l"lN(i mi m LIBRAP"^ OF CONGRESS. ^\n^. Qopi|ng2^t ^c. Shelf -..■.5-.L UNITED STATES OF AMERICA. NOTES Visiting Nurses AND ALL THOSE INTERESTED IN THE WORKING AND ORGANIZATION OF DISTRICT, VISITING, OR PAROCHIAL NURSE SOCIETIES. ROSALIND GILLETTE SHAWE, DISTRICT NURSE FOR THE BROOKLYN RED CROSS SOCIETY. WITH AN APPENDIX, EXPLAINING THE ORGANIZATION AND WORKING OF VARIOUS VISITING AND DISTRICT. NURSE SOCIETIES, B,Y MRS. HELEN C. JENKS. PHILADELPHIA: ^^J{ / ' P. BLAKISTON, SON & CO., IOI2 WALNUT STREET. 1893. ^X'^ 1 55 Copyright, 1893, by P. Blakiston, Son & Co. Press of Wm. F. Fell & Oo , 1220-24 Sansom St., philadelphia. PREFACE. In presenting this work to the public, the writer feels thaf possibly she may interest her readers in a branch of nursing which has by no means been fully canvassed. Work amongst the poor always assumes more or less of a philanthropic character, and appeals to the sympathies of the warm hearted, or arouses the thought of the social economist as to why and wherefore so much energy is needed: and work amongst the sick poor has especial need for con- sideration ; for sickness is one of the accidents in life against which prudence and thrift do not always ensure their most ardent votaries ; and which calls for all the graces humanity can muster to deal with efficiently. To be sick is an evil, all will admit; to be sick and sunk in the depths of poverty as well, so that httle can be done to miti- gate the sufferings attendant upon illness, is an aggravated form of the evil. To lessen the miseries of the very poor when iii IV PREFACE. ill, or to prevent them from ignorantly contracting disease themselves and disseminating it amongst others, by timely cautions and hints, is the voca- tion of the District Nurse. Wisely carried out her mission is an arduous undertaking, and to keep her from discouragement she needs the support and the sympathy of the well-to-do public. These few facts are compiled in the hope that they may prove useful to some who may be glad to cull a hint from actual experience, to help them possibly in a new undertaking. And also with the desire that they may prove interesting to those who would willingly uphold the hands of the workers did they but understand what the work really is. The truth as illustrated in the parable of the Good Samaritan has percolated down through the ages, and reaching us has a very pertinent signifi- cance as regards the neighborliness of life in all of our large cities. We cannot shut our eyes to the exigencies of the situation if we would. The writer is deeply indebted to Mrs. Helen C. Jenks, for her kindly interest in this effort to set forth District Nursing, as is evidenced in the appen- dix, which shows something of the work that has been done, and gives practical hints for those con- templating starting the work in other places ; her PREFACE. V position on the board of the Philadelphia Visit- ing Nurse Society and her prominence in other philanthropic enterprises, rendering her an authority upon the subject. R. G. Shawe. April ist, i8gS' LIST OF CONTENTS. PAGE Preface, v Introduction, 9 The Conditions to be Met, 18 Methods of Work, 25 How not to Pauperize the Poor, 30 Outfit and Personal SuppUes of the District Nurse, 35 General Supplies of the District Nurse, 45 Emergency Cases and their Treatment, 49 Surgical Nursing, 61 Sick Children, 66 Infectious and Contagious Diseases, 80 Medical Nursing, SS Fever Nursing, 93 Obstetrical Nursing, loi Teaching in the Homes, 104 Cookery for the Sick Poor, , . . 109 Appendix, 117 Index, 141 Vll Notes for Visiting Nurses. CHAPTER I. INTR OD UCTOR V. A District Nurse who has her locality well in hand knows of and stands ready to relieve any case of distress in her neighborhood which arises from sickness and poverty combined. This, together with teaching the laws of hygiene to the ignorant poor, we think is her work. The District Nurse is first of all a nurse, just as a physician is a physician, whatever branch of service he may select, although nurses are not yet hedged about by legal protection in the pursuance of their profession, and there are nurses of every grade of capacity, both trained and untrained, who may compete in the carrying on of every branch of the work. The woman who expects to be successful as a District Nurse must thoroughly understand nursing, by whatever method she may practically have 9 lO DISTRICT NURSING. acquired her knowledge. And societies do well to secure the services of the best nurses for district work : by best nurses we mean those of the best education, general and special, of the widest ex- perience in life, capable of reading human nature, tactful, enduring, and of proven experience in other departments of nursing. This point of having the best nurses for district work is of moment to the community at large, for the rich and the poor dwell very nearly together — the health of the one class affecting the well being of the other, so that in times of epidemic none feel safe. The spread of contagion is oftentimes through subtle channels, and the person who deals with the ailments of the poor more often protects the rich than perhaps the rich know of. An attack of scarlet fever or measles or diphtheria can be contracted in all sorts of unlooked- for places ; and many a home mourns the untimely dead, whose lives have paid the penalty for others' sins and ignorance. Understanding nursing in general, a District Nurse should have the further training in special work which can be obtained chiefly in practical service, aided by the written experience of others. In our opinion, novices who desire to enter this work would do well to put themselves in training for a time under a working District Nurse. INTRODUCTORY. I I By natural gift, some nurses are better fitted for work amongst the very poor than others. Any nurse who thinks of taking up this branch of the work had best weigh well her reasons for so doing, and bear in mind that the office is not one for self- " indulgent ease. A thoroughly competent District Nurse works, and works hard. In times of especial epidemic she works through long hours. During the healthiest season she has much to do in teach- ing hygienic laws to the ignorant, if not constantly occupied in actual bedside nursing. She should have sympathy for sorrow and suffer- ing without the slightest taint of maudlin senti- mentality in her composition, for the people she deals with are usually those who require the moral support of a positive nature to aid them ; their very poverty makes them helpless, and tends to further pauperize them, unless there is brought to bear upon them a strong influence to compel them to the utmost self-help in their power. She must constantly be dragging up those who have fallen into a slough of despondency, and no woman can do this work effectively and well, who has not a kind heart combined with a hard head, and who has not at the same time a great love for humanity. Any one may theoretically love little children ; to love little children who are sick, dirty, and unwholesome, and possibly covered with sores 12 DISTRICT NURSING. and vermin, to clean these same little children with her own hands, and to perform the same ofifices for children of a larger growth, the sick, ignorant, dirty adults, who have never properly learned the uses of soap and water, needs a person with a love for humanity amounting almost to a reverence. But there are nurses who stand ready and willing to do just this work. And they look to the more fortunate public to aid them in their labors with moral and material support. Sickness is hard to bear under the most favorable conditions. It is doubly hard to endure in the cramped homes of the very poor, where there is no money to buy necessities. • To make the best of untoward conditions, and to create comfort where none exists, and from the scantiest of materials, is an art the nurse acquires by degrees ; it scarcely comes natural to any woman, although there are some who can do with far less than others. The District Nurse has need to learn to make the very most of her poor and meagre supplies. She values life as life, and seeks to save it and to make it more abounding. Health and strength are to the very poor their chief capital, and she realizes this and seeks by every means in her power to preserve and to conserve their working force. If incurable disease is upon any she can do much INTRODUCTORY. 1 3 to smooth the way through the later stages of a weary hfe. Being, however, only a nurse, she learns to work with other organizations for the relief of other misery than that caused solely by disease. Her- peculiar province being caring for the sick, and teaching the poor how to keep well, she must fre- quently depend upon others to remove the causes which produce and aggravate illness. In these days of complex social conditions the suppression of extreme poverty and the long list of distresses which follow in its train can only be done by the united efforts of many philanthropists. Perhaps there is no person who so fully under- stands the difficulties of dealing wisely with the very poor as a District Nurse. She enters their homes in the times of the greatest distress. She learns the depths of their misery as none other can, and she sees how ver)^ easy it is for the mentally weak and morally shiftless amongst them to lean for support upon any who will assume the burden thereof She learns how little gratitude is often- times shown for benefits received as gifts. And she also knows that jewels of mental and moral Vvorth are found in the most unexpected places. Her work lies in the worst of hygienic surround- ings, for in mean, dirty sections are found the 14 DISTRICT NURSING. dwellings of the very poor. To create cleanliness and an air of thrift in habitations filthy in them- selves and rickety in the extreme is a task similar to that of making bricks without straw ; and yet the District Nurse does contrive to make waste places glad, her kind deeds being the open sesame to brighter lives in very dark homes indeed, and her ministrations doing much toward alleviating the worst forms of suffering. She brings the power of knowledge to offset ignorance in dealing with sick bodies, and with untiring energy combats despond- ency of mind in those physically afflicted. Not that all of her patients need necessarily be under a mental cloud, but too many are so, as all physicians who practice amongst the very poor know. Poverty is in itself depressing, and when combined with bodily disease is apt to darken the outlook for the invalid. Such being the case, it is apparent that none but an exceedingly cheerful, sunny-hearted person is fit to work amongst the very poor. Again, the effect upon the nurse of constantly looking at misery and suffering, unless offset by some mental recreation during some part of each day, is excessively wearing ; the weariness of both body and mind which is induced by the work is ^far greater than any who do not know something INTRODUCTORY. 1 5 of what sickness is and who can realize the de- pressing influence of extreme poverty can well understand. No nurse, any more than a doctor, can afford to become case hardened. Her most effective power . lies in her sympathy, guided by knowledge. With- out this sympathy by far the larger part of the work of a District Nurse would be quite useless. Many of the poor will suffer long and endure much before they will accept a grudgingly bestowed or half- hearted assistance. There are souls so debased as to fawn upon the unwilling rich, but a large num- ber of the sick poor are keenly observant of the spirit which actuates the ministration to their neces- sities. To feel kindly, to act with prudence, and as unselfishly as circumstances will permit, seems to us the imperative duty of the District Nurse. She should look for the best in people and not distrust either their gratitude or their good principles with- out positive proof that both are lacking. Her merci- ful services should rather be rendered in the spirit of a disinterested regard for their best good. In the carrying out of her work in this manner there is a constant drain upon her sympathies, her time, her strength, and her energies; and this wear and tear must eventually tell upon the strongest woman. A nurse who is wise will find suitable recreation during some part of each day to take her mind l6 DISTRICT NURSING. wholly off from the work in hand. This we think the true secret of being fresh for the work of each new day, and of being able to hold out in the pur- suit of one of the most arduous of all callings. As any specific rules as to the conduct of the District Nurse upon all occasions might savor a little of an endeavor to the fitting to a David of a Saul's armor, it seems best that those who attempt the work should study their own strong points, as well as learn their own weaknesses. A trial of a few months' time will soon convince any woman as to her peculiar fitness for the work; as to whether she has the physical endurance requisite for the exertions she is called upon to make, if she can bear the long walks, the needful exposure to all weathers, and has the power to resist the in- breathing of foul stenches in summer, and damp confined atmospheres in winter ; whether she does not revolt at filth and dirt and vermin, combined oftentimes with disease in its worst forms ; whether she has the carefulness to protect herself in caring for infectious and contagious diseases ; whether she has the tact to make friends of all sorts and conditions of men, women, and children, or if she have the gift of plain speech which flies straight home without unduly wounding sensibili- ties ; whether she have the gift of humor which drags the foibles of her patients forth, and turns INTRODUCTORY. 1/ the laugh upon them, and compels the mending of their faults whether they will or no. All this, and much more, a District Nurse learns about herself by experience. As nothing succeeds like success, the District Nurse who finds her patients recovering in health, and seeking her out on all possible and impossible occasions, may conclude she is doing fairly good service. It is not a work in which any woman may be- come unduly puffed up ; for do all one can, there will be far more left undone than accomplished. A few lives saved to their families ; a small number preserved from hopeless invalidism ; another small number made comfortable in their dying hours, and the sufferings of others lessened ; — this is the sum of the work, and in a feeling that a few have been helped by her will lie the chief reward of her faith- ful labors. CHAPTER II. THE CONDITIONS TO BE MET. A District Nurse necessarily works in closely crowded localities. It is in the slums of the cities she finds her most promising fields of labor ; she has to deal with the tenement-house problem in its worst phases ; with poor drainage, bad ventilation, garbage, filth and dirt, lack of sunlight — in fact, with the worst conditions under which sickness can be met. She must work under difficulties which threaten to set all rules of training at defiance. She cannot always command the necessities, much less the conveniences, to work with. No model sick-rooms with the proper apparatus for nursing are found in the homes of the very poor. For every breath of pure air, for every gleam of sunshine, for such quietness for her patient as can be obtained under difficulties, she is grateful. She learns to prize the little, and to be thankful that matters are no worse. Very often the ignorant people she deals with can- not be reasoned into right living nor coaxed into i8 THE CONDITIONS TO BE MET. I9 proper measures for recovery, nor yet has she the support of hospital discipline to aid her in her work. She is oftentimes at her wits' end to know how to make any headway at all. How to meet the diffi- culties of the situation, and how to enforce the commands of the doctor, is a problem always under consideration, and never more than partially solved. She finds that she has entered upon a course of higher education, and the obstacles in the way of her progress make the pons asinorum of her school days seem but child's play in comparison. The evils she deals with are hydra-headed ; she cuts off one branch only to find a new one cropping up close at hand ; v/hatever difficulties can arise are sure to meet her at one turn or another to try her patience and to put her powers of expediency to the test. In one house she will find one thing to be righted, in another quite a different state of affairs, and yet possibly something equally discouraging to cope with. Amongst the perplexities of her work are those arising from the indifference of the people them- selves as to what is healthful and wholesome. Pain, the wise provision of Nature to signal when the running machinery is off the track, is sometimes endured with a stoicism worthy of a better cause, whilst the warning it gives is all unheeded. To be rid of the pain is esteemed a blessing, but the way 20 DISTRICT NURSING. to prevent disease and so have no pain is neglected. This indifference is not always the result of ignorance, but it frequently is, and on occasions this ignorance may be very dense. She sometimes finds the people to be taught are, like the young wife of the Yorkshireman, '' rayther slow at tackin in," if they take in at all. Then there is the landlord and tenant question to be considered. Very few people, if any, who re- quire a District Nurse live in their own houses. Their abodes are rather rented apartments, or small houses. In a very large proportion of the families she visits, there is some lack of decency in the houses they live in. The stairs may be rickety, the hallways unclean, the closets not properly flushed, the drain-pipes poor, the woodwork more or less rotten, and the house in a generally poor sanitary condition ; there may be overcrowding of the in- mates, objectionable neighbors, and, in case of con- tagious disease, no means of isolation ; the question of payment of rent during the stress of illness is always a weighty matter, one of the woes the tales of which are poured into the ear of a sympathetic nurse. The landlords are possibly tentative, and do not care to have a third person interfering in their business matters, and it is only in dealing with most extreme and flagrant abuses the nurse can consideV she has a moral right to annoy them ; THE CONDITIONS TO BE MET. 21 tenants may not take a proper interest in keeping the premises of others in order, and too frequently they cannot be roused into doing their duty. The legal measures for protecting the public health may seem fully adequate so far as the laws read ; in actual practice they may prove very unsatis- factory, not equal to the emergency, and slow and ponderous in action ; the truth may be difficult to arrive at, as people often conceal such matters as should be laid open, and evade inquiry, so that no legal basis can be found upon which to operate. Of all such matters as the number of cubic feet space necessary for the well being of each person, a good water-supply, a proper drainage, the removal of garbage, the cleanliness of the common hallways and the water closets, the law may take note pos- sibly, but the enforcing of its regulations is quite an important and too frequently a cumbersome matter. In the furnishing of the homes there may be tawdry finery, without either wholesomeness or taste, or there may be extreme want of decent belongings. As regards the patients themselves, too frequently they cannot rest during illness. They feel com- pelled to work, whether they are w^ell or ill, until they fairly drop in the harness ; oftentimes they cannot afford to buy proper food. If they remain 22 DISTRICT NURSING. quiet bodily, there is always the mental anxiety of getting bread ; there is sometimes a total lack of comfortable bedding and household supplies, and no proper clothing, and almost always overcrowded rooms to live in. Medical attendance may be given, the nurse's services likewise given, yet, unless these are sup- plemented by the necessities of life, it would seem almost as if their services were a mockery ; to try to sustain life on nothing is a task the bravest can scarcely undertake with hopefulness. The nurse finds she cannot do her work single- handed and alone ; she turns from the misery on the one hand to the kindly-disposed on the other amongst the more favored ones, and begs the needed help to pass on. The work speaks for itself So long as there are charitable hearts to donate relief, and ignorant poor to suffer, so long must the work of the District Nurse be one which most closely appeals to the sympathies of the humane. There is one other condition wherein district nursing differs from other nursing, which it may be well to note, and that is the relation of the District Nurse to the physicians of the community. She meets not one physician only, but many. Sometimes her cases are sent her by physicians who have the patients in charge. Sometimes ladies who are interested in poor families ask for THE CONDITIONS TO BE MET. 23 her services on their behalf. There may be a doctor in attendance or she may be left to supply one. The society employing her may regulate the matter of medical service. But, possibly, she may often be left to her own discretion as to what doctor she shall try to get interested in her case. Medical service is given freely to the sick poor. In our large cities none need ever die without attend- ance of a doctor, free of charge, if there is no money to pay for his advice. The nurse need not fail to find medical treatment for any who may ask this of her if she sets properly about it. She owes it to the profession that she find some suitable phy- sician for every case that needs attendance and comes under her jurisdiction, and that she faithfully carries out or insists on being carried out the orders of the doctor in charge of each patient, whether they meet with her private approval or not. It is her business to inspire her patient with confidence in the ability of the physician in attendance, not to criticise this doctor and that one ; the difficulties in her way are the choice of physicians, the getting the suitable physician for the case, the adapting herself to the methods of practice of varying phy- sicians, and the suppressing of any temptation to the practice of therapeutics on her own account. Amongst the doctors of a large city are those of varying shades of opinion ; to respect the conclu- 24 DISTRICT NURSING. sions of each, and to have none of her own, is a position the nurse must take. Then there are difficulties in the way of teaching hygiene. To adapt the knowledge of a trained in- tellect to the comprehension of an untrained one is sometimes a well-nigh hopeless task, for the pupils add to a childish ignorance the thinking powers of an adult and a corresponding stupidity of apprehension, the most willing sometimes being very dull, and amongst all classes there is found superstition and a lack of openness to conviction. CHAPTER III. METHODS OF WORK. Plainly, the first thing to be done is to map out the district. Let the nurse have a fair idea of the ground she is to cover and of its general hygienic condition ; she should note the lay of the land, as it were, know whether certain spots are healthy or no, understand what diseases are rife in certain locali- ties and why, mark any nuisances to public health, and be able to cope with existing states of things in the most effective ways ; for example, if a certain cesspool has caused an outbreak of typhoid fever, have the cesspool drained rather than wear her strength away nursing case after case of the fever. There should be a constant appeal to legislation. Cities have their Boards of Health, and she should be indefatigable in ferreting out and calling the attention of the doctors in that district to such nuisances as may fall under their jurisdiction. Sun- light and pure air she should ever use as her m^ost efficient aids-de-camp in routing atmospheric mias- mas and in getting rid of foul odors. She ought 3 25 26 DISTRICT NURSING. to understand the uses of the best disinfectants and be provided with them. She should make herself known to all the doc- tors in her district, and be ever ready and will- ing to co-operate with them. Where the choice of a physician falls upon her, she should act impar- tially in her selection. If the patient expresses a wish to see a particular physician, she should secure his services if possible. She can in cases of neces- sity advise special treatment, and find the proper physician or surgeon to treat the case. She should also know the druggists of her dis- trict, and be known by them; they will usually co- operate with her quite willingly and oftentimes be of great service to her. There is in the minds of many of the very poor a strong prejudice against hospital treatment. In cases where such is obviously the best, she can sometimes by a little timely persuasion overcome the dislike, and get the patient transferred from an uncomfortable home to a hospital ward where the surroundings are preferable. From whatever starting-point the District Nurse works, she should be known amongst the people as the friend of the sick and the poor. This celebrity is gained soonest, perhaps, by an unselfish devo- tion to her work, yet she need not despise many of the tactful artifices by which she advertises her METHODS OF WORK. 2/ mission. The gospel of healing must be preached by going forth among the sick, not by waiting for the sick to come to you, for many never will come ; they must be sought out, and among these shy ones are the most needy and deserving patients of all. We think it well for her to keep regular office hours, in which the sick poor can come to her. She can advise many, see some who are not ill enough to be in bed, give out stores from her loan supply or as gifts, and take back such articles as have been loaned. A record of cases should be kept, and something of a history of cases written out. This is an aid to herself in future emer- gencies, or to her substitute if for any reason she be absent from the work ; it will generally prove an aid to the doctor in summing up his estimate of the case. The same families come cropping up again and again. With facts concerning them jotted down in regular order and easily accessible, the nurse can more readily manage them on sub- sequent applications than at first. The District Nurse should be familiar with the workings of all charitable and philanthropic enter- prises in her city. She can usually find the proper assistance in cases of need by so doing. She soon learns the strength of union in the forwarding of her work by utilizing the force of others. 