Chapter IV: Part 4

Bandages.
One strong kitchen table.
Four small tables.
Three common chairs.
One fountain syringe.
Three large basins and pitchers.
One small basin and pitcher.
One piece of rubber sheeting for table.
Two slop-jars or foot-tubs.
One gallon of hot boiled water.
One gallon of cold boiled water,
and always keep a kettle of water boiling on the stove.
Antiseptic solutions as ordered.
Alcohol.
Safety-pins.
Green or synol soap.
Absorbent cotton.
Sterilized gauze.
New wooden nail-brush.
Two dozen towels, and plenty of clean soft cloths.

This list is an outline of the articles usually required; the surgeon will supplement what is necessary for each particular operation, but when a nurse is called upon to prepare for an operation in a private house, where the conveniences of the hospital are not at hand, she will be thankful to have ready a list of the things that are indispensable. I well remember my first operation outside the hospital, and how difficult I found it to construct a modern operating-room from the limitations of a small country house.

All supplies, when possible, should be on hand the night before the operation, and the room cleaned ready for work.

Facing the best light, and about five or six feet from the window, place the kitchen table, and cover it with a double blanket or comfortable, rubber sheeting, and a sheet fresh from the laundry, the whole pinned firmly at the four corners with safety-pins. Lay on the top a small single sheet, a blanket, and very small, firm pillow.

The little tables are to be arranged around the large one, leaving plenty of room to walk between. Cover them with sterilized sheets; if they have polished tops, first put on a piece of oilcloth or rubber sheeting to prevent damage. These tables are for the instruments, gauze, sponges, sterilized towels, and basin of solution for the surgeon’s hands.

A strong screw must be fastened in the wall near the window at the height of about seven feet to support the fountain syringe, which will be filled with whatever solution the surgeon requires for irrigating the wound.

One slop-jar stands at the side or end of the large table, the other beside the table that holds the basin of sponges.

The bureau (covered with a sheet) or the mantle-shelf will serve to hold the dressings and rubber gloves. A small stand or table will be needed by the doctor who gives the anesthetic for his hypodermic, clean towels, and ether or chloroform.

All the basins, towels, and pitchers to be used during the operation must be thoroughly washed in warm soap suds and then boiled for an hour, or—when that is not possible—allowed to stand all morning in a 1: 1000 bichlorid solution, and then rinsed off with sterilized water before using. Two of the basins are filled with sterilized water or salt solution for washing the sponges, another basin holds the wet sterilized towels, and the fourth the solution for the surgeon’s hands.

A small bowl is needed for the soft soap to wash off the part of the body to be operated on, also a small pitcher of 1: 2000 bichlorid and some alcohol.

In the bath-room arrange plenty of clean towels, a bowl of 1: 2000 bichlorid, and one containing alcohol, synol, or green soap, and a sterilized nail-brush for the surgeon’s hands. The surgeon will send instruments, sutures, and anesthetic.

You cannot err in having ready a good supply of sterilized water, as an emergency may arise in which a double quantity would be required. Clean the wash-boiler thoroughly, fill it almost to the top, and boil for half an hour. One boilerful must be prepared in time for the water to grow cold before the operation; it is then poured into pitchers that have been washed in warm soap suds, and rinsed off with the sterilized water. Cover the pitchers with sterilized towels or napkins.

It is of the utmost importance that everything should be in perfect readiness when the surgeon arrives. The nurse will do well to go over the list carefully, so that nothing may be missing.

TO PREPARE A ROOM FOR AN OPERATION.

BY JESSIE MCCALLUM,

Graduate Johns Hopkins School for Nurses.

_From the American Journal of Nursing._

1. The room selected for the operation should be near the bath-room, as a porcelain tub filled with bichlorid solution of the strength of 1: 1000 makes an excellent arrangement for disinfecting the washbowls, pitchers, platters, plates, etc., which are to be used during the operation for the solutions, instruments, needles, and ligatures.

2. If the carpet cannot be removed, it may be protected with oilcloth, rubber sheeting, or newspapers, over which sheets can be pinned.

3. The windows can be frosted by rubbing sapolio on the inner surface, thus preventing any possible observation from the outside.

4. Two small tables placed together to form one of the required size, old blankets being used to make the tables of uniform height and also to furnish a comfortable surface for the patient, can be used for an operating-table, care being taken to cover the blankets with a bed-rubber or table oilcloth and a sheet, securely folded under, and tied to the table with muslin bandages.

5. A Kelly pad can be improvised by tightly rolling a blanket and covering it with a rubber sheet, two ends of which are to be pinned together and used to conduct the solutions into the foot-tub below.

6. An ironing-board or the leaf of an extension table, supported by two chairs, makes a good table for instruments or solution basins.

7. An ordinary clothes-boiler, one-third filled with water, can be used as a sterilizer, the instruments rolled in gauze, and the brushes and orange sticks (for the doctor’s hands) being immersed therein. The necessary dressings, towels, sheets, fountain syringe, etc., are sterilized by hanging them in a hammock or sling hung from the handles of the boiler. A kitchen fork, lengthened by securely fastening to it an iron spoon, makes a convenient utensil with which to remove the articles from the boiler.

8. An ordinary sheet folded over at the top makes an excellent gown for the operator, if the ends be carefully taken up under the arms, crossed in the back, and used as sleeves for the shoulders and upper part of the arm, the middle of the upper hem of the sheet being pinned to the collar in front.

9. Water boiled in the clothes-boiler or tea-kettles can be quickly cooled by placing pitchers of it, covered with sterile towels or cloths, in a dish-pan or foot-tub of cracked ice.

10. A kettle of water kept boiling during the operation is a great convenience.

11. Salt solution filtered into household preserving jars can be sterilized in the wash-boiler with the other articles.

12. A stretcher can be improvised by slipping two window-poles or broom-handles into the folds of a sheet folded the proper size and securely fastened with safety-pins.

