z IMAGE EVALUATION TEST TARGET (MT-3) 1.0 f' I.I ^ 1^ 12.0 125 2.2 L25 1111.4 I M 1.6 6" -sV v.; © o <-^ ,-TH n ^ ^ /.^ «*>^ ^-^ />^^^ - n^^ J ■1? V iV \ \ ^ HkjI Sciences CorDoration ^""^J^" ^ •■^ <<^.1> \ 23 WIST MAIN STRICT WEBSTER, N.Y. 14580 (716) 873-4503 ^•^ ''.•^■f. %•• fi o <•■ o tp '^Ji a. f . ss*! fe CIHM/ICMH Microfiche Series. *'.. %.. ' .^■^ CIHM/ICMH Collection de microfiches. 0. »3 \? ,-9 ;i- Canadian Institute for Historical MIcroreproductions / Institut Canadian de microreproductions historiques e' »©,H ¥SS?f>:'>"::.::^ i-V!-^ ' . •-* •• • L<'.'/.i^.V> Tschnical and Bibliographic Notaa/Notas tachniquaa at bibliographiquaa Tha Inatituta haa attamptad to obtain tha baat original copy availabia for filming. 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Whanavar posaibla. thaaa hava baan omittad from filming/ II aa paut qua cartainaa pagaa blanchaa ajoutAaa lora d'una raatauration apparalaaant dana la taxta. mala, loraqua cala Atait poaaibia, caa pagaa n'ont paa AtA filmtoa. Additional commanta:/ Commantairaa supplAmantairaa: L'Inatitut a microfilm* la maillaur axamplaira qu'il lui a it* poaaibia da aa procurar. Laa details da cat axamplaira qui aont paut-Atra uniquaa du point da vua bibliographiqua. qui pauvant modif iar una imaga raproduita. ou qui pauvant axigar una modification dana la mAthoda normala da filmaga aont indiquAa ci-daaaoua. r~~| Colourad pagaa/ D Pagaa da coulaur Pagaa damagad/ Pagaa andommagiaa Pagaa raatorad and/oi Pagaa raataurAaa at/ou palliculiaa Pagaa diacolourad. atainad or foxai Pagaa dAcolortea. tachatAaa ou piquiaa Pagaa datachad/ Pagaa dAtachiaa Showthrough/ Tranaparanca Quality of prir Quality inAgala da I'impraaaion Includaa aupplamantary matarii Comprand du material aupplAmantaira Only adition availabia/ Saula Mition diaponibia r~| Pagaa damagad/ r~n Pagaa raatorad and/or laminatad/ r~l Pagaa diacolourad. atainad or foxad/ I I Pagaa datachad/ rrj Showthrough/ I I Quality of print variaa/ rn Includaa aupplamantary matarial/ r~1 Only adition availabia/ Tl tc Pagaa wholly or partially obacurad by arrata siipa. tiasuaa. ate. hava baan rafilmad to anaura tha baat posaibla imaga/ Laa pagaa totalamant ou partiallamant obacurciaa par un fauillat d'arrata. una palura, ate, ont AtA filmiea A nouvaau da fagon A obtanir la maillaura imaga posaibla. Tl P< 01 fil O b( t!t ai 01 fil al 01 ■ w M di ar b4 Hj ra m Thia itam ia fiimad at tha raduction ratio chackad balow/ Ca documant ast film* au taux da reduction indiqui ci-daaaoua. 10X 14X 18X 22X 26X aox y 12X 16X aox 24X 28X 32X Th« copy fllmMl h«r« hm b—n raproducMl thanks to th« g«n«rosity of: MMiieil Library McGill Univanity Montraal Tho imag«w appooring hara ara tha baat quality poaaibia conaidaring tha condition and lagibiiity of tha original copy and in icaaping with tha filming contract spacificationa. Original copiaa in printad papar eovara ara filmad baginning with tha front covar and anding on tha laat paga with a printad or illuatratad impraa- •ion, or tha bacic covar whan appropriata. All othar original copiaa ara fiimad baginning on tha first paga with a printad or illuatratad impraa- aion, and anding on tha laat paga with a printad or illuatratad imprasslon. Tha laat racordad frama on aaeh microfieha shall contain tha aymboi «^ (moaning "CON- TINUED"), or tha symbol y (moaning "END"), whichavar appliaa. L'axamplaira film* fut raproduit grica k la gAnAroait* da: Madieal Library MoGill Univanity Montraal Laa imagaa aulvantaa ont 4t4 raproduitaa avac la plua grand aoin, compta tanu da la condition at da la nattati da l'axamplaira film*, at an conformM avac laa conditiona du contrat da filmaga. Laa axamplalraa originaux dont la couvartura wn papiar aat imprimte aont filmia 9n commandant par ia pramiar plat at •n tarminant soit par la darnlAra paga qui comporta una amprainta d'Imprassion ou dlilustration. soit par la sacond plat, salon la eaa. Toua laa autraa axamplairaa originaux aont fllmte an commandant par la pramiAra paga qui comporta una amprainta d'impraaaion ou d'illuatratlon at an tarminant par ia damiira paga qui comporta una talla amprainta. Un daa aymbolaa auhranta apparaltra aur la damlAra imaga da chaqua microfieha, salon la caa: la aymboia -^ aignifia "A SUIVRE". la aymboia ▼ algnifia "FIN". IMapa, plataa. charta. ate., may ba filmad at diffarant raduction ratioa. Thoaa too larga to ba antiraly includad in ona axpoaura ara filmad baginning in tha uppar iaft hand comar. laft to right and top to bottom, aa many framaa aa raquirad. Tha following diagrama illuatrata tha mathod: Laa cartaa, planchaa. tabiaaux, ate. pauvant Atra filmto i daa taux da rMuction diffiranta. Loraqua la documant aat trop grand pour Atra raproduit an un saul cilchi. 