Chapter XIII: The Valley of the Shadow (3)

I would like, if possible, to impress upon the nurse graduate that really there is much to learn after she has left the training school. All the technic of hospital and operating room is fresh in mind, but there is so much that lies necessarily outside the walls of a hospital, and this knowledge that comes with experience is a great part of what makes a successful nurse.

I will not touch here upon what every nurse knows so well, relating to the "preparedness" of clothes, satchel, and instruments. We take it for granted that all this is ready. The case before has been a hard one, we will imagine, and several days have been given to the luxury of whole nights in bed, and whole days of resting; this is all done, and the next case is awaited.

The best thing to do first is for the nurse to examine a little her mental equipment, see what she has stored away in her mind that can help the next patient, or that can assist in fighting the battle of hygienic cleanliness versus disease-bearing dirt. Let her consider whether she reads aloud acceptably, understandingly. Has she a good list of books which most women would enjoy? Does she know what books to suggest for the children? Can she tell what would interest the boys, or what a man would like to listen to? Does she know humorous books, interesting histories, or biographies? Here, then, is occupation for many idle days.

To go to a public library is always a pleasure, to make friends with the librarian is an added pleasure, as is also the making one's self familiar with some good books that can always be procured, and that will give pleasure and profit to patient after patient. This search for good literature will give happiness in the quest, and happiness in the reading. Librarians are usually glad to direct one to the books needed, and many delightful hours may be spent in the library, and all the while the comfortable feeling experienced that the pleasure felt will be transferred later to future patients.

The subject of hygiene is taught in most training schools, and indeed in many day schools as well; but this is a branch of knowledge that is growing so rapidly that, unless the very latest discoveries are learned, the nurse may find herself of use merely when the infection has done its work.

I wonder how many nurses have made use of the bulletins issued by the U. S. Department of Agriculture in Washington. These are called Farmers' Bulletins, but many of them are of use to all mankind, be they farmers or not. They are free to any who ask for them, and up to the present time about five hundred have been issued. They are upon all sorts of subjects--Flies, Malaria, The Destruction of Rats, Care of Food in the House, Fruit as a Food, Cereal Breakfast Foods, etc., etc., subjects _ad infinitum._ Here, then, is a mine of information open to anyone who asks; all one has to do is to write to the Secretary of Agriculture and ask to have sent a list of the Farmers' Bulletins published by his department, and from the list any bulletins may be selected, and they will be sent. Ask for what is needed; it is all meant for the education of the public. The information is absolutely reliable, and represents the best thought of the country--expert advice by the foremost scientists.

I have often thought that a nurse who made the nursing of children a specialty, or even those who nursed children occasionally, would be much profited by a course in a Kindergarten Training School. The private duty nurse, however, having but a few days at her disposal, cannot do anything as extensive as that; but a very good substitute is at hand, in the kindergarten department of any of our public schools. It is most interesting to go to a public school, ask to see the Principal, and let the nurse explain her visit, and show her how helpful it would be to future little sick folks, if she might be allowed to study some of the kindergarten methods, and permission will readily be given. When the nurse reaches the room of the "littlest ones," let her sit down, and quietly watch what is done for them, and how they are managed. The kindergartner will be glad to tell where she finds the charming stories she relates; she will give models of the wonderful things her pupils cut out of paper, the canoes, the men to sit in them, the wigwams, the sleds, automobiles, swings, stoves, trees, apples, etc., etc., articles well-nigh innumerable, and all so simple and so deftly made. A small convalescent could be amused for weeks with the things one could learn in a few hours in one of our city kindergartens. I speak of the things I know, for I have tried it, and I never yet found a Principal who was not glad to have her kindergarten studied, nor a kindergartner who was not pleased to know that she could assist in the work of nursing sick children, even in this seemingly roundabout way.

In all of our large cities are fine art galleries, and in many there are fine loan collections on exhibition every summer. There are, besides pictures in these loan collections, many things; some curious, some beautiful, and all of them interesting. Some days spent in these galleries will bring much knowledge and beauty into one's life. Time must be taken for these visits; no one can appreciate the patience and skill of oriental handiwork in a hurry. If unacquainted with the exhibits, a catalogue should be purchased, and each one studied until one knows why it is there, and what is its beauty. I remember seeing, one day, in a collection, a cup of jade, with a very finely wrought handle; I thought it fine, but did not appreciate it until the Custodian told me that it took the artist twenty years to carve that one cup, jade is such a hard stone. This cup was so valuable that the Kensington Museum, in England, had paid an immense sum of money for it, as a nearly perfect specimen. This information was my reward for close study of an exhibit. In these exhibitions one could spend many vacant days with much pleasure and profit.

