CHAPTER I.
CAUSES OF DISEASE.

The causes of disease are spoken of by authors as predisposing, and exciting. By proximate cause of disease is meant the cause of the symptoms present; this cannot appropriately be dwelt upon here.

By exciting cause is meant the immediate cause of a disease, and the distinction from predisposing cause arises from the fact that when two persons are exposed to something injurious to the health, they may not be equally affected.

It has been said that if twenty persons undergo hardship and exposure from shipwreck, the effect of the wet and cold may be in one to cause catarrh, in another rheumatism, in a third pleurisy, in a fourth opthalmia, in another inflammation of the bowels, and fifteen may escape without any illness at all. A predisposing cause is defined to be anything whatever, which has had such an influence on the body as to have rendered it unusually susceptible to the exciting cause of the particular disease. In most cases the distinction is obvious, but it is sometimes difficult to say of a given cause whether it ought to be ranked among the predisposing or the exciting causes.

Disease is often warded off notwithstanding the presence of the exciting cause, when we ascertain and prevent the predisposing cause of it, and it may sometimes be averted in despite of strong predisposition, if we know and can guard against the agencies by which it is capable of being excited.

When we enumerate causes of disease we see among them many that under ordinary circumstances minister to life, health, and enjoyment; and I can hardly refer at all to the varying circumstances under which they become the medium of pain, disease and death. These circumstances are so various, so many of them are apt to be put in operation at the same time, and so little power have we of excluding them one after the other, so as to ascertain the exact efficiency of each, that our observation respecting their actual effects are open to much fallacy.

We cannot for instance in a given case estimate accurately the effect of impurities in the atmosphere such as organic and inorganic dust, nor the effect of differences in degree of its natural qualities such as extremes of heat and cold, sudden variations of temperature, excessive moisture or dryness, different electric conditions, differences of pressure, a deficiency of light, and the amount of ozone, &c.

OF HEAT AND COLD AS EXTERNAL AGENCIES CAUSING DISEASE.

The range of temperature compatible with human life is very great; men live in the hottest and the coldest climates, where the earth produces any sustenance for them. It requires more care to preserve life under intense cold than under intense heat. Tropical climates are thickly peopled where the thermometer ranges from 80° to 100° for a long time together. In arctic countries on the other hand where the thermometer sinks to 40° or 50° below zero, we still find inhabitants, but they are few and thinly scattered. It is probable that at a degree of temperature a little greater than that of the equator or a little less than that of the poles men would perish.

Man is capable of existing under certain circumstances for a short time, and enduring a much higher degree of heat than the general atmosphere attains in the hottest portions of the earth, but there are generally some deleterious effects from hot climates or continued hot weather.

The effect of HEAT is to stimulate the organic functions of the body, but when considerable heat is applied for some time together its effect is to cause languor and lassitude, want of energy, a disinclination for exertion both bodily and mental; it has a depressing effect generally upon the animal functions or the nervous system, and there are some forms of disease that are distinctly traceable to heat as a cause.

We all know the effect of hot weather in causing perspiration, and when the operation of high temperature is continued for some time it has a marked influence upon the liver, increasing the quantity of bile that is secreted, and altering its sensible qualities; this is sometimes followed by inflammation of the liver.

In this country those attacks of vomiting and diarrhoea which are so common towards the latter end of summer or in autumn are the effects of a succession of hot days. In tropical climates the morbific effects of external heat are still more conspicuous, tending to violent disorders of the stomach and intestines, and also to acute inflammation of the liver and to acute abscesses in that organ.

In these cases the heated atmosphere unduly stimulating the secreting function of the liver creates the predisposition to the disease, while the exciting cause of the inflammation may be exposure to cold.

There may be deleterious effects from exposure to cold where the climate is quite hot. For instance a man may after the heat occasioned by the employments of the day, undress and lie opposite a window, his shirt wet with perspiration, to enjoy the sea breeze at night, and though the thermometer may be as high as 80° he may have a sensation of cold. If there is real chilliness it may be deleterious.

Heat sometimes acts as an exciting cause of disease—it produces sunstroke, or it may produce an eruptive disease such as prickly heat, &c.

The effect of extreme COLD (I use the term cold in the popular acceptation), when its application is continued, is that of a sedative upon the organic functions. Though at first causing pain in the extremities, if continued it causes sleep or overpowering drowsiness. Before this complete stupor comes on there may be a blunting of the sensations and confusing of the intellect, giving to the person exposed to it, the appearance of one intoxicated. When persons in this state are suffered to sleep, and the operation of the cold continues, they become less and less sensible to external impressions until death closes the scene.

But the effect of cold upon the body within certain limits of intensity and duration is that of a tonic. When its refrigerating and sedative properties can be sufficiently counteracted by exercise and warm clothing, cold is stimulating, refreshing, and invigorating to mind and body, it clears and sharpens the faculties, bestows alacrity and cheerfulness of spirits, and may become a curative agent.

Yet exposure to cold is one of the most common causes of various complaints. As a rule it is true that there is danger from sudden vicissitudes of temperature, although the proposition requires limitation. No peril need attend a change from a hot to a cold temperature if the power to evolve heat inherent in the system be entire and active and persistent, not lessened by any of those circumstances which have the effect of weakening it, such as local disease, and fatigue. Cold is dangerous, not especially when the body is hot, but when it is cooling after being heated. At such times taking a large draught of cold water, or cooling the body suddenly some other way might cause death immediately; if not, an inflammation of some internal part of the body might arise.

Every thing that has the effect of weakening the system and so diminishing the power of evolving heat, favors the morbific effect of cold, and is a predisposing cause of disease. The most common of these debilitating circumstances are fasting, evacuations, fatigue, a last night’s debauch, excess in venery, long watching, much study, and rest or inaction immediately after it, or after great exercise.

The faculty of evolving heat is weak in old persons and in the newly born, and these are often the victims of the power of cold.

The bad effects of cold depend very much upon the duration of the sensation. Even slight feelings of chilliness, if long protracted, are apt to terminate in some form of disease.

Cold is more likely to prove injurious when it is applied by a wind or currant of air, and the injurious operation of cold is augmented when it is accompanied with moisture—wetness is the worst way in which cold can be applied. The contact of wet or damp clothes with the skin, both increase and prolong the sensation of cold. A foggy atmosphere is more prejudicial than a clear one of the same temperature. While we are asleep, also, our power of resisting the effects of cold is diminished.

The power of habit enables a person to resist the effect of cold, and we may sometimes turn our knowledge of it to good account in gradually fortifying the system against the influence of cold that cannot be avoided. But we must not, while we fear to render our children effeminate by over care and much clothing, run into the opposite extreme and endanger their health by exposure. The process of hardening is doubly dangerous when it is attempted with children who were originally delicate, and should never be tried on any child or any person who is unsound, who shows any signs of present or approaching disease, or any marked predisposition to future, and especially to scrofulous disease.

An abiding sense of chilliness must never be permitted even when we are endeavoring to accustom a child to cold. If they can be kept in the cold air, and at the same time be kept feeling warm either by exercise, diversion of the mind, or by clothing, the result as regards the health is good.

The cold bath, and especially the shower bath, is a good means of fortifying the body against cold air. When we take a cold bath in the morning, if the sense of cold does not remain long, and is followed by a glow of warmth, the bath is sure to do good. If, however, after the bath we suffer headache, and continue to be chilly and languid or uncomfortable, it should at once be given up as useless and dangerous.

In this country, generally, catarrh and coughs and pectoral complaints of all kinds, are most apt to prevail in the winter and spring months, while bowel complaints are more numerous and distressing in the summer. The mucous membranes of the air passages sympathize with the skin under the agency of external cold; those of the stomach and intestines under that of heat.

The thoracic disorders which commence or grow worse in the winter are often fatal, and there are various other maladies that are aggravated by cold, so that the mortality of winter is greater than that of summer. Bowel complaints are more prevalent at the latter part of summer or early fall, when moderately cold days succeed a long period of hot weather, the high diurnal temperature being the predisposing cause, and the cold exciting or bringing on the disease.

I shall not refer to other causes of disease except to say that if two persons marry each other who have a hereditary predisposition to disease, their children, if they have any, will probably not be healthy.

Symptoms are the signs by which we know that disease is present. Every circumstance happening in the body of the sick person capable of being perceived by himself or others, which can be made to assist our judgment concerning the seat or nature of the disease, its probable course and termination or its proper treatment, is a sign or symptom.

These phenomena are the evidence upon which the whole art of the physician proceeds. It is important that the nurse should know how to note the symptoms, not only that she may know how and report to the doctor changes that occur in his absence, but that she may be able also to minister to those who are suddenly attacked with sickness, and to judge whether in cases of slight indisposition it is necessary to send for a physician.

By arranging and comparing symptoms, and by noting the circumstances under which they occur, the physician can distinguish the disease, and learn what are the indications of treatment—this belongs especially to him. But it is very important that a nurse should know how to note all changes as they occur, and sometimes it is best she should keep a written record of them. An important point in a trained or skillful nurse is that of her ability to observe accurately and describe intelligently what comes under notice in the absence of the physician. She should cultivate the habit of strict observation, and simple and truthful statement—neither deficient, exaggerated, or perverted, stating facts and not opinions.

Symptoms or phenomena which accompany disease may be subjective, those which are evident only to the patient, or objective which are observable by others. Both sorts of symptoms shed mutual light on each other, and as the statements of the patient are not always trustworthy, the nurse should be careful not to let anything pass unseen that can by vigilance be noted.

The following directions will help the nurse to cultivate the habit of observing symptoms:

Try to learn all you can of the previous history of the case; you will sometimes get information which the patient would not be likely to communicate to the doctor in person.

Note the patient’s apparent age with any indications of disguised age, signs of weakness—whether corpulent or bloated; note any deformities, swellings or wounds, and notice the attitudes and expression of the countenance.

A sufferer instinctively takes THE POSITION most conducive to ease. When one lung is affected the patient lies on that side, that the healthy one may have the greater freedom of motion. When there is peritonitis (inflammation of the bowels), he lies on his back with his knees drawn up to relax the abdominal muscles. If there is colic alone he may lie on the abdomen, as pressure may relieve his pain. When a patient has been persistently on his back, if he turns onto his side it is a sign of improvement.

Inability to breathe termed ORTHOPNŒA, occurs in affections of the heart, and also in asthma. Lying quietly in bed is usually a favorable sign. Restlessness and slipping to the foot of the bed, in low stages of fever, are bad signs.

Of the uneasy, morbid symptoms, pain is the most important, and most common. Pain occurs in nearly all inflammations, and it may occur where there is no inflammation at all.

