is often very deep, even laying bare the bone in many instances,
and this with very little pain so that the patient may be unaware
of the existence of the ulcers. The causes of bed-sores are long-
continued and uneven pressure, frequent wetting of the skin, such
as occurs in incontinence of urine, and uncleanliness. Constant
watchfulness is necessary to avoid them in chronic bed cases, espe-
cially when the patient must remain in one position. It is much
easier, however, to prevent bed-sores than to cure them. The beds
must be kept clean and free from crumbs ; the sheets and the patient's
night dress must be drawn smooth and free of wrinkles and should
be changed whenever they get wet or soiled.
The parts of the body most liable to be affected are naturally
those most subjected to pressure, the lower part of the back, the
shoulders, elbows, and heels. These parts should be washed fre-
quently with soap and water, thoroughly dried, and well sponged
with alcohol, whisky, or. a one-per-cent solution of tannic acid in
whisky. After this lanolin may be rubbed in to make the skin
supple, followed by dusting with talcum or starch to absorb moisture.
In addition, pressure should be taken off the threatened points by
frequent changes of position or the use of rubber rings; in the
absence of rubber rings ring-shaped cushions may be made of cotton
batting rolled in a tight cylinder, formed into a ring, and then
wrapped with a roller bandage. In very chronic cases a water or
air bed is necessary.
When the skin is reddened and apparently about to break, it may
be protected by strapping with adhesive plaster or a thin layer of
absorbent cotton may be placed over it and held in place with a
coating of collodion.
After the bed-sore has formed it is treated like any other ulcer;
wet antiseptic dressings are applied, and, after all sloughs have sepa-
rated, balsam of Peru or other stimulating applications are used.
BATHS AND BATHING
BATHS are given for several purposes, among the more important
of which are :
1. To promote cleanliness.
2. To produce sweating or relaxation.
3. To reduce fever.
4. To stimulate the circulation.
5. To quiet the nervous system.
6. For counter-irritation.
According to temperature baths may be :
1. Tepid; at temperature of the body; 98 F.
2. Hot; 100 to 110 F.
3. Cold ; 90 to 70 F.
According to extent baths are classified as:
a. Sitz or pelvic.
Besides water baths, hot-air and steam baths are employed. The
wet pack is a modified form of bath.
To promote cleanliness tepid water is used either in the tub or by
To give a sponge bath in bed, cover the entire bed with a rubber
sheet; on this place a blanket upon which the patient lies with another
blanket or sheet over him ; provide a pail of tepid water, a slop pail,
basin, wash rag, soap, towels, ammonia, alcohol, mouth-wash, orange
stick, nail brush, cotton, and comb. The bathing should be quickly
done in sections, the rest of the body being meanwhile protected from
If the purpose of the sponge bath is to reduce temperature the
water should be cold and the whole body may be exposed ; in such
a case if the patient seems chilly after the bath a glass of hot milk or
a little stimulant may be given.
The sedative bath is for the purpose of quieting excitement and
inducing sleep; it may be continued for hours or even days; the
temperature of the water is usually just below that of the body
about 96 F.
The arrangement is practically the same as for the Brandt bath,
but to keep the water from cooling, the tub must be covered with a
few pieces of board, on which are placed a rubber sheet and blankets ;
hot water must be carefully added from time to time to maintain a
To produce sweating or relaxation, hot-water, hot-air, or steam
baths are used.
The hot-water bath is given in the tub in the ordinary way except
that the head is kept cool by cold cloths or an ice bag. Care must
FIG. 84. Bed Cradle from Barrel Hoops.
be taken not to continue the bath too long, to the point of fainting ;
fifteen to twenty minutes is sufficient, after which the patient is
taken out and, without drying, placed on hot blankets and covered
by three or four more which are wrapped closely about him up to
the neck. Hot weak tea or hot water is given freely to encourage
sweating. After about an hour the blankets are gradually removed,
and the patient sponged off under the last one with alcohol and
water, this being followed by a brisk rub with dry towels.