In whatever town a nurse lives she should familiarize herself with the philanthropic efforts of the place. In the largest cities it is not possible to know them all, but she should know about some of the settlement work, the day nurseries, the babies' hospitals, the rescue work, the homes for aged. Of course she will know about the hospitals and dispensaries, but what is done for the poor, the ignorant, the sinful, and the stranger--these she should learn. Many times she could do much to help these institutions, by relating, simply and truthfully, when occasion offers, what she has seen, of the great needs of such efforts, and the heroic work of those who go down and live amongst the needy and try to uplift them. Many a rich, idle patient might become interested and give money, if not time, to help in these good works; and my experience shows that they generally need all the help they can get. So the nurse should know about the anti-tuberculosis work, the night schools, the playgrounds on the roofs of the school-houses, all the philanthropic work of her town, and she cannot know about it unless she takes some of her vacant days, her days of waiting, and turns them into days of learning, and the expansion of both her mind and her heart.

Another pleasant way to spend some days of waiting is to study the trolley system of the town where you live. Learn how far it can go, to how many other towns. If a river is near, become familiar with its steamboats. Excursions on boat or trolley will be delightful, and will teach the best routes, the best terminal stations, and the best restaurants, and some day when a patient is well enough to take an excursion, some part of his own immediate neighborhood may be shown him which he has never seen before. Believe me, all this will be appreciated. Space fails me to tell of music to be heard, theatres to be enjoyed, and all to be used hereafter for the benefit of those to whom you will be called to minister. The information constantly gathered in the "days of waiting," rightly used, intelligently imparted to the patient or her friends, will make of the nurse such a broad-minded, sympathetic woman that everyone who employs her will appreciate the fact that she has a wide culture, and brings to her patient something besides mere technical skill.

XI

SOME HINTS FOR THE OBSTETRICAL NURSE

THE BABY'S WARDROBE.

When a nurse goes to see a woman who wishes to engage her, some months hence, to care for her baby and herself, it is very nice to be able to give her, should she ask, a list of all the things she will need, both for her own comfort and the baby's.

The following is a good sensible wardrobe, and will be found ample, though many articles more or less fanciful will, most probably, be added by friends. The things enumerated below should last the baby until he is put into short clothes:

Slips, 10. Dresses, 8 to 10. Pinning blankets, 4. Flannel skirts, 4. White skirts, 5. Shirts, 4. Bands, plain flannel, 4. Bands, Jersey made, 4. Diapers first size, 17 inches square, 20. Diapers second size, 20 inches square, 30. Diapers third size, 26 inches square, 30. Knitted blankets, plain white, 2; if with any color, 4 to 6. Knitted sacques, 4 (two sizes). Little pillow (hair), 6 cases. Crib sheets, 6. Crib blankets, 2.

FOR BASKET.

Two small gold safety pins. Large safety pins, I box. Small safety pins, i box. Powder box and puff. Coudreay's powder. Small box of equal parts borax and powdered sugar. Old damask towels. One cake old white castile soap, or Colgate's nursery soap. One bottle unscented vaseline. As many sachets as you can get. Some few yards of the narrowest ribbon, pink and blue. Two old handkerchiefs. One lap protector. Brush and comb. Absorbent cotton.

FOR THE MOTHER.

All the old sheets in the house. Rubber sheet, double width. A square of rubber sheeting single width. An old comforter. [Footnote: When the Kelly pad is used for the delivery, the old comfortable, the blankets and the single width rubber sheet need not be provided.]Two or three old blankets. Fountain syringe. Paper basin. Towels ad libitum. Six or seven night dresses, three of them old. Undershirts, if worn in bed, 4 (large). Bandages, 6. Cheese cloth, 10 yards. Absorbent cotton, 2 lbs. A large flannel sacque, or a nightingale. Soft unbleached muslin, 2 or 3 yards. Colgate's fumigating wafers, I box. Bedpan, I.

Layettes can be purchased at any good department store, but many expectant mothers prefer to make all the clothes for the little one. These lists are for the benefit of these mothers.

These look, perhaps, like two very formidable lists, but a second glance will convince any one that all these articles are absolutely necessary, and none of them are expensive.

The slips should be made very plainly. The material may be as fine as can be bought, but beyond a few tucks about the yoke, and a little lace or fine embroidery about neck and sleeves, should be perfectly plain. The dresses, of course, are somewhat more elaborate, but the fashion now decrees that infant's clothing shall be perfectly plain, and a most sensible fashion it is. Pinning blankets are open all down the front, and are usually made in the shops with a broad band of stiff white muslin, which shows that the people who made them never tried to dress a baby. The band should be of flannel or coarse linen many times washed so that it may be soft, and the pins will go through many folds of it. Flannel skirts are usually made of two breadths of flannel, and are more or less embroidered. These are not left open, except just enough to make the dressing easy. Shirts are made so well in stores that few people care to knit them. They should always be high in the neck and long sleeved, and it is better to get two sizes, as, if the baby is small, it never can be comfortable in a large shirt that does not fit.