13. The Trendelenburg position can be secured by using an ordinary kitchen chair comfortably padded with a rubber-covered pillow and sheet, the back of the chair being placed under the patient.

14. The patient can be put in the lithotomy position by placing under the knees a padded walking-stick, to the ends of which is fastened a sheet folded diagonally, and passed under the shoulders.

AN EMERGENCY STEAM STERILIZER.

Take an ordinary wash-boiler. Make a crate of three light boards and a few slats to fit the interior. Boards should be about six inches high, to escape the water. The slats laid across will support all goods necessary for an operation. Pack parcels lengthwise to permit the full circulation of steam. Sterilize under full pressure of steam for one hour. Then take out and place on a table to dry.

TO STERILIZE AN OBSTETRIC SET OR SMALL PACKAGES.

Use a boiler or small kettle which has two handles. Make a hammock of strong muslin, tie corners to the handles and place packages in the sling suspended an inch or two above the boiling water. Cutting the muslin in a square and folding it on the bias gives more room, as the goods will stretch.

INSTRUMENTS TO USE FOR OPERATIVE CASES.

CURETMENT SET.

1 pair scissors. 1 uterine probe, long.
2 forceps, 8-inch. 4 “ curets, sharp and dull.
2 tissue forceps, long. 6 hemostats, 6-inch.
1 placenta forceps, Barrett’s. 2 tenacula.
1 uterine dressing forceps. 2 volsella.
3 “ sounds. 1 Sims’ speculum.
1 “ dilator. 1 retractor, deep and broad.
1 “ douche point.

HERNIA SET.

2 pairs scissors. 6 hemostats, 4-inch.
2 scalpels. 18 “ 6- “
2 pairs tissue forceps. 3 “ 8- “
1 grooved director. 1 needle-holder.
1 Kocher “ 2 perineum needles.
1 Fenger “ Suturing material and needles.
1 probe.
2 pairs retractors, sharp and dull.

AMPUTATION SET.

2 pairs scissors. 6 hemostats, 4-inch.
1 scalpel. 18 “ 6- “
2 pairs tissue forceps. 2 “ 8- “
1 bone saw. 2 curets.
1 cutting forceps. 2 periosteotomes, long and short.
1 holding “ 1 bone elevator.
2 bone-holding forceps. 2 probes.
1 lion jaw. 1 hammer.
1 rongeur. 2 chisels.
1 grooved director. 1 needle-holder.
1 Kocher “ Needles and suturing material.
2 pairs retractors,
sharp and dull.

LAPAROTOMY SET.

1 pair scissors, curved. 2 pairs retractors, broad.
1 “ “ straight. 2 “ “ narrow.
2 scalpels. 6 hemostats, 4-inch.
2 pairs tissue forceps. 18 “ 6- “
1 grooved director. 3 “ 8- “
1 Kocher “ 2 “ curved, 8-in.
1 Fenger “ 2 tenacula.
1 probe. 2 volsella.
2 pairs retractors, superficial. 2 perineum needles.
2 “ “ sharp. 1 needle-holder.
2 “ “ dull. Needles and suturing material.
2 “ “ deep.

GALL-STONE SET.

1 laparotomy set. 2 gall-stone scoops.
1 lithotomy forceps. Aspirating syringe and needle.
1 long probe. 2 bone curets.

SKIN-GRAFT SET.

1 scalpel. 2 curets.
1 pair scissors. 3 hemostats, 8-inch.
1 tissue forceps, plain. 6 “ 6- “
1 “ “ rat-tooth. 2 razors.
1 Fenger director.

SKULL FRACTURE SET.

1 pair scissors, straight. 18 hemostats, 6-inch.
1 “ “ curved. 6 “ 4- “
2 scalpels. 4 “ 8- “
1 bone-holding forceps. 3 bone curets.
1 bone-cutting “ 2 gouges.
1 probe, long. 2 periosteotomes.
1 “ short. 1 rongeur.
1 Fenger grooved director. 1 lion jaw.
1 Kocher grooved director. 2 trephines.
2 retractors, superficial, sharp. 1 deVilbiss.
2 retractors, superficial, dull. 1 hammer.
2 chisels. 2 aneurism needles.
1 aspirating syringe. 1 bone elevator.
1 “ needle. 2 pair tissue forceps.
Needle-holder and needles. 1 ether mask.

HEMORRHOID SET.

2 pair scissors. 1 grooved director.
2 knives. 6 hemostats, 6-inch.
1 clamp. 2 “ 8- “
2 retractors. 2 “ “T.“
2 tooth tissue forceps. 1 bone curet.
1 plain “ “ 1 rectal dilator.
1 probe. Cautery.

PROSTATECTOMY SET.

1 laparotomy set, suprapubic.
1 hernia set, perineal.

Add to either set:

6 sounds, graduated sizes. 6 filiform bougies.
2 metal catheters. 1 rubber catheter, size 16.
2 grooved staves. 1 “ “ “ 18.

SURGICAL SETS FOR STRANGULATED HERNIA, GASTRO-ENTEROSTOMY, GUNSHOTS, ETC.

1 laparotomy set. 4 intestinal clamps.
2 Murphy buttons.

TUBERCULOUS GLAND AND GOITER SETS.

1 hernia set 2 aneurism needles..
6 hemostats, 6-inch. 1 ether mask.

WIRING OF BONE.

1 amputation set. 4 drills.
2 drill-holders. Wire or plates and screws.

SURGICAL SETS FOR VARICOSE VEINS, VARICOCELE, HYDROCELE.

1 hernia set.

SURGICAL POSTURES.

OPHTHALMIA.

PURULENT OPHTHALMIA (SUPPURATIVE INFLAMMATION OF THE CONJUNCTIVA).

BY CASSIUS D. WESCOTT, M. D.,

Assistant Professor of Ophthalmology at Rush Medical College, Chicago, Ill.