Bones, muscles, tendons, ligaments, the bladder, the kidneys, the uterus, all modify in a manner that is peculiar to themselves the pain that is produced by injury or disease. Such terms as the following are used to express a peculiar character of pain: It is said to be sharp, shooting, growing, burning, dull, heavy, tearing, and so on.

If pain is felt in any part when pressure is made upon it the heightened sensibility is called TENDERNESS, the part is said to be tender. A part may be both painful and tender, as it usually is if the pain continue for a time; it may be tender without being painful as it is usually, if pain continued for a time and then ceased.

Itching is an uneasy sensation allied to pain. It often affects the natural outlets of the body. It occurs about the rectum from the motions of little worms that nestle there, and other causes; and this itching of the rectum, and likewise of the pudendum, are distressing complaints, harassing the patient continually, preventing sleep and requiring medical treatment (F. 195). The tingling and pricking often felt in the windpipe, and provoking coughing, has some analogy to itching.

Nausea is sometimes a direct symptom of gastric disorder, at other times it is a very important indirect result of disease at some distance from the stomach. The nausea which is so troublesome to pregnant women, is an instance of a morbid sensation, sympathetic of irritation in a distant organ.

Dizziness or vertigo results sometimes from disease within the head, and sometimes it is the indirect result of disease of the stomach or of mere debility.

A sensation of sinking, sensations of weight and lightness, of drowsiness, tenesmus, strangury, heartburn, and various conditions of the special senses are mostly SUBJECTIVE SYMPTOMS.

One of the first symptoms of diabetis is a preternatural keenness of appetite, but in most diseases the appetite is lost or impaired or perverted.

Thirst is generally great in diabetis, and there is commonly considerable thirst in inflammatory complaints.

The above named symptoms are mostly subjective, but are accompanied by others that are objective, that show that the functions of certain parts are disturbed or suspended; and it is of especial importance to notice the PULSE, as this is a valuable guide in treating disease.

Each contraction of the heart sends out a wave which distends the blood vessels, and they by their contractility or elasticity carry it on through the entire arterial system. This periodical distention is the pulse.

The PULSE BEATS can be felt wherever an artery approaches the surface; it is usually taken and counted at the wrist; in children it can be best taken at the temporal artery during sleep.

To take the pulse accurately place two or three fingers on the artery making moderate pressure, and note particularly its frequency, its regularity, its forces and its fullness.

The RATE varies with varying circumstances. The average number of pulsations in a healthy adult is from 70 to 75, but there are some persons who, when they are quite well have a pulse of 80 or 90 to the minute, and there are others in whom it seldom rises above 60. It is usually more rapid in women than in men, is much more frequent in early life than in old age, and the average rate in a healthy child is 120.

In disease, the pulse may acquire a great degree of frequency. It may reach 150 or even 200, but in such cases it is generally feeble and can hardly be counted. Besides observing the frequency of the pulse, its character in other respects must be noted.

Irregularity of the pulse generally indicates disease, and there are two varieties of it. In most instances of irregular pulse, succeeding beats differ in length, force and character; in the other variety a pulsation is from time to time left out; the pulse is said to intermit.

In the DICROTIC PULSE a secondary wave or undulation can be felt. It is often met in typhoid fever, and an inexperienced person might be led to count double the number of beats.

Another important quality of the pulse is its hardness or compressibility. The hard pulse ordinarily, though not always, indicates inflammation. This hard pulse may be known by pressing pretty hard with one finger, while we observe with the others whether we arrest or abolish the pulse.

A pulse is said to be full or large if it is felt to strike a large portion of the finger; other departures from the normal standard are spoken of as soft, quick, or sharp, throbbing, bounding, thready, wiry, flickering, &c.

OF THE TEMPERATURE.

The normal standard of the temperature of a healthy person is 98.4°. There is some variation, and indeed a daily cycle of variations, so that in the morning it is 99 or at least 98½ and in the evening 97½, but the range is small, and if the variation is more than that, it is indicative of disease. There is only a deviation of about 15° within which life can be sustained; a temperature of more than 107° or less than 93° will almost certainly prove fatal.

Every mother who can, as well as every nurse, ought to own a clinical thermometer, as thereby she may detect the beginning of a disorder before there are other marked signs of indisposition. She should use it upon the first suspicion of a departure from health and frequently afterwards, until she knows that the temperature is normal. An increase, especially if beginning each day a little earlier, is a bad indication; a decrease from a high temperature each day is a sign of improvement. In pneumonia and generally in such disorders as are initiated with a chill, the rise is sudden and rapid.

In typhoid and some other fevers, the elevation is slight at first and gradually rises. The exacerbations and remissions or other deviations can only be recognized by taking the temperature frequently, and it should be taken at the same hour each day to exhibit the cycle of changes.

An irregularity of temperature in the course of a disease that has a regular type may indicate a complication, or it may depend upon local causes, such as constipation, bad air, &c. The decline of fever and of temperature may be gradual, or it may drop to a steady normal within a few hours.

Before using the thermometer the index must be thrown down to a point below the normal. Hold it with the bulb down and shake till it falls sufficiently.

The part (the axilla) should not have been exposed for washing for at least half an hour before taking the temperature, and it is a good precaution to keep the axilla (or mouth) closed for ten minutes before putting the bulb of the thermometer into it, and a little time may be saved by slightly warming the bulb in the hand before its introduction. If we are careful and see that the axilla is first dried from perspiration, and that the clothing is not in the way, and that the thermometer is held firmly in position a sufficient time, we may get a correct axillary temperature, unless in a very emaciated person. If taken in the mouth the lips must be closed during the process.

The rectum gives the most reliable temperature, and this method is employed for infants. The thermometer should be oiled and introduced for about two inches. Unless the presence of feces prevent, the thermometer will be half a degree higher than if taken in the axilla. It will sometimes take ten minutes or more to obtain the temperature, but some thermometers will do the work in less than five minutes.

THE RESPIRATION.

That respiration and circulation are intimately connected, and that whatever modifies the pulse usually effects the breathing is a fact generally known. That the proper performance of the function of every organ in the body depends somewhat upon proper respiration, is a fact not so generally known and recognized, and as this is an important topic we may properly here enlarge upon it.

By the muscular action of the diaphragm and intercostal muscles, and the consequent contractions and expansion of the lungs, the alternate inspirations and expirations are produced which we call breathing. The lungs are not completely filled and emptied by each respiration, and a certain amount of air remains stationary in them. Were this air which remains stationary constantly in a particular portion of the lungs, the same without change, we would derive no benefit from that portion of the lungs. Practically, however, it is believed that the additional supply breathed in and out is diffused through and alters the character of the whole.

A healthy adult ordinarily breathes about eighteen times per minute, taking in each time about twenty inches of air. It is said that it takes at this rate sixteen respirations to completely renovate the air. This is probably true of our ordinary breathing, but the renovation of the air depends upon our manner of breathing. It is possible for us to breath so that at one expiration we almost displace the air from every portion of our lungs, and then by a full, deep, prolonged inspiration, (throwing forward the chest, throwing back the shoulder, and keeping the body erect,) fill the lungs fully with air and thus not only change the air in our lungs, but change in some degree the character of our blood so as to increase its purity.

In order to test this let me ask anyone who is suffering from any slight indisposition, if it be headache, nausea, pains in different parts of the body, or any sickness, to try to breathe in this manner for half an hour, and observe if they do not feel better, being careful at the same time that the air breathed is good and pure. This point is of so much importance that I will refer to it again hereafter.

The character of the respiration is an important diagnostic symptom and should always be noted. The rate of respiration varies as does that of the pulse, but the former is partly under the control of the will. The respirations are more rapid in women than in men, in children than in adults; it is modified also by position, exertion, excitement, and other conditions. We may count the respirations by observing the rise and fall of the chest, but it is well to put our hand on the stomach where the motions may be felt.

Breathing is in man mostly abdominal, in woman mostly thoracic, but inflammation in the chest or abdomen will affect its character.

Dyspnoea, difficulty of breathing, arises when from any cause the amount of air entering the lungs does not correspond to the amount of blood sent by the heart for purification. The air may be unfit for its work, or disease in the lungs, or air passages may shut it out. Asphyxia results if the supply of air is in any way cut off.

OF THE AIR.

In this connection I will say to the nurse, give the patient pure air. Learn how indispensable this is to life, or health, or comfort; how indispensable to any person, and especially to the sick; how liable the air in the room is to be contaminated by the air breathed or expired by those in the room; by lights burning in the room; by exhalations from the bodies of the sick; by excreta left for a time in the room; by the inevitable floating dust from the floors and walls; from clothing, bedding, and furniture; and from the presence of organic matter in increased quantity, and of most deleterious quality in and around the sick.

A thousand feet of air space where the air is constantly renewed, is necessary for a healthy adult; a sick person should have two or three times as much, because with them there is increased susceptibility to draughts. Be very careful that the sick are not placed so that a direct current of air can blow on any part of the body, but either by the use of fans or in some other way the air must be renewed around their bed.

VENTILATION.

The problem to be solved is, how can fresh, pure air be best supplied? The inequalities of temperature within and without the room produces some natural ventilation, as this sets the air in motion and effects an exchange of air, if there are some apertures around the doors and windows.

This, however, is seldom sufficient, and artificial ventilation is often necessary. An open fire is a good apparatus for this purpose. The draught which it creates carries the air from the room up the chimney, while a fresh supply is drawn in to take its place. This supply should be from the outward air, or from an adjoining room in which the air is not contaminated.

The inlets and outlets for air should be of equal capacity, on opposite sides of the room, and of different heights to secure thorough ventilation. They should be as far as possible from the patient and from each other. In cold and damp weather great care is necessary to keep the air fresh and wholesome and at the same time to avoid chilling the patient. But even in cold weather the doors and windows may be thrown open for a minute at a time, if the patient is at the time protected by additional clothing.

However, during the night and in cold and wet weather, the principal supply of air will be from an adjoining room, air that is warmed, but it should be as pure as possible. When the weather is cold, and especially the latter part of the night, have more heat in the room and not less fresh air; if needed give your patient additional clothing and foot warmers.

The windows may be thrown open once or twice a day in cold weather, if the patient is protected by putting additional clothing on the bed, and using some sort of a screen, (an umbrella may be used for a screen), as a protection from the cold and direct draughts. But as the contamination of the air continues, the purification of it should be equally so, and some fresh air must constantly be admitted—some device used for the purpose. The window may be raised two or three inches and the aperture closed with a board, then the air will find admittance through the opening between the two sash; or when the window is raised three inches, a board six inches wide may be placed on the window sill a little inside of it; thus there will be an aperture both at the top and bottom of the lower sash. Or the upper sash may be lowered a little. The current of air which comes in (this is usually the lower one) should be directed upwards.