28 DISTRICT NURSING. Unless a district is small, the nurse finds she must select her cases, for a few patients well treated are more satisfactory than many just cursorily looked after ; and in the selection of cases there are a few points to be observed ; such as — Visit those who are most seriously ill, particu- larly the dying. Visit chronic cases to make them comfortable, prevent bed-sores, and cheer them. Work especially amongst little children and babies : it is better to teach mothers how to care for their children than to nurse them personally. It is imperative that contagious diseases be stamped out; be vigilant in treating such. Select those patients who are in the most ex- treme poverty. There are the peripatetic invalids, who go from doctor to doctor and from one dispensary to another. Their ailments may be real enough, but she soon learns what specialists in medicine or surgery can best do for them, and she usually can assist them to obtain the help they need, and so put an end to their wanderings. Any disease which is out of the usual course and of particular scientific interest to the medical profession is only too readily made capital of to draw upon the sympathies of the charitable by those who must be treated gratuitously; and here METHODS OF WORK. 29 again the nurse finds she must frown severely upon the tendency to glorify diseases. In seasons of comparative neighborhood health- fulness the time of the nurse can be well employed in following up the lighter cases of illness amongst" the children, in teaching family hygiene and simple nutritious cookery, and in showing the mothers how to effectively clean off vermin from children and how to keep the children clean. We all understand that the surest passport to the confidence and the love of the poor lies in an unsel- fish and self-sacrificing spirit, and no one can less afford to be self-seeking than the District Nurse. And yet underlying her work must be a substratum of strong good sense. She must conserve her own force and not recklessly scatter her time, strength, and service upon incorrigible and comparatively worthless cases ; neither must she show partiality ; the world cannot be blessed or permanently bettered by such waste of energy. As the home is the unit of society, the nurse should show how to improve the home, and no person can better inculcate lessons of personal and household hygiene and teach habits of thrift than she can when she has the confidence of those whom she visits. In fact, her opportunities are boundless and her enthusiasm must be great to keep pace with the openings constantly arising before her. CHAPTER IV. HOW NOT TO PAUPERIZE THE POOR. Social and political economy are studies that are engaging the best thought of many wise men, and therefore we may be excused if we venture to sug- gest that the few ideas we present can by no means be considered as exhaustive ones. From a practical standpoint we recognize the fact that those who receive gifts, whether of service or material aid, readily learn to look for more, and are by so much the less willing to pay for such when needed again, even though the same need for gratuity may not exist. Hence the necessity of -keeping the poor up to a self-respecting and self- helpful standard. There is not a philanthropic enterprise which does not carry within itself the germ of moral evil which certain conditions will surely develop, but we do not fail to recognize the fact that we owe duties to our fellow mortals because in the exercise of these duties we blunder and fail to perfectly perform them. Sickness is a calamity which the rich are 30 HOW NOT TO PAUPERIZE THE POOR. 3 1 not free from ; and, although their money can buy the best service to be had, such service is but too often ineffective. They go hence and leave behind them their accumulated possessions. The poor get sick and they cannot buy service. Sometimes they go hence not having suffered many things at the hands of physicians, but having borne only the kindly pangs of nature. Yet only too often nature is not beneficent in her dealings with sick mortals. Doctors can do much toward mitigating the evils they endure ; and, if life be spared, doctors are often the instruments of health giving. All that physi- cians and nurses can do for the rich and even more they can do for the very poor. To give service where there is no substance to pay for it seems but humane, and that doctors are as a class humane men none can deny, for probably no other body of men in the world give so much of personal service to their fellow-men as do they. It sometimes seems to us that the very poor are beginning to look for free medical service as a mat- ter of course. Between hospitals and dispensaries and all the other ways of obtaining free medical advice, they are educated up to suppose that sick- ness need not be looked forward to ; if it comes, the means of caring for the patient will be provided without cost. We think the very poor are provident when they 32 DISTRICT NURSING. must be. Some of them will almost do without food to keep a small life-insurance policy paid for, for the undertakers will not open a grave without pay. It is far from us to criticise the religious beliefs of any, yet we have seen that the money paid to the church is saved even if doctors go without pay. In fact, the old adage,'^ where there's a will there's a way," is only too fully exemplified in the lives of the poor. But in some instances, and the District Nurse finds such, neither undertaker nor priest could find any pickings, nor is there food in the larder or comfort in the home. Some of our fellow beings are unfortunate to a degree which makes the neglect to minister to. their necessities morally a crime ; and in relieving their needs, it does not, we think, tend to increase their self-respect to fling alms to them without the touch of human sym- pathy. It is the medical profession and their coadjutors who unearth these helpless ones ; and it is oftentimes through them that temporary or even permanent relief must come. A District Nurse who is wise as well as kindly, recognizes how easily people who are partially disabled hy illness sink into helplessness and hope- lessness. It is her duty as well as her privilege to teach such to make the most of their little strength. How few in the ranks of life can boast of perfect HOW NOT TO PAUPERIZE THE POOR. 33 health ! How many of us must go on to the end of our earthly careers more or less physically dis- abled ! The sick seldom realize this, much less the sick poor. They are too apt to think that they are afflicted above all others, when very probably they" may be really stronger than many a person who does not hesitate to render them some slight ser- vice toward alleviating their pain. To strengthen the things that remain is the blessed privilege of a nurse in any branch of her pro- fession. To help the poor to save life, and to make it more abounding, even in the face of woful dis- couragements, is the privilege of the District Nurse. To give ungrudgingly and kindly, expecting no return where it is self evident no return can possibly be made, is also her privilege. To look for some "compensation where there is ability and opportu- nity to render it is her prerogative, and to teach the utmost self-help her duty. She teaches the poor that sickness is an emer- gency in life liable to come to all, and only too apt to be a surprise ; and although she gives, she expects them to be willing to show an appreciation of her services on the return of health ; this keeps up their self-respect and induces them to make efforts in their own behalf. Laziness, drunkenness, disregard of the rights of little children who come into the world unwelcomed, 34 DISTRICT NURSING. and improvidence, furnish work for the philan- thropic. When to all these is added sickness, the harvest is quite ripe for the labors of the District Nurse. In communities where all are sober, indus- trious, and self-respecting outside aid is seldom called for, unless by the way of neighborly kindness. It is the weaknesses and sins of humanity which make her work a necessity. As moral health is restored her labors lighten. In giving either her services or from her stores, or in obtaining help from others, therefore, she must constantly exercise judgment and common sense. When men will not work, they should not eat ; restore a sick man to health, put him on his feet, and command him to do for himself; this is the best way for a nurse to act in order not to pauper- ize the poor. So long as a patient is really ill, however, do not adopt half-measures. Let the nurse see that things are provided needful for doing her work in the best possible manner. A whole-hearted giving is in our way of thinking the best giving. To be ham- pered at every turn in trying to heal the sick is discouraging to the nurse and tends to keep the patient from a full recovery. CHAPTER V. THE OUTFIT AND PERSONAL SUPPLIES OF THE DISTRICT NURSE. Before entering into any discussion as to the ad- visability of distinctive habit, there are a few general rules which District Nurses may do well to con- sider. For both moral and sanitary reasons their dress should be simple and serviceable. Cleanliness of person, tidiness of appearance, smooth hair, and well-kept hands and nails, and well-shod feet should above all mark the District Nurse. The one who teaches cleanliness and orderliness should exemplify her teaching in her own person. This may seem a very easily accomplished matter to those who have not tried the w^ork and learned the difficulties in the way of carrying out the theory. To be clean, the nurse must bathe frequently ; to be fresh, she must sleep well, regularly, and long enough. Hands and nails require time to care for and keep in good condition, particularly while doing the rough work she must oftentimes do. Rain, wind, storm, and undue exposure to the ele- 35 36 DISTRICT NURSING. ments will set the most carefully made toilet awry. Besides, it is dreadfully hard to be thinking of one's own appearance when there is misery to be relieved, or some interesting case from a scientific standpoint to be considered. A woman who walks much learns how impossi- ble it is to walk with ease in a cheap shoe. The nurse's shoe bill is no inconsiderable item. And the laundry bill ! afresh dress for every occasion — for, undoubtedly, wash goods are the best for her wear. It is quite useless for a District Nurse to attempt to study economy in her own laundry work, however much she may try to save the wash- ing for her patients. She must be clean at any cost, or else find that the moral lesson of her " gospel of cleanliness " is quite lost. This may seem to be putting the matter a little strongly, but we fancy none too em- phatically. Plenty of clean dresses, broad shoes, easy to walk in, and a simple outward appearance, not altogether lacking in quiet style, is, we think, the ideal dress for a District Nurse. Any garb will not do, and it is a fallacy to suppose it will. As to the habit, one advantage of a distinctive garb lies in the protection it gives the wearer. Ignorant people reverence a habit with something of a religious awe. A woman can sometimes visit what are known as hard localities with more im- OUTFIT AND PERSONAL SUPPLIES. 3/ punity in a distinctive dress than she could without this aid. Another reason for its adoption is that by it she is known. The neighborhood get to know a Dis- trict Nurse very quickly if she be dressed in the garb of her order. Once adopted there is no change of style, and in a neat, becoming habit a nurse may feel quite at ease as to her outward appearance. When she leaves her work and puts on the ordinary dress of a lady, she leaves behind her all its associations, and by so much the more easily can she cast off the cares thereof, and effect a complete metamorphosis outwardly as well as inwardly. Our democratic feelings rebel, no doubt, at being known by our dress ; but reverence to superiors is dying out fast enough without our aiding and abetting its murder by a false pride of liking to adopt walking, shopping, or visiting costume while engaged in one of the most arduous of undertakings. We both teach a reverence for work and command a reverence to ourselves by being willing to adopt a distinctive dress in the pursuit of our calling. It need not be an ugly dress — far from it. But it should be the badge of our occupation. It is scarcely practicable to plan out a habit for others, yet a few general suggestions may not be unadvisable. Let all the clothing be both light and 38 DISTRICT NURSING. loose, and worn from the shoulders. Heavy- weighted garments are not suitable for any woman who walks much, and uses her arms so constantly as does a nurse ; we think in texture the under- garments should suit the season, according to the thermometer running through the grades of heavy and light wool, gauze^ lisle thread, and linen. During the hottest weather, for example, when the work of the District Nurse is the heaviest, she can- not work efficiently in any but the lightest and thinnest of clothing. A nurse once called upon us on one of the hottest mornings of the season. She was anxious for some experience in the work, and came thinking to make the rounds that day. A short walk in the heat had completely exhausted her, and she seemed sweltering in the August atmosphere. She finally concluded that she should not be equal to the occasion on that day, but must wait for a cooler one before trying experiments. In dress she seemed extremely neat. She wore a gown of well-starched gingham, close fitting, fresh linen collar and cuffs; her whole outward look was as natty as one might desire. Judging from appearance, her corset was by no means worn loose, and we fancied that she had on an orthodox supply of undergarments. In such an attire we could not have worked on that day either. As it was, we were not uncomfortable. One plain linen OUTFIT AND PERSONAL SUPPLIES. 39 undergarment made a good length, the thinnest of bleached, white, lisle thread stockings, thin, broad shoes, a linen bodice waist, and a linen lawn dress made to wear without collars and cuffs, the waist being a blouse and the skirt made with a" Spanish flounce, together with a shade hat, com- pleted our entire costume. And so on through the seasons, as the w^eather varies, the costumes may vary to suit, at least in underwear. For the outer dress in summer brown linen, trimmed with red braid, is quite pretty ; it makes a cool and serviceable dress ; if worn with suitable underwear it can be worn very late in the season. Alpaca is a serviceable material for winter wear and for stormy days. The shoe should always be broad, with either a low heel or a spring heel. Some trained nurses may prefer the distinctive dress of their own school ; others may have the dress worn by them chosen by the Society employ- ing them. A District Nurse should aim to keep her own health in as nearly a perfect condition as possible. She should sleep regularly, long enough, and keep regular hours as regards meals and general habits. As a rule. District Nurses do not go out at night. It would be better if they never did. A district of moderate size will give a nurse plenty of employ- 40 DISTRICT NURSING. ment during the day for fifty weeks in the year, without encroaching on her night time. In times of special sickness her days may be lengthened from the ordinary service of eight or ten hours to twelve or even fourteen hours. In such seasons she must be more than ordinarily particular to get her regular sleep, and not neglect to eat at the proper times. If there is much night work needed, a special nurse should be detailed to meet the de- mand. There is no reason why all large cities should not have a sufficient corps of District Nurses to supply the need for them. A District Nurse should be in the habit of bath- ing daily in hot water; the best time for taking this hot bath is on going to bed. The entire per- son, including the hair, should be plunged in hot water, and quickly dried with soft towels ; the face can be steamed and massaged. If the nurse has been in the presence of contagious disease during the day the hair should be washed in a solution of bi-chloride of mercury 1-2000. In the morning a sponge bath in cold or tepid water is all-sufficient. The underclothing should be entirely fresh and clean each day, and dresses that show the least soilure discarded, if it takes a fresh one oftener than once a day to keep clean. The hands require special mention ; they must often do very dirty work. To keep them soft, OUTFIT AND PERSONAL SUPPLIES. 4 1 white, and in good nursing trim requires great care ; gloves should be worn whenever practicable; always on the street, frequently when nursing. It is well to have a neat-fitting pair of rubber gloves for use in parts of the work ; and any number of pairs of old kid ones can be kept for ordinary use. The nurse should have a good steel nail file and use it night and morning. Very dry and brittle nails can be softened by a persistent use of vase- line. The hands should be frequently washed in hot water with soap, and rubbed with a little Indian meal, then dipped in a solution of bi-chloride of mercury i-iooo, the superfluous skin about the nails trimmed off, and the nails well brushed during the bath. Mutton tallow well rubbed in is perhaps the best ointment for chapped hands ; the sulphur- ous fumes from a burned match will oftentimes re- move stains. After handling any patient who has infectious or contagious disease, the nurse cannot be too careful to disinfect her hands. Clean she must keep them at all times ; doubly clean on such occasions. Odors can be removed from the hands by bathing them in a little mustard and water, A nurse should never under any consideration go into a room where there is a contagious or infectious disease hungry. In fact, always nurse with a full stomach, and when nursing contagious and infectious diseases visit no other patients. 4 42 DISTRICT NURSING. The personal supplies of the nurse are such ap- pliances as are needed in general nursing, and as any good nurse feels she must own, only perhaps greater iii number than for private work. If the nurse have but few to do with, she should not feel discouraged. Very good work can be done with but indifferent tools, and the lack of appliances should not deter her from doing her best. The things to work with will come in time to any nurse who patiently waits for them, and who improves her opportunities of getting them one at a time ; this refers both to personal and general supplies. The list given covers the ground fairly well : — A clinical thermometer. A water thermometer. A thermometer. A nurse's case of instruments. A hypodermic syringe. }^ dozen graduate measuring glasses. Blanks for sick-room memoranda. Note books and pencils. Stick of nitrate of silver in holder. Tablets of bi-chloride of mercury j^^ gr. each. Catheters. Camel-hair brushes. Soap and soft towels for private use. Vaseline. Mutton tallow melted with rose water. OUTFIT AND PERSONAL SUPPLIES. 43 One dozen large white aprons. A pincushion. A small work bag fully equipped. A penknife. Sponges. And arranged in convenient form, tables con- taining the following information ; for, how^ever well a nurse may have learned these things, in the hurry of w^ork memory may prove treacherous, and it is well to have a small vade-mecum in the pocket : Abbreviations. The principal medicines and their doses. Poisons and their antidotes. Emergency hints. In addition, every nurse should have a small library of the best works on her profession to keep for ready reference. In this calling every nurse should grow, and if she be not more capable after some months of ser- vice than she was at the beginning of her career, she may well conclude that she has mistaken her calling. Nothing evinces her interest in her w^ork more than a desire to be well informed as to the history of the work and the methods of others. K x\.\xxs>^ 671 rapport \N\\h. her work likes to sur- round herself with such delicate reminders of the 44 DISTRICT NURSING. lives of others who have lived in the work as shall stimulate her to like exertions. '* The Lady with the Lamp " is a personality to her, even though no authentic portrait is procurable. Among the best works we have seen we may mention the following: — A Century of Nursing. Notes on Nursing, by Florence Nightingale. Text-Book of Nursing, by Clara Weeks Shaw. Humphrey's Manual for Nurses. Handbook for Hospital Sisters, by Florence Lees. Obstetrical Nursing, by Anna M. FuUerton, m.d. Nursing in Abdominal Surgery, by Anna M. Fullerton, m.d. Canfield's Hygiene of the Sick-Room. Starr's Hygiene of the Nursery. The list may be extended to comprise quite a library of really excellent works. Then there are many ephemeral productions, pamphlets, papers, addresses, all good in their way and which fall into the hands of every nurse from time to time. And a nurse should be a subscriber to some good periodical which gives the fresh ideas of other nurses. CHAPTER VI. THE GENERAL SUPPLIES OF THE VISITING NURSE. By whomsoever employed, a District Nurse should have headquarters — a room, in a central locality if possible, where she can be found at a certain hour of each day ; where her supplies may be kept, where letters may be addressed to her, and where her day-books and other data concerning her work may be found, as her home should be ' sacred to her, and not liable to be invaded. Societies who furnish a home for their nurses provide for her comfort during the hours when off duty. She should be in this room an hour or so each day, to look over letters, write up memoranda, select her supplies, and to receive any patients who call upon her. This room should be abundantly furnished with closets, and arranged upon the shelves should be her stores. These stores may be as varied as possible. If few in number, they can be added to from time to time, and no nurse or society should be discouraged because the supplies 45 46 DISTRICT NURSING. are low. An abundance is desirable, but much work can be done with little. However, no appliance ever used in a sick-room is out of place. If not needed in one sick-room, it very probably will be in another at some time when the want of it might prove a sore lack. To make this list of appliances as complete as possible should be the aim of the visiting nurse. A goodly num- ber of articles are enumerated ; the list may be ex- tended to a very lengthy one, or cut down to the absolute necessities by struggling societies : — Cot-beds, with mattresses, pillows, and bedding of all kinds, both new and old. Night wear for men, women, and children. Dressing gowns, bed slippers, and old stockings. Combs, and fine-tooth combs. Soaps and towels. Old linen. Mothers' bags. Old flannel. Bed rests. Oakum. Bed pans. Paper pads. Urinals. Absorbent cotton. Foot tubs. Cheese cloth. Hot-water bags. Tin basins. Ice bags. Catheters. Rubber rings. Syringes. Jackets, of oil silk. Breast pump. Oil silk. Atomizers. Old cotton. Towels. GENERAL SUPPLIES. 