The four flannel bands should be 6 inches wide by 17 or 18 long, torn the length way of the flannel and left just as torn. Not hemmed or ornamented in any way. No hemming or stitching can be so fine that it will not mark the baby's flesh. Besides this, if you have these plain bands and find they are several inches too big, nothing is easier than tearing off a strip and making them fit. If the child has a very large, round abdomen, they can be made to fit over it nicely by taking two little tucks on the lower edge, about half an inch from the middle of the band, and letting the tucks run up about an inch or a little more, tapering it off gradually. When these are discarded and the Jersey made bands are put on, always put them on the baby feet first, as it is hard to get them over the shoulders.

The very best material for the first small diapers is old, soft table damask. The better the quality, the softer it will be; be sure they are exactly square. Nothing is more trying, in a small way, than to get a diaper that cannot be folded true. These should be made double and the edges turned in and sewed around. By the time the baby has outgrown them they will be fit only for the rag- bag, and may be thrown aside. The second size diaper, also the third should be many times washed to make them soft enough for use. These may be used at first folded eight times and put under the baby next the damask diaper, between that and the pinning blanket, and will often save the nurse the trouble of changing the baby's clothing, because it is wet through. In this way they will get more washings and be softer when you have to use them next the baby's skin.

Cotton flannel, with a good nap and not a very close web, is very good also and can be used instead of the damask where that cannot be procured. Put it on with the nap next the skin. It is an excellent absorbent.

The baby should have at least one little (rather flat) hair pillow, covered on one side with blue or pink silk, on the other with plain white over the ticking. The prettiest pillow cases I ever saw were made of broad hemmed pocket handkerchiefs. Two sewed neatly together round three edges, and on the fourth button holes for mother-of-pearl studs. The handkerchiefs may be fine or not, embroidered or plain, and may have lace sewed on the edge, but they can't help being pretty, and the embroidery will never be in the middle. I shall never forget my pity for one poor little mite I saw once, who, on waking from his sleep, was discovered to have the print of an embroidered S on his cheek. It had been worked in the centre of the little pillow case by some loving but ignorant hands. When the baby uses the pillow, let him sleep on the white side; at other times turn up the colored side and the pink or blue will show very prettily through the linen. If you let the child sleep on the colored side he may, most likely will, vomit some sour milk on it, sooner or later, and the beauty of your pillow will be gone.

If the regular little crib blankets are thought too expensive, a very good substitute may be made from white eiderdown cloth, which is warm, soft, and not at all costly.

The gold safety pins are intended for the final pinning of the dress in the front and in the back. Of course any little ornamental baby pin answers the purpose just as well, and, indeed, an ordinary safety pin will do should no other be at hand.

The little box of equal parts of borax and sugar should not be forgotten. Mix the two very thoroughly, and if any little white aphthous spots appear on baby's lips, tongue or cheeks, apply a little of this mixture several times a day, and they will probably all be gone by night. Put it on very carefully with the tip of your finger slightly moistened so that some of the powder will adhere. Examine the baby's mouth every day for these spots. They are likely to appear any time after ten days or two weeks, and are more often seen in weak children, or those who are fed by a bottle. If the spots appear on a child who is taking the breast, the nipples are very apt to be sore. Much care, therefore, must be exercised in this matter.

Sachets are a real luxury in the drawers of the baby's bureau. Atkinson's sachets are the best, though Colgate's violet is very delicate and pleasant. Put one or two amongst the little shirts, and some among the knitted blankets, but mostly have them in the dresses, and be sure when you take out a clean dress, or slip, to take the sachet and slide it into the neck of the slip that will be worn tomorrow. Nothing can be more attractive than a clean, sweetly smelling baby, and, _per contra_, nothing is more disgusting than a wet, sour, cold, crying baby. If he be wet and sour he will surely have cold feet and hands, and as surely will he cry. Poor little thing! It is his only way of expressing his opinion of the state of his toilette.

It is very pretty, when the baby is fresh and clean, and has on a fine slip with lace edging the sleeves, to tie around the wrist, outside of the sleeve, a piece of pink or blue ribbon. Make a nice little bow and let the lace fall over the fat little hands, like a frill. Be careful not to tie the ribbon too tight, and keep it clean. If it becomes soiled or wet, take it off directly.

A lap protector is made by covering a piece of rubber cloth about 14 inches square with several thicknesses of old blanket. To cover this have some slips like pillow cases, of linen or cotton, plain or fancy, as the lady may have time or money. Slip the "protector" in its case, and lay it on your own, or any one else's, lap who wishes to hold the baby, and it perfectly protects from all wetting.