Purulent ophthalmia is caused by a specific germ, and is very contagious.

_Local Treatment._—Irrigate with warm boric-acid solution or normal salt solution every hour. Anoint the edges of the lids with sterile vaselin to permit free drainage. Castor oil and glycerin, of each, equal parts; or borated vaselin may be used for the same purpose. Astringents and caustics, silver nitrate, etc., are usually applied by the doctor.

_For an anodyne_, atropin is principally employed, also cold or hot compresses; in the use of the latter care must be taken to prevent irritation of the skin that will show itself in a permanent livid hue.

In case of excessive swelling a leech may be applied, or the doctor may resort to scarification.

_Medicines_ consist of cathartics, diuretics, diaphoretics, opiates, tonics.

_General Treatment._—Frequent baths, plenty of fresh air. Temperature of the room should be uniform. Moderate and subdued light.

_Diet_ should consist of nutritious food, liquid or soft, according to the condition of the patient.

The gravity of each case depends largely upon the extent to which the cornea is involved.

Treatment must, of course, be modified according to the virulence of the inflammation.

_To Apply a Leech._—Leeches are applied to relieve congestion. Put one in a small vial with a mouth large enough for the leech to crawl through. Cleanse the patient’s temple, and with a sterile needle scratch the skin until the blood shows. Directly over this place the mouth of the vial. The leech will bite almost instantly, and will drop off when it is gorged. If the occasion requires the leech to be taken off before it is gorged, sprinkle a little salt on its head. Hemorrhage should not be checked unless profuse, in which case a piece of ice or alum applied to the spot will arrest the flow. _If possible, the patient should be kept in ignorance of the application._

OPHTHALMIA NEONATORUM.

When the disease develops it will be manifested, as a rule, from three to five days after birth by redness of the eye and a slight discharge. It is the duty of the nurse, as well as of the accoucheur, to examine the eyes of the new-born babe each day during the lying-in period, and at the first sign of trouble, if discovered by the nurse, the attention of the physician should be directed to the matter. During the first two or three days after the disease begins there is usually little or no pus present, and comparatively little swelling of the lids, except in the most violent cases. During this so-called first stage the treatment should be that of an ordinary acute catarrhal conjunctivitis—viz.: iced compresses applied for an hour twice a day if the baby is well and strong; gentle flushing of the conjunctival sac with a warm saturated solution of boric acid. As soon as pus begins to form, the eyes must be cleansed more frequently—every hour during the day and every two hours during the night—and the edges of the lids should be kept constantly anointed with sterile vaselin to prevent their agglutination and the retention of the discharge. Drainage is indicated whenever there is suppuration, and if we can prevent the sticking together of the lids in this way, we allow free drainage and reduce the irritation which invariably results from retention of the discharges in these cases.

In all cases it will be noticed that after the discharge has been washed away from the everted lids there are strings or shreds of mucus in the folds of the conjunctiva. The nurse should endeavor at each cleansing to wash them out by continuous flushing and gentle manipulation of the lids. If she does not succeed in keeping the eyes free from these shreds the physician will remove them at least once a day.

If the conjunctiva of the globe becomes swollen and edematous and rolls up over the edge of the cornea, the nutrition of this precious membrane becomes threatened, and inflammation of the cornea, with ulceration or sloughing, is the cause of the blindness which follows this disease. At the slightest indication of haziness of its surface the iced compresses should be discontinued and hot fomentations resorted to. They may be applied every three hours for fifteen minutes each time. Great care and judgment are necessary in order that the heat be sufficient to be effective without burning the delicate skin of the lids and that it be continuous. The compresses should be changed at least every sixty seconds during their application. When the cornea becomes ulcerated great care must be used in the manipulation of the lids not to make pressure upon the eye-ball for fear of causing perforation. If the lids are slippery from the presence of vaselin or discharge, a single thickness of gauze or a little cotton held between the finger and the lid will be found a great help in opening the eye.

As the discharge of pus begins to diminish, which may not be for several weeks in bad cases, we may somewhat modify our treatment; the strong applications need not be quite so strong, and the cleansing need not be quite so frequent; but the most important item in the treatment of all these cases is the frequent thorough cleansing of the eyes, and if the cleansing is thoroughly done as above described each hour and the lids kept constantly anointed, in order to prevent accumulation of the irritating discharge, more frequent cleansing will not be necessary. Great care must also be exercised to prevent much crying by these little patients. They must be kept warm, regularly nursed or fed, and the slightest derangement of the alimentary canal must be attended to. If the cause of the crying cannot be ascertained and removed, it is wiser to soothe the baby with a simple anodyne than to permit the crying to go on.

It should not be necessary to point out the danger which lies in all things which come in contact with the discharge from these eyes.

Blennorrhea neonatorum is responsible for at least 25 per cent. of all the blindness in the world, and yet not one case in a hundred should result disastrously if skilfully and patiently managed.

EMERGENCIES.

HEMORRHAGES.

Hemorrhage from the arteries may be recognized by its bright red color and by the spurting jets by which the blood leaves the wound. Venous (from the veins) hemorrhages flow in a steady stream and are darker in color. Arterial hemorrhage may be checked by firm pressure over the side nearest the heart or above the wound. Venous hemorrhages may be checked by firm pressure on the side distant from the heart or below the wound. Large veins like the jugular should be compressed both above and below the wound because the vein may bleed from both ends. If possible, digital pressure should be made directly over the bleeding point.

Hemorrhage from the _leg_ may be checked by firm pressure upon the femoral artery, in the middle of the groin at the top of the thigh.

Hemorrhage from the _forearm_ by compression under the inner edge of the biceps against the humerus.

Hemorrhage from the _upper arm_ by compression of the axillary artery against the humerus in the axilla.

Hemorrhage from the _cheek_ by compression on the facial artery against the lower jaw just in front of the masseter muscle.