11 aat film* A partir da I'angia aupAriaur gaucha. da gaucha A drolta, at da haut m* baa, it pranant ia nombra d'imagaa nAcaaaaira. Laa diagrammaa suivanta illuatrant ia mAthoda. 32X 12 3 1 2 3 4 5 6 Ik > ''■'■-. "T} 4 .>-">. ^ '>; '•■"vT^T^-^.-v'' P>?|* H^' :l4:t ^RSiTMEU*rAK0 NURSING v" *:i^:C?-.:*:-y'-r f;v:-^'*";;is:^'ttf-;-?^^%. /' -■■ •■'■:. yf'- ■ '■ ■ i-^^- ■■ vf',--. .'.i- r-: Is,,- : i:-, •- -■'* . -1" . v" h frfusor 6/ tfifrJHgelop td MtjSi/f VnhtrsU] tuii jUryngtbgist to the Mtptrtal Gtneral Hospital x*f':,y \-yy: ^,f- ■»■ "^■^^: ')>'-:, Rtprinted from Traintd Nurse, April, 1897 '''■':>i'- ^TT. ^Jl X"^- ~5"^ 'f ^.i; ' \ 'it. i t ' .", 1 'V t >■ -( iA ■ /.i'^y!'^ V •- ■^ \ ^ '. > > I (' V ^: ,1' J ' .I " V , (' { ."4 - X. w'^V ,'V -I 1 %fl .1 ■ . '4 ■— .'■<..'*'>... \ ■f , ■; 1 ^ ' i \ ^ V ' iM' :^\^\ > <' i ) V ■ •>■ -,■•<-, ,v" '. .', < ..-tU ^^1 1 A- \1 DIPHTHERIA: ITS TREATMENT AND NURSING*. H. S. BIRKETT, M.D. Pro/eisor of Laryngology to MeOill Univfrsily and LaryngologisI lo Ike Moiilrtal General Hospital. H! i-,.-. f'< IPHTHERIA receives its name from one of its most prominent objective symp- toms, namely, the produc- tion of a tanned-leather-like deposit of membrane upon the affected spot, and may be defined as follows: It is a local specific disease due to the presence of and action of the well- known bacillus, discovered by Klebs and more thoroughly studied by Lofifler and now commonly called the Klebs-Lofifler bacillus; it is characterized by a deposit of pseudo-membrane at the site of infec- tion, accompanied by constitutional dis- turbances and followed by nervous symptoms due to the absorption into the circulation of a virulent chemical agent (toxalbumin) which is produced by the local development of the bacilli. As the carrying out of treatment differs accord- ing to the part affected, it will therefore be necessary to give a classification when the disease attacks the respiratory tract, which is arranged as follows in the order of the frequency : 1. Pharyngeal. 2. Nasal. 3. Laryngeal. Diphtheria attacks all ages: it is fairly common under three months and may even attack new-born infants. In some families there seems to be a predisposi- tion to the disease. It is more apt to at- tack scrofulous children and those with large prominent tonsils and co-existing adenoid growth and those with enlarged glands. PHARYNGEAL DIPHTHERIA. Pharyngeal diphtheria is by lar the commonest form of the disease. The membrane is found most frequently on the tonsils, less frequently on the back of the throat. From these situations the disease may extend upward, involving the nose, the tear duct and ears.or down- ward, involving the trachea and its di- visions. The onset is usually that of an ordi- nary sore throat and if the throat be in- spected simple redness may be obser\'ed. These symptoms may be preceded by a sensation of chillness. In children the attack maybe ushered in by convulsions. Following the chill and sore throat there is a feeling of lassitude and depression, with pain in the small of the back, a tired feeling in the legs, loss of appetite and restlessness. There may be slight pain and difficulty in swallowing, a rapid pulse and slight elevation of tempera- ture. Albuminuria may appear in any of the forms of diphtheria and is not of itself to be regarded as of serious mo- ment. As the case progresses examination of the throat shows that the catarrhal stage has been followed by the development of a thin yellowish membrane on the sur- face of either tonsil or both, or perhaps on the posterior wall of the throat. This membrane gradually assumes a dirty gray color; its edges are sharply defined, and the surrounding portion of the ton^jils or pharynx have a deep red or purplish hue. Here and there small hjemorrhagic points may be seen in some cases. Fetor of the breath is perceptible. The glands beneath the jaw and at the back of the neck enlarge and become tender. The temperature varies between the normal * Read before the Canadian Nurses' Association at Montreal. Diphtheria: Its Treatment ami Mtirsing and 101° F. In ordinary mild cases the pulse is not much altered. The occurrence of a rash in the course of any form of diphtheria is not unusual. The rash is usually like that seen in scar- let fever, although eruptions sometimes occur similar to those of measles, roseola or urticaria. In the malignant form a purpuric rash is not uncommon. In the pharyngeal form we occasionally meet with gangrene : this condition is rare and always associated with a severe