Hot-air and steam baths may be given in bed or sitting up. In
the first method the bed is covered with a rubber sheet upon which
is placed a blanket on which the patient lies stripped. Over his
body are placed two or three bed cradles or extemporized bed cradles
BATHS AND BATHING
(Fig. 84). Bed cradles may be extemporized by tying together
at right angles two half barrel-hoops. Over the cradles and tucked
in about the patient's neck is another rubber sheet and blanket. At
the foot of the bed is placed an oil, gas, electric, or alcohol heater
with a section of stove pipe and an elbow to conduct the heat under
the bedclothes, or, if steam is to be used, upon the heater is set a tea-
kettle with a hose attached to the spout for the same purpose (Fig.
85). After the steam or hot hair has passed in long enough to get
perspiration well started, the upper rubber sheet and the cradles are
removed and the blankets tucked in closely around the patient's body,
after which the case is managed in the same manner as the hot-water
To give these baths to a patient sitting up, after removing all
clothing he is made to take his seat upon a chair with perforated
bottom ; under the chair is placed an alcohol lamp, an electric heater,
Fiq. 85. Arrangements for Hot-air or Vapor Baths in Bed.
or a pail of water in which are dropped hot stones or bricks. The
patient is then surrounded from the neck downward by a rubber
sheet and blankets arranged in the manner cf a tent; this is a con-
venient method in the field.
Precautions to be used with hot air or vapor baths :
1. Be careful not to burn or exhaust the patient, or to set fire to
2. Keep an ice-bag on his head.
3. Watch the pulse.
4. Give hot drinks freely.
5. Wrap the patient in a hot dry blanket for an hour aft
bath, then rub with alcohol.
To reduce fever we use either the Brandt system of cold t
cold sponging, or the cold pack. There are also various extempo-
raneous methods for applying cold for this purpose. The general
effect of cold baths, besides reducing the temperature, is to allay
nervousness, quiet the circulation, increase excretion, and induce
The Brandt system of bathing is used chiefly in typhoid fever.
A portable bath tub on wheels is generally employed. The tub is
brought to the bedside half filled with water at a temperature of
about 90 F. ; the naked patient is lifted from the bed and lowered
into the tub feet first, and gradually, so as not to produce too much
shock. For the purpose of lifting the patient from the bed and
supporting him in the tub an open-work stretcher, a hammock, or a
cotton blanket with loops sewed in the edges, is usually employed;
in the absence of these a binder eighteen inches broad should be
fastened across the head of the tub to support the head and shoulders.
His head rests upon a circular air cushion and is kept covered with
cold compresses ; pieces of ice are added to the water so as to reduce
the temperature gradually to about 70 F. To ascertain the tem-
perature accurately a bath thermometer is employed. All the time
the patient is in the bath the attendants should keep up a vigorous
rubbing of his body. The duration of the bath is ordinarily about
twenty minutes, but it may be shortened if there is much shivering,
and blueness of the lips and finger tips.
When it is time to take the patient out, the tub is covered with
a dry sheet which is wrapped about the patient as he is lifted out,
and placed on a dry blanket. If shivering persists a hot-water bag
may be applied to the feet and a hot drink may be given internally,
but he should not be wrapped in blankets. The temperature is
taken in the rectum immediately after leaving the bath and again
an hour later. Ordinarily the bath is repeated whenever the tem-
perature goes above 102.5 to 103 F.
Cold sponging has already been described under the sponge bath.
When the patient does not stand the cold tub bath well or is too
weak to bear the moving, the cold pack may be employed. In this
method the bed is protected by a long rubber sheet, and two sheets
folded one or more times and wrung out of water at 70 F. are
used. One is placed under the patient and the other over him and
tucked in closely about the body and neck ; or a single sheet may be
used enveloping the entire body except the head. The packs are
BATHS AND BATHING 161
changed about every fifteen minutes, and three or four of them
generally produce the effects of a single tub bath.