Flexing the limbs at the joints with a pad between them to make the compression secure and then binding the part may prove a successful method of arresting the flow of blood. A constrictor of rubber tubing twisted firmly around the limb is a ready appliance and a most successful way of checking a flow of blood from an injured limb. But it should not remain on longer than absolutely necessary or gangrene may result from complete stoppage of the circulation.

Wounds should be packed fully and evenly with some absorbent material. Applications of heat and cold are common methods of checking hemorrhages, heat being at all times preferable. Hot water poured on open wounds will encourage coagulation. Bleeding from an ulcer of the leg, which often results from varicose veins, should be stopped by firm pressure over the wound.

_Hemorrhage from the Lungs._—A teaspoonful of salt taken internally may stop it. Place an ice-bag over the chest. Morphin, gr. ⅛-¼, may be given under the instructions of a physician. In all cases put patient in bed and enjoin complete rest until medical aid arrives.

_Nose-bleed (Epistaxis)._—First of all, position and rest should be attended to. The patient should not lie down unless very weak. The higher the head the better. Loosen clothing about the neck and thorax. Caution patient against coughing or sneezing. Holding the nostril tightly closed, with cold applications to the back of the neck, is sometimes successful. Insufflation of ice- or alum-water, or of tannic acid solution may induce coagulation. Profuse bleeding will require packing of the nostrils.

FRACTURES.

_Compound Open Fracture._—The bone is broken and the wound extends from the seat of the fracture to the outside. Such wound may be caused by the injury itself, or may occur secondarily from the protrusion of pieces of bone through the skin.

_A comminuted fracture_ is one in which the bone is broken into a number of fragments.

_An Impacted Fracture._—The broken ends have been forcibly driven into one another, and are thus fixed.

_Multiple Fracture._—The bone is fractured at different points, or when different adjoining bones are broken.

_A complicated fracture_ is one associated with a serious injury to some important adjacent part—_e.g._, a large vessel.

_A green stick or incomplete fracture_ occurs where the bone is soft and bends, and is only partially fractured; it is most frequent in children.

=Symptoms= of fractures are usually pain, loss of function, deformity (seen or felt by passing the fingers over the seat of pain), crepitus or the grating sound produced and felt on rubbing the broken ends against each other, abnormal mobility in the course of the bone, swelling, and discoloration.

The principal point is to keep the part immovable and in a position to give as little pain as possible. Support the limb with something stiff and padded with cotton or remnants of yielding material. Bandages can be made of handkerchiefs, strips of linen, ribbon, etc., to keep the splint firm.

For the _forearm_ padded splints long enough to take in the hand from above the elbow should be applied. Tie firmly with bandages and suspend in a sling.

If the _upper_ arm be fractured, bind it tightly to the side. For the _thigh_, the splints should extend from under the arm to the ankle and should be bound to the body and leg with long towels or sheets torn into strips. A splint made of blankets, rolled up tightly from both sides on broomsticks, allowing space for the limb to rest between the supports, is a good and ready appliance. Always make extension to prevent contractions of the muscles, as this would result in shortening the leg.

For a broken _clavicle_ (collar-bone) bind the arm to the chest. Put the patient on the flat of his back with a small pad between the shoulder-blades. This will keep the broken ends in a normal position.

N. B.—In every case elevate and support the injured member on a pillow, keep in position and give complete rest until medical aid arrives.

DISLOCATIONS.

Dislocation is a displacement of the joint. It may occur with a break of the limb, but usually results from a fall or strain.

There may be deformity and inability to move the injured part. Sometimes an abnormal projection is the first sign. If inflammation arises, apply cold applications. The only treatment a nurse may give is to keep the patient quiet and await skilled help.

SPRAINS.

There may be extreme pain, swelling, inflammation, discoloration, and inability to use the joint. Support and elevation of the limb is of the greatest importance. Use hot or cold applications to allay the inflammation and pain. Cover with a thin soft pad, and bandage evenly and firmly. A sprain should not be neglected, as it may cause future disease of the injured part.

For recent bruises cold applications are best. Give the patient complete rest, support and elevate the injured limb, apply cold or hot applications, and await skilled help.

BURNS AND SCALDS.

In severe cases the constitutional treatment is of more importance than the application of local remedies. If the patient is in shock wrap him in warm blankets, and give him stimulants. In superficial cases where the skin is not broken powder with bicarbonate of soda (baking soda). A ready domestic application is sweet oil. _Exclude the air at all times._ When vesicles have been produced they should be punctured with a sharp instrument, and the serum gently evacuated with absorbent cotton. Apply soothing ointments or wet dressings. IN CASE OF SEVERE BURNS OF THE BODY immerse the patient in a warm bath, keeping it at even temperature. Separating a layer of common white cotton wadding, and wrapping it about the injured part will allay the pain, and the cotton has the advantage of not adhering to the raw surface. Splints and bandages should be employed to prevent contractions.

BURNS OF THE EYE.

For burns resulting from molten lead, strong alkalies, lime, or acids, flush freely with warm water or boric-acid solution, and anoint with pure vaselin or a few drops of castor oil. Do not rub the injured tissues. The applications should be made quickly and very gently. Put on cold compresses until medical aid arrives.

INJURIES TO THE EYE.

For surface injuries a drop of castor oil may be applied, and the eye kept closed for the day with a pad of wadding and a bandage.

SYNCOPE (FAINTING OR SWOONING).

Place the patient in a recumbent position. Loosen all clothing, and dash cold water on the face and chest. Spirits of ammonia or smelling salts should be used with caution, and not brought too near the nostrils. The pulse and general appearance will indicate if condition is serious. Give whisky and strychnin sulphate (¹/₃₀ gr.) hypodermically if necessary.

HYSTERIA.

In hysteria the patient may be apparently unconscious; the body is normal to the touch, the pulse is full and regular, the color is natural, and if an attempt is made to raise the eyelid it will be met with resistance. Do not leave the patient alone, but do not disturb her until she recovers.