In the summer a lamp may be kept burning in the fireplace or grate; flues must in some way be kept heated or they will not draw. Stoves assist ventilation to some extent, but furnaces and radiators do not assist at all to ventilate, and the air is thereby especially dry. A pan of water may be kept boiling in the room, or perhaps merely setting on the stove, or a towel or two may be hung near a radiator and kept constantly wet; these will dampen the air by evaporation, and this is often necessary when the rooms are kept warm by artificial heat. About 66° is a proper temperature for a sick room in most cases, but 60° to 65° is suitable for fever cases; feeble and emaciated persons require a temperature of 70° to 75°.

Be careful to have the room warm when the patient is out of bed.

The ordinary symptoms which characterize inflammation may be known if we observe what takes place when an external part is injured. Let us suppose that a healthy man has a piece of glass stuck in his arm. He soon has pain, then redness in that part of his arm, then swelling, which is hard near the injury, and increases so that some swelling may be observed, though not so hard at a little distance, and the part is quite tender and hot.

These are the ordinary symptoms of inflammation: pain, redness, heat, and swelling, with tenderness that is manifested when the part is pressed.

If the inflammation increases there are signs of disorder in other parts of the body; the patient may be first chilly and feeble, then the skin may become hot and dry all over the body, the pulse fall hard and frequent, lassitude comes on with headache, perhaps pain in different parts of the body; he has also other symptoms of fever; is restless, sleeps ill, loses his appetite, his tongue becomes white, his mouth is dry, he is thirsty, the secretions of the body are diminished, has what is called inflammatory fever, or sympathetic fever, or pyrexia, the last term being now most generally used.

These phenomena, this inflammation, ends in two or three different ways. If measures have been taken for subduing the inflammation—in the supposed case of the arm—if the glass has been removed, it will probably happen that the symptoms above named will disappear. This is to end in what is called RESOLUTION.

When the inflammation goes on until pus is formed it is said to end in SUPPURATION. The symptoms grow more severe for several days, the swelling at length assumes a more pointed form, the skin in its centre begins to look white, and the swelling there gets softer; there is throbbing pain, perhaps the patient has chills or rigors; then when the swelling is cut open or the cuticle breaks a yellow creamlike fluid is poured out which is pus, and there is generally an abatement of the symptoms. If, however, the suppuration or discharge of pus continues for some time, other symptoms are manifested such as frequent shiverings, followed by flashes of heat which end in perspiration; this is HECTIC FEVER.

When the inflammation is still more intense it sometimes ends in MORTIFICATION, the part dies by the violence of the disease, the red color changing to a livid or purplish, or greenish black hue, the flesh losing its sensation and having an offensive odor.

Of course inflammation may be in an organ or structure that is internal, and we determine the seat of the disease, partly by the character of the pain. Sometimes the pain is sharp and piercing; this is its character generally in serous membranes such as the pleura or peritoneum (membranes covering the lungs and intestines.) There is less pain when the inflammation is in the mucous membrane, or in the parenchymatous structure of organs, such as the lungs, liver, and spleen.

There is generally an aggravation of pain upon pressing a part that is inflamed. Pain caused by air distending the bowels and stretching the nerves may be relieved by pressure. Spasmodic contractions of the muscles will cause pain without much tenderness.

OF HEAT AS A SYMPTOM OF INFLAMMATION.

The temperature of an inflamed part exceeds that which belongs to it in health. In inflammation as in fever, it has been known to rise to 107°. The increase of heat depends upon an influx of arterial blood, and therefore of oxygen into the part. There is probably always some increase of heat, though it may not always be noticed in every case of inflammation.

There is more REDNESS than is natural in a part that is inflamed. There is more blood than usual in the vessels that carry red blood, and the red blood enters into the small vessels where the red particles cannot commonly be seen. All the minute vessels seem to be enlarged. The redness often remains sometime after the inflammation has ceased.

The degree of SWELLING in different cases depends partly on the nature and structure of the part affected and partly on the intensity of the inflammation; in some instances there is so little that it is not appreciable.

Almost all the swelling results from the presence of matters thrown into the inflamed part. In the central hard portion the hardness is to be ascribed to an effusion into the areolar tissue of it, of a fluid which is transparent at first, afterwards becoming opaque, called coagulable lymph. Serum is effused into the areolar tissue of the softer swelling at the circumference.

ŒDEMA, DROPSY, ANASARCA.

Even under moderate inflammation some amount of effusion takes place into the texture or from the surface of a part. This effusive serous fluid called also serosity, resembles and probably is the scrum of the blood. When this passes into the areolar structure of a part it is called oedema, (though this is not always by inflammation) and if the serosity passes out extensively over the body, the disease is called anasarca or general dropsy.

If a considerable amount of this serous fluid is poured out in a short time from the peritoneum, it is a form of ascites or abdominal dropsy. If it is thus poured into the pleura it causes apnoea, or difficulty of breathing, and requires aspirating.

CHAPTER III.
DIAGNOSIS OF DISEASES IN CHILDREN, EARLY TREATMENT, &C.

It is not often that a correct diagnosis can be made of a disease by a single symptom, but there are marked and characteristic symptoms which indicate some diseases in children with considerable certainty.

A strongly marked nasal or palate sound in the child’s cry indicates an abscess behind the pharynx. When this nasal tone is heard we should palpate with the finger on the throat to ascertain the degree of soreness.

A long drawn, ten times lengthened, loud sounding expiration with normal inspiration, and no dyspnoea is sufficient for the diagnosis of CHOREA MAJOR (St. Vitus dance.)

A high thoracic continually sighing inspiration, the upper part of the thorax doing the work of breathing, and with a sighing or groaning sound, shows the commencement of HEART WEAKNESS, CARDIAC PARALYSIS OR FATTY DEGENERATION OF THE HEART, and will probably be followed by such symptoms as cyanosis, coldness of the extremities, &c.

Strongly marked diaphragmatic expiration accompanied by a fine, high whistling sound, points to BRONCHIAL ASTHMA. This sound, however, resembles that made in croup. If there is a pause between the end of expiration and the beginning of inspiration, croup may be excluded.

Sleepiness, lasting twenty-four to thirty-six hours, occurring without fever or other disturbance to account for it, is an initial symptom of MENINGITIS, though it might be caused by narcotics or uremia.

A prominent, firm fontanelle means increase in quantity of the contents of the cranium-exudation of some sort. It cannot be caused by fullness of the vessels alone if it is firm and resisting. We know that we have cerebral disease with DROPSY or exudation (Hydrocephalus).

When the fontanelle is deeply sunken, it points to loss of blood or other nutritive juices, as in cholera, &c.

A sharp, shrill cry, accompanied by an expression of fright or great anxiety, and occurring about an hour after the child has fallen asleep, is the only symptom of the “Alp”—night terrors, sudden awaking from bad dreams.

Periodical crying, lasting from five to ten minutes, should always make us think of spasm of the bladder or PAINFUL URINATIONS.

Violent crying at stool with fear of the act, and general avoidance of it, points to FISSURE OF THE ANUS, and is usually accompanied with constipation.

A violent cry full of pain and almost continuous, with the throwing about of the head on the pillow and grasping it with the hands, means OTITIS or EARACHE.

Weakness or immobility of the child, after a comparatively slight or short illness, points to SPINAL PARALYSIS.

Delayed ossification of the cranial bones is an early sign of RICKETS, as is crying continued for weeks (increased on touch of the extremities), accompanied with fever and incessant sweating.

Vomiting of all kinds of food continued for weeks in children of closed cranium but with large cranial measurements, when there is no fever, pain, idiopathic disease, or a cerebral tumor, indicates chronic HYDROCEPHALUS with an acute onset.

Congestion of the cheeks in children, excepting in cases of cachexia and chronic disease, indicates an INFLAMMATION or a febrile condition.

Congestion of the face, ears and forehead of short duration, strabismus with febrile reaction, oscillation of the iris, irregularity of the pupil with falling of the upper lids, indicates a brain affection.

Enlargement of the spongy portions of the bones indicates RICKETS.

A thick and purulent secretion between the eyelids may indicate great PROSTRATION of the general powers.

Passive congestion of the conjunctival vessels indicates approaching DEATH.

Long continued lividity, as well as lividity produced by excitement or exercise, the respirations continuing normal, are indices of FAULT IN THE FORMATION OF THE HEART, or great blood vessels.

A temporary lividity indicates the existence of a grave acute disease, especially of the respiratory organs.

Irregular muscular movements, which are partly under the control of the will, indicates the existence of CHOREA (St. Vitus dance).

The contraction of the eyebrows, together with a turning of the head and eyes to avert the light, is a sign of cephalalgia (headache).

When the child holds its hand upon its head, or strives to rest the head upon the bosom of the mother or nurse, it may be suffering from ear disease.

When the fingers are carried to the mouth, and there is besides great agitation apparent, and when it turns its head from one side to another, there is probably some obstruction or some abnormal condition of the larynx.

A feeble and plaintive cry indicates a trouble in the abdominal regions.

If the respiration is intermittent but accelerated, there is capillary bronchitis. In bronchitis the cough is clear and distinct.

A hoarse and rough cough is indicative of true CROUP. When the cough is suppressed and painful, there is PNEUMONIA or PLEURISY.

In diseases of the stomach, liver or bowels we have usually a coated tongue; a white tongue indicates FEBRILE disturbance or some THROAT trouble; a brown moist tongue, INDIGESTION; a brown dry tongue, DEPRESSION, BLOOD POISONING or TYPHOID FEVER; a red moist tongue, INFLAMMATORY FEVER; a broad, pale flabby tongue accompanies a DROPSICAL CONDITION of the system; a tremulous, moist and flabby tongue indicates FEEBLENESS, NERVOUSNESS; a pale flabby tongue which shows the pressure of the teeth, a generally relaxed condition of the system; the irritable or strawberry tongue with its red papilla, points to an irritated stomach, and is met with in SCARLET FEVER; a furred and dry tongue is indicative of VIOLENT LOCAL INFLAMMATION; if afterwards clean, red and dry, protracted INFLAMMATORY FEVER.

Wheezing cough and wheezing breathing indicates ASTHMA; dull, heavy aching pain at the base of the chest, ACUTE BRONCHITIS; urgent desire to go to stool, DYSENTERY; diminished secretion of urine, INFLAMMATORY and FEBRILE DISORDERS; cold hands and feet, NERVOUS DISEASES and low states of the blood.

