leaf, 105 poultice, 105 Nails, care of, 56, 57 Narcotics, 59 Nausia and vomiting, 52, 181, 187 Navel cord, 194, 204 Neosalvarsan, 112 Nephritis, 75, 143 in diphtheria, 265 in scarlet fever, 261 New skin, collodion, 61 Newborn babe, 180 Newspaper pads, 28, 191 Night air, 234 sweats, 270 Nipples, 190, 197 Normal salt solution, 100, 243 Nose, foreign body in, 158 Nose-bleed, epistaxis, 154 Nurse, dress, 19 hands, 19 in quarantine, 255 rest and recreation, 19 shoes, 19 Nursery, 206 Nursing babe, 197 bottles, 216 care of, 218, 220 points on, 17-19 Nutrition, 126-137 Nutritive enemata, 102, 136 processes in outline form, 136, 137 Oatmeal water, 220 Objective symptoms, 83 302 INDEX Odors, 18, 51, 52, 239 Oil bath for baby, 203 carron for burns, 155 castor, 112, 148 enema, 100 Ointments, 111 Operations in home, 245, 246, 247 Ophthalmia neonatorum, 108, 184, 193, 242 Oral cavity, 84, 127 hygiene, 55, 56, 187, 205 Orange juice in infant feeding, 214 Osmosis, 134, 137, 180 Otitis media, 55 in mumps, 275 in scarlet fever, 261 in typhoid fever, 272 Ova, 174 Ovaries, 174, 184 Ovulation, 174 Oxygen, 95 cycle, 51 Packs, cold, 73 hot, 75 Pads, newspaper, 28, 191 vulva, 171 Pain as subjective symptom, 83 Pancreatic juice, 130 Pandemic, 253 Paraffin for burns, 155 Paralysis, 185 in diphtheria, 265 Parasites, 231 Parotitis, mumps, 274 due to neglected oral hygiene, 55, 272 Parturition, 192 Pasteur, 249 treatment in rabies, 159 Pasteurized milk, 213, 219 Pathogenic bacteria 227, 231, 232, 249 Pediculi, lice, in hair, 57 Perforation in typhoid fever, 272 Perineal binder, 72, 161 Perineum, laceration of, 195 Peristalsis, 129, 133 Permanganate of potash and formalin in fumigation, 257 Peroxide of hydrogen, 243 Personal attentions, 50 Perspiratory glands, 67 Pertussis, 273 Phagocytes, 250 Phenol, carbolic acid, 240 Phthisis, 270 Physical agents in destruction of bacteria, 236 signs and symptoms, 83 Physiological effect of drugs, 116 of heat and cold, 68, 69, 70 Pillow case, 45, 46 Piston syringe, 23, 100, 103 Pitting in dropsy, 85 Placenta, 180, 181, 194 Plaster of Paris bandage, 161 Plasters, 106 Pneumonia, 268 Poisoning, 147 ptomain and ivy, 148 Portal circulation, 135 vein, 135 Portals of entrance for disease, 249 Position as symptom, 85 Postoperative care of patients, 247 Postpartum care, 195, 198 hemorrhage, 154, 195 Pott's fracture, 150 INDEX 303 Poultices, 104 Precautions in handling and giving of medicines, 113, 114, 115 Pregnancy, 179-191 breasts, 190 care in, 185 changes due to, 185 clothing, 189 constipation, 188 diet, 187 excreta, 188 exercise, 190 mental condition, 190 nausea and vomiting, 187 senna and prunes, 188. signs of, 181 skin, 189 urine, 188 Premature babe, 199 labor, 192 Prenatal care, 182, 185 Preparations for fumigation, 256 for labor, 192 for night, 58 for operation in home, 246, 247 Pressure for hemorrhage, 153, 154 sores, 60 Procreation, 173 Prodromal symptoms, 80, 153, 154, 258 Propping a patient in bed, 65 Proprietary milk foods, 215 Protective forces of body, 250 Proteins, 124 Protoplasm, 137, 223, 231 Protozoa, 223, 224, 233 pathogenic, 224, 225, 232 Proud flesh, 109, 149 Prune juice sputum, 84, 269 Prunes and senna in pregnancy, 188 Ptomain poisoning, 148 Ptyalin, 128 Puberty, 173 Publications on social hygiene, 182 Puerperal fever, 196 Pulse, 91 diastole and systole, 91 dicrotic, intermittent, 93 how to count, 92 nature, 92 where felt, 92 Punctured wound, 149 Pus, 231 Puspans, 31 Putrefactive bacteria, 231, 