4/ A good, surgical tray, Cupping glasses. well furnished. Alcohol. Bandages. Ammonia. Medicine glasses. Whiskey. Medicine droppers. Brandy. Alcohol lamp." Old clothing, shoes, children's toys, and the like, need never be despised ; they can be made useful. Flowers and delicacies for the sick are always ac- ceptable ; and some way of getting needful food supplies for those w^ho are utterly destitute must be on call. Much of this stock maybe loaned out to be returned when the need for its use is past. For example, an easy chair will last for months in con- stant use from one patient to another. Lists may be tacked to the inside of closet doors. The amount in stock, the amount loaned out, and the names and addresses of the parties having stock in use. These lists may be altered as stores are given away, and fresh supplies brought in, or loaned articles returned. There should be a map of the city for ready re- ference, and a street directory ; also a list of charit- able institutions should be kept, and their latest reports, in order that their scope and method of relief may be thoroughly understood. The names, addresses, and office hours of all the doctors in the district should be known. 48 DISTRICT NURSING. It is well also to keep such works as are obtain- able on philanthropic work, the simpler text-books on household hygiene, and plain talks with work- ing people can be on hand for ready reference. There are many such simple works which are thoroughly reliable, and embody scientific facts in popular form. The District Nurse may not be able to inaugurate courses of lectures on hygiene, but she should pre- pare the way for their reception, and in home teach- ing she has great need of the accumulated wisdom of many thinkers on these subjects. CHAPTER VII. EMERGENCY CASES AND THEIR TREATMENT. In our large cities the promptness of the ambulance service practically renders emergency nursing a minimum in the work of a District Nurse. Yet occasionally such may fall into her hands, and she should thoroughly understand what to do " until the doctor comes." • She has long since learned the anatomical struc- ture of the body, understands somewhat of the circulation of the blood, the elements of physi- ology, drugs and their actions, poisons and their antidotes, and knows the simpler methods of deal- ing ^yith fractures, dislocations, and sprains, with hemorrhages, and wounds, with ordinary syncope from emotions, with concussion and compression of the brain, convulsions, asphyxia, epilepsy, apoplexy, intoxication, hysteria, shock, drowning, sunstroke, burns, scalds, and frostbites, poisoning, with foreign substances in the orifices of the body, 49 50 DISTRICT NURSING. and can manage ordinary cases of midwifery with- out a doctor. The first thing for the District Nurse to do in case of any emergency, is to send the quickest ob- tainable messenger for a doctor, with information as to the nature of the accident, in order that he may come properly equipped. If the injury is of such a nature as to indicate hospital treatment an ambu- lance may be called for. If the patient must be moved from the scene of the accident an improvised stretcher can be made by fastening any smooth cloth over poles of suffi- cient strength to bear the weight of the patient. In most cases it is best not to move a patient until the doctor comes. If any of the bones of the body are fractured or dislocated the nurse should immediately put the parts at rest, making them immovable, and protecting them ; in some cases using impro- vised splints and bandages. If the fractures are compound some form of antiseptic dressing may be applied over the wound. The nurse need not attempt to reduce a fracture, for in a large city some surgeon can be obtained within a reasonable time. The injured part should be handled as little as possible, although the cloth- ing may be ripped or cut away. Almost any firm flat substance maybe used for an improvised splint, EMERGENCY CASES AND THEIR TREATMENT. 5 1 thin wooden boards being the best, yet in a pinch pasteboard or stiffly folded papers, or any substance which will give firmness to the padding can be used ; and the padding may be any soft substance, easily procured — a pillow, folded clothing, hay, oakum, etc., and anything which can be used to hold the splint and padding in place, can be used for a bandage. In applying these improvised splints let the limb fall into as natural a position as possible, and put them on gently and smoothly ; not so tight as to cause any further pain to the patient. They should be long enough to extend some dis- tance above and below the injury, and generally include the near joints. In fracture of the cranial bones the patient should be laid on his back and kept perfectly quiet. Cold maybe applied to the head; ail stimulants must be ayoided, and the eyes should be shaded from the light. In fracture of the jaw bone shut the teeth firmly together and hold the jaw in place b}^ a four-tailed bandage. If the spine be injured let the patient lie in the posture most agreeable to him, with the face turned so as to breathe freely. Apply cold to the injured part. For fractured ribs apply a bandage snugly around the chest. 52 DISTRICT NURSING. For a fractured clavicle lay the patient flat. If the shoulder-blade is fractured, place the arm of the affected side in a sling. „Fractures of the bones of the arms and legs are best bound in long splints. Dislocations are of the articulation of the bones, and usually the soft ligaments are more or less in- volved ; these should be as speedily reduced as convenient; that of the lower jaw is fortunately quite rare, but it is the one the nurse would be best justified in slipping into place, as any delay in getting this joint set is exceedingly painful to the patient; the nurse should wrap her thumbs in a soft cloth and place them upon the back teeth, pressing firmly downward and backward, meanwhile tilting the chin upward with the fingers ; this slips the jaw into place, and it is held there by the four-tailed bandage. Sprains are wrenchings or twistings of the joints. Hot fomentations should be applied at once, and the parts laid completely at rest. Contusions are most safely temporarily treated by hot fomentations, which help to alleviate the pain. Wounds are variously classified and as variously treated : the imperative need in an emergency case is to understand the kind of wound and to treat it accordingly. If it be from a poisonous bite suction should be applied to draw the poison out ; the juice EMERGENCY CASES AND THEIR TREATMENT. 53 of plantain leaves, which is not officinal and is not kept in the drug stores, is good applied to these bites, especially those from snakes or spiders. Strong stimulants can be administered, such as muriate of ammonia in whiskey or brandy. For lacerated, incised, or punctured wounds where there is danger from hemorrhage, this should be arrested so far as practicable ; any wound should be examined, and foreign matter removed therefrom. A wound should be washed off by squeezing water over it with a clean sponge. An antiseptic solution may be used. Incised wounds may be temporarily brought together by strips of adhesive plaster; the injured parts sometimes need to be supported and pro- tected by compresses and bandages; the nurse will probably have some soft material she can use as a compress, such as linen, absorbent cotton, or anti- septic gauze, in her bag. A punctured wound can have a soothing applica- tion of some antiseptic lotion applied. In checking hemorrhages distinguish between arterial, venous, and capillary. An improvised tourniquet of a handkerchief twisted in place with a stick is oftentimes useful. If in any case of injury the nurse finds lockjaw approaching, she should instantly summon the nearest physician. 54 DISTRICT NURSING. If artificial means must be used in arterial hemor- rhage, elevate the injured part, and if the flow be slight use pressure on the artery between the wound and the heart. Use the thumb or a com- press, and if possible press the artery against a bone ; in severe cases, and where practicable, if the wounds are situated so that digital pressure cannot be used, tampon the wound from the bottom up ; this method must be thoroughly applied, as poor tam- poning is worse than useless ; absorbent cotton is good for this purpose. In venous hemorrhage remove any ligature which may retard the flow of blood, and finding the suitable point beyond the injury from the heart, firmly compress the wound. Capillary hemorrhage may be checked by the application of either cold or hot water. For internal hemorrhage keep the patient quiet and cool, with the head elevated, and bandage the limbs to temporarily diminish the blood in circula- tion. Uterine hemorrhage may be controlled by hot uterine douches long continued (for one or two hours at least). In case of severe nose bleed, throw the head back, elevate the arms, and apply cold sponges to the back of the neck and over the bridge of the nose ; syringe the 'nasal cavity with cold salt and EMERGENCY CASES AND THEIR TREATMENT. 55 water ; if nothing better is at hand drop a cold key down the back. In all cases of hemorrhage rest is essential to help form and retain the preventative clot. In concussion of the brain keep the patient quiet and apply cold cloths to the head. If the shock is great, use warmth for the extremities. In com- pression of the brain, keep the patient very quiet, apply cold compresses, and avoid stimulants. In dealing with shock, keep the head low and apply warmth to the surface of the body, and give stimulants in very smiall and oft-repeated doses. When the patient cannot swallow, stimulants can be given hypodermically. Perhaps the quickest and best way for a nurse to deal with a burn is to cover it at once with flour, soda, or carron oil ; then wrap the part in soft linen. Scalds should be treated in the same manner. In case of shock from severe burn stimulants should be administered. If fire catches hold of the cloth- ing wrap the victim in' a woolen blanket and smother the flames. If one must pass through smoke and flame hold* a wet towel over the mouth and nose. Frostbites must be treated in a cool room with snow or cold water; if indicated, stimulants may be given in small quantities. In cases of syncope loosen all the clothing, lay 56 DISTRICT NURSING. the patient with the head lower than the body, and apply stimulating inhalations to the nostrils. In case of intoxication, let the patient be left quiet and resting. When in a fit of epilepsy, lay the patient on his back, loosen the clothing, and put a cork between the teeth to prevent self injury. In an attack of hysteria ignore the patient. For apoplexy, slightly elevate the head and apply cold water; loosen the clothing about the neck and waist and apply warmth to the extremities. Avoid stimulants. In case of heat-stroke have the patient removed to the nearest shade possible ; loosen the clothing about the neck and waist, take off any constriction, such as garters, and sponge the head and body with cold water; in extreme cases wrap the entire body in sheets kept wet with cold water, and if there is depression of the vital powers, stimulants should be administered in small quantities ; in cases when a high fever is absent and there is much depression, no cold need be applied, but mustard applications over the heart and on the calves of the legs may be used. If a person has been nearly drowned, first remove all sand and mucus from the mouth and nose, draw the tongue gently forward, and turn the patient with the face downward in order that the water may EMERGENXY CASES AND THEIR TREATMENT. 57 escape from the air passages ; then, keeping the mouth open by a cork or some other hard substance, endeavor to induce respiration ; when this is estab- lished give stimulants and apply friction and warmth to the body ; respiration is not always immediately restored and artificial means must be resorted to. There are several methods in vogue to induce arti- ficial respiration, Sylvester's being as good as any. Let the" clothing be loosened and place the patient on his back with a roll under his shoulders ; the tongue is drawn forward and held in place by a bandage or a hat pin ; the attendant, kneeling at the head of the patient, grasps his elbows and draws them upward until the hands are above the head ; this movement elevates the ribs, expands the chest, and produces inspiration ; the elbows are then car- ried downward, placed by the side, and pressed in- ward against the chest, thereby producing expira- tion ; these movements are made very slowly, not above fifteen a minute, and are continued for two hours or more unless respiration is established before that time. In any case of asphyxia, remove the cause in order that the lungs may be supplied with pure air; if much depression has resulted from the loss of oxygen in the blood, stimulants should be given. If any substance is lodged in the larynx, turn the patient head downward with a quick jerk, and 5 58 DISTRICT NURSING. sometimes the obstruction will roll out ; the back can be sharply slapped between the shoulders to help the patient cough the substance out ; foreign bodies in the pharynx are frequently coughed or vomited up ; in case of a pin, fish-bone, or other sharp substance, the white of an egg may be swal- lowed ; if the fingers can reach the offending article well and good, but all manipulations must be made with great care, and unless there is much pain and distress nothing should be done until the doctor arrives. Bugs in the ear may be drowned out by warm water, either syringed or gently poured in. Children who have swallowed any foreign sub- stances should drink freely of gruel ; no emetics or cathartics need be given unless the doctor so orders. During convulsions the patient's head should be wrapped in cold water compresses and the body immersed in a hot bath with mustard in the water. Poisons are of two kinds, narcotic and irritant ; the first cause no local irritation, the latter destroy the tissues with which they come in contact ; in any case of poisoning the first treatment is to re- move it from the stomach by means of emetics or the stomach pump, then the proper antidote is administered. Vomiting may be induced by tick- ling the throat with a feather, running a finger down as far as possible, or by giving common EMERGENCY CASES AND THEIR TREATMENT. 59 emetics, such as mustard in warm water, syrup of ipecac, or even warm water. If a person is suffering from narcotic poisoning the stomach can be washed out by an ordinary fountain syringe, the rubber tube without the attachment being introduced through the oesophagus ; give strong coffee for narcotic poisoning. Obstetrical emergencies are dealt with according to the general directions given in the best w^orks on obstetrical nursing. The handbook written by Anna M. Fullerton, M. D., is one of the best works of its kind and covers' the ground fully. A District Nurse frequently has slight ailments to deal with which are of scarcely enough import- ance to call in a doctor, such as the extraction of splinters, the dressing of blisters, and chafed skin ; the first can be gently drawn out with forceps, the blisters can have a needle and thread run through them to puncture the skin and let out the water, while fuller's earth is perhaps the best application for a chafed skin. Mutton tallow applied slightly warm, and a thin coating left on the excoriated parts, is soothing and curative for chapped skin. When the skin is abraded cover the wound with white of egg or paint with collodion. Bedsores are usually left for the nurse to treat. Unless the doctor gives special orders as to the dressing of these painful and weakening wounds, 60 DISTRICT NURSING. the nurse must use her best judgment in deaHng with them. They are far more easily prevented than healed ; they are the result of long-continued pressure upon particular parts of the body, and all bedridden invalids are liable to contract them, most particularly those of lowered vitality. Parts subject to pressure should be kept very clean, and the sheet under the patient quite smooth, the bed quite clean, free from wrinkles, crumbs, or lumps; the clothing of the patient must likewise be kept quite clean and drawn smoothly in place ; the skin may be hardened by daily bathing in alcohol ; if there is much pressure bathe several times a day, and dust the skin with finely powdered oxide of zinc ; re- move the pressure from the part by rings of rubber or oakum ; water beds are among the luxuries which most District Nurses are not yet able to command; if bedsores are already formed the alco- hol used in bathing must be diluted with water. A simple abraded surface may be treated by a dress- ing of oxide of zinc ointment ; if slough has formed, a charcoal poultice may be required to remove the gangrenous portion, after which lint dipped in aristol may be placed on the sore. CHAPTER VIII. SURGICAL NURSING. After the surgeon arrives the nurse leaves the entire direction of the case to him, holding herself ready to assist as he may give orders, and antici- pating his wishes, as her previous training has taught her to do. Very important operations are better performed in a hospital than in most of the homes a District Nurse visits, and yet cases of major operations where home treatment is the only alternative do occasionally fall into her hands. She should walk into the house fully determined to have the surgeon's orders fulfilled to the letter, in- sist upon the best room being used for the patient, and get together in the neatest and most convenient manner possible such articles as are essential for use during and after the operation ; have all per- sons not directly interested in the operation sent out of the room, and insist upon the apartment being quiet. It is for the surgeon to say if any im- mediate friend or relative of the patient may or may not be present ; but the nurse can strive to 6i 62 DISTRICT NURSING. quiet and soothe all undue excitement and unwise display of feeling. Upon her tact, firmness, and discretion, rest the ease with which the surgeon can do his work. Where there is time for the nurse to send to her headquarters for supplies she can procure such things as are needful for the operation ; otherwise she may be sadly put to it for make-shifts, and to her adaptability the surgeon is indebted if he finds no important article, or substi- tute for it, lacking as he proceeds to the business he is called for. In preparing for an operation in district work where the people are very poor, the nurse should see to it that the room is made as clean as time and circumstances will permit; that superfluous articles are bundled out of the room ; that the temperature of the room is about 70° F. (unless otherwise ordered). Have the window so protected that nothing can be seen from the outside, while a good light falls within. Let a firm, long table for the patient to lie upon be brought in ; lacking this, use planks upon barrels ; let there be a side-table or two or three chairs, to place dressings and instru- ments upon ; in every case the nature of the opera- tion determines the number and the amount of articles needed for use, and a District Nurse under- stands what to collect for each special case. If possible to avoid it, she should not stint in any way. SURGICAL NURSING. 63 It is a great mistake to suppose that just enough or a little less is as good as a bountiful measure. With a proper regard for cleanliness, the unused articles can be collected and kept in stock for another occasion. There must be plenty of soft . towels, basins, soap, hot and cold water, at any operation. If a District Nurse have a surgical tray in her room ready to be sent for on occasion it should be so complete that nothing will be lacking. The bed of the patient requires attention. In some homes the bed and bedding are far too filthy for use; for such, the nurse must have her spring cot for loaning brought, and such mattresses, pads, and bedding supplied as shall make the bed firm and comfortable. The cheap oilcloth sold for table- covers answers very well for a mattress covering. • The nurse should know whether the patient be in a fit condition to be etherized or no ; that is, if he have partaken of a hearty meal within a short time ; and she should properly prepare the patient for the ordeal, as in nursing a private case. Pos- sibly she may have to administer the anaesthetic. The operation fairly over, the bed having been pre- viously made ready, the patient is placed as com- fortably in it as possible ; while the same attention as is requisite in hospital practice to ease the patient, if nauseated from the effects of the anaesthetic, is needed. The parts operated upon must be kept 64 DISTRICT NURSING. perfectly quiet, and the nurse must take charge of the patient as the surgeon leaves. He may have given the most explicit directions to the family as to the treatment of the case, going into detailed particulars, but with her lies the task of enforcing attention and knowing that they properly under- stand what is to be done. The nurse must rem.ain with the patient until he is thoroughly over the effects of the ether and is made as comfortable as circumstances will permit. Then the room is cleaned up, the extra dressings packed in the tray, and the family put in charge of the patient. The nurse reiterates the directions of the surgeon and tries to make them very plain. She particularly enjoins the necessity for perfect quietness of body on the part of the patient, lest the work of the surgeon be undone and made of no avail, points out the danger from hemorrhage or from a re-dis- location, and tries to divert the mind of the sufferer away from his accident and forward to the time when he shall have recovered the full use of his bodily powers again. If a limb have been removed, she can bid him be of good courage and wait patiently for the artificial substitute. The surgeon may use antiseptic treatment. If he does, she very likely brings much of the lint, absorbent cotton, disinfectants, etc., in her bag daily when she comes to dress the wound. SURGICAL NURSING. 