In general, the diagnosis of diseases of children is easy if we simply compare the objective symptoms with those which should obtain in a healthy child of the same age. But we must remember that with children symptoms which appear very grave are often evanescent, and on the other hand the indications of very serious disease may be disregarded on account of their natural vivacity and recuperative powers. In each case each child should be studied by itself considering its antecedents, its peculiarities, its surroundings, and its relations to them.

The mother has the best chance to know these; she sees the child when awake and asleep, when dressed and undressed; she knows its history, what has been its diet, what her own health has been, her own habits, her surroundings and occupations, and whether there may or may not have been anything to cause sickness of the child in her own toils or trials. The nurse and the mother should note all the facts, for their own guidance and for the guidance of the physician if he is called.

EARLY TREATMENT OF INFANTILE DISEASES.

Very few of the symptoms heretofore mentioned can be neglected with impunity. While some cases of sickness may be left to the powers of nature to restore health, others require judicious early treatment, and a physician should be called. We should generally enjoin rest, but we should act by our medicines to meet every positive indication.

We are the assistants of nature; we must act by removing the causes where they can be reached; we must relieve pain, but we must not by officious kindness do too much and interfere with the natural return to health. Remember that drugs are not all powerful, that time, rest, diet and numberless little things are the means by which we aid in the fight against disease.

It is an excellent plan not to continue medicine too long. Place the child on the road to health and see if it will not with a little supervision improve—still, however, using proper rest, diet, &c.

But as the apparently trifling symptoms of to-day may become the full fledged attack of to-morrow, we must pay attention to every untoward symptom. Parents are liable to be unnecessarily scared, and afterwards go to the other extreme and neglect calling a physician until serious injury has occurred.

I will here give you a few aphorism and general rules: Treatment of the sick should be according to the patient as well as according to the disease. Adult males are not so sensitive as females; young children, whether male or female, are sensitive, tender and excitable, and alive to every irritation. But young children differ in their constitution, and some have peculiarities or idiosyncracies so that medicines of ordinary activity act very powerfully or even violently.

Small children are always sensitive to the action of medicine, and small doses only are required for them. And in consequence of the activity of the vital powers, and the quickness and force of the circulation, there is a remarkable susceptibility to inflammatory action, disease sometimes running on rapidly to organic and incurable mischief.

In treating children employ the mildest remedies at first, and aid their action by regimen. When an emergency demands, use those articles which experience has shown to have power to meet such an emergency. Exhibit such medicine in the minimum dose and increase or repeat until the desired effect is produced. Be very careful not to fill the child with nostrums for some imaginary ill, lest you thereby make it ill. Always remember that the first step in treatment is to change the conditions which produced the disease—remove the cause and assist nature to repair the injury.

CHAPTER IV.
TREATMENT OF INFLAMMATION IN ITS INCIPIENT STAGES.

Usually the nurse or the mother does not treat disease, or administer medicine except under the direction of a physician, and it is not always necessary for her to know the principles that guide in their administration, or why particular medicines are given. But it is sometimes necessary for the nurse or mother to decide what shall be done, and to act before the doctor can be consulted. Accidents and emergencies occur, distress and sickness may suddenly attack some member of a family at any time, and little ailments are complained of every day by some of them; the question arises, what shall be done?

It is not necessary every time to send for the physician, and he cannot at a moment’s notice be obtained. For many ailments the mother prescribes, and many times the early and judicious use of medicines or regimen not only relieves present suffering, but also prevents the developement of serious, and protracted and dangerous maladies. This is especially true in regard to incipient inflammation, and I shall here speak particularly of its treatment.

What has heretofore been said about inflammation gives us some guide to enable us to know whether the case calling for our care is one of an inflammatory character. If the pulse is full and hard and a little more frequent than usual, and there is restlessness and some pain we may conclude that there is IRRITATION that precedes inflammation at least, before such symptoms as depression, chilliness followed by heat, headache, a furred tongue, loss of appetite, and apparent weakness come on. But if any of these symptoms are present we should search for the cause. Perhaps if the inflammation is external we shall be able to ascertain what produces the trouble. In every case we ought to know the cause if possible, as we thus have more clear indications for treatment.

But we may use the sedative treatment in all cases where these symptoms come on in a person who has previously been healthy. Of course you will not bleed—that, if done at all, should be done by the doctor. But all sources of irritation ought to be removed, so that the patient may enjoy perfect quiet; the sick room should be ventilated, and kept at the temperature of about 60°; let the diet be light; allow ice and cold water freely, and if there is much febrile excitement use sedatives and saline refrigerants. The best sedative is veratrum viride, and the following is a convenient way of administering it: Drop 30 drops of the fluid extract of veratrum in 30 teaspoonfuls of water and give 1 teaspoonful every two hours. To adult subjects if there is considerable fever two drops of the extract, or two teaspoonfuls of the diluted preparation may be given at first and the dose may be repeated in an hour, but it will not be best to continue such large doses. Aperients may be given if there are fecal accumulations in the bowels. Although quinine is a tonic, six to ten grains of it are sometimes given with good effect in a case of inflammation.

Opium is a good remedy judiciously given; one dose (1 grain for an adult) is good in a case of catarrh or cold; successive doses are necessary in a case of peritonitis or enteritis, but this should be given on a physician’s advice. It acts probably by quieting the nerves—by sustaining the faltering action of the heart, and by keeping the inflamed part at rest. Sometimes cold, and sometimes hot applications are made to inflamed parts, and it is said that the sensations of the patient are the best criterion of their usefulness. Except, however, in cases of inflammation of the brain, and perhaps even then, I think that hot applications are the best. When we wish to promote suppuration hot fomentations should be applied.

Counter irritants relieve inflammation of the deeper parts by drawing the circulating fluid and the nervous energy to the surface. The milder kinds called rubefacients, produce merely local warmth and redness; these may often be used advantageously. Mustard applied so as to redden the skin is generally useful.

Vesicants, epispastics, or blistering agents are safe appliances but they are distressing, and their use may be deferred until a physician advises them.

I have said that the diet should be light while the pulse is hard and full. Afterwards when the pulse is natural, or if it becomes irregular or small, good broths or other nutrients are to be given, milk, cream, and even raw eggs may be administered. In general food should not be pressed upon a patient.

OF TOPICAL APPLICATIONS FOR INFLAMMATION.

I have mentioned counter irritants and I think it best at this time to advert to all the various topical applications, irritating, soothing and protective, and to give such instructions as I can in regard to them.

Counter irritants are frequently applied over or near the seat of the disease, and often also at a remote part to obtain what is called revulsive action. In both instances, however, their action may be revulsive. If applied to the thorax or chest, for example in a case of pneumonia, the cuticle to which it is applied is almost as remote from the lung by the way of the circulation, as is the cuticle of the wrist or ankle. But practically a sinapism may be very useful applied at either place—possibly more useful if applied over the seat of the inflammation, because there is a sympathy between the parts—they may be used very beneficially in domestic medication.

In a few succeeding pages I give some directions to the nurse who acts under the doctor’s orders.

Ammoniacal liniments, and other washes and embrocations that are sufficiently irritating to produce redness when rubbed on the skin, should be rubbed on briskly so as to produce considerably increased circulation in the capillaries, &c. One of the most commonly used rubefacients is mustard. To make a mustard plaster, or sinapism, take one part of powdered mustard, and about three times the quantity of flour and mix into a paste with tepid water, and spread it evenly between two pieces of thin muslin. As hot water or vinegar weakens the active principle of mustard, tepid water is best, even if it seems cold when applied to the patient. Good sinapisms are conveniently made also by doubling brown paper several thicknesses, wetting it and sprinkling on the mustard alone.

The mustard must not be left on long enough to vesicate; usually it should be taken off within half an hour (or moved,) except when applied to the soles of the feet, when they may commonly be left on for several hours. Their action must be carefully watched upon an insensible or delirious patient, or a little child. In mixing the plaster for children glycerine may be used, and then the plaster may remain on longer. Confine in place by a bandage. If the patient complain of the burning or smarting after the plaster is removed, dust the part with starch or fine flour, or dress with vaseline to exclude the air.

You may make a cayenne pepper plaster in the same way that a mustard plaster is made, or you may sprinkle pepper upon a thin slice of pork. This makes good draughts for children and may be useful sometimes for sore throat if applied to the neck. But capsicum plasters, &c., can be bought at the drug store. In the country it is generally convenient to obtain and apply horse radish leaves; these are good rubefacients. In order to produce immediate VESICATION I have known a doctor to heat an iron spoon until it was sufficiently hot, and then rub it over a small space of skin; and a small blister may be quickly made by saturating a bit of cotton with hartshorn, putting it in a top thimble and applying it to the skin to remain seven or eight minutes. But the agent most commonly used to produce vesication is the CANTHARIDEAL PLASTER. If you are to produce a blister with this, the part should first be washed and dried, shaved if there is any hair upon it, then if you wish the blister to rise soon wet the plaster and also the skin with vinegar; apply, and secure the plaster in place by a bandage. Most commonly it will rise in from four to eight hours, but without waiting for it to rise fully you may remove the plaster and apply a poultice which will produce the desired effect. Do not tear the skin in taking the plaster off. When the blister is well raised make a slight incision or two for the escape of serum, and dress with vaseline or tallow. This is the usual way, but in some cases the physician may direct differently, perhaps may leave the blister undisturbed and allow the fluid to be reabsorbed.

Strangury and congestion of the kidneys sometimes follow the prolonged use of cantharides; to prevent this, it is sometimes recommended that tissue paper be well oiled and interposed between the plaster and skin. And as camphor corrects the action of cantharides upon the bladder, it is recommended that in case of a child particularly, a solution of camphor in ether be sprinkled upon the plaster. If a blister is applied to a young child, it should be carefully watched and not allowed to remain too long. In two or three hours the skin will be well reddened, and the plaster may be removed and a poultice applied.

Tincture of iodine is sometimes applied as a counter irritant, but several coats and repeated applications are necessary to produce a blister.

Local stimulation can be obtained from bits of cantharideal plaster kept on for an hour or two, and removed or changed before the point of vesication is reached. The same effect follows the rapid passage of a hot flat iron over a piece of brown paper or flannel laid upon the skin. It is generally best that the flannel should be wet first; and should an emergency arise when from hemorrhage or some other cause there is danger of immediate collapse, the application of heat in this way may rouse the sufferer and prevent immediate death. This or the actual cautery is sometimes used to relieve lumbago, or rheumatism. If you have thereby a slight burn, you may dress it in a solution of bicarbonate of soda and cover from air with rubber tissue.