EPILEPSY.

The attack comes on very suddenly. The patient utters a sharp cry, and falls to the ground. The muscles are rigid, the eyes staring, and there may be frothing at the mouth. The muscles soon relax, and there are twitchings of the whole body. The attack may last only a few minutes. Place the patient on his back with the head slightly elevated, and loosen all clothing. Put a wedge between the teeth, give him plenty of fresh air, and do not attempt to stop the movements.

DROWNING.

_Begin artificial respiration at once_, then soon as possible remove or loosen all clothing about the back, chest, and abdomen. Free the throat and mouth from mucus and foreign substances. Secure the tongue with a dry cloth or handkerchief; keep it drawn forward and to one side, as this opens the windpipe. Then turn the patient face downward, allowing the abdomen to rest on a roll of goods. Make firm pressure on the back and on both sides of the thorax to evacuate the lungs. Envelop the body in warm blankets, apply heat to the feet, and stimulate with hypodermic of strychnin, whisky, and coffee.

SUSPENDED ANIMATION FROM NOXIOUS GASES.

Remove patient at once into the fresh air. Employ artificial respiration, apply heat, and stimulate hypodermically.

METHODS OF ARTIFICIAL RESPIRATION.

=Sylvester’s Method.=—Lay the patient upon his back; kneel above the head, take firm hold of the arms above the elbow, and move them horizontally—first away from the body, then over the head until the hands touch behind; pull them backward for a few seconds. This process expands the chest cavity, and the lungs are filled with air, inducing inspiration. Return the arms to the first position, and make strong pressure on the sides of the chest and epigastrium to expel the air and effect expiration. Movements should not be too rapid; they should be repeated about sixteen times a minute. In case of apparent want of success, persist in the treatment until it has been ascertained that the heart has ceased to beat.

=Marshall Hall’s Method.=—Roll the patient over on his breast, make gentle pressure on the back, then turn the body gently but completely on the side, and again make gentle pressure on the back. Repeat these movements fifteen times every minute.

Artificial respiration may be kept up for hours before the faintest symptoms of life are shown.

SUNSTROKE.

Two conditions result from exposure to excessive heat: thermic fever and heat exhaustion.

In =thermic fever=, after prodromal symptoms consisting of headache, nausea, and vomiting, there are stupor or coma, fever ranging from 105° to 110° F., flushing of the face, contraction of the pupils, a rapid, full pulse, and noisy respirations.

_Management._—Pack the patient in ice, and rub with ice. Ice-water enemas may also be given. Bleeding and the subcutaneous administration of normal salt solution are sometimes efficacious.

In =heat exhaustion= consciousness is not lost; the skin is cold and moist; the respirations are shallow and rapid, but not noisy; and the pulse is feeble.

_Management._—The patient should be covered with blankets and surrounded with hot bottles. Aromatic spirit of ammonia (30 minims), whisky, and black coffee are useful stimulants.

BATHS AND PACKS.

WARM PACK FOR PNEUMONIA PATIENTS.

Articles needed:
4 blankets. Foot-tub for hot water.
1 rubber and towel for head. Basin and ice.
1 long rubber sheet. 2 compresses for head.

Place under patient: First, blanket, then rubber sheet, covered with second blanket. Place small rubber piece, covered with the towel, under patient’s head. Third blanket put over patient. Leave patient on side while woolen blanket is wrung out of hot water. Place this blanket quickly under and about the patient, removing lower dry one at the same time. Leave feet out of wet blanket, wrapping them up dry, and use hot-water bottle if necessary. Cold compresses to head. Leave in pack 45 minutes. Wipe dry; give alcohol rub. Take temperature and pulse every half-hour after removing from pack.

COLD PACK TO REDUCE TEMPERATURE.

Articles needed:
1 long rubber sheet. Foot-tub.
3 blankets. Pitcher or sprinkler.
Basin of ice. Rubber and towel for head.
2 compresses for head.

Place under patient: First, blanket, then rubber sheet, covered with second blanket. Have blanket over patient with patient on side. Wring a cotton blanket or sheet out of warm water to wrap about patient, leaving feet out, covering them with a dry blanket, using hot-water bottle if necessary. Compress on head. Sprinkle with tepid water. Use friction. Turn patient once in midst of pack and iron back with ice, and again just before he is removed. Leave in 30 minutes. Change compresses frequently. Give plenty of water to drink. Have sea sponge to take up water. Leave patient between blankets; give alcohol rub. Take temperature and pulse half an hour after removing the pack.

SPONGING TO REDUCE TEMPERATURE.

Articles needed:
2 blankets. Basin of ice.
3 towels. Basin of warm water.
Rubber and towel for head. Compresses or ice-cap for head.

Place patient between blankets. Rubber and towel under head. Towel across loins. Wash face and apply cold compress to head. Sponge chest, arms, legs, and back with warm water. Cool water and sponge chest. Apply cold compress across chest. Turn patient on side. Sponge arms, leaving upper part of body exposed. Fold blanket up and sponge back. Change compresses frequently. Give plenty of water to drink. Continue sponging from 20 to 30 minutes. Rub with alcohol and put patient to bed. Take pulse and temperature half-hour after sponging.

HOT PACKS TO INDUCE PERSPIRATION.

Articles needed:
4 blankets. 1 sheet.
2 long rubber sheets. Basin of ice.
1 short “ sheet. Foot-tub of hot water.
Rubber piece for head. Old woolen blanket.
2 towels. 2 compresses.