233 Pyogenic bacteria, 23 Quarantine, 255 Quickening, 181 Rabies, 159 Radial artery, 92 Radiation of temperature, 88 Rectal feeding, 102, 136 temperature, 91 tube, 24 Recreation and rest of nurse, 19 Rectum, 98 Regurgitation, 211 Relapses in typhoid fever, 55 Removing a bandage, 164 Repair of fracture, 150 Reproduction, 173, 224 Reproductive organs, 173-174 female, 174 male, 177 Resetting thermometer, 36 Resistance to disease, 250 Resolution in pneumonia, 269 304 INDEX Respiration, artificial, 141, 145, 146, 147 Cheynes-Stokes, 96, 143 counting, 96 dyspnea and apnea, 96 internal and external, 95 mechanics of, 95, 143 sterterous, 96, 141, 143 variations, 96 Restraint of children, 62 of patients, 62 Retention of urine, 86, 188, 196 Reverse spiral bandage, 165 Rhinitis, cold in head, 267 Rice water in infant feeding, 220 Rigors, chills, 85 Ringworm, tinea, 227, 275, 276 Roller bandage, 161 Rubber bedpan, care of, 30 diaper, 29 gloves, 247 ring, 28, 60 sheets, 28 Rubefacients, 104 Rubella, 260 Rubeola, 259 Russian bath, 78 Saline cathartics, 135 Saliva, ptyalin in, 128 Salt enemata, 100 rubs and salt water baths, 78 Salts, 125, 135 epsom, 110 Saprophytes, 231, 233 Scabies, itch, 275 Scalds and burns, 154 Scarlet fever, complications in, 261 nursing care in, 261 scarlatina, 260 strawberry tongue in, 261 Schaefer method of artificial respiration, 146, 147 Schick test for diphtheria, 264 Scurvy, water soluble C vita- min in, 126 Sebaceous glands, 67 Sedative bath, 69 enemata, 101 Seidlitz powders, 112 Semisolid or soft diet, 120 Senna and prunes in pregnancy, 188 Sepsis, 149 Septicemia, 196 Serums, 254 Serving table, 37, 38 Sexual reproduction, 224, 227 Shivering, 68, 89 Shock, 94, 100, 101, 152, 155 Shoes, 19, 189 Sick, groups of, 19 Sickroom, choice and location of, 20 Sigmoid flexure, 132 Signs used in administration of medicines, 115 Silver nitrate, 242 as prophylaxis, 242 Simple enema, 100 fracture, 149 Sims' position, 99 Sitz bath, 74 Skin, 67, 84, 189, 251 diseases, 275 new, 61 Sleep, 59, 85 of baby, 207 Sleeping sickness, 225 Sling, foot, 161 Slops, 52 Smallpox, variola, 262 vaccination, 254 305 INDEX Smear, 228 Soap as disinfectant, 242 Soapsuds enema, 100 Social hygiene publications, 182 Sordes, 55 Spanish influenza, 268 Special sense organs, care of, 204 Specimens, collection of, 244 milk, 244 sputum, 245 urine, 245 water, 244 Spermatozoa, 177, 178 Sphygmograph, 93 Sphygmomanometer, 93, 94 Spica of thumb, 167 Spiral bandage, 165 reverse, 165 Spirilla, 228, 229 Splint in fracture, 150 Sponge bath, 71 Sponges for dressing, 170 Sporadic diseases, 253 Spore formation, 229, 230 Sporulation, 226, 230 Spots, Koplik, 259 Sprains, 151 Sputum cups, 34, 270 "prune juice," 84, 269 purulent, 84 specimen of, 245 Square knot, 167 Starch enemata, 101 poultice, 105 Steapsin, lipase, 131 Stegomya, transmission of yel- low fever, 225 Sterility due to venereal diseases, 183 Sterilization, 235-242 by steam, 237 in home, 237 Sterilized milk, 213 Sterterous respiration, 96, 141, 143 Stomach, 129 absorption in, 133 capacity of baby's, 210 digestion in, 129 peristalsis, 129 pump, 24 Strawberry tongue, 261 Stroke, 142 Stupe wringer, 34, 106 Stupes, 106 Stye, 252 Sudden changes in patient, 59 Suffocation, 144 Sugar content of blood, 136 Suggestions on serving meals, 120 Sulphur, 242, 257, 258 Sunburn, 156 Sunstroke, 144 Supplies and dressings for labor, 191 Suppositories, 110 soap, 210 Suppression of urine, 86 Suppuration, 231 Surgeon's knot, 