65 In cases of extreme emergency, if the nurse have not the needful suppHes, she must beg them if pos- sible, for, unless she can have the proper materials to work with, she may well give up her work as futile. If the injury of the patient is of the head, the nurse should see to it that the room be kept cool and dark. If tracheotomy has been performed, the air must be moist and warm. If such bones have been operated upon, or limbs taken off, as require the weight of the bedclothing to be taken from the injured part, a cradle can be made of barrel staves and hoops. Let there be pads under the wound to protect the bed ; these can be changed whenever needful for cleanliness. • All the precautions needed in surgical nursing in hospitals or in private homes are doubly essen- tial in district work to prevent blood-poisoning, or to keep from taking cold in suppurating wounds. All important cases must be visited daily ; sometimes twice a day is needful. Any surgical case of much import must be the especial care of the nurse, and if she cannot herself stay, she should endeavor to see to it that some responsible person is constantly in charge of the invalid. CHAPTER IX. SICK CHILDREN. These form the major part of nursing in district work : partly because of their large number, and partly because the District Nurse stands in a sort of maternal relation to the mothers of her little com- munity. Tired, overworked mothers look to her for advice and sympathy when their helpless little ones are ill, and it is these mothers who most need her ser- vices. When children come into a family, the loaf must be subdivided. What was competence for the young couple when first married, becomes bare subsistence by the time the tenth baby arrives, and sometimes long before that ; babies die and funeral expenses put the family into debt. There may be dull times, and work not obtainable ; the husband and father may get sick, but expenses go on, and he finds it hard to catch up on recovery ; any draw- back to regular earnings entails a time of severe privation. To young mothers just starting to raise a family, 66 SICK CHILDREN. 6/ the nurse may put the case strongly, enforcing the lesson of thrift, and teaching the young couple the injustice of bringing more children into the world than can be fed properly. Some are reached by her words and will pay heed to their doings, and so save • the community from the infliction of large, miserable families. In dealing with those already here, the nurse must be kindly and sympathetic. Be the baby the youngest of a troop, its rights are the same as if it were the only child ; and the mother, worn by ex- cessive child-bearing and the care the little folks brought with them, is to be pitied for her ignorance and helped in her misfortunes. So long as all the children keep well, matters run comparatively smooth ; a little want is not felt, yet the great privations of the poor predispose their children to disease ; but, even so, it is always easier to keep children well than to restore them to a nor- mal condition after they have contracted illness, and in teaching mothers how to keep their children well the nurse finds much work ; the instincts of motherhood will usually lead even a thoughtless woman to try to do all she can for her children, but, in her ignorance, she makes many and woful mistakes. She is so apt to make herself a willing slave for them when they are ill, that she often- times wears her own strength quite out without 68 DISTRICT NURSING. doing them any good, and all this is mistaken kind- ness. Children sicken very quickly and recover almost as rapidly, and even a slight indisposition in a child should not be passed over as of no account, lest it prove the precursor of a more serious illness. Miss Catharine Wood says : " Illness at first shows itself in a child by listlessness and loss of ap- petite ; the eyes look heavy ; the child may be fret- ful, especially if disturbed, or it may be drowsy ; it will feel hot, and, if the temperature be taken, the thermometer will generally show an elevation above the normal ; but this, in itself, must not be regarded with disquiet, as a very little suffices to disturb the normal heat of the body ; in nearly all cases there will be vomiting and some bowel disturbance, and then special symptoms will declare themselves ; . . . . the best treatment is to wait and see what is coming, at the same time placing the child in favorable cir- cumstances ; that is, keeping it quiet and away from its fellows, giving it light food easy of digestion, seeing that the bowels are not overloaded, and then waiting for the diagnosis of the medical attendant." Whatever the doctor may direct in regard to the child the nurse should see done, teaching the mother how to do it, and in teaching her taking nothing for granted, but making every step of the process plain to her. Sometimes hospital treat- SICK CHILDREN. 69 ment may be advised as being best for the child physically and morally. Sick children are as individual in their tastes, likings, and antipathies as are grown people, and* with but little diplomacy in their composition, • having not yet learned the value of dissimulation in getting on in the world, they openly show their likes and dislikes. To nurse a child properly one must have its confidence, and the gaining of the good-will of the little children is one of the first duties of the District Nurse. She needs a mother's heart big enough to adopt any member of the human family, yet a child, who may need her care, and this means a great deal. When mothers find their little ones take kindly to the nurse and see that she can do with them much as she pleases, most will listen to her advice as to the management of the little people, and by timely hints she can contrive to save many a child from serious illness. In dealing with a sick child let him be treated as nearly like a well one as possible ; that is, let regularity of habit be kept up. On first awakening in the morning sponge off its face and hands, rinse out the mouth, and give some nourishment ; let the room be tidied and aired, the clean clothing aired, and the patient dressed in fresh clothing and the bed made. 70 DISTRICT NURSING. Be very careful not to waken a child out of a sound sleep, unless particularly ordered to do so by the doctor. Be very exact in giving medicine and nourish- ment ; if the patient have slept over the hour, give it on first awakening, and commence the time table anew. Keep the room very quiet. Avoid too bright a light if it falls directly on the eyes of the patient, or in the room, if it seems to disturb him. Keep the room well ventilated ; always have the air sweet and fresh. Do not let the patient feel any draught. Cover him lightly over when airing the room. Remember that children cry continuously only from one of two causes, hunger and earache ; if children are hungry, and it is not yet time for food, let them cry if they cannot be soothed by some other means than feeding them. A little cold water will often satisfy the thirst. To induce a baby to put out its tongue, put a little sweet on its lower lip down toward the chin. Castor oil can be given in hot milk. Babies get thirsty and need a little water to drink several times a day. Have mothers prepare for night during the day ; it saves time and strength. SICK CHILDREN. y\ Take the temperature of a child by rectum, and count the pulse during sleep. To give a sick child a bath, wrap him in a warm blanket and let him down into the water gradually ; the water should be about ioo° Fah. ; on taking out after five minutes or so, wrap him in a dry, warm blanket and wipe him, without exposure if possible, with soft towels. Treat children gently so far as handling them is concerned, but be firm in carrying out the doctor's orders, letting neither tears, screams, nor kicks inter- fere with doing your duty. In teething children watch the gums lest they require lancing ; swollen gums sometimes make babies very restless and feverish. If children have sore eyes (conjunctivitis) trickle upon the lids, letting the stream run toward the nose, warm water in which a pinch of salt has been dissolved ; this disease is quite contagious, and the towel used by a child afflicted with it should never be used by other children in the family. In sponging a patient do not fill the sponge to overflowing, but wring out the water until it will not drip when held in the hand. By this means wetting the bed clothing is avoided. If the doctor orders a cold pack, the child is laid on a canvas cot which has been previously 72 DISTRICT NURSING. covered with oilcloth, and over this a large sheet laid ; the sheet is folded over him, and the head of the cot is raised a little from the floor to allow the water to flow toward the foot and into a tub placed there to receive it ; a continuous spray of cold water is played over the child from an ordinary watering*pot ; the doctor advises as to the length of time this treatment should be kept up. To give a child an enema, turn it on its left side with the knees drawn up, and pass the nozzle of the syringe into the rectum, directing it a little to the left. Force the fluid in gently, and keep it in the bowel for some little time after the tube is re- moved by holding a folded towel as compress over the anus, letting the child remain quiet in the posi- tion it was placed. . If a leech must be applied, have it in a place out of sight of the child. Rub a little sweetened milk over the spot where it is to be placed to induce it to bite ; when it should come off, drop some salt on it and carefully remove it. If the bowel protrude, lay the child on its side and gently push the intestine back into place ; wash the parts with a little warm water and hold a warm compress at the anus for a short time. No class of sick children appeal more strongly to the sympathies of the District Nurse, than those SICK CHILDREN. 73 afflicted with hip disease, or with Pott's disease ; such cases require special treatment, which she should endeavor to obtain for them. Little babies when sick must be closely watched for all the objective signs of illness, as, being quite unable to tell how they feel, there is little else for the doctor to rely upon in diagnosing the disease. All the movements, such as the tossings to and fro, twitchings, jerkings, the cries, whether they be sharp and piercing, or moaning, or long, loud, and tearful, and the looks of the child, whether it be pale or flushed, should be noted. Asleep or awake there is much to be noticed in the appearance of a child, and a nurse can tell a mother just what to look for in her sick child. Babies often have quite a high fever from an acute attack of indigestion, a happy trick of Nature to alarm the mother in time to the dangers of bad feeding, and one that furnishes the nurse a fine opportunity to teach the importance of attention to the baby, and the need of feeding it judiciously. Colic in a baby is sometimes relieved by a few spoonfuls of hot water and by putting a hot flannel over the abdomen. The food may be too alkaline and should be changed. In arranging an ice bag for the head, as in con- gestion of the brain, the ice should be smashed and placed in a flannel bag (if a rubber one cannot be 6 74 DISTRICT NURSING. procured), with soft towels under it to absorb the water ; the pillow for a sick child should be of hair. Children in convulsions should be put into hot water without waiting for the doctor to come. If a baby is restless it can sometimes be soothed by turning it into a different position. If children will not open the mouth to take medi- cines, hold the nostrils between the thumb and forefinger ; they will open the mouth to breathe, and will swallow during inspiration. During the hot weather babies should be very simply dressed and kept cool. Heat is one of the most potent factors in the production of entero- colitis, popularly known as cholera infantum. Babies suffering from this should be kept out-of-doors, in the parks, or by the seaside during a large part of each day; not, however, in the direct rays of the sun, nor yet exposed to a draught of air, a sud- den chilling of the surface of the body being one of the worst possible exposures for a -little child, whether sick or well, and at the root of many infan- tile disorders. The diseases of very young children are notably those of the respiratory system, or of the alimentary tract, and one of the commonest causes of illness is overfeeding ; if for any cause the child is uneasy or fretful, the mother snatches it up and nurses it or gives it the bottle to suck. Summer complaints. SICK CHILDREN. 75 indigestion, inanition, and entero-colitis are the direct result of this course of treatment, therefore, to regulate the diet is of the first importance in dealing with sick babies ; and as such are apt to be quickly amenable to treatment, it proves oftentimes all the help they need. Mother's milk is undoubtedly the best food for infants under one year old, yet babies must be individualized in this matter. Some babies thrive best on artificial food, and the milk of many mothers is poor and lacking in nutritious elements. The personal hygiene of any mother who is nursing her baby should be closely looked after. It is always a pity to feed a child artificially entirely : when a woman can nurse her baby part of the time she has a recourse in case of illness which the mother who depends upon the bottle has not. Nothing soothes a fretful, irritable child sooner than suckling it. In dealing with all babies who are ill, the nurse works under a physician. She is happy if the doctor understands infant dietetics. She, however, can shirk the grave responsibility of trying this food or that preparation until one is found which suits the baby's stomach. The doctor is responsible for the suggestions, and she congratulates herself that he is, for in the matter of infant feeding there seems to be a great diversity of opinion ; on a sub- jG DISTRICT NURSING. ject of such grave import she may well safely rest the entire responsibility with the doctor. Her duty lies in a diffecent path, and that is, the thorny one of knowing that the doctor's sugges- tions are heeded and acted upon. The carelessness of mothers as regards taking advice as to the feed- ing of their children is something stupendous. Mere infants are table fed from the time they can lay hold of food with their little fists, and the baby rules the family in choosing his food ; the others do not eat so recklessly, but baby may eat anything, provided he does not choke in swallow- ing it. To get mothers to feed their babies rationally is one of the hardest tasks a nurse has to do. Dentition in children is a natural process and is not always attended with physical disturbances. The prevalent opinion amongst poor mothers is, that a child must be sick when teething as a matter of course; this is a fallacy the nurse must combat. After the children are weaned the food must be given with judgment. No child is capable of choosing what is good for itself. Perverted ap- petites are of very sudden growth and strong in their demands. A wise mother chooses the food which is good for the growing child, and gives him no opportunity of rejecting it. She does not refuse SICK CHILDREN. 'J'J to make it palatable, but she pays no heed to ab- normal cravings. The children of the very poor are only too apt to suffer from an insufficiency of food ; this the nurse cannot always remedy ; and by reason of too little food and bad surroundings she cannot bring these children up to the standard of health they would reach under different conditions. Rachitic children especially, require a generous diet and warm flannel underclothing, particularly in cold or damp weather. Children suffering from any form of tuberculosis should have food good in quality and plenty in quantity. If all such could have even a moderately comfortable life the misery attendant upon their illness would be greatly lessened. Specific disorders in small children are usually inherited, are difficult of eradication, and the nurse must see to it that the advice concerning diet and cleanliness is acted upon, that the towel used for the afflicted child is not used by any other member of the family, and that all proper precautions are taken to keep others from being infected with the poison. In w^hooping cough there is danger that a child may die from exhaustion, or that capillary bron- chitis may supervene. It is well, therefore, to guard against the occurrence of these complica- 78 DISTRICT NURSING. tions early in the disease, and in even slight attacks. Spasmodic and membranous croups usually come on suddenly, and must be dealt with with alacrity. The former rarely proves fatal, the latter nearly always does. It is considered by many physicians as identical with diphtheria, and the treatment for it is similar. We have found that the steam from washing carried on in the home is productive of many ill- nesses of the respiratory tract, and very aggravat- ing to many more. It is a great pity that in all of our large cities some provision is not made for having washing done either in public laundries or in wash-rooms outside of the tenement houses. Children with infantile paralysis, or undeveloped muscles are sometimes benefited by massage, while cases of malformation should pass under the eye of a surgeon before being given up as incurable. Then there are always cases of neglected, half- starved, and vermin-covered children for the District Nurse to look after. To rid children's heads of pediculi, the tangled masses of hair should be cut off, and the head washed in kerosene oil. After the oil bath the head should be wrapped in a towel to dry off Extreme cases call for ung. hydrarg., which must be used with care, particularly if there be sores upon the scalp. SICK CHILDREN. 79 In all skin affections much care must be taken to maintain cleanliness, not always by washing in soap and water, for this is often interdicted by the doctor; but in wiping off the parts with oil and a soft rag, and in keeping the clothing scrupulously clean. Impure soaps, and hard water, should always be avoided in w^ashing children. CHAPTER X. INFECTIOUS AND CONTAGIOUS DISEASES. These ailments form a goodly proportion of those a District Nurse has to deal with. There are always difficulties in properly caring for them in the homes of the poor, isolation in many cases being well nigh impossible; but the nurse can insist that superfluities be removed from the room in which the patient lies ; if the family all live in one room, the patient should be removed to a hospital as a matter of public health. Such cases are to be reported to the Health Boards for their supervision. In times of cholera epidemic, whole communities get roused to taking sanitary precautions ; but a neighbor's child may die of diphtheria, and very little be thought of it by families contiguous. Cholera proves fatal in perhaps half the cases at- tacked by it, while a far greater proportion of cases striken with diphtheria die, and diphtheria germs are readily disseminated and hard to kill. Scarlet fever is to be dreaded amongst little 80 INFECTIOUS AND CONTAGIOUS DISEASES. 8 1 children, for although they may recover from the fever, there are apt to be sequelae which make the lives of the victims a burden. When measles or chicken-pox attack the children of a neighborhood, dozens may take the diseases, unless prompt measures are taken to stamp them out. There should be a physician to visit every case of contagious disease in the home, and the nurse must be watchful lest the proper precautions for the protection of the family and to prevent the further spread of the disease in the neighborhood are neglected. The importance of carefulness must be impressed upon the minds of the people, and much of the w^ork of the nurse lies in giving in- structions, such as : — ' *' Make this room as nearly empty as possible. " Have this bed clean, and keep it so. '' Keep the air pure. " Protect the patient from a draught. " No one except the one caring for this patient shall come into this room. '' Keep a w^ash dress to w^ear in this room, pro- tecting the hair by a close-fitting cap. " Nothing used about the patient or in this room shall be taken from^ the room until it has been washed in boiling water." If the patient is dying, do not let the family 82 DISTRICT NURSING. gather around, but instruct them to quietly submit to the inevitable. They should be taught to save their own strength, to care for the invalid in turns, and to eat before going into the room. It is not an impossible matter to prevent disease spreading. Boiling water will kill the germs of most diseases ; and an abundance of pure air will oxidize and purify any putrid matter there may be. In ventilating the sick-room do not let the air blow into the other rooms in the apartment, nor yet let the family suppose that because disinfecting solu- tions are freely used that they can dispense with pure air ; no disinfectant is so valuable or takes the place of this ; we think it far better to abstain from using any sweet-smelling deodorizer to deaden the foul smells of a room, for the reason that so many consider this all that is needful ; it is better to let people comprehend that all foul odors can be dis- sipated in the free air, only have the quantity sufficient. The family should be made to understand that the amount of disease germs are circumscribed ; they may be practically countless, yet there is an end to their number, and every one destroyed is one less to inoculate some one else with ; teach them to thoroughly disinfect the vomit, the sputa, and the defecations of the patient ; if the disease is com- municable through the desquamation of the skin. INFECTIOUS AND CONTAGIOUS DISEASES. 83 let the body be rubbed with oil to prevent the scaly particles flying off into the air. If a nurse in making her rounds finds a child ailing without any disease having positively de- veloped itself, let her watch the child carefully for a few days lest it be coming down with some con- tagious disease ; if there be no doctor in attendance, let her above all things examine its throat ; let her instruct the mother to give it a warm bath at bed- time and keep it out of draughts, and to watch for the appearance of any rash upon the surface, and to note the nature of the eruption if any appear. Some diseases are more readily communicable than others. Smallpox is given at any stage and can be taken from a patient even during the period of incubation. It is more generally dreaded than any other ailment, and people will take precaution- ary measures to avoid it more readily than in case of any other disease. In all large cities the Health Boards attend to the vaccination of the poor, and the public schools reject pupils who are not vaccinated. The germs of smallpox are long-lived and develop under suitable conditions from hidden sources, so that the public do well to guard against it. If a case appears it is immediately removed to a special hospital for treatment. The risk of infection from measles and whooping- cough is greatest in each in the early stage of the 84 DISTRICT NURSING. disease. Scarlet fever is most readily taken during the third or fourth week, when the skin begins to peel ; typhus fever germs are not nearly so infec- tious as those of typhoid, but in certain conditions of the system they are readily developed. Typhoid fever, yellow fever, cholera, and dysentery are not directly transmissible. The excretions are the media through which the germs are carried into the atmosphere gr into the water, and from thence taken up into human systems. They are sometimes drank in infected milk. In nursing these cases, everything that comes from the patient should be disinfected by pouring over it boiling water. This is the simplest and easiest method of dealing with all excreta. If there is a lack of flush water supply in the water closet these excreta may be mixed with sawdust and burned. Of all the scourges which visit the homes of the poor we think diphtheria the one to be the most dreaded. It attacks chiefly young children from two to nine years of age; and if one member of the family has it the others are quite liable to take it. The simplest precautions against infection from diphtheria are, to avoid inhaling the patient's breath or other exhalations from his body ; be very care- ful that nothing spit from the mouth lodge any- where to dry and become diff'used in fine particles INFECTIOUS AND CONTAGIOUS DISEASES. 