type of the disease. It usually attacks the soft palate and often results in the destruc- tion of the uvula or one of the palatine arches. The tonsils are rarely involved in the gangrenous process. Delirium does not usually occur in mild cases, but is almost invariably pres- ent in the graver forms. It is usually of a mild, wandering character. A severe attack is usually accompanied by rigor; a temperature of 105° to 107° or subnor- mal and is attended with nervous symp- toms, as vomiting, convulsions, etc. If the membrane is forcibly or accidentally removed it is rapidly reproduced. The lymphatics are very quickly involved, and the glandular and peri-glandular structure infiltrated. The neck on the affected side is much swollen, the mem- brane dark and the odor very offensive. Now we pass to the NASAL FORM. This may be either primary or secon- dary. When secondary the disease has extended up the back of the nose from the pharynx. The invasion of the nasal tract may be suspected when nasal res- piration is obstructed and the patient breathes chiefly or wholly through the mouth. A thin, ichorous, muco-puru- lent discharge appears on one nostril or both; small excoriations and ulcerations form at the entrance to the nares, on the upper lip, or wherever the discharge is allowed to rest. Nasal diphtheria is es- pecially apt to occur in children who have more or less large collections of adenoid tissue in the vault of the pharynx. Such children are usually mouth breathers or become so when they take the slightest cold. They snore at night and their sleep is restless and broken. When they contract diphtheria it usually spreads rapidly to the narcs and seriously complicates the case. Bleeding from the nose is apt to occur and may be the only symptom which may attract attention to the nose. The next portion of the respiratory tract most likely to be involved is the LARYNX. Laryngeal Diphtheria may be either primary or secondary. The more com- mon form is the secondary : it is then an extension of the morbid process from the nose or pharynx downward. The onset of laryngeal diphtheria is recog- nized by a harsh, dry, shrill or hoarse muffled cough. The voice is husky, weak, and sometimes almost inaudible. Associated with the cough is a spas- modic closure of the narrowest part of the larynx (glottis) and a temporary in- crease of dyspncea. Such being the clinical pictures of the vaiious forms of diphtheria involving the respiratory tract, what are we to do for our patients? • Isolation. — A large airy room should be selected, preferably at the top of the house and on the sunny side: it is diffi- cult or impossible to isolate a patient completely on the lower floors. An open fireplace is an advantage. Carpets, cur- tains, mats, ornaments and all unneces- sary articles of furniture should be re- moved. A sheet kept wet with a disin- fectant solution (such as carbolic 1-20 or bichloride 1-500) should be hung out- side the door. No one other than those Diphtheria: Its Triatmait and Nursing directly acting in the case should be per- mitted in the room. Dishes, towels, clothing, bedding and utensils used in the room should be kept there and not allowed to be carried through the house or used elsewhere. Dishes and utensils should be washed in the room or in a sink or wash room not used by other members of the household. Soiled clothes should be coveretl with a boiling disinfectant solution before be- ing taken from the room. The discharges from the nose or mouth should be re- ceived in an earthenware or glass utensil containing sublimate solution (1-5000) or in pieces of clean old soft linen which should be burned immediately. The ex- creta should be received in glazed earth- enware utensils containing sublimate solution (1-5000). Cats, birds, dogs, or other household pets should not be al- lowed in the room for they are often the means of spreading infection. The room should be kept clear of flies, for they too have been accused of having carried in- fective particles from room to room and from house to house. Food should not be allowed to remain exposed in the sick room; milk is particularly apt to ab- sorb impurities from the air. Diphtheria is highly contagious, the infective bacilli being present in particles of diphtheritic exudation which are coughed, sneezed or spat up. They are found also in the saliva, nasal mucus and discharges from a diphtheritic patch wherever present. They may even be breathed out and thus infect the air. These infective particles readily attach themselves to the clothing of the patient, the nurse, to the walls, furniture, bed- ding, dishes, books, papers