Bed tub-bath. To give a patient a bath in bed, pass under him a
rubber sheet the size of the bed, a bed sheet, and over this a large
rubber sheet about three feet wider and two and one-half to three
feet longer than the mattress. Attach a small rope or cord to the
head and foot of the bed, on each side, about six inches above the
mattress, and stretch it firmly. Over this cord pass the large rubber
sheet and fasten with clothes pins, thus forming a trough to carry
off the water; direct the lower end of the rubber sheet into a pail
at the foot of the bed, and raise the head of the bed a few inches
Remove the top covers and place a towel over the patient. The
water, of desired temperature, may be sprinkled on with a watering
pot, or from a pitcher or a syphon connecting with a pail placed
above the bed. If the bath is cold, patient should be well rubbed
during its administration. After it is over, drain off the water, and
with a towel wipe the rubber sheet dry, withdraw it from beneath,
and dry the patient with the sheet on which he will then lie.
Alcohol baths. The patient is usually rubbed with alcohol after
an ordinary bath, or it may be given alone, for its soothing and
quieting effect. Fifty per cent alcohol is ordinarily employed, and is
well rubbed in by the hands of the nurse. The bedding covering
patient, except the sheet, should be removed, and the lower sheet
protected by bath towels ; the body is then gone over systematically,
one portion at a time, using only enough alcohol to avoid wetting the
bed. A pint will usually be sufficient for one bath.
In the field when the folding field tub is not available, substitutes
may be extemporized. An ordinary camp cot may be taken, the
canvas bottom punched full of holes and a piece of rubber sheeting
tacked across the frame below the canvas in such a way that it will
form a gutter draining toward a pail placed at the foot. On this
cot the patient is to be placed and cold water sprinkled or poured
over him ; or an upright frame may be made, to the sides and ends
of which rubber sheeting may be attached in such a way as to form
an extemporized tub.
Bakes. Small hot air cabinets for baking different parts of the
body are furnished by instrument makers, and especially adapted for
the part to be baked.
It is necessary, in the use of these appliances, to strictly follow
the directions and to take good care to avoid burning the patient.
Special protectors are supplied for this purpose, but need to be
Electric light baths. Special appliances are required for these
baths, and directions for their use accompany them.
Local baths. The foot bath may be given in bed. It is employed
in sprains to control the hemorrhage about the joint, and in internal
diseases to draw away the blood from the congested part. For the
latter purpose mustard is usually added to the hot water.
To give a mustard foot bath in bed turn up the covers from the
foot end of the bed, place a rubber sheet across it, and on this a pail
or foot tub full of water as hot as can be borne. Dissolve a couple
of tablespoonfuls of mustard in a cupful of hot water until a uniform
cream is formed and stir it into the pail of hot water. If the dry
mustard is added to the pail of water without previous solution,
particles of mustard will float around, adhere to the legs, and may
When all is ready the patient, lying on his back, should flex his
legs and immerse them in the hot solution until the skin is quite red.
The legs are then withdrawn, dried quickly, and wrapped in a
In the Sitz bath the patient sits in a tub or deep basin of hot water,
the feet rest on the floor.
ENEMATA, IRRIGATIONS, DOUCHES, CATHETERIZATION
AN enema is an injection of fluid into the bowels. When the
injection is made into the rectum through a tube passed just within
the anus it is known as a low enema or simply an enema ; when the
liquid is carried high up into the colon through a soft-rubber tube
introduced fifteen or eighteen inches it is known as a high enema.
Enemata are further classified according to the purpose for which
given, into laxative, nutrient, and medicinal or therapeutic enemata.
Laxative enemata are of various kinds according to the special
indications of the case. The one most commonly used is composed
of two or three pints of soap suds made with any good soap and
water, either hot or cold. To give such an enema the patient is
placed on his left side with the hips raised and resting upon a folded
towel placed upon a rubber sheet for the protection of the bed. A
bed pan or commode should be at hand, and also a towel to control
the anus if necessary.
A rubber bulb or a fountain syringe may be used, the former
being generally considered preferable on account of the intermittent
pressure which it permits of; -either, however, is effective and safe
if properly used.
A soft rectal tube is attached to the tube of the injector by a short
piece of glass tubing, the rectal tube lubricated with soft soap and
then passed in gently for eight or ten inches. The fluid is made
to pass in slowly, the bag in the case of the fountain syringe being
raised or lowered as necessary so as not to cause any pain.