85 through the air; let one person at a time only be in attendance upon the patient ; let no one who has the care of the patient go into the room hungry or too tired, if the weariness can be avoided, and let the attendants as well as all the members of the family gargle their mouths and throats with salt vinegar and water. Diphtheria germs will not thrive in acid secretions. In any case where a child has a throat dusky red, let it be gargled with the mixture of salt, vinegar, and water, and call a doctor's attention to the child ; it is better to be over particular in trying to prevent diphtheria than a little careless. When a contagious disease ends by the patient's recovery, or by his death, the room he has been in should be disinfected ; if the patient dies, all the clothing used about him should be at once burned; if this seems too much of a hardship, they must at least be put into boiling water, and boiled for some time, and then rinsed in a solution made of — Sulphate of zinc, 4 ozs. Common salt, 2 ozs. Hot water, I gall. The clothes may be soaked in this for two hours, and then washed out in the usual manner. After death occurs, there should be as little hand- ling of the dead body as possible, and the funeral should be strictly private. 86 DISTRICT NURSING. The walls of the room vacated should be washed down with a disinfectant and the room fumigated with sulphur. In burning sulphur it is well to remember that the best effects are obtained only in a moist atmosphere, so that kettles of boiling water should be put into the room just before the sulphur is ignited. The steam can be increased by- putting into these kettles very hot bricks. A room may be opened twenty-four hours after fumigation and thoroughly ventilated. All drains and closets should occasionally be flushed with boiling water. Copperas, and chloride of lime, may be thrown into them dry. There are dozens of disinfecting solutions, but unless the physician in charge of the case order a special one, the District Nurse can ver)^ well manage with plenty of pure air, boiling water, and bichloride of mercury, the latter to be used by herself, as, being a deadly poison, she may not trust it for family use. In dealing with contagious diseases the sputa of consumptives should not be overlooked; every consumptive should be taught to spit either in old rags or soft papers which can be burned, for the dried particles of sputa which rub off from the handkerchief, clothing, or any receptacle which con- tains it will float in the air and, coming in contact v/ith a mucous membrane ready to receive it, will INFECTIOUS AND CONTAGIOUS DISEASES. 8/ produce consumption in the new patient. As con- sumptives near the end some things can be done by the nurse toward alleviating their suffering, such as elevating and bandaging their lower limxbs if swollen, applying dry heat or friction over the thorax to relieve pain, and giving some warm drink early in the morning to ease the vomiting. For hemorrhages table-salt can be given, and for night sweats the body can be lightly sponged off with alcohol and water; the garments worn during the night can be taken off, turned, shaken in the open air, sunned, aired, and alternated with another set to keep them fresh and comfortable; and tasty nutritious foods, can be prepared. It is usually customary for the visiting nurse to confine her services to these cases exclusively when attending them. Many societies make this an imperative rule. When a society has several nurses working under it one can easily be detailed to such cases. This, of course, does not apply to consump- tive patients, but only to such diseases as are spread through contact. A careless nurse could easily do more harm than good if she disseminated disease germs from one house to another. CHAPTER XL MEDICAL NURSING. The District Nurse finds that in the course of her work she deals with many and various diseases, and that she must understand the general treatment of them all. For convenience, she classifies them under dif- ferent types, and suits the general treatment to the special needs of each case as best she can. There are chronic cases to be dealt with ; those that general hospitals do not care to take, as being in the main incurable and of no special clinical interest. The consumptives already spoken of are found among this class; for a patient suffering from consumption the treatment given by the nurse is palliative. She tries to make the ventilation of the apartment as complete as possible, and to see that the invalid has as good food and care as she can arrange for. One im- portant factor in dealing with respiratory troubles lies in teaching the patients how to cough. This should be after a full inspiration. Coughing in ex- MEDICAL NURSING. 89 piration helps to force out accumulated matter with the air, as unavaihng hacking does not. A provocative cause of lung trouble is the steam from damp clothes, and it is one of the miseries of the very poor, that the smell from wet garments must be inhaled, when they are drying by the only fire to be afforded. In tending upon cancerous patients the nurse must insist upon perfect cleanliness of dressings in order to keep the foul odors subdued. In kidney and heart troubles the District Nurse can usually do a good deal toward alleviating the miseries the patients must endure. She can band- age swollen limbs, procure easy chairs, and other sick-room appliances, and brighten their lives in many ways. In caring for fever patients the nurse must teach the members of the family how to give baths ; to take the temperature, respiration, and pulse; how to feed the patient; how to change the bed-linen; in fact, the entire minutiae of fever nursing, as she cannot be present during any lengthened time, and the attendance upon fever patients must be con- stant. This matter of teaching nursing applies to very much of the work of the nurse ; she must show others how to do nursing easily and well, by actual bedside instruction. In different sicknesses a 7 90 DISTRICT NURSING. screen is needed. An ordinary clothes-horse covered with a blanket is a very good improvised one. A simple bed-rest is formed by a chair placed behind pillows. In such illnesses as require much lifting of the patients the nurse should assist when she can be present, and show the family how to manage when she is absent, and this with the least annoyance to the patient. She must be cau- tious in handling medicines, and impress upon the attendants the importance of exactness as to quan- tity and time of administration. She must teach them also to watch a sick patient during the early morning hours, just before daybreak, when vitality is at its lowest ebb, and the air is apt to be chilly. If the patient seem to need it, external warmth should be applied and warm drinks given. In special instances the doctor in charge will rely upon the District Nurse to personally perform such duties as cupping, leeching, giving enemata, etc., etc. There are always many such things she must do, and she arranges with the physician as to times and metho'ds. In some forms of gastric and intestinal disorders, perfect rest in bed must be insisted upon, and the diet carefully looked after. In the matter of feed- ing these patients the District Nurse must be on her guard, explicit in her directions, entering into a minutiae of detail which the doctor cannot take MEDICAL NURSING. 9 I time to do ; showing how to prepare the food per- fectly, and how to serve it in a neat, orderly manner. For patients suffering from gastritis, dysentery, diarrhoea, and peritonitis the stomach and bowels should be kept warm by a light flannel bandage, but no weight of bedclothes should be allowed ; the bed-pan should be warmed before use, and boiling water poured over the stools before the pan be emptied. So far as possible, keep all odors of the kitchen from the sick-room. In the event of approaching death the District Nurse must prove herself the sympathetic friend. In such seasons of grief there is the touch of hum.an sympathy which makes all men kin ; rank, station, and wealth produce seeming inequalities, which sink into comparative insignificance in the presence of the arch enemy of the human race. Busy doctors cannot always take time to stand by and comfort the living and ease the dying. The District Nurse can usually do so. Too frequently there is no money to pay funeral expenses. We think it should be the aim of every District Nurse to have a fund to loan on such occasions. Whether or no this fund may not be the investments of the poor themselves is a mooted question. We think it easily might be. Penny savings make dollars if long enough continued ; 92 DISTRICT NURSING. and a sort of mutual insurance company could readily be started in almost any neighborhood. Business men have found the advantage of such investments. We find the carrying of a small life insurance policy not an uncommon thing among the very poor. That there may be slight grief shown at the loss of one whose life is insured is apparent enough at times, for one of the evils of extreme poverty lies in its tendency to callously harden the finer feelings; yet with vigilance on the part of the doctors in signing death certificates any criminal carelessness as regards the treatment of the sick whose lives are insured can be reduced to a minimum amongst the poorer classes. CHAPTER XII. FEVER NURSING. Fever in the human system is always marked by a rise in temperature, and this is usually ac- companied by increased frequency of respiration and a heightened pulse-rate ; it may be due to many different causes and may accompany many different diseases. Both the muscles and the nerves are affected by fevers, and in nursing any case of fever both rest and quiet should be insisted upon. To the observer watching the course of a fever, there seems to be a sort of conflict going on to decide as to the resisting power of the individual to the injurious effects of prolonged high tempera- ture. Heat of the body is dissipated through the skin, and is used in the respiratory acts : hence the sick- room should be airy, well ventilated, and with an even temperature of about 60^ F. ; the bed, how- ever, must be placed out of a direct draught, as this, blowing over a patient tends to check the free ac- tion of the skin ; let the clothing and bed-covering 93 94 DISTRICT NURSING. be light, yet sufficient to protect the patient from variations in the external temperature; both must be frequently changed, as the effluvia from a patient suffering from fever is offensive and unwholesome ; the skin should be frequently sponged off with tepid water, or with water and a little vinegar or alcohol or bay rum; this helps to keep it from becoming dry and harsh and from losing its elasticity and power of throwing off waste products. During the course of any fever the functions of digestion are apt to be more or less impaired, ren- dering the administration of food in small quantity, yet at short intervals, a necessity. Milk as food, and water to slake thirst, can usually be freely given; in any exceptional case the physician will give orders to the contrary ; let the food be given with regularity. Fevers, according to their type, may be ushered in by a severe chill or by one less pronounced, or yet may be preceded by a longer or shorter season of malaise, lassitude, drowsiness, or by restlessness, vomiting, or irritability, with, perhaps, headache. In children very trivial ailments may be accom- panied by a fever quite out of the ordinary propor- tion of rise of temperature to disease in the adult. A child will have high and low temperatures vary- ing in the most irregular manner, and yet be not so very sick ; the safest way in either child or adult is FEVER NURSING. 95 to go at once to bed and await developments ; if the fever passes quickly off, well and good ; if it has come to run a longer course, the system is fortified against the disease by resting in the early start. Fevers are classified according to the causes pro- ducing them, their general effects upon the system, and the symptoms attending them ; in any case of fever it is best for the patient to remain in bed so long as the attack continues. Good nursing in the case of fever patients consists in keeping the air of the room fresh and wholesome, the patient, his bed, and his room clean, maintaining quiet, alleviating distressing sym^ptoms so far as possible, and observ- ing the utmost regularity in giving food and medicine. To keep the air of a sick-room wholesome there must be a constant supply of pure air coming in, and some means of exit for the vitiated air. If the weather is too cold to admit of the window being constantly open, the patient can be well covered, the window thrown open top and bottom, and the door swung rapidly back and forth ; this winnows the air and changes all in the room in a very few minutes. To protect a patient from a draught an improvised screen can be made of a clothes-horse covered with a blanket. To ensure the cleanliness of the patient and his bed, there must be frequent changes of linen. Soft g6 DISTRICT NURSING. old clothing and bedding, are by far the best in case of fever. The person of the patient must be frequently sponged off, and any soilure of the cloth- ing or bed at once remov^ed ; and everything about the patient kept fresh and sweet. In bathing a patient who is weak, only a portion of the body need be gone over with at a time. Either tepid water, or water and vinegar, or water and alcohol, or yet water mixed with bay rum may be used for bathing purposes. If the patient be too weak to rise, the body linen may be torn up the back ; the sleeves can be easily slipped off and on ; sheets can be rolled under a patient from side to side. Bathe the patient before putting on the fresh linen. Be- ginning at the face and neck, pass the sponge rapidly down over the upper limbs and trunk and down the lower limbs to the feet. The patient may be rolled to one side and the back lightly gone over ; this is all done by passing the hand contain- ing the wet sponge underneath the sheet or blanket. All noises so far as possible should be kept far from the sick one; the step of the attendant should be soft and springy rather than shuffling and heavy. Any one caring for a person very ill should learn to move quietly about the room, performing all the little offices of the nurse noiselessly as well as deftly. No starched dresses or rustling skirts FEVER NURSING. 9/ should be worn, nor should the fire be poked and coal rattled in keeping up the heat ; the ashes can be gently shaken down and coal dropped piece by piece in paper to renew the fire. No loud talking should be indulged in within hearing of the patient. The methods of alleviating the symptoms of fever largely depend upon the kind of fever and the treatment adopted by the doctor attending the case. Any very bright light should be excluded from the room of a fever patient, although it is a mistake to keep the room too dark. In the milder cases of continued fever cooling drinks, particularly alkaline waters, such as Seltzer or Vichy, can be given, and milk, light broths, cus- tards, whey, and jellies taken for food. • In almost any fever the hour just before dawn, or from three to five in the morning, when the vital powers are at their lowest, is apt to be one of extreme depression ; frequently the patient requires artificial heat and some stimulus given at this hour. The visiting nurse supplies the blanks for keep- ing the record of her patient's condition, and fills out the bedside notes so far as she is able herself, but depends upon the family to aid her so far as practicable. The temperature can be taken 9o DISTRICT NURSING. by placing the thermometer under the tongue, in the axilla, or yet in the rectum. The latter is by far the best way with children. The mercury in the instrument is shaken down below the normal degree of 98° F., and the bulb is placed in one of the posi- tions indicated, and kept there from five to seven minutes ; the rise will mark the degree of fever. When removed from the body the thermometer should be carefully washed and returned to its case. If the doctor desires the temperature taken fre- quently the nurse must instruct some member of the family how to do it. If there is no watch .in the house by which to count the respiration and pulse, the second-hand of a clock will answer. The food and medicine must be given just as the doctor orders, promptly on time and exact as to quantity. If the patient sleep over the hour the doctor will probably have left his instructions so explicit as to cover such an exigency. If he has not, have the family ask for directions at his next visit. A patient suffering from fever should not be need- lessly disturbed ; the nurse or attendant should avoid fussiness. A drink will often be taken if placed at the lips when the patient is too weak to ask for it. Parched lips and cracked, should have a little FEVER NURSING. 99 glycerine applied on a soft linen rag quite fre- quently; and sordes on the teeth should be cleaned off with soft rags. Sometimes there may be distressful vomiting which does not yield to the remedies given. A nurse may use such simple means as a weak mus- tard plaster over the stomach, or if the skin is too irritable to bear this, a little bruised mint, such as is found at the green-grocers, wetted with brandy, may be laid over the stomach, or a slice of toast wetted with brandy may be used in the same way. The pillow of a fever patient should be frequently turned and shaken to keep it cool and soft. A patient should not be lifted suddenly to take either food or drink or medicine, or for any other cause. If the heart is in any degree weak, this sudden movement may cause it to stop beating. Some of the cases of heart failure arise from this cause, no doubt. Delirious patients must be watched w^ith unre- mitting attention, lest they get up and harm them- selves. Headache may sometimes be relieved by cold compresses applied over the forehead or ice- bags to the head. In summer time the air of the room may be extremely hot. To cool the atmos- phere cold water may be poured over the floor, or sheets or blankets wrung out of ice-water hung lOO DISTRICT NURSING. about the room. To relieve extreme thirst bits of cracked ice may be frequently put into the mouth. Frequently fever patients relish their food and drink extremely cold. The beef-tea may be frozen for such. Those who can retain very little on their stomach will frequently keep down a few spoonfuls of clam broth, or a little plain ice-cream, when other food would be thrown up. In some cases hot milk can be taken with benefit. The special directions for nursing different fevers depend largely upon the mode of treatment of the doctor in charge. The nurse finds out his special methods and instructs the family of the patient ac- cordingly. When stimulus is ordered it must be given as exact in quantity as the medicine is in dosage. The nurse must prepare the family to meet emergencies as best she can. CHAPTER XIII. OBSTETRICAL NURSING. * The little babies keep coming, and although small boys and girls in the city do not suppose they grow on apple trees, that fiction being reserved for the comprehension of country lads and lasses, yet a great many children do suppose that the doctor or the nurse brings them, and on her temper in the matter lies the reception the little strangers receive in homes already full to overflowing. Every baby should have a birthright of welcome and love; that every one does not is a misfortune and a disgrace. Finding a woman anticipating a near confinement, the nurse must speak as happily and encouragingly to her as she can, and strive to help her in all little ways possible to make ready for the expected new- comer. Doctors can always be found to look after these cases, and one should be engaged sufficiently long beforehand to make the proper examination and arrangements for the approaching lying in. The nurse should see to it that the needful appli- ances be not lacking. If she be caring for patients ill lOl I02 DISTRICT NURSING. with contagious disease she should send a substi- tute to the lying-in patients. No District Nurse should feel bound to go to such cases in the night; the woman can usually find some friend or neighbor to be with her during labor ; but if the nurse have taken a proper interest in the case the arrangements have been well made beforehand and everything needful is in readiness. It occasionally falls to the lot of a nurse to deliver a woman, and she should be well prepared for such an emergency. A Httle hand-book on obstetrical nursing, written by Anna M. Fullerton, M. D., completely covers the ground, and in such a masterly way as to leave us no alternative but to recommend it as a text-book for all District Nurses. It is published by P. Blakiston & Son, of Philadel- phia. Obstetrical nursing in district work has some drawbacks which are not met with in private prac- tice or in hospital treatment. These are chiefly in the way of carrying out antiseptic treatment; the room, the bed, and the clothing of the lying-in woman may be filthy ; they are rarely ever clean ; and the most the nurse can do is to approximate toward cleanliness. Hard work and poor food may have reduced the woman's strength so that she makes a slow recovery. Very rarely, however, does a District Nurse find it OBSTETRICAL NURSING. IO3 needful to visit the mother or child after the tenth day; by that time she is able to be up and can dress the baby herself, although the nurse cautions the mother not to take up all of her work for some- time longer. We have met women who resumed their labors in outside work, washing, scrubbing, and the like, by the third week with no apparent discomfort, yet we never advise any woman to such a course, but would rather prevent a suckling woman from doing any work outside her own family if possible. When the nurse has met the woman some little time before the confinement she can explain many hygienic laws, so that mother and child are great gainers thereby. Very young mothers have need to be taught nearly everything in regard to the morale, of motherhood — how to work, how to sleep, the regulation of their marital relations, how to eat, and how to prepare for the baby. Women who have already borne children do not always ac- quire wisdom by experience. The nurse finds that she must feel the way to the understanding of different women and adapt her teachings to the need of each individual patient. CHAPTER XIV. TEACHING IN THE HOMES. In her visitations from house to house the District Nurse sees much that can be righted; the import- ance of setting matters straight grows upon her, and she cannot hold her peace, even if she did not consider teaching as a part of her work. Her position makes her a natural Mentor to the people she visits. But one thing must always be kept in mind, and that is that people do not like to be preached at even by the most kindly disposed ; and a very large proportion of the poor will equally resent being patronized; being *' apt to teach" therefore means being very gentle, kindly, and tactful. Lessons are usually given as side issues ; they may be the principal object of the visit and do the most per- manent good, but ostensibly they are not the primary cause of the call of the District Nurse. Let poor people once get the idea that nurses go about as general nuisance inspectors and critics of their mode of life, they will speedily cease to 104 TEACHING IN THE HOMES. IO5 make her welcome in their homes ; but having won her way to their hearts, she can usually find a way to their heads as well, and manage to give many a lesson in personal and household hygiene which will bear fruit in after years. The question. What to teach ? opens up a wide vista. All knowledge w^hich shall tend to better people physically, and so improve mind and morals as well, is surely a nurse's province ; but it must be conveyed in simple form easily understood. But as practically there must be limits, a nurse must systematize her teaching, and work upon well- defined lines. She should show^ people how to make their homes neat and wholesome, and how to keep their bodies strong and well ; also the simplest and easiest ways of caring for their sick ; the amplification of these subjects, even in con- densed form, could be made to fill volumes, so that a nurse need