and pets or may float about in the dust and air of the room. It is manifestly of tlie utmost im- portance to collect and destroy immedi- ately those discharges which are the vehicles of infection, and keep the air pure by thorough ventilation. During convalescence the patient should have a change of apartments, if possible, one for night and another for day, so that the rooms may be aired and fumigated when not in use. Fccdiifg. — As the tendency of diphthe- ria is to debilitate, and as recovery often depends upon the strength and staying l>ower of the patient, it is obvious that the greatest care must be taken from the outset to keep up nourishment. Asa rule, solids should be avoided and the most nutritious and digestible liquids selected. It is needful sometimes to give nourish- ment in concentrated form when the stomach is irritable, or to peptonize it, to feed by cnemata, or by means of gav- age: of this latter method I shall have more to say. Milk and cream, alternated with beef or chicken broth or jelly, should be given regularly and at frequent inter- vals. Those foods. should be selected which contain much nourishment in small bulk. Garage is the method of feeding by means of a tube introduced into the stoma '\ cither through the mouth or through he nose, and is a method which is especially useful in cases of laryngeal diphtheria which have required intuba- tion; in cases of post-diphtheritic paraly- sis where the ability to swallow is almost nil, and in cases where the child posi- tively refuses to take food in the usual way. The method of carrying out this way of forced feeding is as follows: The child is pinned in a blanket so as to prevent any movement of the arms and placed lying on the back. A glass funnel about 4-5 inches in diameter is attached to a Jacques soft rubber cathe- ter with the intervention of a bit of plain Diphtheria: Its Treatment and Nursing glass tube. Tlic catheter should be from 7° to 15° F., according to the age of the patient, the larger sizes being the more desirable. The well-oiled catheter is passed quick- ly but quietly along the floor of the nares. Just as it passes into the oeso- phagus there is usually slight resistance and gagging, otherwise no trouble is found. A small amount of water is al- lowed to flow down and without allow- ing arvy air to enter, the milk and medi- cine are immediately poured into the funnel. In withdrawing the catheter it should be pinched, that the few drops re- maining may not flow out and irritate the pharynx. In this way the child is fed every four hours, the following amount being given: Water, i oz. ; milk, 4 to 6 oz. ; brandy, ^ to 2 drachms or more (Jackson). Another method of feeding the intu- bated child is that suggested by Wax- ham. According to his method the child is laid across the nqrse's knee in such a way that the head hangs lower than the rest of the body, the food being given to the child in very small quantities at a time, about a little less than a teaspoon- ful. Treatment. — There is no disease about the treatment of which more has been written than diphtheria. Drugs and ap- plications innumerable have all had their champion, but all are now relegated to the dark ages, since the brilliant discov- ery by Roux & Yersin of antitoxin. This is the recognized medicinal agent in the treatment of diphtheria, and its re- sults are so satisfactorily established by experience that its use is now univer- sally adopted by most medical men. It has been the means of reducing the death rate 50 per cent, in this much dreaded disease and has, in so far as my experience goes, reduced very consider- ably the necessity for intubation or trach- eotomy, especially when used early in the disease. Antitoxin is administered hypodermi- cally, the dose varying trom 500 to 2,000 units, according to the age of the patient and the severity of the case. In preparing for its administration, the nurse should thoroughly sterilize the syringe and needle to be used for its in- troduction. The place where the injection is to be given (by some between the shoulder blades, by others just above the mam- mary region) should be thoroughly ren- dered aseptic in the usual way. Just as the needle is to be withdrawn the nurse should be ready with a small piece of adhesive rubber plaster, which should be immediately placed over the site of entrance of the needle after its withdrawal. A symptom often noticed within four to twelve hours after an injection of an- titoxin is a rise of the temperature, vary- ing from 1° to 2° : a diffuse erythematous rash is occasionally met with. Albumi- nuria is also known