Place under patient: First, blanket, then rubber sheet, covered with the second blanket. Third blanket place over patient. Wrap feet up dry. Have patient on side. Wring fourth blanket out of hot water and place quickly about patient, bringing well up around neck and in between the arms. Wrap well about the legs. Bring under rubber sheet up about the neck well and place a long rubber sheet snugly over that. Wrap feet, then bring under blanket up over rubber sheet, and top blanket tucked over all, seeing that all folds of blankets are snug around the neck. Rubber and towel under head. Compress to head. Place sheet over patient not tucked in. Give hot drinks freely unless liquids are restricted. Take pulse before placing patient in pack and every 15 minutes while in. Leave patient in 45 minutes and then in dry blankets half an hour, Take out of pack, rub dry, and give alcohol rub.

TUBBING.

Articles needed:

1 long rubber sheet. 1 sea sponge.
2 blankets. 2 pails.
1 tubbing sheet. Basin of ice.
1 towel. Siphon.
2 compresses or ice-cap. Piece of rubber tubing.
1 bath towel.

Place under patient: One blanket covered with long rubber sheet, then with tubbing sheet, over which place muslin sheet widthwise. Place towel over loins. Bring sheet up around patient, tubbing sheet rolled in from sides and tied to the four corners of the bed. Use four pails of tepid water, gradually cool to 60° or 70° F. Apply friction most of the time. Compresses to head. Give water freely. Leave feet out of water. Turn patient and use friction on back once while in and before taking out. Take pulse frequently. Leave patient in pack 20 minutes. Turn patient and remove water with siphon and sea sponge. Lower patient, removing tubbing and wet sheet, leaving patient between blankets with hot-water can at feet. Take temperature half-hour after removal. Give alcohol rub and make bed.

ALCOHOL SWEAT.

Articles needed:
6 old blankets. 8 hot bricks in bags
1 piece of old blanket. (woolen preferred),
2 long rubber sheets. 12 × 12 inches.
1 short “ sheet. Basin of ice.
1 piece “ for head. 2 compresses.
1 towel. Alcohol.
1 sheet. Hot drink.

Place under patient blanket covered with a long rubber sheet and then second blanket. Wrap shoulders in a blanket. Place folded blanket and small rubber sheet around the feet. Cover patient with blanket, and over that place long rubber sheet. Fold back upper rubber sheet blanket over patient and then one under patient. Place covered bricks on folds of lower blanket. Pour one tablespoonful of alcohol on hot bricks covered with outer edge of blanket, on which bricks rest, then with blanket over patient, folding it in between bricks and patient. Bring under rubber sheet up and upper one down. Tuck each rubber sheet and blanket well in about the neck. Bring folded blanket and short rubber sheet over feet, under the long rubber sheet. Arrange opposite side in like manner. Place over all 2 blankets and tuck in. Cover these with clean sheet, not tucked in. Rubber and towel under head. Apply the cold compress to head and change frequently. Give a hot drink unless contraindicated. Take patient’s pulse before placing in sweat and every 10 minutes while in. More often as condition of patient indicates. Leave in one hour. Do not expose patient while removing bricks and blankets. Leave one blanket under and two over patient for half an hour. Tuck blanket about patient, sheet over all. When removing these blankets dry patient and give alcohol rub.

MASSAGE—MECHANO-THERAPY.

Massage (meaning to knead or manipulate) is one of the oldest therapeutic measures employed for the relief of disease. It is probable that the Chinese used this method of treatment several thousand years ago. The Japanese and the Greeks and Romans also were ancient users of massage. To-day it is recognized as one of our most useful adjuvants in the treatment of a great many disorders. Unfortunately, like some other therapeutic measures, it has been misused for personal gain by unscrupulous parties to the great detriment of this form of treatment; because of this many physicians have hesitated to adopt its use extensively for fear of being classed with the army of quacks and charlatans who endeavor to guile the public with a pretended knowledge of massage. It not being possible for all nurses to become proficient in the art of massage while doing general nursing (as it requires time, patience, and a great deal of experience to succeed), massage has become somewhat specialized, and we find many nurses who devote their time and attention exclusively to this work. Yet all nurses should have a general knowledge of the physiologic effects of massage and how to give it. The best results are obtained only when massage is given under the direct supervision of a physician, as massage may influence the function of almost every organ and tissue of the body.

Some general rules may be given as to the hour and duration of each treatment. A great deal depends upon the nature of the disorder in each individual case. In the treatment of neurasthenic patients where insomnia is often a troublesome symptom, massage given one or two hours before the patient quiets down for the night frequently results in improved sleep. Again, other patients will do better to have the treatment one or two hours after the morning meal. Individual peculiarities must be considered always in giving massage. The room should be of such temperature that the patient when exposed will not feel chilly. Absolute quiet should be maintained during the treatment, and after the treatment the patient should remain quiet in a recumbent posture for an hour or two as the condition may require. The oft-used expression “that a masseur or masseuse possesses a great deal of electricity which is transferred during the treatment to the patient,” should find no place in the intelligent mind in considering the effects of massage. It is true that one operator by his method of administering massage may please a patient and accomplish more than another, but this is due only to the fact that one understands how it should be given, and the other does not.

All the different movements in massage may be classed under the following: First, stroking; second, friction; third, kneading; fourth, vibration; fifth, percussion; sixth, joint movements.

=Stroking.=—This procedure may be given with two or three fingers or the palmar surface of one or both hands. The movement should be gentle, and the contact made as lightly as possible. Stroking should be done always in one direction, and, as a rule, in the direction of the blood currents in the arteries. The physiologic effects when properly applied should be sedative, as the purpose should be to diminish the blood-supply to the part. It produces a certain effect upon the cutaneous nerves which is very quieting. It is often found useful when applied about the forehead for sleeplessness. Nervous headache may be relieved by the same procedure. Neuralgic pains and the vague, but nevertheless uncomfortable, sensations complained of by neurasthenic patients are often relieved by this measure.