TABLE FOR ESTIMATING THE PROBABLE DURATION OF PREGNANCY

Two hundred and eighty days, forty weeks, ten lunar months, or nine calendar months are here estimated as the usual duration of pregnancy (the actual computed average being 276-2/3 days). The exact day of conception (_not_ the fertile coition), can never be accurately determined; the only date from which conception can be dated, and the probable confinement day predicted with some chance of certainty, is the first day of the last menstrual flow, adding to this one week (seven days) for the average duration of the flow (with a few days lee-way). We count nine calendar months forward, and have the approximate date of the expected confinement. The most ready method is to add seven days to the first day of the last menstrual flow, count back three months, and add one year, when we have the future date when, or about when, delivery may be expected.

An _exact_ estimate is but guess work; errors of one or two weeks either way may be made by the most experienced, as in cases where conception occurred shortly before the next menstrual period, which did not then appear.

The present table is constructed on the above principle, the second column representing the day of quickening, nineteen weeks after the beginning of the last menstruation, with seven days added; and the third column still twenty weeks later. The date of quickening is still more variable than that of delivery, from one to four weeks.

Intermediate dates may be fixed by adding the necessary number of days to each column. Thus, for Jan. 11th, the second column should read 31st of May, and the third column, October 18th, and so on.

Beginning of last Quickening. Confinement. Menstruation.

Jan. 1st.........May 20th.........Oct. 8th. Feb. 1st.........June 20th.........Nov. 8th. March 1st.........July 18th.........Dec. 4th. April 1st.........Aug. 18th.........Jan. 6th. May 1st.........Sept. 17th.........Feb. 5th. June 1st.........Oct. 8th.........March 8th. July 1st.........Nov. 17th.........April 7th. Aug. 1st.........Dec. 18th.........May 8th. Sept. 1st.........Jan. 18th.........June 6th. Oct. 1st.........Feb. 17th.........July 8th. Nov. 1st.........March 20th.........Aug. 8th. Dec. 1st.........April 19th.........Sept. 7th.

ARTICLES FOR THE MOTHER'S USE.

Perhaps it is not necessary to say why it is better to use old sheets for the bed of a parturient woman, but I will repeat that old ones are to be preferred, and really new ones, that is, only once washed, never used. New towels are of course objectionable, as being too harsh. If the patient likes a rough towel, use a regular bath towel, if you can get it. Be careful, never to let loose and wet ends of the wash cloth drag along exposed parts of the body. It is a good plan to sew your wash cloth into a bag, and to slip your hand inside, and work with it put on like a mitten. A rubber or fibre sponge is to be preferred. Keep one for the face, neck, arms, and hands, and another for the feet and legs. The vulva is bathed best by means of a fountain syringe used as an irrigator, and a little sterilized gauze twisted around your dressing forceps. The gauze can be changed as often as necessary, and is much more satisfactory than anything else, especially if there has been a laceration.

The square of rubber sheeting, single width, is most useful. For the confinement the bed should be made by first spreading over the mattress the wide rubber sheet, over this put an old blanket, then the under sheet; upon the right side of the bed, where most likely the woman will lie, place the square of rubber, over that the old comfortable, four double, and hold all in place with a sheet folded like a hospital "draw-sheet." This must be firmly tucked in at the sides under the mattress. It will seldom be found necessary to change the under sheet, if the bed is made this way, and the rubber square is drawn carefully away, with the comfortable and draw sheet, when it is time to make the patient clean and dry after the birth. It is a good plan now to tear this square in two, and keep one piece directly under the clean draw sheet for the first few days. This saves much washing.

An old blanket and a small one will be found invaluable for all sorts of things--for example, to spread over the shoulders and chest when the bandage is being pinned; to warm and wrap up the feet and legs, if they show any signs of being cold; to cover one knee and part of the body when using the irrigator, which when there has been _any_ laceration, is a delicate piece of business, as every nurse knows. Always fold up this invaluable and constant friend, and put it in some handy but inconspicuous place; it _is_ a friend, and a good one; but it is not a beautiful object to look upon, and others not knowing its virtues would think you untidy if it was in a noticeable place. The fountain syringe is absolutely indispensable; and, though it may seem unnecessarily large, yet I think a four-quart bag better than any of the smaller sizes. To be sure, you never might need four quarts in the bag, but it is so much easier managed, so much less liable to spill over, if you have a large bag and put it only half or three-quarters full. Then, too, you get so much more force if you have more water in the bag, you need not use it all. A Davidson syringe is very nice for some things that a fountain syringe could not be used for. Oil enemas, for instance, also nutritive enemas. After an oil enema be sure to wash your syringe _thoroughly_ with a strong solution of washing soda or ammonia, else you will find the rubber of the bulb and tubing becoming pasty, and your syringe will be utterly spoiled. The paper basin is very light and easily handled and much to be preferred to a large china affair, which may easily slide from warm, wet, slippery hands.