never feel that her lines are restricted even if she do riot touch upon all the ologies and isms in the universe. Combined with her work, simple popular lectures to small audiences can be given with manifest benefit ; it is as easy to talk to a dozen or more upon some subjects as to one. To draw out a classified schedule of lessons to be given, properly arranged in regular sequence, would I06 DISTRICT NURSING. comprise a volume in itself. We will in this work, therefore, only touch upon a few points which it is .well, we think, to make prominent in teaching. Teach the importance of cleanliness in the house, particularly the keeping of water-closets and privies free from filth and bad smells. Teach the importance of good ventilation, and show how best to secure it. Show also how to economize heat, and yet have pure air to breathe. Teach the need of clean, comfortable beds. Show famiHes how to secure privacy for the dif- ferent members when living in crowded rooms. Exalt the dignity of simplicity. Teach plain, nutritious cookery. Try to save young, growing girls approaching puberty from overwork, exposure to evil influences, and undue care. Teach members of families to respect one another's rights. Try to save mothers from overwork and worry. Show mothers how to dress their children. Teach the importance of regular habits, par- ticularly as regards the daily evacuation of the bowels. Teach the need of thrift in preserving a proper self-respect. TEACHING IN THE HOMES. TO/ Teach the wrongfuhiess of excess in all ways, and the wickedness of indulgence in unlawful pas- sions. Help the poor to make the most of their con- veniences in sickness, and show them how to give the invalid proper attention without infringing on the rights of other members of the family. Try to overcome the prejudice to hospital treat- ment when such would be manifestly the best. And, above all, try to convince people that a very great part of medication lies outside the use of drugs ; for ignorant people of all classes seem to look upon human bodies much as they do upon clocks ; if they are out of running order a little tinkering by way of surgery, or a few drops of oil administered in the form of nauseous dosage, or a good cleaning, such as a violent cathartic will pro- duce, is all that is required to put it in perfect order again. The wonderful mechanism is as much be- yond their powers of comprehension as the differen- tial calculus beyond the powers of the little school- boy struggling to form the numerals upon his slate. In all teaching the nurse must rely largely upon the confidence she has inspired, in order that the people may take her words upon trust and in good faith. She cannot always make plain even the fun- damental truths underlying her words. She must I08 DISTRICT NURSING. sometimes assert, '' Do as I say, for I know best; *' impressing upon people that the Hne of obedience is the only safe one for them to follow. Elementary instruction is well enough, and know- ledge that is more than elementary an excellent thing; but multitudes never will be able to grasp physical truths in anything like fullness enough to be of great practical service to them. Such people must always be dealt with through the confidence which inspires them to follow blindly the stronger mind. This is a truth which those who deal much with the poorest people find forced upon them, however loth they may be to accept it in its ultimate con- clusions. District Nurses deal with facts, and very stub- born ones, and a comparison of different members of the human race as regards intellectual, capacity she finds presents marvelous inequalities. CHAPTER XV. COOKERY FOR THE SICK POOR. Many of the diseases of the very poor are directly induced by want of nourishing food, and the lowered vitality consequent upon a lack of proper nutriment has compelled many a person amongst them to seek the help they feel they need in alcoholic stimulus. Insufficient food materials and slatternly cooks have done more to keep open the smaller liquor stores than all other causes combined ; and to our temperance crusaders, we would from what we have seen suggest, that good nutritious food, be made as cheap as poor whisky. When this is done a long stride has been taken toward closing the market for vile whisky and manufactured beer. In dealing with the sick poor the District Nurse reaches those who suffer more from an inability to get food than a well-to-do public can have much conception of Such things must be seen to be ap- preciated. Good groceries, meats, and other food products 109 no DISTRICT NURSING. cost as much for poor people as they do for rich ones, and the needs of the human body in both classes are pretty much the same. It is a very com- mon, yet a mistaken, idea that the table of a rich family should of necessity be much more costly than that of a poor family. If the approximate cost were more nearly the same it would be better for both parties in multitudes of instances. In speaking thus I would not be understood as making a sweeping assertion that all expensive luxuries should be dispensed with on the tables of the rich, or that the very poor cannot study a wise economy even in necessities. Only, that the general amount of food ingested by the human body to keep up the highest physical health should be so nearly alike, in both rich and poor, that the cost of this food cannot vary so widely as an unscientific public might suppose. If the rich partake too freely of highly concen- trated foods they induce special diseases about as hard to combat as those ailments brought about by a low, meagre diet. Amongst all classes much good food is spoiled in the cooking, and when even one meal is rendered unpalatable by the poor woman her family must suffer for it. One of the greatest possible safeguards toward the moral and physical health of the lower classes COOKERY FOR THE SICK POOR. I I I is in multiplying little shops where good, pure foods may be purchased at a trifling advance over wholesale cost prices. Call them diet-kitchens, soup-houses, anything you will, only make them a reality and give them a local habitat. In all cases of ordinary disease the food differs from that required in health by being somewhat lighter both in quantity and quality. Special dis- eases, such as diabetes or gastritis, must be spe- cially dieted, and by the orders of the physician in charge. In cooking for the sick poor, therefore, a District Nurse tries to bear in mind that a wise selection of necessities is needful, in order that not a particle of food may be wasted. If she cannot always stop to do the actual work, she can carefully instruct the family in just how to prepare an appetizing meal for the invalid. And she can see to it that it is served nicely ; one of the reasons the poor look so distressed is the dirty manner in which they eat their food. Very good viands are sometimes served with as little regard for decency as though the family were dumb brutes. It is never very difficult for a nurse to procure some decencies in the way of old table- linen and napkins, and these, carefully laundried, make the invalid's tray look neat. 112 DISTRICT NURSING. All water used for drinking purposes should be first boiled and then allowed to cool ; this is better than iced water. Milk used for little children should be sterilized ; this is best done by putting fresh cow's milk into small, clean bottles ; small, new soda-water bottles are good for this purpose ; a bit of absorbent cotton is fitted in with the cork, and the bottles are set upon little blocks of wood in a boiler of cold water; the milk is brought to scalding heat without actually boiling it; it is kept at this temperature about twenty minutes ; the bottles are then cooled off and kept corked until needed for use. Artificial koumiss is made from fresh milk ; to each pint of milk a tablespoonful of good yeast is added ; also a iablespoonful of sugar ; the milk is put into bottles or jars and is kept at the tempera- ture of about 80^ F. for six hours ; the bottles are shaken occasionally while the contents are ferment- ing. The milk is then kept in a cool place for two or three days, when it is ready for use. Curds and whey are frequently relished by an invalid; it can be prepared with rennet; a nurse should keep a bottle of this ready for use. A glass of warm milk is frequently the most nutritious food which can be given to a sick person ; it should be drunk very slowly. COOKERY FOR THE SICK POOR. II3 Fresh buttermilk for those who like it is often good and nutritious. In all foods a very little salt should be mixed — in the milk for babies as well as the stronger foods for adults, salt being the '^ chief agent by which osmosis through animal membrane is effected." Porridges and gruels should be made in a double saucepan ; a pail set in a pot of hot water will serve the purpose and they should not be burned or smoked. Smoked gruel is distasteful to any sick person, yet the poor invalid feels compelled to eat it rather than waste it, or go without. All gruels should be well cooked ; a raw taste is almost as bad as a smoky flavor. A very good soup for an invalid is made by boil- ing one cup of barley and the same quantity of wheat grits in a quart of water very slowly for two and a half hours ; add a cup of rice and con- tinue to boil until the rice is soft; pass through a sieve and add stock to make the soup of creamy consistency; season with salt and pepper, bring the whole to a boil, and on removing from the fire stir in gradually the yolk of an egg. A raw egg may be lightly beaten into a cup of weak coffee, tea, or cocoa; this is nourishing. A white of egg well beaten with a pinch of salt, a teaspoonful of lemon juice, and the same of sugar can be taken when a light nourishment is required ; 114 DISTRICT NURSING. the yolk of the egg can be beaten in a glass of milk, or, made into a cup custard for some other member of the family if the patient cannot use it. Cottage cheese is frequently very wholesome for convalescing patients. An excellent mutton broth is made by adding to each pound of lean mutton one quart of water, a little chopped parsley and celery, and a handful of barley, letting the whole simmer three hours before straining. Every particle of fat should be taken off from the top before reheating the broth for use. Lean beef just warmed over the fire without being burnt can have the juice pressed out by a lemon-squeezer; this juice is very nourishing; it can be added to milk; in summer time it is nice frozen or made very cold. Stewed tripe if quite tender is relished for a change by many invalids, and is very cheap. Very ill patients can frequently only take food in concentrated forms ; if such be given cold, let it be very cold. In using ice, be careful where the ice is obtained. Children picking up ice near an undertaker's have been known to have contracted diphtheria. Children of the very poor do not always dis- criminate as to their food. Melon rinds and other produce of the garbage pails are seized and eaten by them with avidity, and sometimes make COOKERY FOR THE SICK POOR. II5 them very ill. Teach the poor that bad food is worse than no food. The nurse can always keep toasted bread, browned crusts for coffee, and such concentrated foods as she can obtain, on hand, to carry to her invalids. APPENDIX. INTRODUCTORY. The frequent questions about nursing among the poorer inhabitants of our cities and towns — which questions press all the more closely because of the danger that a great epidemic maybe close upon us — have led to the publication of this book. In addition to the practical suggestions in regard to a nurse's own duties, it has been thought desirable to give a list of the societies already engaged in similar work. They vary in some respects, but are all united in the main idea — that nursing \s needed by all the sick, whether wealthy or poor, in hospitals or outside, and that it is a duty for the well to provide for the sick the best nursing that circumstances will permit. A number of the societies make the instruction of the people a first object, that by degrees a better understanding of the laws of health and disease may spread through all classes. Other societies in- sist that the nurse shall in no way seek to influence 117 Il8 DISTRICT NURSING. the patients either politically or religiously, while others make it a chief point '' to carry the gospel of Christ to all homes." Some give food, clothing, and other help, while others maintain that it is for the greatest good of the community if the people are expected to supply such wants for themselves, or if necessary to obtain them through the regular channels for relief Some again think that the worthy only should be helped, while one society says bravely that it searches out the unworthy, striving to teach them '' those things that will be for their physical, moral, and spiritual advantage." Our largest cities take an interest in this work of nursing, and in several of them it is a well- established fact, and can no more be abandoned than can the large hospitals. Some smaller towns show that even with limited means and an extended area it is still possible to maintain a District Nurse, while at Waltham, Mass., a large training school has grown from a system of peripatetic instruction given by the physicians to young women willing to earn their education by working, at first for the needy classes and later by taking private cases while still under the direction of their preceptors. All information thus far collected goes to show that where District Nursing has been thoroughly established it has never failed, and it is strongly urged that those who can appreciate the comfort of APPENDIX. 119 skilled care in sickness will consider how greatly it is needed in homes where poverty or ignorance tend constantly to greatly increase the preventable miseries of ill-health. DISTRICT NURSING AND THE ORGANIZA- TION OF SOCIETIES. By this general term is known that branch of intelligent care for the sick which extends some of the benefits of hospital treatment to the poor in their own homes. '' Every physician who knows about it would be glad to have such nursing for every one of his patients, poor as well as rich," says a gentleman who has carefully studied the subject and has himself established a school, where men and women are instructed as professional nurses."^ In England more than a quarter of a century has passed since a determined effort was made to nurse the sick poor in their own homes, but in this country the oldest associations for the purpose have only been at work eight years. The various Catholic Sisterhoods and some Protestant Churches min- istered to the distressed of all classes long before ■^ " The Training Schools of the Future." By Dr. Edward Cowles, Superintendent of the McLean Asylum, Somerville, Mass. I20 DISTRICT NURSING. this time, but their effort was limited by other duties, and could, therefore, never become general. With the increased interest of modern times in the well being of those about us, with the knowledge that the illness or filth-of one portion means danger to the whole community, comes a desire to care for the sick, to insist on sanitary precautions, and to consider the best and most economical methods for the maintenance of the public health. The first idea of those who have not looked deeply into the subject, is that the poor should avail themselves of the numerous hospitals which are to be found in all our large cities, but even were they of twice their present capacity, they could not receive all of the sick. Then, too, is separation from home necessary or advantageous in every case ? A mother with a family of little ones would far rather stay with them, even if she must remain ten days in bed, than to break up the establishment or entrust it to strangers for that period. A consumptive, seeing before him, in the intervals of depression which are mingled with hope in this disease, only one end to his long suffering, clings to his home and dreads the depressing sights of a hospital. In many instances a mother will endure all sorts of poverty and privation rather than part from a sick child. These are a few of the instances where the people will not accept hospital APPENDIX. 121 care but there are also many cases when hospitals cannot admit those in need of attention. The poor " chronics " belong especially to this class. To the sick outside of hospitals the District or Visiting Nurse devotes herself and if she loves her work she can see on all sides the blessing that it carries; nowhere else is the direct effect of charity so visible. The tired, uncomfortable patient is soothed, bathed, and laid amid clean surroundings, the room is made tidy, the attendants urged to more systematic care and a suitable diet suggested, the latter sometim.es even provided by the nurse if it appears necessary to her. Of the various systems for district nursing pre- vailing in this country, those of chief interest can perhaps be best shown by a rather detailed account of the methods used in Boston and Philadelphia, those in other cities resembling one or the other in a greater or lesser degree, according to the local arrangements and the views of the managers. The Instructive District Nursing Associa- tion OF Boston. — In Boston the city is divided into districts, a nurse being assigned to each by the Instructive District Nursing Association, which also details two of its managers to supervise the work of each nurse. At first only a few such districts were undertaken but as the means have been supplied new ones have been added, two 9 122 DISTRICT NURSING. managers being elected with each. The last printed report (for the year ending January 30, 1892) shows seven such "district committees;" another was added in 1892 and it is hoped that early in 1893 there will be yet another; possibly all the dispensary districts, of which there are ten, will have nurses this year. There is also a '' nurse at large " for cases that do not belong to the Dispensary. This society has admirable arrange- ments for its loan supplies, and its system of instruction to those about a patient is most valuable as an educational movement. To quote from its last report : " The Instructive District Nursing Association, organized in 1886, provides and sup- ports nurses, duly certified by some w^ell-known training school, who, acting under the immediate direction of the out-patient physicians of the Boston Dispensary, care for the sick poor in their own homes instead of in hospitals. As an integral part of their service the District Nurses are required to instruct the families they visit, by example and by precept, to take better care of themselves and their neighbors, to promote their own welfare and the public health by obeying the laws of wholesome living and by practicing the simpler arts of domestic nursing. This work is intended to supplement, not to duplicate, the proper function of hospitals ; ordinarily only those cases are attended which the APPENDIX. 123 hospitals do not receive. Special nurses are sup- plied on the request of any physician of standing, according to the formula upon a postal card, which may be procured from the agent of the Associa- tion, who is in daily attendance at the office from 9 A. M. until 2 p. M." '' The nurses receive ^40 per month during the three months' probation, and then ^45 per month ; after two years' service the salary is ;^50 per month. In addition, each nurse is allowed $4 per month for car fares and $2 per month for charwoman and the necessary washing for patients ; also one month's vacation without loss of pay, a substitute at 1^40 per month being provided. A new nurse may thus cost the Association ^637, and one two years in service $^12. Besides the nurses' salaries there are the running expenses of the Association, including rent, supplies and the agent's salary, the rent for a room in Park Building for the use of the Board of Managers and agent and for two rooms — one at the North End and one at South Boston — where the supplies are kept and where the nurses rest at noon." The Visiting Nurse Society of Philadelphia. — The name of this organization shows that it differs from those preceding in its original plan of work. The districts are not considered, but the cases are divided according to their nature. The 124 DISTRICT NURSING. nurses attending maternity patients do not take general surgical work. One whose care is for cancer does not dress other open wounds, etc. This division of the labor, of course, entails more trouble and expense, for in a large city the car fares are a very heavy item and the time taken in the long rides is greatly to be deplored ; still, the theory of preventing the spread of disease is para- mount and for this reason all infectious cases are refused. The nurse must tend her patients so much more closely than a doctor does that she is more likely to carry away germs in her clothing and the first rule of this Society is, therefore, to ** run no risks." It is not usual in American district nursing to include maternity cases but it has been found in this city a most useful branch, the results being especially satisfactory in the health of the mothers after confinement. In Philadelphia the nurses are paid salaries, which do not include board, as that is furnished in the home provided. In this home the nurses sleep, and to it they return for their meals, the whole being under the charge of the Head Nurse or Superintendent. Some of the nurses have been fully trained to hospital service, some are pupils learning general practice under the Head Nurse, after some special or accidental training. APPENDIX. 125 To satisfactory pupils a certificate is granted at the end of the term of service. These nurses visit patients of all degrees of social standing, the very poor being attended gratis and others paying according to their ability. Often a physician needs a nurse for an office examination, or a patient confined to bed desires a bath or some other occasional attention, which those about her are unable to give, and for which she does not desire to retain the services of a permanent nurse, but for which she can fully pay. When the general work of the Society will permit, the pupil nurses can remain a short time, a few days or a week, with a patient of moderate means, the charge in such a case only slightly exceeding the salary paid to the nurse. The total expense for one year (ending Feb- ruary 29, 1892) was $4474.22, or, deducting the share borne by the patients, ;^3673.28.'^ The expenses will be materially diminished for the next year by the loan of a house (1340 Lom- bard Street) rent free, which has recently been offered to the Society. In Philadelphia the plan of having a house for the nurses was found essential, * The exact cost of a nurse cannot be given here, as the pupil nurses receive but a small salary at first, their pay increasing with their usefulness. The trained nurses receive twenty-five dollars a month besides board and washing. 1 26 DISTRICT NURSING. as their individual homes were far removed from their work and it was hard to secure them a com- fortable mid-day meal. By this plan, also, the cases come under the frequent supervision of the Head Nurse, while the office, which is always open, encourages doctors and friends of the patients to call to leave necessary directions. There is at this office a small registration bureau for nurses willing to accept low fees. For these ** outside nurses " the Society is not responsible, although it does what it can to secure reliable women. While the chief work of the Society and its nurses is to secure' good home nursing for the sick, yet atten- tion is also given to other needs, it being the rule that no patient must suffer if relief can be found. There cannot be good nursing if there is no food nor fire nor bedding. Nourishment is sent in generous quantities to the office, and from thence carried by the nurses to those who need it. The Charity Organization Society and other benevolent associations are asked to help, or, if the case is one where entire destitution, absolutely unhealthy sur- rounding, or other causes make proper home care impossible, every effort is made to place the patient in a hospital or home. The classification, the searching for other modes of relief, the placing in hospitals, the caring for child as well as mother in maternity work, and the APPENDIX. 