If a SETON is inserted in the skin, the silk should be moved daily and the matter well cleared out.

Wet cups are applied to relieve congestion and to abstract blood, the skin being first scarified.

Dry cupping is most practiced for the relief of pain and to draw the blood away from an inflamed organ. Small tumblers may be used in the absence of cupping glasses, if the edges are smooth. When you apply the cups have at hand also a lamp, a saucer of alcohol, a bit of sponge or a wad of lint fastened to the end of a stick. Have the cups perfectly dry, dip the sponge in the alcohol which you will ignite from the lamp, (they being near the patient), and let it burn for an instant in the inverted glass, then withdraw and extinguish it, and rapidly place the cup over the intended spot. As the heated air in the glass condenses in cooling, the skin will be forcibly sucked up, and the blood drawn towards the surface. Each cup will remain on from three to five minutes. Do not attempt to apply them to a bony and irregular surface, and be very careful not to burn the patient by getting the edges of the glass too hot. To remove the cup press with the finger close to the cup so that air will be admitted.

Wet cupping will be attended to by the physician, who will provide the scarificator, and adhesive straps. See that plenty of soft towels are provided.

There are two varieties of LEECHES used in this country, the American and the foreign. The latter differs from the former in having five or six stripes down its back instead of three, and it will draw from five to six times its own weight of blood as it is larger and more voracious than the American variety.

The domestic variety is sometimes preferred for children, as it will draw a sufficient amount of blood usually. Leeches should not be applied over any large vessel, and preferably should be over a bony surface where pressure can be made to stop the blood if it continues to run. The leech should not be handled, it may be washed and dried in the folds of a towel.

To induce them to bite, the part to which they are to be applied must be perfectly clean, and it may be best to pick or scratch the skin so that the leech has first a taste of blood; or you may put the leech in a wine glass, test tube, leech glass, or small bottle filled with water; cover with a cord and invert over the place; hold it close and slip out the paper. The leech will then probably take hold and the glass can be taken off, and the water absorbed by a towel. If one is to be applied inside the mouth or nostril, put a thread through its tail to prevent its being swallowed. If such an accident should occur have the patient drink freely of salt and water, and induce vomiting.

If the leech seems sluggish when applied stroke it gently with a dry towel. When full it will drop off. If you wish to take them off sooner, do not remove by force, but put a little salt on their heads. If the bleeding from the orifice continues too long it may be checked by a compress of lint, an application of ice, or by touching with nitrate of silver, or carbolic acid. Leeches not used may be kept in a jar of water with sand in the bottom, and a perforated cover, or it may be covered with a linen cloth. The water in which they are kept should be changed twice a week in winter and oftener in summer. Salt will make a leech disgorge the blood with which it is filled, but if kept afterwards it is liable to be diseased, and to cause disease in those that are with it.

By FOMENTATIONS or stupes is commonly meant the application of flannels or towels wet with hot water or some medicinal decoction. If hot water only is used, they are a convenient means of applying warmth and moisture, but they require constant attention, needing to be changed every ten or fifteen minutes. They are chiefly of use in relieving pain and inflammation, and in promoting suppuration when that is desirable.

Two pieces of flannel should be at hand each doubled to the desired size; they are to be saturated with boiling water and wrung out dry as possible. To wring it out without scalding one’s fingers, put it inside a towel, and this may be made with a hem at the end so that a stick can be thrust through it. Wring the flannel so dry that it will not make the bed or bed clothing wet. Cover with oiled muslin a little larger than the fomentation, and over that lay some dry flannel or cotton. If the stupe is put on hot, and frequently changed, it derives or draws blood towards the skin, and is often useful in relieving spasm and pain; and the continued use of them prevents suppuration. Medicaments are sometimes added to make them more irritant or sedative; then they are not changed so often, but they must not be allowed to get cold. After the fomentations are discontinued, carefully wipe the parts dry to which they have been applied, and cover with a warm, dry flannel.

I subjoin a few useful fomentations in which decoctions or medicines are used.

1. Add one ounce muriate of ammonia and two ounces spirits of camphor to 1 quart of boiling water just before dipping the flannel into it.

2. For a fomentation to the bowels, chest, &c., of a child, take 1 oz. paragoric, 1 oz. Jamaica ginger, and 4 ozs. hot water.

3. Twenty drops spirits turpentine may be sprinkled over each stupe, but be careful about blistering the skin or making a sore.

4. A decoction of chamomile flowers, hops, or conium, may be used for the fomentation instead of water.

5. Twenty drops or more of laudanum may be dropped over each stupe. This might soothe pain without causing stupor.

Poultices, like stupes, are means of applying warmth and moisture. If applied early, it is believed they may prevent the formation of pus, as they bring about a resolution of the inflammation. When suppuration has commenced they facilitate the passage of matter to the surface, and lessen the extent of the disease. When applied to an inflamed part or swelling they should extend over considerable surrounding surface, but for a suppurating wound they should be but little larger than the opening.

Avoid putting them on very hot in a case of paralysis and also upon children, though they should be applied quite hot usually.

To make BREAD POULTICES pour boiling water on slices of bread without crust, simmer a few minutes, then beat up the bread quickly and spread it upon a piece of muslin previously cut of the desired size, leaving about two inches of margin upon each side. Then put on the poultice some lard or oil or vaseline to keep it from getting dry and hard, and to make it less likely to stick. It will be well to put on it a cover of thin muslin or mosquito netting, or tulle, or illusion, and then fold over like a broad hem the edges of both the covers. The poultice should be evenly spread about a quarter of inch in thickness and may be carried to the patient on a small tray or board, and if you are changing the poultice you should also have a small basin to carry away the old ones. After applying the poultice cover with some impervious material (oiled muslin or rubber cloth) to keep in the heat. Such a poultice as this will keep warm for five or six hours, but it should not be allowed to become cold and hard. Milk should not be used in making poultices as it quickly sours.

Poultices are made of various materials. Flax seed meal, starch, powdered slippery elm, Indian meal, and oat meal are used. They should all be made of such a consistence that they will be tenacious as possible, and should have at least a little oil on them to prevent their getting dry.

For PUTRID SORES some disinfectant solution may be used instead of water in making the poultice, such as a weak solution of chlorinated soda.

Yeast poultices are used to hasten the separation of gangrenous sloughs. Mix six ounces of yeast with the same quantity of water at blood heat. Stir in fourteen ounces of wheat flour and let it stand near the fire until it rises. Apply while fermenting, or, “Take of wheat flour a pound, yeast half a pint, mix, and expose the mixture to a gentle heat until it begins to rise.”

The following are old officinal forms for poultices:

Alum cataplasm. Take the whites of two eggs, of alum a drachm, shake them together so as to form a coagulum. (A common mode of preparing the alum poultices is to rub the whites of two eggs briskly in a saucer with a lump of alum till the liquid coagulates.) The curd produced by coagulated milk with alum is sometimes used as a substitute. The alum cataplasm is sometimes employed in incipient or chronic opthalmia as an astringent application. It is placed over the eye enveloped in folds of cambric or soft linen.

Cataplasm Carbonis ligni. Take a sufficient quantity of wood charcoal red hot from the fire, and having extinguished it by sprinkling dry sand over it, reduce it to very fine powder and incorporate in the simple cataplasm in a tepid state. Charcoal recently prepared has the property of absorbing those principles upon which the offensive odor of putrefying, animal substance depends. In the form of poultice it is an excellent application to foul and gangrenous ulcers, correcting their fetor and improving the condition of the sore. It should be frequently renewed.

Conium Cataplasm. Take of extract of poison hemlock (conium) two ounces, water a pint. Mix and add of bruised flax seed sufficient to produce a proper consistence. This cataplasm may be advantageously employed as an anodyne in cancerous, scrofulous, and other painful ulcers, but its liability to produce narcotic effects in consequence of the absorption of the active principle of the hemlock must not be overlooked.

Sometimes a bag is made to contain a poultice, and such a bag should be used if we desire to apply a large poultice to the chest or abdomen. One can be made for the breast and for the back at the same time, and two straps over the shoulder may unite them. A hop poultice is a thin bag loosely filled with hops and wrung out of hot water.

Dry fomentations are sometimes employed. Thin bags filled with heated sand, ashes, salt, bran, or hops are used, to keep the heat applied to the skin; and to warm the feet and quicken the circulation in the extremities, hot bricks, bottles filled with water, &c., are applied. These should be rolled in hot flannel or at least enveloped in something.

OF THE APPLICATION OF COLD.

Cold applications are sometimes used to subdue inflammation in the early stages. They are not good when matter is forming, or during sloughing. When they are used they ought to be continuously applied so as to keep up a constant cooling effect. Sometimes either water or some lotion is used with the design of cooling by evaporation. If a part is wet with water, alcohol, vinegar, a solution of muriate of ammonia, or other fluid, and left uncovered, the effect will be to cool it. When you design to cool by evaporation do not lay on more than one thickness of muslin or lint, and this must be wet so often that it does not get nearly dry. But a part may be cooled by several folds of muslin wet in ice water, and changed for fresh ones before they get warm. It is important that they do not become warm, and hence they should be frequently changed; alternate cooling and reaction is hurtful rather than beneficial. A steady cold stream of water is one means of cooling, and another device is to carry across a part a long strip of muslin or lamp wicking, having one end in a vessel of cold water higher than the bed, and the other leading to a basin below it. Protect the bed well with India rubber cloth so that both the patient’s clothing and the bed are kept dry.

Rubber bags are made to contain ice, and these are made in different shapes to be adapted to different parts of the body. They should not be more than half filled, and as soon as the ice melts the supply must be renewed. The ice used should be finely broken; this may be done by wrapping it in a fine cloth and pounding it. If mixed with one-third saw dust the ice will keep longer. A fold of muslin should be interposed between the ice bag and the skin, and they should be kept in their place by a bandage or some other means. An ice bladder for application to the head can be kept from pressing on the head by being folded in a napkin, which may be attached to the pillow by a pin. A cup shaped sponge may answer in the place of the ice cap to contain the ice; this must be wrung out before it is saturated, so that the pillow may not become wet.

Collyria are best applied to the eye at the outer angle; a glass dropper or a camel’s hair pencil may be used—this same one should be used for nothing else. Draw down the lower lid, and tell the patient to look up at the same time that the drop of eyewater is slid in. Do not leave moist cloths bound upon the eye as they become hot and may do harm.

If you rub in liniment with your hand, wash the hand carefully before touching a sensitive spot, as some of the ingredients may cause smarting or other injury.