I often wonder that the women of our day, who are so sensible in many things, should have abandoned the fashion of short night gowns, which our grandmothers always provided for themselves at these times. I remember asking one lady, when talking over what she would need for her first baby, and for herself, at the time of its birth, if she had not something short and plain that she could wear. She looked very thoughtful for a moment and then said that she thought she did have _one_ night-dress that did not have a ruffle or embroidery around the bottom. She could wear that. It certainly is not from motives of economy that our wealthy patients do not have these most sensible of garments. I think they know nothing about them, and they should have their virtues explained to them. A pocket could be added to this garment, I think, and it would be a real comfort to a woman. I know it would be to a nurse, who usually has to hunt up the ever missing pocket handkerchief a dozen times a day. Men always have pockets in their night-shirts, and they are not sick half as much as the women. I wonder why women do not imitate this most sensible custom. If your patient will not let you cut off any of her old night-dresses, you must use the long ones, of course, and change them as often as necessary.

Bandages should always be made of soft unbleached muslin; double is best, though I have used them of the single fold, and hemmed, but they are firmer if double. They should be wide enough to come down to the great trochanters, and up to a place two inches above the umbilicus; long enough to fit the woman before she became pregnant. She has likely some measure, or could get it from her dress-maker. Women vary so much, it is hard to give an exact measure in inches, but you might begin with a bandage fifty inches long, and if the ends are too long, cut them off, and turn in the edges of the cloth and overhand it neatly.

Obstetrical binders, or bandages are now seldom put on a parturient woman, but in case they are to be used, I give the best kind I know of. They are sometimes made to order, but I never knew one of these to fit, or wash well.

The method of their application is of course taught in the schools. The nurse should always know from the doctor, or the prospective patient, if binders are to be worn, and instructions given as to how to make them. Four or six will be enough.

Two or three yards of soft, unbleached muslin for breast-bandages should be provided in case they are needed. A six-tailed bandage is, I think, the best for this purpose. Tear down the first two "tails" to within three inches of the others, and these passing over the shoulders, and fastening to others, which are adjusted over the breasts, keep the whole bandage in place.

It is not necessary to speak of the napkins or pads; these are universally used, and readily bought, sterilized, and ready for use. All sterilization is so thoroughly taught in the schools, I have taken proficiency in this particular for granted.

There should always be a disinfectant or antiseptic of some sort on hand.

Carbolic I-30, Platt's chlorides, permanganate of potash, or something that will answer the purpose; bichloride of mercury, etc. You must find out from the physician which he prefers, and of what strength.

I must not forget to say that when you go to see you prospective patient, and she shows you the room she expects to occupy, it would be well to cast your eyes about for some rug, that you can, if necessary, turn wrong side out and spread at the side of the bed. Some doctors are very neat about their work, but some are-- well, perhaps I better not say it; we must not criticise the doctors.

But sometimes it is best to have protection for the floor, it gives the nurse a comfortable feeling quite beyond description to know, that, no matter what may happen, the carpet will not be ruined.

XII

AS TO WASHING THE BABY

In the first place get together everything you will need for the bath and subsequent dressing. Have the clothes all laid in order over a chair-back before an open fireplace, or over a radiator, or if no better expedient suggest itself, fill bottles with hot water, or get a hot water bag and fill that, and lay it _over_ the clothes arranged in the order you will need them, beginning the pile with the dress and having the band the last. Have _two_ large, soft towels and keep them warm. If possible, have an apron made of rubber cloth to tie about your waist. At your side, on the floor, have a small blanket ready to lay over the rubber apron when needed. Put your baby basket where you can reach it, be sure that it contains all the things you will need--sponge, soap, powder, pins, vaseline, etc., and an extra diaper or two. Now get the tub (tin) and pour in the water until it is about four inches deep. Have the water no warmer than 100 degrees F. Bath thermometers are made that are quite cheap, and a great convenience; one should always be at hand, as no nurse should ever trust her feelings as to whether the water is hot enough or not. Always test any water to be used for the sick or the delicate with a thermometer. Another point a nurse should be most careful about, is to be careful that her hands are warm before she takes the baby, as her cold hands on his warm flesh will surely make him scream.

All being now ready, take the baby and sit down with him, spreading the blanket over your knees as you do so, and having the tub just in front of you on another chair. The sponge is best to use for the washing, but a piece of old table damask is very good. Wash the eyes very carefully first, then the face, and dry on the towel. Now hold the baby's head over the tub and give that a good washing with soap on your bare hand, and rinse it well with plenty of water, always holding the left hand under the head and neck. Bring him back on your lap and thoroughly dry his head, then wash and dry the ears carefully.

When you get this far you may undress the baby completely, being most careful yet not taking any unnecessary time. When he is quite ready for the tub, grasp him firmly with the right hand, letting the buttocks rest in the palm of the hand, the fingers being outspread, and the thumb coming up almost to the pubic bone. With the left hand hold the head and shoulders. Lower him _very_ gently into the water. Any sudden movement is most injurious, as a baby must never cry when the band is off, if it can be avoided. He will often put out both hands as if trying to catch hold of something. If he seems frightened at the same time, and cries violently, let the buttocks rest on the bottom of the tub, and with the right hand hold both of his, and he will be comforted.