After the entire amount has passed in, the patient is directed to
hold it for about fifteen or twenty minutes if possible, and may be
assisted by pressing a towel firmly against the anus. The longer
the fluid is retained the higher up the contractions of the bowel
extend and the more complete the resulting evacuation. Should a
more active enema be necessary thirty grammes of Epsom salts and
fifteen Cc. of turpentine may be added to the soap suds, or sixty Cc.
of castor oil and fifteen Cc. of turpentine may precede the suds by
half an hour. Fifteen Cc. of glycerine diluted with an equal amount
of water, and given with a
small hard-rubber syringe,
makes a very effective
The nutrient enema is
always given high, as the
rectum itself has very little
absorbent power and still
less digestive capacity; if
the bowels are loaded they
must first be emptied by a
laxative enema. Nutrient
enemata must not exceed
one hundred and twenty-
five Cc. in bulk so as not
to cause peristalsis and
lead to their own rejection ;
they must also be concen-
trated, nonirritant, and
predigested or easily di-
gestible. They should not
be repeated oftener than
once in four to six
Among the food prep-
arations most suitable
for this purpose are
peptonized milk with or
without the addition of
an egg, and beef juice
or beef extract.
Water to relieve thirst
is often given by high
enema; for this pur-
pose as much as a pint
should be used, and it
i 1 j t < 1. j F IC - 87. Irrigation of the Bowels. Second step,
should be of body tem-
perature so as to cause as little irritation as possible.
FIG. 86. Irrigation of the Bowels. First step.
DOUCHES, CATHETERIZATION 165
A nutrient enema is given through a rectal tube or large catheter,
warmed, well oiled, and introduced for about twelve to fifteen inches ;
in the outer end of the tube a funnel is placed, and the liquid food
slowly poured in from a pitcher. When nutrient enemata are given
frequently the bowel should be gently washed out with warm water
before each one ; the tube and funnel are used for the washing, the
latter being alternately raised and lowered before all the water has
run out so as to secure siphon action.
Medicinal enemata may be given for their general effect as when
chloral, opium, or stimulants are used, or for their local effect, on
inflammation or hemorrhage, when astringents, emollients, or anti-
septics are employed. The last class of medicines is, however,
usually employed by irrigation instead of enema. The most common
emollient enema is the well-known starch-and-laudanum mixture.
To prepare it take a tablespoonful of ordinary laundry starch, add
enough cold water to dissolve it, and then sufficient boiling water
to form a thin paste ; into this stir fifteen to twenty drops of lauda-
num, and inject while warm with a hard-rubber syringe.
An irrigation differs from an enema in that it is desired that a
considerable portion of the liquid introduced shall be absorbed and
that the remainder shall be allowed to flow away at once. The
irrigation may be given for cleansing purposes only, or disinfectants
such as nitrate of silver or quinine may be employed. Before the
funnel is lowered, enough fluid should be introduced to gently dis-
tend the bowel without causing pain ; it is important "to see that the
funnel is lowered while some fluid is still visible ; otherwise there is
difficulty in starting the outward flow (Figs. 86, 87).
The tubes and syringes used in giving enemata and irrigations
must be kept thoroughly clean ; for this purpose, after use a stream
of water should be allowed to run over and through them, after
which the syringe should be hung up to drip and the tubes and
nozzles placed in an antiseptic solution. When the tubes or nozzles
have been used in an infectious case they should be boiled before
being employed for another patient.
Urethral injections are used in gonorrhea. In the hospital these
injections are given under the supervision of the nurse, who should
instruct the patient how to give them correctly. Having placed a
basin on a chair in front of him or standing in front of the urinal,
he should first pass his water to vrash all the pus out of the urethra.
The syringe is then filled and the nozzle inserted in the meatus and
held there firmly with thumb and forefinger of the left hand, after
which the piston is driven slowly home, the syringe withdrawn, and
the urethra firmly compressed for a couple of minutes in order to
retain the injection. At least two syringefuls are used each time.
A douche is a stream or jet of water propelled with some force.
Spinal, vaginal, nasal, pharyngeal, eye, and aural douches are em-
ployed, the latter being the most frequently used in military hospitals.
The spinal douche. The patient should sit on a board across the
end of the tub furthest from the spigot and with his back toward
the spigot. Use the spray as directed.
If the spray is to be hot test it first on your own arm.
If the patient is unable to
the douche may be
bed which is pre-
pared as for a bed-bath.