The fact that certain diseases are contagious is one that throws some grave responsibilities upon the nurse, and on account of the importance of the subject, I will here discuss it in the light of modern science.

Infectious diseases are supposed to be propagated by the agency of minute living parasites given off from the body of the sick and conveying the specific virus. The germ thereby includes this for the cause of all the zymotic diseases—diseases that are contagious and produced by some morbid principle or germs acting on the system like a ferment. They are claimed to be a vegetable growth of a fungoid nature, and the theory is that during the process or period of each—a period of growth like mildew—the victim is a sufferer from a more or less violent fever; that the period varies; in typhoid it is twenty-one days, in other forms of fever perhaps a shorter time, till the microscopic fungoid growth may be said to effloresce and shed its spores. Some diseases also that are not contagious are believed to be caused by organisms in the air. There are various kinds; monads, bacteria, vibriones, &c., are among the substances found in the atmosphere of a large city, and elsewhere.

A very great variety of these forms called fungoid growth have been seen and distinguished, and it is demonstrated clearly that certain forms cause certain diseases. For example, cholera or choleraic symptoms have been induced in animals by the introduction of the cholera bacillus into their intestines, and almost invariably the dead animals showed a great abundance of the characteristic bacillus in the intestinal tract. The diseases which are now known or believed to be caused by such virus are very numerous, and directions for preventing a disease from spreading are based upon this theory; epidemic and endemic diseases are generally attributed to such a cause. The list of germ diseases is about as extensive as the list of contagious diseases.

Epidemic diseases are those that act upon numbers of people at the same time. Probably there is generally, though not always, disease organisms diffused through the air.

Endemic diseases are confined to particular localities. Sporadic cases of disease are those occurring singly, or scattered considerably.

Disinfectants are such substances as act upon the specific germs or minute living particles to destroy them. Antiseptics are such as prevent decomposition or putrefaction.

Septic germs are generally destroyed when widely diffused in the air. It is believed that oxygen acts as a disinfectant, at least dry air is not favorable to their growth. A dry heat of 300 degrees will destroy them, and they are generally killed by a freezing temperature. Against communicable diseases the chlorine class of antiseptics including iodine, iodoform, bromine, and sulphur are the most effectual, and chlorine and sulphuric acid may without danger be used in the sick room to a sufficient extent to do some good.

The most rapid and powerful of the disinfectants is the solution of the bichloride of mercury (corrosive sublimate). The solution most commonly used is of the strength of fifteen grains to the quart. It can be applied directly to floors, beds, walls, sinks, drains, vessels, &c.

For clothing use a solution of common salt and sulphate of zinc, two ounces of the salt and four ounces of the sulphate to a gallon of hot water; soak the clothes in this and then boil them in water with borax, or soap or soda.

When a disease is known to be very contagious and dangerous, especial care is necessary to avoid contact on the part of patients and nurses with outsiders. All superfluous things must be taken out of the room before the patient is put into it, and care will be necessary continually to make the quarantine effectual. Every article carried out of the sick room must be disinfected; a set of dishes should be kept for the patient’s exclusive use, washed only by the nurse; the bedding, clothing, &c., must be washed by the nurses themselves, after being soaked in a disinfecting solution; dressings and other cloths, such as old cloths used for handkerchiefs, may be burned; all excrementitious and vomited matter must be disinfected; the broom that is used to sweep the room must not be used elsewhere; no current of air must be permitted to pass from the sick room to the rest of the house; and it is well also to hang about the room cloths wet with some disinfectant solution; hang over the doorway a sheet similarly disinfected; and the nurse should cover her head with a close cap.

Lest the confinement and isolation make the nurse sick she must take care of her own health. Two nurses should be employed for every such case, so that neither may be obliged to sleep in the same room with the patient, and each should change her clothes and go out of doors for a time every day and take a brisk walk in the open air.

The ventilation is of especial importance in contagious diseases, as no disinfection can render the air entirely pure. To prevent the infectious particles that are thrown off the skin in cases like small pox and scarlet fever, from polluting the air of the room, the clothes should be frequently changed, and the patient’s body be washed and anointed with some ointment.

Charcoal placed about the room in shallow vessels does some good by means of its property of absorbing gas; and solutions of carbolic acid, chloride of lime, soda, and zinc are germicides, but the chief use of the carbolic acid family is where suppuration is going on, to prevent the spread of septic infection. It is also a means of disinfection perhaps, if the spray is used in malarial disease. Condy’s fluid and sulphate of iron are used as antiseptics, but these stain clothing.

Chlorine should not be used with sulphuric acid, or carbolic acid.

Either copperas or chloride of lime may be thrown dry into water closets. A little disinfectant should be kept standing in all sputa cups, urinals, and bedpans, and in cases of typhoid, and cholera, the stools must be carefully disinfected. These diseases are not only directly infectious, but the germs in the discharges may multiply and spread the disease. Cover the bottom of receiving vessels for stools with copperas or chloride of lime, and after use add crude hydrochloric or sulphuric acids in quantity equal to half the bulk of the discharge. Cover closely and carry from the room, and empty into a trench prepared to receive them, at a distance from the water supply, and all clothing and bedding soiled by the discharges must be disinfected and boiled.

After a case is ended the room must be subjected to a cleaning and fumigation. Everything that can be so treated should be either boiled or subjected to a heat of 220° in a disinfecting oven. Rubber sheets and aprons may be cleaned with bichloride solution, and the floors, woodwork, and perhaps the walls should also be washed with a solution of bichloride of Mercury. While the room is being fumigated, drawers and closets should be open and things not thoroughly disinfected should be hung up in it. A good way to fumigate the room is to burn sulphur in it, but you may evolve chlorine from common salt in the following way: Mix an equal bulk of common salt and black oxide of manganese in a shallow earthen dish, add two pints of sulphuric acid previously diluted with two pints of water, and stir with a stick. It is best in using this to have also steam in the room.

To fumigate a room have the doors, windows, and fireplace closed, and paste paper carefully over the cracks. If sulphur is used put it in iron pans, allowing two pounds to every thousand cubic feet of space; set the pans on brick, so that they will not burn the floor; pour a little alcohol on the sulphur and ignite, then leave the room quickly so that you do not breathe the gas; paste up the door when you go out; keep it closed for twenty-four hours, then open all the windows and let the room air.

Those directing the disinfection should always remember the bleaching and corroding power of chlorine and sulphurous acid gas.

When a patient has died from any infectious disease the body should be washed in some disinfectant solution, or soap should be used containing bichloride of mercury, and a sheet should be wrapped around the body wet with the same. Saturate also a large wad of cotton with it and leave it under the hips. The burial should be soon and private in these cases.

OF THE NURSE’S DUTIES IN CARING FOR THE DYING AND DEAD.

Certain duties devolve upon the nurse in cases of DEATH from any disease, and I prefer to refer to those duties here.

Among the signs that indicate approaching dissolution are a peculiar sharpness of the features; coldness of the toes, fingers and nose; a dusky shade about the finger nails; cold perspiration, restlessness, and muscular twitchings or stupor. When you are sure that the end is near it is best that the friends should be informed. While there is slight grounds for hope do not give up all efforts, but do not disturb the dying by useless ministrations. Note the exact time at which death takes place; this is usually, though not always, obvious.

There may be a rise of temperature, and the body be quite warm a short time after death; this is produced by chemical changes, but after a short time its temperature corresponds with that of the room in which it is lying. Then the peculiar stiffening of the muscles called RIGOR MORTIS sets in which lasts for a time and then disappears. Before rigor mortis comes on prepare the body for burial by washing it (using a weak solution of chlorinated soda or carbolic acid), closing the eyes, arranging the lips naturally, and combing the hair. Bandage the jaws closely, stuff all the orifices of the body with absorbent cotton to prevent discharges, and bind a cloth around the hips. A clean night dress or shroud or any other clothing desired can be over this, then cover the face and all with a sheet.

The arrangements can be put in the hands of an undertaker, but it is quite likely the friends will wish you to superintend them. If the body is to be kept for several days it must be packed in ice, and after twenty-four hours the face has a more natural appearance. The dark discoloration of the skin observable a few hours after death on the neck and sides and more dependent parts, is caused not by mortification, but by the blood settling or gravitating downwards. Slight discolorations about the face can be made less conspicuous by dusting them with toilet powder.

After the body has been taken from the house, the bedding must be sent out to be disinfected, all the appliances of sickness removed, the room put in order, and the windows left wide open for several hours.

SOME GENERAL LESSONS IN NURSING.

Rule 1. Do not get out of temper, but try to make the sick chamber the pleasantest and yet the quietest room in the house. Do not appear anxious however great your anxiety.

2. Do not converse in whispers; invalids generally are suspicious and will imagine all sorts of things if they see their friends conversing in this manner.

3. Do not urge the invalid to eat and drink when she does not feel like it.

4. Do not ask a convalescent if she would like this or that to eat and drink, but prepare the delicacies and present them in a tempting way.

5. Do not allow the nauseating medicine bottles to stand in the sight of the patient.

6. Study all the peculiarities of your patients, and instead of opposing them by arguments or otherwise, humor them whenever they do not interfere with the physician’s orders or instructions.

7. In all cases keep everything that is used by the patient perfectly clean.

8. If the patient is not allowed to drink as much as she desires, give her the limited quantity instead of a full glass. If she is allowed to drain the glass she will probably be satisfied.

9. Do not allow flowers or plants to remain in the room over night, and always remove flowers from the sick chamber as soon as they become stale.

10. In all cases the patient should have baths so often that the skin is kept clean, and the pores are not stopped up.

11. Take care not to chill or fatigue a patient while bathing. A sponge bath can be given in bed, the bed being protected by an extra draw sheet.

12. The mouth should be often washed and the teeth brushed or wiped off with a soft cloth.

13. The hair should be combed at least once daily. The ladies’ hair is braided or twisted on top of the head so that she will not have to lie on a knot.

14. Do not light a sick room at night by means of a jet of gas burning low.

15. Preferably use sperm candles.

16. Do not have the temperature of the sick room much above 60°.

17. Do not allow offensive matters to remain; but in a case of emergency where these cannot be removed at once, you can wring a heavy cloth out of cold water and use as a cover, placing over this ordinary paper.

18. Do not neglect during the day to attend to necessaries for the night, that the rest of the patient and family be not disturbed.

19. To avoid making a noise by throwing coals on the fire, place it in paper bags and lay them on the fire.

20. Do not lean or sit upon the bed, if this is disagreeable to the patient.

21. Always remember that nothing which contributes to the welfare of those who require the nurse’s care, is too trivial to demand her attention.