I think it well to wash the whole body with your bare hand, well soaped. Be careful to wash under the arms, in the bend of the elbows, the groins, and under the knees, rinse him with the wash cloth or sponge, and now lay one warm towel on your lap, and take up the baby just as you put him in, slowly, and without shock, and lay him in the warm towel. Lay the second one over him, and draw over all the blanket, wrapping him up warm and snug. Put your hand inside the blanket and dry him. This can be easily and quickly done without at all uncovering the child. Pass the hand with a slight squeezing movement over each arm and leg, and over the front of the body. When this is done, you must undo the blanket, and take the upper towel and dry most carefully all the creases, and powder everywhere, especially if he is very fat. Get down to the very bottom of every crease, and be sure it is dry and powdered. Lay over the navel a compress of absorbent cotton, unless the child is over four weeks old, and over this the band, which should be unhemmed, and wide enough to extend from the hip to the armpit. Lay the palm of your right hand firmly over band and pad and turn the child carefully, holding your right hand still under him, and with the left, clear away all damp towels, and then straighten out the band that is wrinkled under one side. Keep your knees close together. Now take away the right hand, and see that the baby's knees are on the right side of your knee, and the elbows well over the other side of your lap. Now you have the baby where he can kick, but he can't wriggle or spring off your lap. See that the back is dry, rub it a little with your hand, and powder. Look carefully in the deep dimple just at the coccyx and see if it is clean. Now pin the band snugly, but not too tight. Use the smallest safety pins, and never pin directly over the spine. Sometimes the abdomen is very large and it will be necessary to make two little tucks in the lower edge of the band in front to make it fit snugly.

While the baby is still on his stomach, lay in place the diaper, and next the shirt, which should be open in the front, and the pinning blanket. Lay all of these just as they should be, as regards the back, and turn him, being careful to hold all the clothes in place. If he is liable to chafe, or the movements of the bowels are in any way irritating, use vaseline about the buttocks. Now put the arms in the shirt sleeves and tie or button it up, and then pin the petticoat or pinning blanket. Lay an extra diaper folded many times under him, and fold the pinning blanket just in three, bring the hem up to the waist and pin in place.

The dress goes on feet first. Slip it on over the pinning blanket, and pass the right hand up under the buttocks, and with the left, pull the dress into place, put the little hands in the sleeves, and get it perfectly straight and smooth over the chest. Now pass the fore-finger of the left hand down inside of all the clothes, beginning at the neck, until you find the band (the first garment), take a small safety pin or any small ornamental pin, and pin thoroughly through everything. This last pin I consider most necessary, as it keeps the dress, shirt, band and all in place. Turn the baby over once more and put a similar pin in the back of the dress, being very careful to get at the band. While the baby is in this position put the blanket he wears during the day over him, and a final turn brings him around, and he is washed and dressed all but his mouth, which must be carefully washed with clean, warm water or borax and water. This should be also done many times each day, if the mouth is sore, and always a sharp watch kept for white patches on lips, cheeks and tongue. If the baby has hair to brush, it is well to brush it. It makes him look very cunning, but if he is tired or sleepy, do not trouble him. This washing and dressing should not occupy more than twenty minutes, I have done it in fifteen where the baby was very well behaved.

Be sure that the room is warm and that the windows and doors are kept closed. Do not allow admiring relatives to come and go, opening and shutting the doors as they do so. If they want to see the operation, let them come and stay. A baby should never be bathed in a tub until the stump of the cord is off and the navel well and strong. If there is any inclination to pouting of the navel, wash the child on your lap and do not take off the band until the rest of the baby is all washed, dried, and powdered. Then take off band and compress, and put on fresh ones as quickly as possible, turn the child and pin as before directed.

In taking the clothing off, it is not necessary to turn the child at all, the band being the only thing pinned in the back.

N. B.--This method of bathing is for a normally healthy child, from the time it is one week old, until it is six months or more.