to follow an injection of antitoxin and the urine should be carefully examined daily for the presence of albumen, as it may occur independ- ently of the use of the serum. The advisability of the further use of antitoxin will, of course, rest with the attending physician. LOCAL TREATMENT. The best application locally in diph- theria is, in my opinion, a solution of bi- chloride of mercury (1-5000) and its method of application will depend uf)on the site of the aflfected area. Should the membrane be situated on the tonsils or pharynx or both, then the solution should be applied by means of cotton rolled on a wooden stick about the length and size of an ordinary meat I 1 I I Diphtheria: lis Treatment and Nursing- s 1 skewer: this should be destroyed after once being used. In making the appli- cation it is well to depress the tongue by means of a spoon or tongue depressor and in this way thoroughly bring the affected parts into view; the application should be made hourly and the patient kept in the recumbent posture. When the nose is affected then the so- lution may be dropped (two drops in each nostril) by means of a pipette. An atomizer as means of applyitig this solution is not advisable, as improper use of it may lead to mercurial poison- ing. In making these applications it is well that the nurse protect her own clothing by means of a large piece of cheese-cloth wrung out of a solution of bichloride (1-500) and fastened so as to cover that portion of her clothing which is exposed to the secretion which might be coughed out by the patient. Should the disease have attacked the larynx then the ordinary methods of making applications are beyond the skill of the nurse and steam inhalations are therefore advisable. The use of steam inhalation is a matter ot opinion of the attending physician — for my own part since the introduction of antitoxin I never find them of much service and add only to the discomfort of the patient and to the work of the nurse. If they are prescribed the drugs most often used are tr. benzoin Cc: oil of eu- calyptus, carbolic acid, etc. About the cot or bed of the patient a tent may be easily extemporized so as to limit the space and thus keep the at- mosphere of that space well charged with moisture and the medicinal agent used. The ordinary croup kettle is the means used in volatilizing such remedies, or in place of it a kettle may be kept boiling at a safe distance from the bed and the steam from it conveyed into the tent by means of a rubber tube. It is in the laryngeal form of diphthe- ria that the patient requires the most careful watching. If obstruction to the breathing increases, as evidenced by the aggravation of the symptoms already mentioned, it becomes our duty to inter- fere and relieve the obstruction mechan- ically if possible. This may be done in two ways — by intubation or tracheoto- my. For surgical measures to have a fair chance of success early interference is necessary. The patient must not be al- lowed to drift along into an almost mori- bund condition before we operate if we expect any good results from the opera- tion. When the breathing has become strid- ulous, inspiration difficult, the spaces be- low the clavicles, the intercostal spaces and abdomen retracted; when the child is tossing about extending its neck in the vain effort to get air; when the lips are cyanotic and the face of an ashen hue — we may give temporary relief by operat- ing, but the chances of ultimate recovery are not as good as if we had interfered before the onset of the graver symptoms. The operation of intubation is now generally preferred to tracheotomy. It is performed as follows : First the patient is wrapped in a blan- ket with the arms close to the sides of the body and the forearms crossed over the abdomen. In this position the blanket is firmly pinned. The nurse holds the child so that his head lies against her left shoulder; with her left hand the head of the child is steadied in this position; the nurse's right arm holds the body of the child and the legs of the patient are firmly held between the nurse's knees. As soon as the tube is properly in the Diphtheria: Its Treatment and Nursing • :v -f. * • . • * . larynx the first thing noticed is that cough sets in which lias a decidedly tubal character and once heard is not readily forgotten. The more or less cya- notic condition usually disappears and the child becomes more quiet, in fact, in some cases I have seen the child fall asleep in the nurse's arms before there has been time to place the little patient in his cot. Some operators leave this stiing at- tached to the tube for some time aftei* wards and in such cases the itring must t)e passed over the child's left .car and retained there by means of a strip of •jV. adhesive plaster placed over the cheek. /•. The child is very apt to snatch the string '.".and thus pull the tube out. so that it is [■ .better whilst the child has the tube so at- "-.taclied to .fasten his hands to hit sides, .