22. The following may by some be called little matters, but attention to them will add materially to the well being of the sick: Refrain from constant enquiries of patients as to how they feel, for sick people are easily annoyed; anticipate the wants of your patient if possible; never tiptoe about the room; if the patient is very sick have the courage to tell the friends who call that the invalid cannot see friends, if able to see them their stay must not be prolonged; do not allow a patient to sit up in bed without covering the shoulders with some light wrap; support them properly with pillows, or a chair and pillows; when obliged to leave the room take something with you which is no longer needed, and bring back necessary articles, thus saving annoyance to the patient and labor to yourself.

23. To AVOID MISTAKES IN GIVING MEDICINE it is a good rule to always read the label before and after measuring the dose; no medicine should ever be given in the dark; tie a ribbon on bottles that contain remedies for external use; shake a bottle before opening it; do not leave a bottle uncorked; generally keep medicines in a dark closet which is cool as possible; have every medicine that is dangerous taken internally labeled “poison”; keep them under lock and key.

24. The nurse should know the ordinary doses of medicines and the symptoms of overdosing. Every unusual and inordinate action of a drug may be a good reason for omitting a dose or two till the physician is seen and new directions are given, otherwise be always regular and prompt in the administration of medicines.

25. But in general the nurse can best display her knowledge and exercise her skill by faithfully carrying out the instructions she has received from the physician. If the directions are not what she would expect, it may be an exceptional case; the doctor and not the nurse is the judge as to what is exceptional; she must obey his orders. Do not receive orders from the physician in silence, and when he is gone refuse to obey them. The nurse should never hide anything from the doctor, even if she has done wrong; it is a serious thing to think that life should be risked in order to conceal wrong doing. Never be afraid of troubling the doctor; he will always be glad to hear anything that will help in the diagnosis or treatment of the case. The nurse has much to do with an art whose end is the saving of human life; any neglect to act openly and intelligently becomes a crime.

26. Remember that kindness and tenderness as well as faithfulness are needful to successful nursing.

BEDSORES.

Every precaution should be taken by the nurse to avoid bedsores on her patient. These appear most frequently upon the hips, but may develop elsewhere in parts subjected to pressure. To harden the parts they must be frequently washed with soap and water and thoroughly dried. A draw sheet should be placed under the patient that can be changed as often as it becomes wet and damp. Be careful to keep the sheet free from wrinkles and inequalities, and the patient’s clothes must be kept smooth under her. Occasionally rub on the skin oil or vaseline, and then dust on some fine powder such as oxide of zinc, fine starch, or toilet powder.

Plasters that are entirely unirritating may be applied either before or after there is an evident sore, and if change of position is not possible, it may be necessary to obtain air cushions or a water bed.

An air mattrass or air cushions may be put on any bed, but a water bed must be put in a trough or wooden frame made of just the right size. The water in a bed of this kind should be of a temperature of 70° and renewed every two weeks. To prevent a water bed from sticking to the boards some old cloths must be interposed.

Reddening and roughening of the skin, and pain on pressure indicate an approaching bedsore before there is an abrasion of the skin. Those washes that cause smarting must be discontinued, and sulphate of zinc ointment, and unirritating plasters used.

If a part is dead and likely to slough off, apply charcoal or yeast or chlorinated poultices until the gangrenous parts can be removed. After the separation of the slough you can apply lint smeared over with carbolated cosmoline or whatever application the surgeon or doctor may direct. The sore must be washed and applications renewed each day, and at each time it may be covered with a piece of oiled silk or muslin, or rubber tissue confined in place by adhesive straps.

The SPONGE BATH or washing can be done partly under the bed clothes, and but a small part of the body need to be exposed at a time. Do not bathe immediately after a meal.

Always have a bath of the temperature directed by the doctor. The following terms are used to indicate different temperatures:

To put a feeble patient in a bath wrap her in a sheet and lower her gently down in it. When she is taken out wrap her in a warm dry sheet and over this fold a blanket. After a few minutes’ rest and a little wiping with a soft dry towel the clothes may be put on.

Do not give a cold bath when the patient feels chilly, when there is perspiration, or there is inflammation or congestion of an internal organ.

The temperature of the body may be lessened by means of the wet pack in cold water, or by means of a sheet wrung out of cold water wrapped around the patient, and changed every ten or fifteen minutes, or by applying towels from the neck downwards, wrung out of cold water.

For the wet pack the sheet may be wrung out of either hot or cold water. Spread a comforter and two blankets on the bed and over these a sheet wrung out of the water. Remove all the patient’s clothing, lay her in the middle of the sheet, then draw over one side after another of the blankets and comforter, wrapping her from the neck to ankles; apply something to the feet to keep them warm, give plenty of drink, and put a wet compress on the forehead. If this is intended to induce perspiration or repose, the patient may remain in the pack two or three hours.

A BLANKET BATH is used as a means of sweating. A blanket is wrung out of hot water and wrapped around the patient. She is to be packed in three or four dry blankets and allowed to rest quietly for thirty minutes. Then the surface of the body must be well rubbed with warm towels, and the patient made comfortable in bed.

Cold or tepid sponging is sometimes directed when there is a fever. Commence at the head and sponge downwards, then wrap in a blanket and leave her undisturbed for an hour or more.

The effect of the HOT BATH if long continued is to induce languor and weakness. Watch by the patient while she is in the water, and take her out if there is any sign of fainting. Do not give a hot bath during a menstrual period.

A hot foot bath is one of the best means of revulsion to relieve the head. Let the water come nearly to the knees, cover both the patient and tub with a blanket, keep the feet in the hot water for about twenty minutes.

If a HOT AIR BATH or a VAPOR BATH is given, some device should be used to keep the blankets from pressing upon the patient. Two half hoops may be tied together so that they answer the purpose. By the same means steam may be diffused around her, if hot bricks wrapped in wet flannel and put on dishes are placed in the bed beside her, or steam can be conducted from a boiling teakettle under the blankets. Or place the patient in a large cane seated chair, and surround both completely with blankets, letting them extend to the floor and be secured about the patient’s neck. Under the chair, place a basin of hot water with an alcohol lamp beneath it; bring the water to boiling, and the patient will soon be in a perspiration which may be carried to any extent.

For a BRAN BATH, boil two pounds of bran in a gallon of water and add to the bath.

For a SALT BATH, add one pound rock salt to every four gallons of water.

For a SULPHUR BATH, add twenty grains sulphuret of potassium to a gallon of water. Used for skin diseases and rheumatism.

In cases where there is a high fever, especially in children, the warm water bath is given to reduce the temperature. If a child that has a temperature of 104° is immersed in water heated only to 98° for fifteen or twenty minutes, it will part with some of its heat.

BATHING OF INFANTS.

The bath for very young infants should be quite warm—about 97°. Some nurses ascertain if it is an agreeable warmth by dipping an elbow in the water. The temperature may from week to week be lowered gradually to 85° or 80°. Two baths a day may be given. The evening bath should be warmer than the morning. A brisk, gentle rubbing after the bath is beneficial. If a child gets blue and shivers the bath is too cold. The warm bath will often serve to put a restless and feverish child to sleep.

To bathe an infant support its head on your hand and arm, dip the baby into the bath; then rub the whole surface of the skin rapidly with a soft sponge or piece of flannel soaped; next again immerse the body in the water, then quickly and thoroughly dry with a fine warm towel.

Before giving a bath have every thing likely to be needed at hand, and the room warm.

CHANGING CLOTHING.

Before raising up a patient to put on a chemise or night dress, pull up the soiled one towards the neck, and as soon as the head and shoulders are raised, the soiled garment can be slipped off over the head and a clean one put on; then pull this down smoothly under the back before laying the patient down.

If two garments are worn one can be slipped inside the other, and they can be slipped on as one.

CHAPTER VI.
SURGICAL NURSING.

Before I dwell particularly upon surgical cases and wounds of all kinds, I will refer to some general duties of the nurse who attends during a surgical operation.

Generally the patient to be operated on should have a bath the previous night, and perhaps an enema on the morning of the operation; if the operation is on the female genital organs a warm douche should be given.

Prepare the room by having it well cleaned and aired and of a temperature of about 85°. Such things as are likely to be needed; for example, vaseline, carbolic acid, basins, sponges, towels, scissors, needles, pins, ice, hot and cold water, should be provided. If you have to make bandages, an old cotton sheet is good material from which to tear the strips. To join the strips lay two ends flat on each other overlapping for an inch, and baste together all four sides. A roller bandage may be from two to twelve yards long; it must be rolled as tightly as possible; the selvage and all loose threads must be trimmed off.

The proper cleaning and preparing of sponges is important. If one has been used it should be well washed and left in a solution of sal soda, and then kept for several days in a five per cent. solution of carbolic acid. New sponges should be prepared with twice as much care.

In a case where there is to be an operation upon the female genitals, a T bandage may be required; this should be put on before the ether is given, at least the part above the hips, the other part may be left free till after the operation, to be then brought between the thighs and attached to the other in front.

Only a little light food should be taken for three or four hours before etherization. Prepare the patient for going to the room by having her hair combed and braided, artificial teeth must be taken out, and all tight bands loosened. Arrange the clothing so that it will be protected, and so that it can be changed afterwards easily. See that she passes the urine the last thing before taking her place for the operation.

Have a bed ready that is properly made and protected, to which she can be moved when the doctors allow it, and where she can be kept quiet. If there is nausea and vomiting, the effects of the ether, you may quiet it by letting her sip a little hot water or by putting a hot, dry cloth on her neck and chest. During the operation you had simply to wait on the surgeon, now the patient will be principally in your care.

You will receive instruction from the surgeon in regard to things needing peculiar watchfulness and every point must be carefully noted.

As the wound may need to be watched during the first twenty-four hours for hemorrhage, it must be so arranged that it can be looked at without waking the patient.

The danger to which surgical cases are liable are, 1. Shock; 2. Hemorrhage; 3. Erysipelas; 4. Pyemia; 5. Tetanus. If there is TRAUMATIC ERYSIPELAS the edges of the wound are red and swollen, the secretion of pus ceases, and by the next day the skin around the wound becomes of a peculiar red color. There will be fever, headache, nausea, and a coated tongue.

Erysipelas can be generated by inattention to sanitary laws. It is infectious and spread by fomites, and the virus of erysipelas may give rise to puerperal fever. It is not proper for a nurse that has had the care of a case of erysipelas, to soon be the nurse of a lying-in woman, even if she is careful about using disinfectants on her hands and changing her clothes.