Until the stump of the cord has sloughed off, a baby should never be put into the tub. If after the stump has sloughed there seems to be any protrusion, or indeed any ulcerated look about the naval, it is best to bathe the child on your lap. In all such cases undress the baby as previously directed, until you come to the band (flannel belly band). Wash, rinse, wipe and powder him, being careful to make every part absolutely clean and dry. If the band is soiled or wrinkled, or out of shape in any way, remove it and put on a fresh one--looking every day, after three days, to see if the stump has come off--and if it is still adherent, being most careful not to disturb it in any way. Apply the fresh band immediately. Turn the baby on its stomach, and when the back is exposed, wash and rub the back gently with your warm hand. If the band does not need changing, unpin it, rub the back, pin it up again, and proceed in dressing as before. When the cord is once fairly off, and the navel smooth and clean, you can put the baby into the tub, very gently, slowly, and cautiously, remembering that a sudden movement on your part may, in fact, always will make him scream, and screaming with no band or compress on is for a baby a very frequent cause of umbilical hernia. If the cord is small when the child is born, there will be less danger of hernia, but if it be a large one, then beware! It will not always be your fault if the baby's navel is not small and flat when you are leaving your case, but you will always be blamed for it, if it is not. Notice carefully every morning when you bathe the child if there is any umbilical protrusion, and report it without delay to your doctor, if there is any, no matter how slight. This is not, however, the place to treat of umbilical hernia, and we will go on with the washing, If the child's skin is very tender, chafing easily, wash with castile soap suds, rinse and dry carefully, after every time he urinates, as well as when you bathe him. Powder with talcum powder. Sometimes no powder will do it any good, then try vaseline. If that will not do, ask the doctor if you can try oxide of zinc ointment. Ordinarily, extreme care in washing, drying and powdering will be sufficient, but it must be done every time the diaper is changed. In this, as in other things, eternal vigilance is absolutely necessary.

When the baby is about two or three weeks old, it is a good plan to put some alcohol into the water in which he is bathed--two or three ounces to the amount of water used in bathing. Have a small bowl of cooler water, 70 degrees to 80 degrees, for the face, and after that is washed, add a tablespoonful of alcohol to that also, for the head. It helps to toughen the skin, and prevents the baby from taking cold so easily.

If the baby seems much frightened by being put into the tub, spread a bath towel or small thin blanket over it and have someone hold his hands, so that he will not clutch so wildly at everything, then lower him into the water, towel and all, and he will not notice it so much.

I know of no place where deftness of handling shows to such advantage as with a baby. He knows well enough if he is handled properly or not, and his fretful cry, or violent screams, will tell you without delay if he is not comfortable.

Once more, let me impress upon the minds of all who read this, the necessity of having everything used about the tub and subsequent dressing, warm. Anything cold will make the little one scream, and I think all nurses will agree with me, that there is no more nervous work than washing and dressing a baby who is crying (and once he begins, he is only too apt to keep it up during the entire time). This is especially true if a weak, ignorant mother is made nervous by the noise, or a doting grandmother hovers about, making remarks about "new fashioned ways," and wondering why this child should cry when his mother was always so good, as a baby, in her bath.

Now, as to the time of washing a baby. The morning is unquestionably the time, but if the baby be very young (less than two weeks) and has been wakeful during the night, I would let him have his nap, even if it did delay you and interfere with your plan of work. If he sleeps he is comfortable, and, unless for some more serious reason than the bath, he ought not to be disturbed. This, for babies in private practice. Hospital babies cannot be so tenderly cared for. When there are ten or eleven to be washed in one morning, choose, of course, the ones that are awake, as far as you can, but there will always be one or two sleepy, warm little ones about whom you will have some twinges of conscience as you begin to wash their faces, but the work presses so, it must be done.

A baby should not be bathed just after nursing, or when he is hungry. Yet, most little babies go to sleep at the breast, and very often do not waken until they are once more ready for eating. This seems like stating a difficult problem, and I know it is not always easy to select just the proper time, but the best way, I think, is this.

If the baby is nursing from the breast, tell the mother, after this nursing you wish to wash the child, and not to let him go off for sound sleep. She can prevent it, and keep him for the twenty minutes or half an hour it is necessary to wait after his meal, meantime you have time to get everything in readiness for the bath. It is a great mistake to attempt to bathe a baby when he is hungry. He will scream for his food from the beginning to the end of the performance, hesitating occasionally when something warm touches his mouth, and he eagerly seeks his meal, only to redouble his cries when not satisfied. Nothing is so persevering in its endeavors, as a hungry baby. Satisfy its appetite first and wait a reasonable length of time, wash him deftly and quickly, and he will be so sleepy by the time you are through, you can lay him in his bed and he will be asleep in a moment, when you can pick up all the soiled clothing and the general "mess" of the bathing operation, and leave the room once more tidy.

And just here, let me say a little about the washing of the baby's clothes. Of course the dresses or slips, skirts, and the diapers go to the laundress. Begin every morning on an entirely new, that is newly-washed, set of diapers. Gather up all that have been used the past twenty-four hours and have them washed. Perhaps they may not be ironed, but washed they should be, every twenty-four hours, even if you have to do it yourself, and I do not think a nurse should ever be called upon to do this. Still, I would rather do it than use a diaper over and over again.