=Friction.=—In this procedure the whole or part of the palmar surface of the hand is moved over the surface of the body with considerable pressure. The principal effect of friction is upon the superficial blood-vessels and the lymphatics. In the lower extremities the movement should be from below upward in the direction of the venous flow. The same may be said of the upper extremities. The thumb may be made to follow the course of the larger veins, in this manner stimulating the venous circulation. Some patients object to friction applied by the dry hand, in which case some lubricant may be used; pure vaselin, cocoa-butter, and talcum powder are among the best for this purpose. Friction should always be used in the beginning of massage, especially if the surface of the body is cold.

It is not the intention here to give minute instruction as to the methods of procedure with all the different parts of the body; only general instructions can be here given, and those requiring further information should consult text-books upon this subject.

_Physiologic Effects of Friction._—First, reflex effects upon the vasomotor nerves producing dilatation of the peripheral blood-vessels with increased circulation, aiding the venous and lymphatic circulation. It is useful in all conditions accompanied by poor peripheral circulation. It not only stimulates the circulation, but aids materially in elimination and increased nutrition. It aids in the relief of general dropsy and hastens the absorption of inflammatory exudates resulting from sprains and various joint affections, etc.

=Kneading.=—Kneading is one of the most important procedures in massage. It consists in the alternate compression and relaxation of the tissues, the hand not being allowed to slip over the surface as in friction. It may be administered in various ways, such as rolling, wringing, and the use of the palm or fingers. Furthermore, it may be deep or superficial. Superficial kneading stimulates all the functions of the skin, increases superficial circulation in the blood-vessels and lymphatics. In deep kneading the object is to influence the deep-lying muscles, and care should be exercised in this procedure not to injure the large blood-vessels and nerves. Here a knowledge of anatomy is essential. In the beginning of deep kneading little pressure should be exercised until tolerance is established; then greater pressure may be exercised without discomfort to the patient. It is quite essential that each muscle group be gone over carefully and thoroughly, so that every muscle so far as possible shall be included in the treatment. The physiologic effect of deep kneading is a stimulation of the functions of the nerves, blood-vessels, lymphatics, and cellular metabolism of the muscles. It is of especial benefit to patients who are unable to take a sufficient amount of active exercise, such as those suffering from neurasthenia, rheumatism, chronic neuritis, locomotor ataxia, and from localized disturbances, such as fractures, sprains, etc.

=Vibration.=—This procedure consists of vibratory movements to the body of the patient through the hand of the operator. It may be given by using the palmar surfaces of the hand or the finger-tips. This procedure stimulates the superficial circulation and acts as a mild general stimulant. It may be used in conditions of poor circulation from any cause, but is contraindicated in conditions of hypersensitiveness.

=Percussion.=—This procedure consists of blows or taps with varying degrees of force. The tips of the fingers may be used, the two hands alternating, or the palmar or the ulnar surface of the hands may be used for the same purpose. In any case, the force should not be sufficient to bruise the tissues. The physiologic results of percussion are stimulation for functions of the skin and a marked effect upon the underlying structures, muscles, nerves, and blood-vessels. It is useful in such conditions as sciatica, inactivity of the liver, chronic constipation, poor circulation from various causes, and to produce reaction after a cold bath, etc.

=Joint Movements.=—Under this procedure we may mention flexion, extension, abduction, adduction, pronation, supination, circumduction, and stretching. The movements may be passive or resistive. In passive movements the exercise is almost entirely confined to the joint, the patient offering no muscular resistance. With the resistive movements a certain degree of muscular activity is enforced by the patient, thus not only exercising the joints, but the muscles connected with the joints. The physiologic effect of joint movements is to markedly stimulate all the parts about the joint, and is indicated in various joint disorders which may have resulted in the lessening of the normal movements of the part, as in rheumatism, gout, chronic synovitis, and the stiffness that follows immobilization of the joint in the treatment of sprains, fractures, etc. Care should be exercised in the beginning not to use too much force in the manipulation, otherwise the existing condition may be aggravated, and more harm result than good. Increased force may be exercised with each treatment, always bearing in mind the necessities of each case.

ELECTRICITY.

BY DR. JAMES C. GILL,

Rush Medical College, Chicago, Ill.

Electricity is a useful and important therapeutic agent, and an understanding of its effect when applied to the human body is as essential as a knowledge of any other therapeutic measure. Too often the therapeutic use of electricity is committed to those having very little knowledge of it, and consequently good results are not obtained.

It is a great mistake to allow or advise patients to use electricity themselves; no greater mistake would be made or more harmful results follow if they were advised to go to the drug store, and help themselves to any drugs they might choose. Electricity should be administered by a physician, or under the directions of a physician by a nurse who has been thoroughly taught its use.

In medicine we have usually considered three different forms of electricity: First, Galvanism or Chemical Electricity; Second, Faradism or Induced Electricity; Third, Franklinic or Static Electricity. Now, we add a fourth and a very important one—namely, _X_-ray. A nurse should have a general knowledge of these different manifestations of electricity and their effect when applied to the body.

In electricity we have units of measurements as we do in weights and measures. For instance, the force that drives the current of electricity along, as we might express it, is called the electromotive force, and its unit of measurement is a volt. The resistance which the current must overcome is measured in ohms, and the strength of the current is measured in amperes, or, as we measure it in medical electricity, the thousandth part of an ampere, a milliampere.

Galvanic or chemic electricity has certain properties not obtainable in the other forms. Comparatively speaking, it is a current of considerable quantity, but low electromotive force. The galvanic current passes always from the positive to the negative pole. It possesses the power to decompose various compounds, such as water, the tissues of the body, etc. This is called the electrolytic action, and may be used to destroy certain tumors, for the removal of superfluous hair, etc. Again this current has the power to convey certain substances in solution into the tissues. This is called cataphoresis, and is used to produce local anesthesia by the use of cocain applied to the positive pole. This is one of the best methods we possess of obtaining local anesthesia.