Certain influences augment the susceptibility of the body to the agency of the poison. Among the influences are intemperance, low spirits, anxiety, insufficient nourishment, and foul air. There should be great care in regard to ventilation, and clearing and cleaning the room where it has been present.

The disease cannot be cut short by active remedies, but may be made to terminate favorably by the use of the perchloride of iron, &c. (F. 177.)

Tetanus (lockjaw) may follow slight wounds. At first the muscles of the jaw are rigid, but the rigidity or spasms may extend all over the body. It may result from exposure of the wound to cold, and some cases of tetanus in infants have been attributed to the funis, in instances where as much as three or four inches were left attached to the umbilicus. In a case of tetanus the patient should lie in a darkened room, and noise should also be excluded.

Incised wounds, made in the flesh by sharp cutting instruments, of course may be trivial cuts, or deep incisions, and may sometimes be treated by the nurse, either because they are slight injuries or because a surgeon cannot immediately be obtained.

If there is not much bleeding there will not be very much to do. It is well to have a little carbolic acid in the water with which it is washed. The bleeding will soon cease if only small vessels are divided. If there is any extraneous matter on the surface of the wound it must be removed. Then put the surface of the lips of the cuts together, and take measures to keep them in this state till they have become firmly healed. If sutures are necessary take one or more stitches. The most common method of keeping the surface of divided parts in contact is by strips of adhesive plaster. Apply them after having put the wounded parts in a position favorable for bringing the edges of the wound together, then while one holds the lips of the wound evenly together secure them in this position by strips of adhesive plaster applied across the line of the wound. Leave a little interspace between each two strips of plaster. It is not best to bind it up so that there is no passage or exit for blood. But slight wounds may become serious if some poison or virus gets into it; you may need to put on lint or a compress over the strips of plaster and then a roller or bandage.

But some incised wounds instead of being immediately dressed and bound up, demand that immediate attention should be paid to the hemorrhage. We may usually know whether the bleeding is arterial, venous or capillary. If the wound is open, blood from an artery will spurt out in jets and is of a bright red color. Unless the artery is very small a surgeon will be needed, but you may be required to act very promptly to suppress for a time a dangerous flow of blood. If a large artery is cut or punctured the hemorrhage may be fatal in a short time. The application of heat or cold, and the elevation of the part injured, may suffice in slight cases, but in these severe cases other means are necessary.

First endeavor to arrest the rapid flow of blood by pressure upon the wounded artery with your thumb. Then if the wound is in a limb let some one tie a handkerchief loosely around the limb, and if you know the course of the artery have the knot directly over it and between the heart and the wound. Then put a stick in under and twist the handkerchief so that it is tight enough to compress the artery. The hemorrhage can thus be checked until the surgeon arrives. If the wound is over a bone in the head or body, the bleeding may probably be checked by binding on a hard compress where the artery is cut, thus making direct pressure upon it. A ligature upon a limb ought not to remain very tight more than an hour.

If the hemorrhage is from a leg below the knee it may be checked by putting a firm roll of cotton in the flexed joint, and pressing the lower part of the leg against the thigh; this will compress the artery.

Contused wounds are not often attended with serious hemorrhage. If there is in the bruised part only slight subcutaneous laceration, nature may soon repair the injury. But if there is considerable contusion indicated by the ecchymosis where small blood vessels have been lacerated and the blood extravasated into celular tissue, causing the dark discolored spots and other evidences of severe injury, there will be subsequent inflammation, perhaps suppuration, demanding treatment. A proper mode of dressing at first is to bind on a compress saturated with a four per cent. solution of carbolic acid, and for the fever and inflammation one drop doses of ext. veratrum may be given.

But in all cases where wounds are severe the services of a physician will be required.

A PUNCTURED WOUND signifies one made with a sharp pointed instrument, the external opening being small compared to its depth. It is a good rule in these cases to leave a free vent for any discharge that may be set up. The danger in these cases is from serious injury to the deep seated parts, and from suppuration which may burrow and extend still deeper if there is not free exit for the pus.

One mode of treating POISONED punctural wounds (serpent bites, &c.), which of course are peculiarly dangerous, is by applying cups over the wound.

Any wound that suppurates much or sloughs causes a cavity to be filled up, and the process by which the wounds and sores heal is called granulation, and cicitrization. The wound is gradually filled up to the surrounding level by new tissue appearing in the form of small red granules bathed in pus. Healthy granulations on an exposed or flat surface rise nearly even with the surrounding skin, and often a little higher, but when they are much higher, and take on a growing action, they are what is called proud flesh. Their growth may be checked by the application of active astringents; nitrate of silver or burnt alum may be used, or adhesive straps may be applied. The skin with which it is covered when healed is formed from the surrounding skin, and the process which is called CICITRIZATION does not go on well except when the granulations are nearly level with the adjacent skin. The centre of a sore has power to form new skin when there is a particle of live skin there, and for this reason skin is sometimes grafted in.

A patient suffering from a suppurating wound becomes enfeebled from the discharge of pus, and should have his strength kept up by nourishing food. A surgeon will always endeavor to prevent the retention and decomposition of discharges, and to protect from external contamination. He will direct the time and means of dressing the wounds, but the nurse must remember that decomposed animal matter acts as a virulent poison introduced into the system as it may be through any abrasion of the skin. All instruments used about a wound must be thoroughly cleansed before being put away. Dressings which have been next the wound should be burned; those which are to be washed should be disinfected. Avoid soiling your own hands with discharges; protect with a bit of plaster every place where there is any cut, or scratch, or sore. If you fear that any virus has got in where there is any sore, or where the skin is broken, touch it with carbolic acid.

FRACTURES AND DISLOCATIONS.

One of the signs of a FRACTURE is crepitus, the sound made by the rubbing of the ends of broken bones together. This sound cannot always be obtained, even when the bone can be moved so that the ends rub each other, and as such motion causes considerable pain the nurse should not seek for it, except as she harkens when the limb is accidentally or necessarily moved. The separation and inequalities of the ends of the fracture (when the bones are superficial), the change in the form of the limb, and the shortening of it, are circumstances communicating information in very many cases, and the diagnosis is made pretty certain if there is unnatural mobility of the limb. In other cases there is loss of motion or immobility, swelling and pain in the injured part, &c., but it will possibly require the services of the skillful surgeon to detect the existence and character of a fracture; and generally the coaptation or setting of the bone, can be deferred until he arrives. The nurse can do something in the meantime—can have the patient and fractured limb put in as easy a position as possible; perhaps have something ready for bandages and splints. A splint may be made of anything that will hold the bone securely in place; it should be longer than the bone that is broken. Sole leather is sometimes used; cut the required size, softened in hot water, moulded to fit the part and left on until dry, when it will be of the desired shape. Plaster of Paris bandages are sometimes used. These are prepared by rubbing into the ordinary muslin rollers dry plaster. They are then rolled. When they are applied, soft flannel bandages are first put on the broken limb, then the one containing plaster is (after being dipped in water, and some of the water squeezed out), applied over the flannel. It takes ten or twelve hours for this to set and become hard, and the broken limb must be kept still during the time. Dust the part over with toilet powder before the bandage is applied. The success of the surgeon depends very much on the good constant care of the nurse. If it is necessary to move the limb keep up some extension on it and do not twist it. Be very careful that the directions of the surgeon are carried out, and it will probably be necessary to keep up extension all the time, otherwise the deformity may return and the limb be shortened.

Dislocations are not so easily reduced as fractures, but after the setting and reduction of a dislocated joint the action of the muscles tends to keep it in place. There is always some laceration of the ligaments and sufficient injury to the soft parts to excite a little inflammation, but the pain is relieved as soon as the bones are replaced.

In general recent dislocations are easily reduced, but when the head of a bone has been out of its place for several days the reduction becomes exceedingly difficult, and as a rule the difficulty of reduction arising from the muscles is proportioned to the length of time that has elapsed from the period of the accident. For this reason a person who has a little general knowledge on the subject of dislocations, should sometimes make an attempt at reduction immediately after the accident.

The signs of dislocations are pain, incapacity of motion in the limb, change in the length of the limb and in the direction of its axis. Sometimes the dislocated limb is nearly incapable of any motion, and sometimes the destruction of the means of union, allows the limb to obey any extraneous influence.

The replacing of the dislocation would require very little effort or force were it not for the resistance of the muscles and tendons attached to them. In reducing a luxated bone the main point is to apply force until the head of the bone dislocated can be slipped into its place, which is generally when it is nearly to a level with its socket. This is easily effected immediately after the accident, because at that time the resistance of the muscles is not great; it may be best to attempt it, but there should be no delay in sending for a surgeon.

I recommend that an attempt be made to set a DISLOCATED THUMB or FINGER by making extension on the lower member and at the same time pressing the head of the bone towards its natural situation. If the reduction is effected, the thumb or finger should be rolled with tape and surrounded and supported with pasteboard; and the hand and forearm put in a sling. A surgeon may be necessary even in a case of dislocated thumb or finger, but bones out of joint are so much more easily set at first, that it is best to attempt to set them then, and the same may be said of some larger bones.

For instance, if there is a DISLOCATION OF THE ELBOW, the patient being settled, let one man take hold of his arm near the shoulder, to make counter extension while another makes extension at the wrist. You yourself being seated grasp the elbow with your two hands by applying your fingers to the anterior part and your thumbs to the posterior, press on the projecting point of bone downwards and forwards. You will generally be successful, but I do not advise five minutes’ delay in sending for a surgeon. I only advise that an effort be made immediately.

After thus reducing a dislocation of the forearm backwards at the elbow, apply a bandage in the form of a figure of eight; apply some lotion or liniment, and keep the arm in a sling. At the end of seven or eight days when the inflammation has subsided, the articulation can be gently moved, and the motion may be increased every day.

The figure of eight bandage is a roller applied alternately above and below a joint, the roll being carried obliquely over a central point.

The art of putting on a roller bandage is an important one for a nurse to acquire, and I may here give a few general principles though no exact directions can be given. In applying a bandage care must be taken that it is put on tight enough to fulfil the object in view, without running any risk of stopping the circulation. A bandage must lie smoothly, without wrinkles, and making an even pressure. For bandaging an arm or leg a roller from two to three inches wide may be used; a few turns may first be given on the hand or foot, and after this every circle is to be applied so as to ascend up the limb in a gradual spiral form and cover about one-third of the turn of the roller immediately below it. To accommodate it to the shape of the limb reverses are made. The bandage is doubled back by placing a finger on the lower edge to hold it firmly, and turning the bandage downward over itself, at such an angle as properly shapes its direction, and these turns can be made as often as is necessary.