But it is of the little shirts I particularly wish to speak. I think the nurse should wash these, also the socks when they need it, and the knitted shawls most babies wear. It takes very little time to do this, and if you know how, you will do it much better than any laundress. The best way to wash these things is in cool borax water, and if there is any one place the baby has vomited on, put a little dry powdered borax on (the place being wet), and rub it in. Then wash by plunging it in the water and squeezing it out. Do this again and again until the garment is clean. Rinse in clear cool water, and wring as dry as possible in a towel; then pull in shape and lay it on a clean towel to dry. It is a good plan to lay it on a folded towel over a half shut register and place a single fold of towel over. It will dry very soon. If you are washing a baby's knitted shawl, be very careful about the wringing. Lay a large towel (bath towel is the best) out flat, and, having squeezed the most of the water from the blanket, lay it carefully on the towel and roll both together, and wring very tightly. If this towel gets wet take a second. When you are satisfied that it is as dry as you can make it, lay it out on a folded sheet on the floor, in some room not much used, and pull and arrange it into its original shape and size.

Anything made of Germantown wool stretches terribly, but you can arrange it as it ought to be. It will look ruffly here and there and ridgy all over, but when it is dry it will shrink down all right. Only do not hang it up, and when it is dry you will be surprised to find it looks as good as new. If you are ever consulted beforehand as to what would be nice for the baby, use all your eloquence against _any_ color being put into these knitted shawls. Germantown wool is the best to use, and plain knitting or brioche stitch is the best to wear and wash, and these things must be washed with the most careful handling. On the nicest baby they will become dirty, and the delicate blues and pinks become the dismalest wrecks when washed. Therefore, tell your patient not to put any color in these first plain little comfortable shawls. They should be a yard long by about three- quarters wide. Two or three will be all you will need, and do not use any of the fancy blankets sent in by friends. Lay these all away, with a sachet bag or two, in some convenient drawer, and never take them out unless the baby is required to look very fine for a brief display to some friend. These delicate, fancy trifles when once wet through or vomited on are ruined, and it should be your aim to leave everything as good as you found it when you go from the house. There will be plenty of time after you have left, for the fond mamma to spoil all the pretty things, and as she does so she will appreciate more and more your care of them.

XIII

THE VALLEY OF THE SHADOW

I suppose that no nurse deliberately chooses to go to an incurable case, yet most of us who have done private nursing have found ourselves at some time caring for one who slowly, and painfully, creeps nearer day by day to the great End. We have gone perhaps to stay a few weeks, for some acute disease, but symptoms have changed, and instead of recovery, a long, slow decline is to be faced, the nurse feeling she is needed, decides to stay and do what she can for the poor failing body, and so the weeks drag on in the dreadful monotony of that one sick room, until we feel that we have been left out of the real nursing world, that we are stranded with our patient upon an island of pain, that there is no outlook but the one dread Valley, no moving object but the river of Death, and no hope for the life we are guarding. Each week we grow more and more rusty as to our hardly-won surgical technic, more out of touch with those who come and go to one patient after the other, and who not unnaturally count upon so and so many victories over the very enemy who we know will overcome the life we are fighting to save. Yet we realize that all our care will never bring victory, all our skill can but help to smooth the rugged pathway, down which the feet must tread alone. The endless repetition of the same symptoms is wearying, the only possible variation being some new pain, which indicates another stage in the development of the disease. An improvement hardly cheers us, as we know it is but temporary, and maybe followed by an exacerbation of the trouble.

Often the actual nursing calls but for a portion of the day, but that portion is so necessary that the nurse's presence is imperatively demanded. The remainder of the time little is to be done, except perhaps a guard maintained over the failing strength, a watch kept for untoward accidents that might snap the frail thread that binds the spirit still to earth. Probably the bedroom must be kept tidy, and the patient's clothing cared for, and the nurse feels she has degenerated into a servant.

One who has gone through with an experience like this, and who has courageously remained with her patient to the end, has passed through a training more severe than any she has had in her hospital life, and she has earned a new diploma.

There are some things which the nurse may do to lighten these dark days, some things which may help both herself and her patient, and these I will try to show.

_Firstly_, it is well to study your case from a pathological view point. Find out the heredity, the manner of the daily life, the first manifestation of the disease, what circumstances led to it, how it was treated, what success the treatment seemed to have, what symptoms can now be noted, what complications have shown themselves, and their influence on the original disease. A careful history could be written embracing all of these points, and as new symptoms appear they should be observed and noted. All this should be valuable and should help some future day to show some one who has but started on the dreaded pathway, how to avoid what will surely be a fatal disease. Many a valuable paper could be written in the long hours when the nurse feels she is losing her time, if she would intelligently study her case, and write the story of the disease, what led to it, and how it is being combated.

Perhaps, if it could be arranged, the nurse might be spared part of a day once or twice a week, and she could go to her hospital out patient department, or to some dispensary and do some work that carries a little feeling of success with it; work in a babies milk station, or almost any of the numerous charitable activities, would rest and refresh one who has for months been with the same patient.