127 distances to be daily traversed in so large a city, all tend to restrict the number of visits paid, but it has been considered that the ultimate good is increased by this useful, though unrecorded labor. The Society can only hope that its larger house and its lessened living expenses will now enable it to increase its force of workers, thereby reducing the proportional cost of each patient. LIST OF ASSOCIATIONS FOR THE CARE OF THE SICK NOT IN HOSPITALS. BOSTON. The Instructive District Nursing Association, Room 64, No. 2 Park Square, Boston. President, Miss Phebe Adam ; Sec- retary, Mrs. W. T. Sedgwick ; Treasurer, Mrs. Otis Norcross.* Tts object is caring for the sick poor at their homes, the in- struction of the families visited in domestic nursing and in the laws of wholesome living. It was founded in 1886. Total cases for one year, 3122. The visits paid were 37,188, besides 28 whole days and 35^ whole nights. Eight nurses were employed. The patients pay nothing for the service. The nurses are under the immediate direction of the out-patient physicians of the Boston Dispensary. The Association gives no help except in nursing, but will lend various articles useful in sickness, and co-operate with other charities for the relief of suffering. The nurses visit all classes of ca?es, except normal confinements. After attending con- tagious diseases they are limited in regard to other patients, are required to change clothing and use means of disinfection. * Report for the year ending January 31, 1892. 128 DISTRICT NURSING. . The New England Deaconess Home and Training School 45 East Chester Park, Boston — Rev. W. N. Brodbeck, President Mrs. E. H. Watkins, Secretary ; Mrs. J. W. Cashing, Treasurer — has for its objects the training of young women for Christian work, and the assistance of deaconesses to all " who need either physical or spiritual help." Last year 2387 hours were spent in nursing, and 10,494 calls were made. The Home was founded November 20, 1889. There are two nurses, but the other workers nurse occasionally. The patients do not often pay, but are expected to do so if they are able. The nurses are called by a physician of either school of medicine, also by friends of the patients. 5019 garments were given last year to the needy, 278 baskets of food and ^122.40 worth of fuel. The nurses attend all cases, except those of a decidedly contagious character. It is hoped a hospital may be built before long when this work will be enlarged and the nurses trained for district cases. Nursing is one of the duties of the Friendly Society of the South Congregational Church (Dr. E. E. Hale's), corner Newbury and Exeter Streets, Boston. Mrs. J. W. Andrews, Presi- dent; Mrs. M. S. Childs, Secretary; Miss E. M. Eustis, Treasurer. The objects of the Society are to care f jr the sick and poor of its di-^tricts, to aid other charitable objects and to extend the hospitali- ties of the church. It was founded March 13, 1833 ^^^ engaged a nurse in 1881. The cases average 200 annually, the nurse's visits nearly 1700. Only one nurse is employed. The patients do not pay for the service and the nurse is at the call of the sick within the district taken by the church. She can give food and clothing if needed; clothing is also loaned to the sick. She takes no very sick cases. As her name implies, she enters the homes as a friend, teaches the inmates how to care for each other, how to prevent a cold turning into a fever, etc. She works on the principle that " an ounce of prevention is worth a pound of cure." APPENDIX. 129 NEW YORK. In New York the work is undertaken by The Woman's Branch OF The New York City Mission and Tract Society, 401 United Charities Building. Mrs. M. K. Jesup, First Directress , Miss M. E. Mitchell, Treasurer ; Mrs. R. M. Field, Secretary. Its object, in addition to its chief work, which is missionary, is '* to minister to the sick poor, providing things necessary for their recovery in their homes or removing them to hospitals if necessary." The Society was established in 1822. Its report, dated December, 1877, says : *' A new power for good has been introduced this year, the Missionary Nurse. Prepared in the Training School she is thor- oughly competent to do all that is necessary in cases of extreme illness and has been an unspeakable comfort to many who have had no one to minister to them." The nurses' cases numbered in 1891, 1260; in 1892, 1127. It has from five to nine nurses at work, but tlie patients pay noth- ing. The nurses " call on any needy person in their district, New York below Fourteenth Street." They give both spiritual and tem- poral help, the latter including food, necessary clothing and occa- sional loans. They have a large number of maternity and a few fever cases. Surgical cases are generally sent to a hospital. The District Nursing Section of the United Relief Works (Society for Ethical Culture) seems to have no address of its own but can be reached through its officers — Leo G. Rosenblat, President; Louis Seligsberg, I021 Park Avenue, Secretary; Pro- fessor Felix Adler, 123 E. Sixtieth Street, Treasurer. The object is '' Remedial Charity," to nurse the sick poor in their own homes under visiting physicians' orders, also to teach proper care, diet, etc. This work w^as begun in 1878. The chief nurse paid 2800 visits in 1892. Two nurses are now employed. Formerly there were five, but three are taken by the Dispensary and paid by it. The patients never pay for the service. Each nurse is attached to a dispensary, can act only under the doctor's orders and only in her own district. They give all the help needed by their patients, 130 DISTRICT NURSING. except scrubbing, cleaning, etc., for which they can engage assist- ance. They care for all kinds of illness. These nurses have a fund with which to assist needy cases, to give food, help, stimulants, etc. The Sewing Society of the Society for Ethical Culture provides bed-linen, night-clothing, baby out- fits and shirts of all kinds. At Christmas and Thanksgiving an extra fund is supplied and in summer the sick children are sent to the country by private aid or by the '* P>esh Air Fund." The Red Cross Society in Brooklyn, N. Y., has its office at 195 Montague Street. H. Beeckman Delatour, M. D., President; Miss Clara Matthews, Secretary; Mrs. Marion Bowen, Treasurer. Its special objects are : 1st. "To teach ready methods of rendering temporary aid to the sick and injured." 2d. "To give instruction in house nursing and the laws of health." The district nursing part of the work has been in operation for three years but is not yet quite organized as it is intended to be. There is thus far one nurse who responds to the call of any sick person in Brooklyn, taking all sorts of cases, obstetrical, contagious and everything, so far as her strength will permit. PHILADELPHIA. The Visiting Nurse Society. — The Visiting Nurse Society, 1203 Race Street (to remove June i, 1893, to 1340 Lombard Street). Mrs. Henry C. Lea, President; Miss Mary Moss, Secre- tary ; Miss Maria Hopper, Treasurer. Its object is to give to the poor and to those of moderate means the best home nursing possible under existing circumstances. It was founded in 1886. Total cases for one year 612, visits paid 7464. The number of nurses varied at different times, but there was an average of five at work. The service is free to the very poor ; other patients pay according to their means; the receipts from this source amounted to ^800.94.*^ The nurses are at the call of all needing them, and during this year worked under 209 different physicians, representing both ■^ Report for the year ending February 29, 1892. APPENDIX. 131 schools of medicine. The Society promises no help except nursing, but its nurses gladly distribute nourishing food to the patients, which is often provided by those interested. The cases undertaken consist of all, including maternity, except those of a decidedly con- tagious character. The Philadelphia Dispensary, 127 South Fifth Street, Dr. Thomas Wister, Secretary. Its object is medical relief of the worthy poor. It was founded in 1876, but has only employed a nurse for about three years. It has about 25,000 cases annually, of which six hundred are confinements. It has one nurse, *' who shall visit every lying-in case and attend to the wants of the mother and child under the direction of the physician in charge." The patients pay nothing. The nurse can only be called by a physi- cian belonging 10 the Dispensary. She gives no help except nurs- ing (unless food or clothing has been sent her for distribution) and attends only maternity cases. District nursing is undertaken by the Mary J. Drexel Home AND Mother House of Deaconesses, 2100 South College Avenue, the officers in charge being Sister Superior Wanda Von Oertzen ; Rev. Blum pro tempore. The deaconesses' labors embrace all kinds of charitable works, one of them being district nursing and assisting the poor. The parish work was commenced in 1 890 in St. Paul's and Zion Lutheran congregations and comprises visits to the sick 1200; visits to the poor 144; night watches 50. There is one nurse in each parish (St. Paul and Zion). The sisters are not allowed to take anything from the patients, neither money nor presents. The parish sisters are trained in the German Hospital but are attached to the Mary J. Drexel Home and sent out from it. They are bound by contract to the con- gregation which pays the Mother House a certain sum to maintain each sister. The parish sister is under the special superintendence of the clergyman also at the disposal of the Ladies' Aid Society. She is at the call of every person in the parish. They do all work needed in a family, such as cleaning rooms, washing, cooking, dressing and taking care of the children, but only when the mother 132 DISTRICT NURSING. is sick or dead and no other person is at hand. The nurses attend all cases, especially contagious ones, as it has been found that such are particularly neglected. Patients needing hospital care (exclud- ing contagious diseases and maternity cases) are sent to the German Hospital or to the Children's Hospital of the Mary J. Drexel Home, both of which are under the care of sisters. BALTIMORE. The Deaconesses of the Home Missionary Society of THE Methodist Episcopal Church, 2013 East Pratt Street, visit the sick and expect to have a graduate nurse before long to assist in the w^ork. They maintain that *' it is impossible to do much for the soul until the body is made as comfortable as possible." They go to the rich and poor alike, regardless of disease, but are not paid for their service ; if a patient offers remuneration it is put aside for the use of the poor. 1200 visits were made last year, but not more than a quarter of these for nursing, the greater part of which was in summer. They often carry diet, clothing, and bed- linen; the latter is sometimes given, sometimes loaned. Sick room appliances are also furnished by them. There is no hospital or dispensary connected with this organization. Another society in Baltimore is called The District Nursing System, 321 N. Paca Street; O. Edw. Janney, M. D., is in charge. Its object is " to supply nursing to the poor at their homes." It was founded October i, 1892, and has about twenty cases a month. It employs one nurse and "the patients are expected to pay what they can." The nurse is not attached to any hospital or dispensary, but is at the call of all persons needing her ; she gives food and neces- sary clothing and attends all cases, except those that are contagious. The Evening Dispensary for Working Women and Chil- dren, 614 South Charles Street, is making a tentative effort in regard to district nursing but has by no means decided to undertake the work. The Dispensary is managed by a committee of five lay and two medical members, Miss K. M. McLane, President; Miss J. APPENDIX. 133 R. Rogers, Secretary and Treasurer. Since July, 1892 one nurse has been employed by the Dispensary to be present at the afternoon and evening clinics (four evenings, two afternoons) and to visit such cases as the medical staff of the Dispensary (all women) are prepared to undertake. The recent average of visits paid by this nurse is six per day. The patients are not charged for the nurse. There is no regular help given except medical care but when clothing is sent it is distributed to the most needy. All cases are thus far accepted, except the contagious. The nurse has her room at the Dispensary and sleeps there. CHICAGO. The Visiting Nurse Association of Chicago has an office open from 9 A. M. to 12.30 p. M. daily, at Masonic Temple, Room 1 1 , 16 State Street. The officers are Mrs. E. C. Dudley, President, 1 6 19 Indiana Avenue; Mrs. Hermon B. Butler, Secretary; Mrs. Wm. T. Con- ger, Treasurer. *' This Association is formed for the benefit and assistance of those otherwise unable to secure skilled attendance in time of illness, to promote cleanliness and to teach proper care of the sick and to establish and maintain one or more hospitals for the sick, or a home or homes for the accommodation of nurses." It was organized in 1 889. In 1891 total number of patients, i>407 "visits, 13439 In 1S92 '' " " patients, 2,478 " " " " visits, 17,346 Nine nurses are now employed, one of these being a head nurse. From the very poor no pay is expected. Occasionally a patient is able to give something to the Association. No nurse is paid by the patients. The nurses are at the call of any one needing them, the Associa- tion being independent. The nurses distribute old clothing, food, beef teas, condensed milk, milk tickets, malt, cod-liver oil, etc. They attend every kind of case, fevers, maternity, surgical, except 134 DISTRICT NURSING. the well-known contagious diseases, small-pox, scarlet fever, and diphtheria; to those a special nurse is sent. NEWPORT, R. I. For the past two years, since Feburary 15, 1890, a trained nurse has been employed in Newport, Rhode Island, for district nursing among the poor. She is under the superintendence of the Secretary of the Charity Organization Society. The nurse reports daily to Mrs. Curtis at the rooms of the Charity Organization Society and receives any special directions and supplies through her. No money passes through the nurse's hands but she is allowed to take small comforts to the very poor and to prepare simple food for them at their own houses. During the past year, 1892, she has had 152 patients and made 1987 visits; about two-thirds of the cases are confinements, the remainder including all kinds of diseases not contagious. She also assists the doctors when necessary in surgical cases. Patients able to pay are charged thirty cents an hour for the services of the nurse, and the money so raised is spent in food for the very poor. About ^12 was the amount paid by patients last year. The very poor always have the preference when the nurse is pressed for time. The Charity Organization Society has on hand a good supply of clothing, beddingj etc. and a cot-bed, mattress and pillows, which are loaned to the nurse's patients when necessary and returned to the Organi- zation when the emergency passes. The Overseers of the Poor, acting in harmony with the Organization, have also kindly provided her with blank orders which enable her to supply many small com- forts when needed. The nurse has a tricycle at her disposal and finds it extremely convenient. Bedding, baby outfits, etc., including the cot, mattress and pil- lows, have been furnished by a little society of poor girls, a branch of the Working Girls' Club, who meet every week to sew for charity and save their pennies for the same purpose. They give the work, the ladies most of the materials, not all. APPENDIX. 135 BUFFALO, N. Y. The District Nursing Association, 65 Franklin Street, Buf- falo, N. Y., has for its officers Miss Mary A. Lewis, President; Mr. Charles D. Marshall, Treasurer, and Mrs. Bernard Barton, Secre- tary. It object is to provide free nursing for the sick poor. It was founded in 1885 and attends between 400 and 500 cases annually, having three nurses and giving the service without charge. The nurses are at the call of any doctor, the friends of the patients, and the agents of the various charitable societies. They give tickets for food from the diet kitchen and also carry nourishment and various articles for the comfort of their patients; they attend all cases, only excepting those known to be able to pay for the service of an attendant, confinement cases where a midwife is engaged, and those of a positively malignant character. ROCHESTER, N. Y. In Rochester, N. Y., the "Margaret Harper Nurse" is con- nected with the Rochester Homoeopathic Hospital ; her support is given annually by the payment of $300 as a memorial, by her daughter, to Mrs. Fletcher Harper. The work was begun in 1890, and its special object is visiting among the sick poor of the city. In the past year the nurse made 747 visits, 3 1 being maternity cases. The Margaret Harper Nurse is from the class belonging to the Training School connected with the hospital, twelve nurses serving during the year, each having one month. This is considered one of the most valuable parts of the lessons received during the two years' course. No remuneration is received from any patient, and the nurse is at the call of any who need her. There is a fund from which the nurse may provide anything absolutely necessary, such as food, clothing, etc. All cases are attended, calls being as much from the Allopathic as from the Homoeopathic school. 136 DISTRICT NURSING. HAMPTON, VA. District nursing is a feature of the Hampton Training School FOR Nurses, at Hampton, Va. Dr. S. K. Towie, of the National Soldiers' Home, Va., is the President ; Miss A. M. Bacon of the Normal School, at Hampton, is Secretary. The object of the School is to train colored nurses for missionary, hospital or private nursing. The first nurses were taken in June, 1891. Since October, 1892, about 45 cases have been cared for by the District Nurses and about 150 visits paid (February, 1893). There are ten student nurses; of these any may be detailed at any time for district work. The patients do not pay for the service. The nurses are all attached to the Dixie Hospital and Hampton Training School but respond to every outside call as far as is possible. They often give help by carrying special diet, clean bed-clothing or other necessaries from the hospital to the patients' homes. They attend all classes of cases, although the first year nurses do not go to the contagious ones, as they must return daily to the hospital for lectures. ROXBURY, MASSACHUSETTS. The Society for Relieving the Sick Poor in Roxrury, Rooms of the Roxbury Charitable Society. Mrs. James Guild, President ; Mrs. Wm. C. Williams, Treasurer ; Miss Elizabeth Huntington, Secretary. The object is nursing with instruction. The work was started in 1888. Between 200 and 300 new patients are attended yearly and from 1200 to 1300 visits paid. There is only one nurse and the patients pay nothing for the service. The nurse is at the call of doctors of any school of medicine or of any person needing her. She lends necessary clothing and sick-room appliances as far as her stores will permit and can give diet of milk or eggs on the order of the physician in charge of the case. She can attend all persons not able to pay for a nurse but does not take maternity work unless at leisure from other calls. In visiting APPENDIX. 137 contagious diseases she is required to change her clothing and use means of disinfection before visiting other patients. WALTHAM, MASS. In Waltham, ^lassachusetts, district nursing is done by the Waltham Training School for Nurses, rear of 716 Main Street. A. Worcester, M. D. President ; Miss S. M. Wellington, Treasurer. The objects of the School are, " to supply trained nurses to the community at moderate prices or gratuitously and to train young women to a noble profession." It was started in the spring of 1885, and has between iioo and 1200 cases annually, the nurse remaining twenty- four hours or more; it has also 1800 or 1900 call cases where the nurse pays an average of six or seven visits to each. There are from thirty to forty nurses. The patients pay for the service if possible but if very poor no charge is made. In the first year in the School the nurses are sent only to families where one of the physicians connected with the School is in charge, as much of a nurse's instruction is received at the patient's bedside. In the second year the nurses go wherever they are needed, in town or out, and supply the Waltham Hospital with nurses, although the Training School is not attached to the Hospital in any way. They do not as a regular thing give any help except nursing, but they are taught to make themselves generally useful in the families where they nurse, and this often entails cookery and other housework not strictly for the patient. They are often the medium through which food and clothing are given to the poor. They attend all cases except contagious ones out of town. NEW HAVEN, CONN. In New Haven, Connecticut, there is no regular district nursing, but where the Training School of the State Hospital receives contributions for missionary work, it will, if possible, send an *' Externe," that is, a nurse who is having some months of private 10 138 DISTRICT NURSING. practice before she receives her diploma. Nurses cannot under- take contagious cases, and are (to the great regret of those in charge of the Hospital) unable to accept many free cases, as the support of the Training School depends upon the money earned through the '* Externes." NORWICH, CONNECTICUT. Visiting Nurse Department of the United Workers of Norwich. Miss Eliza P. Perkins, N. Washington Street, Chair- man of Nurse Committee. Its object is to *' give the best home nursing possible under existing circumstances." The first nurse was employed in 1887. The number of patients in 1892 was 126, and in January, 1893 the one nurse employed paid over 200 visits. The patients pay nothing and the nurse is called by physicians of either school of medicine or by friends of the patients. The nurse gives diet when it is sent her for distribution and can also have soup made once or twice a week at the United Workers' House. She attends all cases except those of a decidedly contagious char- acter. Her difficulties are greatly increased by the remoteness of her patients. She goes the length and breadth of the town, using cars where she -can, and, when she must, the carriage of the city missionary. WILMINGTON, DELAWARE. The Associated Charities of Wilmington, Delaware, 837 Tatnall Street, Mrs. A. T. Clark, Superintendent, will in some cases provide a nurse for out-patients through co-operation with the city hospitals which will lend a nurse when not too busy. The Society provides sick diet for the patients in their own homes and will assist them to enter hospitals when necessary. KANSAS CITY, MISSOURI. In Kansas City, Missouri, The Instructive Nursing Associa- TION, 723 East Ninth Street, has for its officers Mrs. Henry Van Brunt, President; Mrs. Frank Simpson, Treasurer; Miss E. B. APPENDIX. 