167, 168 Surgery in home, 245 Surgical emergency, 148-159 burns and scalds, 154, 155, 156 dislocations, 151 dog bites, 159 foreign bodies in eye, ear, nose, throat, 156, 157, 158 fractures, 149, 150 frostbites and freezing, 156 hemorrhage, 152, 153, 154 shock, 152 306 INDEX Surgical emergency, sprains, 151 wounds, 148, 149 Swab, 36, 55, 243 Sweat baths, hot and cold packs, 72, 73, 74 glands, 67 Turkish and Russian baths, 78 Sweeping, bacteria after, 54 before meals, 55 Sweet oil vs. olive oil, 100 Sylvester method of artificial respiration, 145 Symptoms, detection of, 80, 210 objective and subjective, 83 prodromal, 258 Syncope, 140, 153 Syphilis, 143, 184 Syringes, 22, 23, 24 Davidson, 23, 101 hard rubber, 23, 101 Systole and diastole, 91 Tangles in hair, 57 T-bandage, 72, 161, 163 Tea for gargle in tonsillitis, 266 Teaching home nursing, 17 Teeth, prenatal care of, 187 Teething, 209 Temperature after chills, 85, 87 atmospheric, 88 constancy of, 88 how to take, 90, 91 of baths, 71 range, 89 room, 53 variations in, 88 Tetanus, 149 Thermal phenomenon, 87 Thermometer, bath, 37 clinical, 36, 90 Thermometer, resetting, 90 Third degree burn, 155 Thoracic duct, 135 Throat compress, 108 culture, 243 Thrush, 211 Toast, 51 Tongue depressors, 35, 243 fur on, 55 Tonsillitis, 266 Tonsils, 265 chronic, 267 Tooth brush, 55 Tourniquet, 153 Toxins, 231 in diphtheria, 263 Transmission- of disease, 253 Trauma. See Wounds. Tray in serving meals, 122 Triangular bandage, 161, 162 Trypsin, 131 Tsetse fly as carrier of sleeping sickness, 225 Tub bath, baby's, 204 Tuberculosis, 228, 270 and amenorrhea, 177 Turkish bath, 78 Turning mattress under pa- tient, 49 patient in bed, 47 Turpentine enema, 100 stupes, 107 Twins, 179 Tympanites, 24, 85 Typhoid fever, 54, 61, 271 complications, 272 Typhus fever, 271 Ulceration in typhoid, 272 Unconsciousness, 140 Urinals, 30 Urinalysis in pregnancy, 188 307 INDEX Urinalysis in scarlet fever, 261 Urine after labor, 196 in pregnancy, 188 retention, suppression, incon- tinence, 86 specimen, 245 Uterus, 174 involution, 195 Vaccination, 254 in chronic colds, 268 Vaginal douches, 102 Varicella, chicken-pox, 263 Varicose veins, 35, 93, 161, 186 Variola, 262 Varioloid, 262 Vehicles for carrying disease, 253 Venereal diseases, 183 Ventilation, artificial, 52 constancy of atmosphere, 51 definition, 50 methods of, 51 natural, 52 Vermin in hair, 26 Vesicant, 108 Villi, 134 Vinegar jug, 26 Vitamins, A, B, C, 125 Voice, as symptom, 83 Vomiting, to check, 102 Vomitus, 84 Vulva pads, 171, 194 Water, 232 municipal, 233 on camping trips, 241 self purification of, 233 specimens of, 244 sterilization of, 233, 234 Water-borne diseases, 223 Water-proofing materials, 29 Weaning baby, 197, 209 Weight of baby, 198, 207, 208 Whispering in sickroom, 18 Wipes for surgical dressings, 170 Whooping-cough, pertussis, 273 complications, 274 Womb, 174 Wounds, 148, 149 X-ray in fracture, 150 Yeasts, 225 Yellow fever, 225 Zygote, 179, 180 The editions you find here may not be the latest. Write us about the books which interest you. Saunders' Nursing Service Books FRIEDENWALD AND RUHRAH'S DIETETICS Fourth Edition, Published August, 1917 The strong feature about this book is the practical information it gives you on the dietetic management of your cases. You get, for instance, exact directions for feeding infants and children in health and in the various infantile diseases; you get the special diets for pregnancy and the puerperium, rectal feeding, feeding through the stomach-tube, diets for the various infections, stomach and intestinal diseases, liver, respiratory, circulatory, genito-urinary, and nervous diseases; diets in diabetes, gout, arthritis deformans, scurvy, obesity, and skin diseases. You get. the milk cure, the dietetic manage- ment of surgical cases, anesthesia and diet, etc.