The nasal douche. Use a
fountain syringe with a nasal
tip. Incline the patient's head
forward and to one side so
that the nostril of entrance is
uppermost; if one nostril is
obstructed this should be the
entrance; tell the patient to
keep the mouth open and
breathe through the mouth
and not to cough or swallow,
this to prevent the passage of
the fluid into the eustachian
tube; use no force; hold the
irrigator only two or three
inches above the patient's
nose; have the water hot.
The eye douche. Use warm boric acid solution. Arrange the
patient so that the eye to be douched is lower than the other one ;
wipe off any secretion with a wet cotton sponge from within out-
FIG. 88. Syringing the Ear.
DOUCHES, CATHETERIZATION 167
ward ; evert one lid and direct the solution over it from within out-
ward, holding the basin in such a position as to catch the flow ; treat
the other lid in the same way; if drops are to be put in afterward
place them at the outer angle of the eye so that they will not imme-
diately escape through the tear duct.
The aural or ear douche is used for cleansing purposes or to
remove foreign bodies, especially hardened wax. Either a fountain
syringe with a straight glass medicine dropper or a nozzle, or a
hard-rubber syringe, is employed. The former is to be preferred, as
the pressure can be more easily regulated.
To remove hardened wax a warm, five-per-cent solution of soda
is employed ; the coat and collar of the patient having been removed
and a towel placed about his neck, he sits in a chair with the head
inclined toward the affected side; a basin or bowl is held firmly
against the neck just below but not touching the lobe of the ear; the
ear is then drawn upward and forward to straighten the canal, and
the tip of the nozzle placed against the upper wall, along which the
jet of water is directed with the object of passing behind the plug
of wax and washing it out in the return flow along the floor of the
ear (Fig. 88). A quart or more of water may be used at a time
and repeated until the mass comes away in one piece or in fragments.
When the wax is removed the ear should be dried out with a wisp
of cotton, a little of which is left in the canal for a day or two until
the. sensitiveness has subsided.
Catheterization is the art of drawing off the urine from the bladder
by the aid of a catheter. The dangers of catheterization are injury
to the urethra from undue force, and cystitis or inflammation of the
bladder caused by the introduction of germs on an unclean catheter.
The precautions to be taken are absolute cleanliness of everything
which may come in contact with the catheter and avoidance of all
force in introduction. The catheter to be used should usually be
of soft rubber only ; failing with this a noncommissioned officer may
use a silver instrument.
To introduce a soft-rubber catheter it is first washed in running
water, then wrapped in gauze or a towel and boiled five minutes;
the attendant washes his hands and the penis of the patient with
hot water and soap, followed by an antiseptic solution, and surrounds
the base of the penis with a clean towel ; the catheter is then lubri-
cated with sterilized oil, held in a dressing forueps, and gently passed
in until the escape of urine announces that it has reached the bladder.
Should an obstruction be met with, the catheter is withdrawn a
little, and again pushed on as before. After the flow of urine has
ceased, the instrument is gently withdrawn, taking care to compress
the end between the fingers as the last portion is withdrawn from
the urethra in order to prevent the urine remaining in the catheter
dripping out on the bed. After use the catheter should be thoroughly
washed in running water and either hung up to dry or placed in a
Irrigation of the bladder for cystitis and other diseases is done in
much the same manner as irrigation of the intestines, using either a
single or double current catheter.
Catheterisation of the ureter is always done by the physician ; the
nurse's duties are to see to the sterilzation of the instruments, and
that specimens of the urine from the two kidneys are kept quite
separate, for this purpose he marks the urethral catheter as well as
the necessary vessels " right " and " left."
AMONG the external applications most commonly used are heat
and cold, lotions, counter-irritants, and caustics.
The application of heat may be general or local; the general
application has already been described in Chapter IV. The local
effects of heat are to relieve pain, allay inflammation, and relax
spasm. Dry heat is applied in the form of the various dry hot-air
apparatus, electric heaters, hot-water bags, bottles, or cans, salt bags
and hop bags, hot bricks, etc. The dry hot-air apparatus must be
used with considerable care and according to the directions which
accompany each appliance. Bags, bottles or tins of hot water