The effect of iodin may be obtained by the use of a solution of potassium iodid, and the negative pole may be used to affect local swellings, etc. Muscular tissue may be made to contract by the application of the current, either when applied to the motor nerve supplying the muscle or when applied directly to the muscle. Upon sensory nerves the positive pole is sedative, and may be used to relieve pain in cases of neuralgias, etc. The negative pole is stimulating, and may be used in conditions requiring increased nutrition, etc.

In using galvanism a good battery and outfit are essential. First, it is necessary to have a milliampere meter, an instrument to measure the strength of current used. The quantity of electricity used should be measured the same as the quantity or dosage of drugs prescribed. Another essential instrument is the rheostat, by which the current strength may be gradually increased or decreased without interrupting the current. The electrodes which are attached to the poles of the battery may be metal, metal covered with sponge, cotton, etc., preferably cotton, which may be renewed with each application, thus avoiding the possibility of infection, always present in the use of a sponge-covered electrode, which cannot be changed with each application.

In the use of galvanism we may speak of two different methods. First, what is called cerebral galvanism, second general. By experimentation it has been clearly demonstrated that all the deeper tissues and organs of the body, such as the brain, spinal cord, liver, etc., may be influenced by galvanism. In cerebral galvanism the object is to influence the brain and spinal cord. In applying it to the head, a sponge or cotton-covered electrode 4-5” in diameter may be used. The positive electrode is applied to forehead, the negative at nape of neck, using a current of 5-10 milliamperes for from five to fifteen minutes, care being taken not to suddenly make or break the current, as this would produce a disagreeable shock to the patient. The circulation of the brain may be affected also by placing an electrode at the nape of the neck, and a smaller electrode (1-2” in diameter) passed up and down along the border of the sternocleidomastoideus muscle, using a current of 3-5 milliamperes. Galvanism used in this way is beneficial in such conditions as cerebral anemia, neurasthenia, insomnia, etc. In applying to the spine, one electrode may be used at the upper and the other at the lower part of the spine; or a large-sized electrode may be placed over the abdomen, and the other electrode moved up and down the spine without breaking or interrupting the current, the strength of which may be from 10-20 milliamperes, and the duration of each application varied to suit the condition of the patient. This treatment is indicated in such disorders as neurasthenia, infantile spinal paralysis, locomotor ataxia, etc.

General galvanization may be given by placing a large-sized electrode at the spine, over the abdomen, or at the soles of the feet, the other electrode, smaller in size, being passed over the entire surface of the body without interrupting the current, which may be from 5-8 milliamperes. This procedure will stimulate the peripheral circulation, elimination, and nutrition. The muscles may be exercised by using an interrupted current of sufficient strength only to cause contraction. General galvanization is very beneficial in such conditions as neurasthenia requiring the rest treatment, convalescence from various diseases, paralysis, multiple neuritis, etc. In the use of electricity it should be remembered that patients show idiosyncrasies as in the use of drugs, so that each case should be given the amount of electricity best suited to individual peculiarities. Unless this point be kept in mind, we will be surprised to find at times that the use of electricity aggravates the patient’s condition.

Faradism, or the induced current, is characterized by a high electromotive force and a low amperage or quantity. It is an interrupted current, and from the secondary coil it is an alternating current. It cannot be used like the galvanic for electrolytic-cataphoric purposes. Its effect upon the body is almost entirely mechanical; also unlike the galvanic, there is practically no polarity. It cannot be used to affect the deep-lying structures, such as the brain, spinal cord, etc. The current-strength is not measured by a milliampere meter. It will produce muscular contraction only through the motor nerve supplying the muscle. This is a point to be remembered. Its use is confined largely to exercising muscles and stimulating peripheral circulation, and is useful in such conditions as paralysis where the cause of the paralysis is in the brain (because where the lesion producing the paralysis is in the spinal cord or peripheral nerves the muscle will not contract when faradism is applied), and in convalescence and all conditions requiring exercise which cannot be obtained actively. In applying this form of electricity (if the object be to stimulate circulation), the strength of the current should be regulated to suit the feelings of the patient. The technic is practically the same as described above for general galvanization. If we wish to exercise the muscle, then that current should be used which is just strong enough to produce muscular contraction and no stronger, care being necessary not to over-stimulate and exhaust the muscle. As a means of muscular exercise only this current is preferable to galvanism, being easier of application and less likely to produce harm.

Franklinic, or static electricity, is seldom administered by a nurse unless in a hospital or in a physician’s office. The current is produced by machines of various makes, such as glass and mica. The plates vary in diameter from twenty inches to three feet or more, and in number from two to sixteen or more. Its current then generated is characterized by an enormously high electromotive force, but a very minute quantity or amperage. Unlike the other two forms of current described, its use does not necessitate the removal of clothing. It may be used by placing the patient on an insulated platform and charging him with this current of high electromotive force, which very markedly stimulates circulation; or it may be used by applying or drawing sparks directly from the patient’s body, in this manner producing counterirritation, stimulating circulation, relieving localized pains, etc. It has been found useful in such conditions as chorea, neurasthenia, muscular rheumatism, lumbago, chronic inflammation of nerves, etc.

Nurses probably will never be called upon to use the _x_-ray, but this most wonderful manifestation of electro-force has recently taken a prominent position as a diagnostic and therapeutic agent. Parts of the human body heretofore only revealed by the use of the knife or post mortem are now plainly discernible during life through the use of this force. The field of its therapeutic application is a large one, and disorders which have been considered incurable or difficult of cure by other means now yield readily to the _x_-ray.

FOOD CONSTITUENTS.

=The Wise Combination of Food.=—In order that each meal may be planned to meet the needs of the body it is necessary that it contain protein, fat, carbohydrate, mineral matter, and water. Some flavor foods should enter into each meal.

Flavor is important because it stimulates the appetite and because it stimulates the flow of digestive fluids and thus aids digestion. Such foods are only injurious when they are used to excess. In that case the nerves which control the flow of digestive fluids are overstimulated and at last become weakened. Avoid the use of too many flavors at one meal.