-prac- tical through and through By Julius Friedenwald, M. D. Cloth, $2.25 net. £ £ AMERICAN POCKET DICTIONARY Twelfth Edition, Published July, 1922 Many thousands American Pocket Medical Dictionaries are now in use. It is the standard and is used in all the important training-schools. Because of this large sale the "American Pocket" is frequently revised, so that you always get the new words-hundreds of new words not defined in any other dictionary. It makes a specialty of the terms you-the nurse-want to know, and its definitions are clear. In addition to the complete vocabulary, you get tables of muscles, nerves, arteries, veins, bandages, baths, bacteria, diets, dressings, ene- mata, ointments, positions, pulses, rales, reflexes, su- tures, etc., in all, 75 tables of valuable information. Edited by W. A. Newman Dorland, M. D. Flexible binding, $2.00 net; indexed, $2.50 net. 2 2 Saunders' Nursing HARDING'S HIGHER ASPECT OF NURSING Published April, 1919 Miss Harding's book is a study of character building founded on personal experience. The nurse will find it a decided help both in training-school and in private practice. She points out the disastrous consequences of laxity in following these ideals-yet her book is not a sermon. She describes the difficult problems that you daily have to solve, and tells you how to meet and overcome them. She tells you just the things you want and need to know-the things that make for efficiency. By Gertrude Harding. Cloth, $2.00 net. a % GOODNOW'S FIRST-YEAR NURSING Second Edition, Published February, 1916 Miss Goodnow's work deals entirely with the practical side of first-year nursing work-the application of text- book knowledge. It tells you how to do those things you are called upon to do in your first year in the training-school-the actual ward work. Indeed, the book may truly be called the Practice of first-year nursing. There are chapters on fumigation, ventilation, bed- making, serving meals, preparation and application of various baths and packs, surgical nursing, bandaging, gynecologic and obstetric nursing, nursing in eye, etc. By Minnie Goodnow, R. N. Cloth, $2.25 net. BECK'S REFERENCE HANDBOOK Fouith Edition, Published April, 1919 Beck's book has been aptly called "the nurse's ency- clopedia.'' In it you get information on every question that comes to you in your daily work. It gives you such information as action, use, and dosage of drugs, poisons and their antidotes, special mixtures, solutions, oint- ments, enemata, poultices, etc.; tests for albumin, in- fant feeding, nursing in the acute fevers, disinfection, emergency helps, baths and packs, massage, electricity, recipes, obstetrics, nursing in children's diseases, etc. By Amanda K. Beck. Cloth, $1.50 net. Service Books 3 MCCOMBS' DISEASES OF CHILDREN Fourth Edition, Published May, 1921 Dr. McCombs emphasizes just those points you most want to know. He gives you a short but adequate description of each disease, considerable attention to prophylaxis, methods of nursing, emergency measures, illustrated descriptions of how to take the temperature, pulse, respiration, perform intubation, give hypoder- mics, etc. You get also special chapters on infant feed- ing, modification of milk, and therapeutic measures em- ployed in childhood, always laying special stress on the nurse's duties. "We have needed a good book and this admirably fills the want."