-.; uiileia; he be so obedient .a» not to re- ' -.quire it, but this is not often the case, .." so careful watching. is absolutely neces- Personally I strongly object to leaving .' the string and remove it immediately I ..am satisfied that- the tube is all right, be- '■- cause the. string: I regard ks unnecessary • :. after its duty is fulfilled- and it enables ■■ the. nurse to" give, lier- attention to the child in other ways) and its absence al- • lows -the child to. take its nourishment •more. easily. ". -.' '.The feeding of intubated children I . ■ have - already spioken jibout and given you the metliods- of parrying these out. ■ Should the. tube be -expelled, as it often • is during- a. fit of coughing, it is ncces- ..sary that you iacquaint .the medical at- . tendant of this Occiirrence at once, as the -. '..sudden. reliH noticed. after its expulsion -'may be a ItJll b^for^ the storm which • means the onset of an attack of dyspncea ■ which may perhaps prove fatal. It is possible'that in the exptilsion of the tube the.child may not spit the tube out, but swallow it, and it is here that your observation as trained nurses will stand you in good stead. You will at once notice the absence of the tubal character of the breathing, indicating that the tube is out, and if you have not seen the tube, then the child has swal- lowed it. Norn zvc consider tracheotomy, — You .will prcpari^.^he patient ^^d t^ie site of the - --—^ -• vi-*.-. fc > .-. - i'. fhc° StthjNH^t greatest carcfull) dttefided to. -. The inner ■bng-'*ia^: -• ^j'cmovcci every-ljalf hour ind tlioroii^hf>i. ' . cleansed by placing it in boiling water. '' A piece of cotton wool firmly wrapped •' on a stick and moistened thoroughly in a solution of bichloride (1-5000) is used ** to free the outer tube of any adherent secretion or fragments of membrane and immediately burned. It has happened that a child has ex- pelled the outer tube and unless the nurse has presence of mind what to do at this critical moment the life of the pa- tient may be greatly endangered or even lost. It is always well to have a pair of retractors at hand so that the edges of the tracheotomy wound may be held apart to enable the child to breathe and in the meantime send for skilled assist- ance to reintroduce the tube. Should you be left without a pair of retractors bear in mind y^u have always at hand what will answer the purpose, namely, hairpins. Take two hairpins and bend the rounded end at right an- gles to the extent of half an inch ; intro- duce them together directly downwards into the wound and separate them; thus you will open the wound and allow the patient to breathe again. There is no difficulty in feeding pa- tients after tracheotomy, as they take ^« -Li. ri'>^-Cr^^X , til a ,i .. a ■- lat nil at lal lot al- ou of Diphtheria ; Its Treatment and Nursing ,Kf •- . •. ••• K'-W • . ed • in ed •• nt ' tid • . 4 i: food ill the usual way without the slight- est trouble. During convalescence the patient re- quires continuous careful nursing. One important feature which is nearly always present is the tendency to syn- copal attacks. This may be avoided in a great measure by not permitting the pa- i^tienl to rise when being fed,, and by ^•keejiing hi^ in the recumbeni position a*s much as possible. All sources of excitenrent should be '. excluded; relatives and. visitors should be excluded. from the room and exciting conversation and news prohibited. In fact, absolute quiet should be maintained as far as possible. If the nurse suffer from catarrhal trouble it is wise that she should spray her own nose and throat with a mild al- kaline and antiseptic solution, such as Listerinc in the proportion of a tea- spoonful to a wineglassful of warm water and use it night and morning. (The substance of this lecture has largely been drawn from the work I con- tributed to "Hare's System of Practical Therapeutics.") :i# -A^:^ i>'--^/'Hf^?;S' X- lie lo a- en of of Id id it- ® '3 of ys ie, iis ti- 0- Js Lis le a- ce >\t 1-; ^ O -nC '„/ - ( V", o ^0'.3 Cp. qZI<1__ CD b ^rO @ ©..- &,-. o -" r-n °?o°oo,o CO , o o'^b oo Q - o o o o O -' O O ^ C --> O _-':d ^ o O 5^ O .O oo \s V ( Coo_^ o - r~) U O D A *^- mi -f "^ ;"). 'J^^-T '„0 ■:^^._eJ O. L;^0 GO, 'C^'r. " W-A«-; 'x'_o^riii&3°J, Cb^