139 Allen, Secretary. The object of this Association is " to provide vis- iting nurses to those otherwise unable to secure skilled attendance in illness, and to teach cleanliness and the proper care of the sick." It was founded April 4, 1 891, and during the first part of the year 146 cases v^ere attended, 2258 visits paid. One regular nurse is employed and assistants as needed. When charity patients do not occupy the nurse's time fully she is permitted to visit those who pay. She is at the call of any one who needs her. She gives nourishing food and lends garments. She attends all cases save those of con- tagious diseases and for them a special nurse is provided. ENGLAND. Of district nursing abroad little can be said within the limits of this work. It is undertaken in many, if not all, of the larger towns in England, having been established there for over twenty-five years. In Manchester, England, the District Nursing staff consists of 29 nurses, residing in three Homes, each under the supervision of a matron. Each nurse is allotted to a certain district ; she can give medical necessaries and comforts and lend medical appliances ; she attends the sick free of charge, but those who are able are encouraged to give a small sum as a thank-offering. Any one may send notice of a case of sickness to the matron of the nearest Home. The Society derives its support from a general fund made up from sub- scriptions, legacies, the Hospital Sunday and Saturday Grant, etc., but as this sum is not sufficient, each home must secure a supple- mentary income by subscriptions through the members of its own committee. There is also a " Good Service Fund" for the nurses, supported by special donations, etc. At present, one nurse is receiv- ing a pension from this fund after twenty-six years' service. The name of this Society is the Manchester and Salford Sick Poor,. AND Private Nursing Institution. As its name implies, one branch of its work is supplying nurses to private cases. From this branch some revenue is received which helps the charity work. The Institution was founded in 1864. 140 DISTRICT NURSING. The sixth annual report of the Southport and Birkdale District Nursing Society was presented the first of this year (1893), and shows four nurses at work, one of them being a midwife. There is no home, only a room at No. 4 Stanley Street, Southport : each nurse has her own address given on the Society's report. The work is that of the ordinary District Nurse, and some instruction is given to the friends of the patients. The Liverpool Training School and Home for Nurses, Ashton Street, Liverpool, is a large organization under the charge of a " Lady Superintendent and Assistant Lady Superintendent." Its objects are: — The training of nurses for hospitals (Royal Infirmary attached). The training of nurses for private families. The training of nurses for attendance on the sick poor in their homes. It was founded in 1862. The cases attended in the districts range from 3000 to 3500 annually, with over 90,000 visits. There are twenty nurses distributed over the city, which is divided into twenty districts. They are lodged in four houses, N., E., S,, W., and each house is under the charge of a District Matron who is herself fully trained and who follows her nurses in their district v/ork to super- vise and direct it.-^ The patients pay nothing for the service. No relief is given except medical comforts, etc. No infectious or maternity cases are taken. The East London Nursing Society, office No. 49 Philpot Street, Commercial Road, London, E., is doing a large work, but, unfor- tunately, cannot be spoken of in detail, as no report has been received. There are also other societies in the United wStates and Canada, but their replies to the series of questions asked have not been received in time for classification. The writer extends most hearty thanks to all the friends to District Nursing who have so wilUngly given the data required to compile this list, and hopes most earnestly that the work may spread until every town and neighborhood can have its friendly visiting nurse. INDEX. Addresses, of doctors, 47. " charitable institutions, 47. Ambulance service, 49. Apoplexy, 57. Appeals to the public, 22. Appendix, 117. Asphyxia, 57. Assistance in case of need, 27. Associations for the sick not in hospitals, Bed sores, 59. Beef juice, 114. Books for reference, 44. Bones, fractured, 50, 51. " dislocated, 52. Brain, concussion of, 55. " compression of, 55. Burns, 55. Buttermilk, 113. Clothing of the nurse, 37. Cheese, cottage, 114. 127. Boston, 121, 127. Baltimore, 132. Chicago, 133. England, 139. Hampton, Va., 136, Kansas City, Mo., 138. New Haven, Ct., 137. Newport, R. I., 134. New York City, 129. Norwich, Ct., 138. Philadelphia, 124, 130. Roxbury, Mass., 136. Rochester, N. Y., 135. Waltham, Mass., 118,137. Wilmington, Del., 138. 141 142 INDEX. Chicken-pox, 81. Children, sick, 66-74. *' rachitic, 77. " specific disorders in, 77. " with whooping-cough, 77. " with croup, 78. '* with infantile paralysis, 78. *' with skin disease, 79. " dentition of, 76. Choking, 58. Chronic invalids, 28, 88. Conditions to be met, 18. Contusions, 52. Contagious diseases, 28,41, 80, 81, 82, 87. Convulsions, 58, 74. Cookery, for the sick poor, 109. Curds and whey, 112. Diet, special, iii. Diphtheria, 80. Dislocations, 52. District nursing, 9, 17, 18, 22, 117, 119. " nurse, 9, 10, 11, 13, 16, 26, 27, 29, ^6, 37. Druggists, should be known by nurse, 26. Drowning, 56. Ear, foreign substances in, 58. Eggs, 113. Emergencies, 49, 50. Epilepsy, 56. Fever nursing, 93-100. Food supplies, 21, 77. " for infants, 75. " of children, 114. *' concentrated, 115. Frostbite, 55. Fuller ton, Anna, 3L, M. D., 59. General supplies, 46. Gruel, 113. Hands, care of, 40. Half measures futile, -34. Headquarters of the nurse, 45. Heat stroke, 56. Hemorrhage, 53, 54. Homes of the poor, 21, 29. INDEX. 143 Hospitals, a prejudice against, 26. " insufficient in number, 120. Hygiene teaching, 24, 105, 108. Hysteria, 56. Ice, 114. Infant feeding, 75. Infectious diseases, 84, 85. Intoxication, 56. Introductory, 9. Invalids, the peripatetic, 28. " partial, 32. Koumiss, 112. Landlord and tenant, 20. Laundry work, 78 Lectures, 48, 105. Legal measures for protecting public health, 21. List of personal supplies, 42. " general " 46. Loan fund, 91. Lockjaw, 53. Measles, 81. Medical nursing, SS, 90, 91. Methods of work, 25. Milk, sterilized, 112. '* warm, 112. Mothers, young, 56. Nuisances, to be reported, 25. Office of nurse, 27. Obstetrical emergencies, 59. ^' nursing, loi, 103. Operations, 62. Outfit of nurse, 35, 36. Pauperizing the poor, 30. Philanthropic work, ^^. Poisons, 58. Porridge, 113. Poverty, depressing, 14. Rent, payment of during illness, 20. Records of the nurse, 27. Salt, 113. Scarlet fever, 80. Shock, 55. Societies engaged in district work, 117, 121, 127, 129, 130, 140. 144 INDEX. Soup, 113. Sprains, 52. Supplies, general, 45. " personal, 42. Surgical nursing, 61, 65. Syncope, 56. Teaching in the home, 104, 1 08. Tracheotomy, 65. Training school at Waltham, Mass., 1 18, 137. Union, the strength of, 27. Water, 112. Wood, Miss Catherine, 68. Wounds, 52, 53. CATALOGUE No. 7. APRIL, 1893. A CATALOGUE OF BOOKS FOR Students. INCLUDING THE ? QUIZ-COMPENDS ? CONTENTS. PAGE PAGE New Series of Manuals. 2.^,4, "^ Obstetrics 10 Anatomy, . . 6 Pathology, Histology, . .11 Biology, . II Pharmacy, . . . .12 Chemistry, . . 6 Physical Diagnosis, . . 11 Children's Diseases, . . 7 Physiology, . . . .11 Dentistry, . 8 Practice of Medicine, . 11, 12 Dictionaries, 8, 16 Prescription Books, . . 12 Eye Diseases, . 8 ?Quiz-Compends ? . 14,15 Electricity'-, . • 9 Skin Diseases, . . .12 Gynaecology, . 10 Surgery and Bandaging, . 13 Hygiene, • 9 Therapeutics, , . .9 Materia Medica, . • 9 Jrine and Urinary Organs, 13 Medical Jurisprudence . ID Venereal Diseases, . . 13. Nervous Diseases, . ID PUBLISH lED BY P. BLAKISTON, SON & CO., Medical Booksellers, Importers and Publishers. LARGE STOCK OF ALL STUDENTS' BOOKS, AT THE LOWEST PRICES. 1012 Walnut Street, Philadelphia. *4t* For sale by all Booksellers, or any book will be sent by mail, postpaid, upon receipt of price. Catalogues of books on all branches of Medicine, Dentistry, Pharmacy, etc., supplied upon application. Pr r^cV i^^ce^^ts } 3000 Questions on Medical Subjects. "An excellent Series of Manuals/' — Archives of Gynecology, A NEW SERIES OF STUDENTS' MANUALS On the various Branches of Medicine and Surgery. Can be used by Students of any College. Prioe of each, Handsome Cloth, $3.00. Full Leather, $3.50 The object of this series is to furnish good manuals for the medical student, that will strike the medium between the compend on one hand and the prolix text- book on the other — to contain ail that is necessary for the student, without embarrassing him with a flood of theory and involved statements. They have been pre- pared by well-known men, who have had large experience as teachers and writers, and who are, therefore, well informed as to the needs of the student. Their mechanical execution is of the best— good type and paper, handsomely illustrated whenever illustrations are of use, and strongly bound in uniform style. Each book is sold separately at a remarkably low price, and the immediate success of several of the volumes shov/s that the series has met with popular favor. No. 1. SUBG-BRT. 318 Illustrations. Third Edition. A Manual of the Practice of Surgery. By Wm. J. WalshamJ m,d., iVsst. Surg, to, and Demonstrator of Surg, in, St. Bartholomew's Hospital, London, etc. 318 Illustrations. Presents the introductory facts in Surgery in clear, precise language, and contains all the latest advances in Pathology, Antiseptics, etc. ** It aims to occupy a position midway between the pretentious manual and the cumbersome System of Surgery, and its general character may be summed up in one word — practical." — The Medi- cal Bulletin. •' Walsham, besides being an excellent surgeon, is a teacher in its best sense, and having had ver^'' great experience in the preparation of candidates for examination, and their subsequent professional career, may be relied upon to have carried out his work successfully. Without following out in detail his arrange- ment, which is excellent, we can at once say that his book is an embodiment of modern ideas neatly strung together, with an amount of careful organization well suited to the candidate, and, indeed, to the practitioner." — British Medical Journal. Price of each Book, Cloth, $3.00 ; Leather, $3.50. THE NEW SERIES OF MANUALS. No. 2. DISEASES OF V70MEN. 150 lUus. NEW EDITION. The Diseases of Women. Including Diseases of the Bladder and Urethra. By Dr. F. Winckel, Professor of Gynsecology and Director of the Royal University Clinic for Women, in Munich. Second Edition. Re- vised and Edited by Theophilus Parvin, m.d., Professor of Obstetrics and Diseases of W^omen and Children in Jefferson Medical College. 150 Engrav- ings, most of which are original. '* The book will be a valuable one to physicians, and a safe and satisfactoi-;^' one to put into the hands of students. It is issued in a neat and attractive form, and at a very reasonable price." — Boston Medical and Surgical Journal . No. 3. OBSTETRICS. 227 Illustrations. A Manual of Midwifery. By Alfred Lewis Galabin, M.A., M.D., Obstetric Physician and Lecturer on Mid- wifery and the Diseases of Women at Guy's Hospital, London; Examiner in Midwifery to the Conjoint Examining Board of England, etc. With 227 Illus. " This manual is one we can strongly recommend to all who desire to study the science as well as the practice of midwifery. Students at the present time not only are expected to know the principles of diagnosis, and the treatment of the various emergen- cies and complications that occur in the practice of midwifery, but find that the tendenc}'^ is for examiners to ask more questions relating to the science of the subject than was the custom a few years ago. * * * The general standard of the manual is high ; and wherever the science and practice of m.idwifery are well taught it will be regarded as one of the most important text-books on the subject." — London Practitioner. No. 4. PKYSIOLOG-^". Fifth Edition. 321 ILLUSTRATIONS AND A GLOSSARY. A Manual of Physiology. By Gerald F. Yeo, m.d., F.R.CS., Professor of Physiology in King's College, London. 321 Illustradons and a Glossary of Terms. Fifth American from last English Edition, revised and improved, 758 pages. This volume was specially prepared to furnish students with a new text-book of Physiology^ elementary so far as to avoid theories which have not borne the test of time and such details of methods as are unnecessary for students in our medical colleges. '*The brief examination I have given ir was so favorable that I placed it in the list of text-books recommended in the circular of the University Medical College." — Prof. Lewis A. Stiinson, m.d., 57 Eait ssd Street, Neiv York. Price of each Book, Cloth, $3.00; Leather, $3.50. THE NEW SERIES OF MANUALS. No. 5. DISEASES OP CHILDREN. SECOND EDITION. A Manual. By J. F. Goodhart, m.d., Phys. to the Evelina Hospital for Children ; Asst. Phys. to Guy's Hospital, London. Second American Edition. Edited and Rearranged by Louis Starr, m.d., Clinical Prof, of Dis. of Children in the Hospital of the Univ. of Pennsylvania, and Physician to the Children's Hos- pital, Phila. Containing many new Prescriptions, a list of over 50 Formulae, conforming to the U. S. Pharma- copoeia, and Directions for making Artificial Human Milk, for the Artificial Digestion of Milk, etc. Illus. *' The author has avoided the not uncommon error of writing a book on general medicine and labehng it ' Diseases of Children,' but has steadily kept in view the diseases which seemed to be incidental to childhood, or such points in disease as appear to be so peculiar to or pronounced in children as to justify insistence upon them. * * * A safe and reliable guide, and in many ways admirably adapted to the wants of the student and practitioner." — American Journal of Medical Science. No. 6. MATERIA MEDICA, PHARMACY, PHARMAGOLOG-Y, AND THE- RAPEUTICS. JUST READY. A Handbook for Students. By Wm. Hale White, M.D.J F.R.C.P., etc.. Physician to, and Lecturer on Ma- teria Medica, Guy's Hospital; Examiner in Materia Medica, Royal College of Physicians, London, etc. American Edition. 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By Frederick Taylor, m.d., Physician to, and Lecturer on Medicine at, Guy's Hospital, London ; Physician to Evelina Hospital for Sick Chil- dren, and Examiner in Materia Medica and Pharmaceutical Chemistry, University of London. Cloth, 2.00; Leather, 2.50 4^ See pages 14 and IS fo^ ^i^i 0/ ? Quiz-Compends f 12 STUDENTS' TEXT-BOOKS AND MANUALS. Practice : — Continued. Roberts' Practice. New Revised Edition. A Handbook of the Theory and Practice of Medicine. By Frederick T. Roberts, m.d., m.r.c.p., Professor of Clinical Medicine and Therapeutics in University College Hospital, London. Seventh Edition. Octavo. Cloth, 5.50 ; Sheep, 6.50 Hughes. Compend of the Practice of Medicine. 4th Edi- tion. Two parts, each, Cloth, i.oo; Interleaved for Notes, 1.25 Part i. — Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc., and General Diseases, etc. Part ii. — Diseases of the Respiratory System, Circulatory System, and Nervous System ; Diseases of the Blood, etc. Physicians' Edition. Fourth Edition. Including a Section on Skin Diseases. With Index,, i vol. Full Morocco, Gilt, 2,50 From. John A. Robinson, M.D. , Assistant to Chair of Clinical Medicine ^noiu Lecturer on Materia Medica, Rush Medical Col- lege, Chicago. *' Meets with my hearty approbation as a substitute for the ordinary note books almost universally used by medical students. It is concise, accurate, well arranged, and lucid, . . . just the thing for students to use while studying physical diagnosis and the more practical departments of medicine.*' PRESCRIPTION BOOKS. Wythe's Dose and Symptom Book. Containing the Doses and Uses of all the principal Articles of the Materia Medica, etc. Seventeenth Edition. Completely Revised and Rewritten. Just Ready. 32mo. Cloth, i. 00; Pocket-book style, 1.25 Pereira's Physician's Prescription Book. Containing Lists of Terms, Phrases, Contractions, and Abbreviations used in Prescriptions, Explanatory Notes, Grammatical Construction ot Prescriptions, etc., etc. By Professor Jonathan Pereira, m.d. Sixteenth Edition. 32mo. Cloth, i. 00; Pocket-book style, 1.25 PHARMACY. Stewart's Compend of Pharmacy. Based upon Remington's Text-book of Pharmacy. Third- Edition, Revised. With new Tables, Index, Etc, Cloth., i.oo ; Interleaved for Notes, 1.25 Robinson. Latin Grammar of Pharmacy and Medicine. By H. D. Robinson, ph.d.. Professor of Latin Language and Literature, University of Kansas, Lawrence. With an Intro- duction by L. E. Sayre, ph.g.. Professor of Pharmacy in, and Dean of, the Dept. of Pharmacy, University of Kansas. i2mo. Cloth, 2,00 SKIN DISEASES. Crocker. Diseases of the Skin, their Description, Pathology, Diagnosis, and Treatment, with Special Reference to the Skin Eruptions of Children. By H. RadcliiFe Crocker, f.r.c.p., Phy- • sician for Diseases of the Skin in University College Hospital. Second Edition. Revised and Enlarged, with 92 Wood-cuts. Cloth, 5.00 Van Harlingen on Skin Diseases. A Handbook of the Dis- eases of the Skin. By Arthur Van Harlingen, m.d. 2d Edition. Enlarged. i2mo. Cloth, 2.50 4^^ See pages 2 to 5 for list of New Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 13 SURGERY AND BANDAGING. Moullin's Surgery. 500 Illustrations (some colored), 200 of which are original. • 2d Ed. Cloth, net 7.00; Leather, net 8.00 Jacobson. Operations in Surgery. A Systematic Handbook for Physicians, Students, and Hospital Surgeons. By W, H. A. Jacobson, b.a. Oxon., f.r.c.s. Eng. ; Ass't Surgeon Guy's Hos- pital ; Surgeon at Royal Hospital for Children and Women, etc. 199 Illustrations. 1006 pages. 8vo. Cloth. 5.00; Leather, 6.00 Heath's Minor Surgery, and Bandaging. Ninth Edition. 142 Illustrations. 60 Formulae and Diet Lists. Cloth, 2.00 Horwitz's Compend of Surgery, Minor Surgery and Bandaging, Amputations, Fractures, Dislocations, Surgical Diseases, and the Latest Antiseptic Rules, etc., with Differential Diagnosis and Treatment. By Orville Horwitz, b.s., m.d.. Demonstrator of Surgery, Jefferson Medical College. 5th Edition, Enlarged and Rearranged. Many new Illustrations and Formulae. i2mo. Cloth, 1. 00 ; Interleaved for the addition of Notes, 1.25 *:J:*The new Section on Bandaging and Surgical Dressings con- sists of 32 Pages and 41 Illustrations. Every Bandage of any importance is figured. This, with the Section on Ligation of Arteries, forms an ample Text-book for the Surgical Laboratory. Walsham. Manual of Practical Surgery. Third Edition. By Wm. J. Walsham, m.d., f.r.c.s., Asst, Surg, to, and Dem- of Practical Surg, in, St. Bartholomew's Hospital; Surgeon to Metropolitan Free Hospital, London. With 318 Engravings. See page 2. Cloth, 3.00; Leather, 3.50 URINE, URINARY ORGANS, ETC. Holland. The Urine, and Common Poisons and The Milk. Chemical and Microscopical, for Laboratory Use. Illus- trated. Fourth Edition. i2mo. Interleaved. Cloth, i.oo Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- trations. i2mo. 572 pages. Cloth, 2.75 Marshall and Smith. On the Urine. The Chemical Analysis ot the Urine. By John Marshall, m.d.. Chemical Laboratory, Univ. of Pjnna ; and Prof. E. F. Smith, ph.d. Col. Plates. Cloth, i.oo Memminger. Diagnosis by the Urine. Illustrated, Cloth, I.oo Tyson. On the Urine. A Practical Guide to the Examination of Urine. With Colored Plates and Wood Engravings. 7th Ed. Enlarged. i2mo. Cloth, 1.50 Van Niiys, Urine Analysis. Illus. Cloth, 2.00 VENEREAL DISEASES. Hill and Cooper. 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Fifth Enlarged Edition, including Visceral Anatomy, formerly published separately. 16 Lithograph Plates, New Tables, and 117 other Illustrations. By Samuel O. L. Potter, m.a., m.d., m.r.c.p. (Lond.), late A. A. Surgeon U. S. Army, Professor of Practice, Cooper Medical College, San Fran- cisco. Nos. 2 and 3. PRACTICE OF MEDICINE. Fourth Edi- tion. By Daniel E. Hughes, m.d., Demonstrator of Clinical Medicine in Jefferson Medical College, Philadelphia. In two parts. Part I. — Continued, Eruptive, and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc. (including Tests for Urine), General Diseases, etc. Part II. — Diseases of the Respiratory System (including Phy- sical Diagnosis), Circulatory System, and Nervous System; Dis- eases of the Blood, etc. # *^* These little hooks can be regarded as a full set of notes upon the Practice of Medicine, containing the Synonyms, Definitions, Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each disease, and including a number of prescriptions hitherto unpub- lished. No. 4. PHYSIOLOGY, including Embryology. Sixth Edition. By Albert P. Brubaker, m.d., Prof, of Physiology,. Penn'a College of Dental Surgery ; Demonstrator of Physiology in Jefferson Medical College, Philadelphia. Revised, Enlarged, with new Illustrations. No. 5. OBSTETRICS. Illustrated. Fourth Edition. By Henry G. Landis, m.d.. Prof, of Obstetrics and Diseases of Women in Starling Medical College, Columbus, O. Revised Edition. New Illustrations. BLAKISTON'S ? QUIZ-COMPENDS ? No. 6. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Fifth Revised Edition. With especial Reference to the Physiological Action of Drugs, and a complete article on Prescription Writing. Based on the Last Revision of the U. S. Pharmacopoeia, and including man}'- unofficinal remedies. By Samuel O. L. Potter, m.a., m.d., M.R.c.P. (Lond.), late A, A. Surg. U. S. Army; Prof, of Practice, Cooper Medical College, San Francisco. Improved and Enlarged, with Index. No. 7. GYN/ECOLOGY. A Compend of Diseases of Women. By Henry Morris, m.d., Demonstrator of Ob- te tries, Jefferson Medical College, Philadelphia. 45 Illustrations. No. 8. DISEASES OF THE EYE AND REFRACTION, including Treatment and Surgery. By L. Webster Fox, m.d.. Chief Chnical Assistant Ophthalmologicai Dept., Jefferson Med- ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39 Formulae. Second Enlarged and Improved Edition. Index. No. 9. SURGERY, Minor Surgery and Bandaging. Illus- trated. Fourth Edition. Including Fractures, Wounds, Dislocations, Sprains, Amputations, and other operations; Inflam- mation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Testicles, Anus, and other Surgical Diseases. By Orville Horwitz, a.m., m.d., Demonstrator of Surgery, Jefferson Medical College, Revised and Enlarged. 84 Formulas and 136 Illustrations. No. 10. CHEMISTRY. Inorganic and Organic. For Medical and Dental Students. Including Urinary Analysis and Medical Chemistry. By Henry Leffmann, m.d., Prof, of Chemistry'- in Penn'a College of Dental Surgerj'^, Phiia. Third Edition, Revised and Rewritten, with Index. No. II. PHARMACY. Based upon " Remington's Text-book of Pharmacy." By F. E. Stewart, m.d., ph.g. , Quiz-Master at Philadelphia College of Pharmacy. Third Edition, Revised. No. 12. VETERINARY ANATOMY AND PHYSIOL- OGY. 29 Illustrations. By Wm. R. Ballou, m.d.. Prof, of Equine Anatomy at N Y. College of Veterinary Surgeons. No. 13. DENTAL PATHOLOGY AND DENTAL MEDI- CINE. Containing all the most noteworthy points of interest to the Dental student. Second Edition. By Geo. W. Warren, D.D.S., Clinical Chief, Penn'a College of Dental Surgery, Phila- delphia. Illustrated. No. 14. DISEASES OF CHILDREN. By Dr. Marcus P. Hatfield, Prof, of Diseases of Children, Chicago Medical College. Colored Plate. Bound in Cloth, $1. Interleaved, for the Addition of Notes, $1.25. J|@* These books a7'e constantly revised to keep up with the latest teachings and discoveries, so that they contain all the new methods and p7'inciples. No series of books are so complete in detail^ concise in language, or so well printed and bound. Each one forms a complete set of notes upon the subject tinder consideration. Illustrated Descriptive Circular Free. GOULD'S NEW Medical Dictionary. Based on Eecent Medical Literature. Small 8vo, Half Morocco, as above, with Thumb Index, . . ^4.25 Plain Dark Leather, without Thumb Index, . * 3.25. A compact, concise Vocabulary, including all the Words and Phrases used in medicine, with their proper Pronunciation and Definitions. **One pleasing feature of the book is that the reader can almost invariably find the definition under the word he looks for, without being referred from one place to another, as is too commonly the case in medical dictionaries. The tables of the bacilli, micrococci, leucomaines and ptoma'mes are excellent, and contain a large amount of information in a limited space. The anatomical tables are also concise and clear. . . . We should unhesitatingly recommend this dictionary to our readers, feeling sure that it will prove of much value to them." — American Journal of Medical Science. JUST PUBLISHED. GOULD'S POCKET DICTIONARY. 12,000 Medical Words Pronounced and l)efined. Cloth, $1.00; Leather, ^1.25