--National Hospital Record. By Robert S. McCombs, M. D. Cloth, $3.00 net. SMITH'S OPERATING ROOM Published October, 1916 Here you have a book for nurses written by a nurse, whose years of experience have taught her how to solve just such problems as those which face you daily. There are many chapters of unique value, such as those on formulae and directions, lists of instruments for cer- tain operations, with accessory articles, and details of actual operating-room nursing care, linen of the operat- ing room, improvised operating room in a humble home, and chapters covering the progress of the nurse from pupil to head nurse. By Amy Armour Smith, R. N. Cloth, $1.75 net. AIKENS' TRAINING-SCHOOL METHODS Second Edition, Published April, 1919 Miss Aikens solves for you those many problems that constantly arise in the management of a training-school. There are chapters on the probation period, courses of study and training, principles and methods of teaching, teaching materia medica, the choice of books, training in conservation, bedside teaching, ward housekeeping and general management, the chief surgical nurse, and the night supervisor. "There is not a chapter that does not contain valuable suggestions.''-Trained Nurse. By Charlotte A. Aikens. Cloth, $2.25 net. 3 4 4 Nursing Service Books PORTER'S PSYCHOLOGY FOR NURSES Published September, 1921 Years of experience in schools and colleges, in a neuro- logic hospital and a large city general hospital convinced Miss Porter that it is of little avail to cure the body and let remain with the patient a "sick attitude." To teach nurses how to prevent this attitude, or avert it, is the aim of this book. Every well-trained nurse should consider it an essential to her professional success to leave her patient imbued with the will to health and better equipped to attain it because the sick attitude is not present. The simple principles of psychology as here presented will enable the nurse to treat the sick mind as well as the sick body. By Mary F. Porter. Cloth, $1.50 net. % % COWAN'S BANDAGING Published December, 1920 The aim of this book is to give the student nurse the fundamentals of the science of bandaging in as con- densed form as possible. For this reason the various bandages, together with the steps in the technic of their application, are shown by unusually clear illustrations. These illustrations are new and particular emphasis is laid upon those little details which spell success. The work is really an atlas of bandaging, written for the use of nurses by a superintendent of nurses. By M. Cordelia Cowan. Cloth, $2.00 net. WARNSHUIS' SURGICAL NURSING Published March, 1918 Dr. Warnshuis presents facts gleaned from his own personal experience. You are told the definite, specific things you must do throughout the entire surgical procedure-how to prepare the room, the patient, your- self, the instruments, and materials. You are taught postoperative care, postoperative emergencies, how to care for wounds, to anesthetize, keep a chart, make a plaster-cast, give the morning bath, make dressings. By Frederick C. Warnshius, M. D. Cloth, $3.25 net. w. B. Saunders Company West Washington Square Philadelphia