opposite side, for the reason that, as an ovary | ectopic gestation, and on the following Friday increases in size and becomes heavy, it gravi- this was confirmed by operation. I now show tates to the lower portion of the pelvis and, you the temperature record, which, prior to there increasing in size, it may push the intes- the operation, reached, for several days, a tines up on the same side as that from which it maximum of 104° F.; subsequent to its originated. We can say, however, that here performance the maximum has been 101° F.; we have a cyst, for the absence of resonance this morning it is 99° F. This patient, over the entire surface of the tumor indicates from a diagnostic point of view, has prethat it does not result from free fluid within sented much of interest, and has afforded us the abdominal cavity. There is a certain a great deal of gratification. You remember amount of resistance to the hand. The mass that the patient suspected herself pregnant, can be picked up and pulled from one side to and was satisfied that an abortion took place the other, and in so doing sensation of crepi- in February, 1893. Subsequently her abdotation is recognized, indicating that the rapid men continued to enlarge, and she later recogdevelopment of the tumor has produced a nized foetal movements. Her menstruation certain amount of irritation and peritonitis. after this supposed miscarriage did not return Further, that it is a cyst is evident from the until the following October. Subsequent to distinct fluctuation we are able to detect. this date, until she came under our observaPlacing the hand on one side we feel a wave tion, the last of March, 1894, she menstruated of fluctuation. The absence of resonance and regularly. Her abdomen had become as large presence of fluctuation indicate that we have as a woman between the seventh and eighth fluid confined within a sac. It is true that we months of pregnancy. The abdominal dismay have an abdomen so distended with fluid tension is centrally situated, projecting, possibly, that the mesentery will be too short to permit a little to the right. The tumor was regular the intestines to float to the surface, or the in outline until we reached the left side, low mesentery itself may be contracted by inflam- down, when a projection or more firm, resistmatory adhesions so that the intestines are ing mass could readily be distinguished. The withheld from the abdominal surface. In tumor itself had an elastic feel, and upon perthese cases superficial percussion will give dull- cussion fluctuation could readily be distinness, while pressing the hand well down upon guished. It differed from an ordinary cystic the abdomen we will find resonance. In other tumor, however, in the fact that its entire surwords, the intervening layer of fluid by this face was resonant, naturally leading us to action is displaced, and the abdominal wall is expect that the sac contained air or gas. Our pressed down against the air-containing intes- palpation did not enable us to recognize any tine. Here, however, we are not able to solid mass excepting that situated upon the accomplish this displacement, for the reason left side of the abdomen. that we have a mass within the abdominal ination the cervix was felt high up behind the cavity. Having determined that we have an symphysis, where it had been pushed by the ovarian tumor, the question for consideration mass, which had extended deeply into the is, What shall be done for her relief? The only pelvis and was a part of the abdominal tumor. method of treatment in such cases that affords This mass was so closely connected with the the slightest probability for permanent relief uterus posteriorly that it was difficult to say would be the removal of the cyst. If we that it was not a part of it. The question of should attempt to relieve her by emptying the interest became, What was the character of cyst, we would find that it would soon again the abdominal distension present in this fill, producing a similar train of symptoms, and patient? The fluctuation would lead us to the withdrawal of so large an amount of fluid suspect that we had an ovarian or fibro-cystic from the system has a depressing influence tumor. On the other hand, its surface was upon the patient; so we shall advise this patient resonant, while in an ovarian or fibrous cyst to undergo the operation of ovariotomy. dullness is present. Its walls also seemed too thin, and fluctuation was too distinct to lead us to believe it was a fibroid growth. In carefully analyzing the symptoms presented, we were forced to the conclusion that we had to Ectopic Gestation. The next patient is one in whom we have had a great deal of She was examined before you two weeks ago to-day, and a diagnosis made of By vaginal exam only suture infected, we feel that we have been fortunate. The convalescence has been as rapid as could have been expected. deal with a case of ectopic gestation, where | duced into the sac-wall; but, as this was the probably the period of gestation had been completed, and the fœtus had died, undergone maceration, as a result of which there had been a development of gas in the sac, causing resonance upon percussion. We were led to this conclusion by the history of the case, which comprised the supposed pregnancy and abortion at the second month; the subsequent enlargement of the abdomen, associated with foetal movements and absent menstruation; finally, cessation of foetal movements with a return of the menstruation, and, at a late date, presence of resonance over the sac. That this was engendered by decomposition of the sac-contents was rendered still more probable by the marked elevation of temperature from which this patient had been suffering during the last two weeks,—an elevation associated with loss of flesh, strength, and appetite, and a depressed, anxious appearance of the countenance. This association of symptoms led me to commit myself to you that we had to deal with a case of ectopic gestation. When the abdomen was opened a large, red, fleshylooking mass was found, which was apparently closely associated with the intestines and omentum, and below with the posterior surface of the uterus. This mass was opened, when there was at once a gush of dirty, greenish looking fluid, and the limbs of the foetus were quickly seized and a macerated foetus at full term withdrawn. The placenta was found attached to the anterior wall, and, as a consequence, was removed with its basal wall attached. Examination disclosed the remaining portion of the sac was associated with the intestines, so much so as to render it unwise to attempt its enucleation. The sac and abdominal cavity were thoroughly washed out, the sac itself packed with several layers of iodo form gauze and the peritoneal surfaces attached to the parietal peritoneum, the wound above closed; in this way the peritoneal cavity was shut out from any possibility of infection from the sac cavity. The gauze packing was permitted to remain four days, when it was removed, and two rubber drainage-tubes, of good size, inserted to the bottom of the sac behind the uterus, and the cavity then washed out two or three times daily with a sulphurousacid solution. At one time there was a stitchabscess at the point where the suture was intro Displaced Kidney.—The patient is 38, married; has a good family history; puberty occurred at 17; menstruation every two weeks and lasting two days, scanty and painful; was married when 18 years of age and has never been pregnant. Three years since she underwent abdominal section, for what cause she is unable to inform us, but states that she is no better than she was before the operation. She suffers from pain in the abdomen, especially on the left side just below the last rib, and continuous pain in the back. She has not menstruated since the operation, her appetite is poor, and bowels regular. Upon examination we find the ribs and crest of the ilium lie almost in contact; we can hardly press the finger between the lower rib and iliac crest. This is one of those cases in which operation on the kidney through the loin would be exceedingly difficult. As you look at this left side you will notice some desquamation of the skin, evidently a result of a recent blister. The patient complains of more or less distress in this region. She also speaks of having noticed a mass situated in the left side of the abdomen, which increases and decreases in size. The question becomes, What is the character of the growth, if any, which has given rise to these symptoms, and from what has the growth itself arisen? We recognize that such a growth, even if this patient had not the scar over the abdomen indicating that the peritoneum had been involved, is not probably a result of ovarian disease, as it is situated too high. We are not likely to have ovaries displaced upward unless the tumor is so large that it can no longer find a position in the pelvis. So we disavow the probability of this being an ovarian growth. The organs which may possibly furnish a tumor in the lateral region are the kidney, the spleen, the omentum, or the wall of the descending colon. These are situated upon the left side. Now, this patient, in addition to the symptoms she has already given, complains of being exceedingly nervous, has frequent attacks of palpitation of the heart, difficulty in breathing, and a sensation of faintness. I can distinctly feel, although the abdominal muscles are not very much relaxed, a mass close to the spine, which is not very movable, seems to be more or less fixed, is in close contact with the abdominal | the human heart,-unselfishness and devotion aorta, and I can feel the pulsations of that to the care of others. A halo of romance has vessel through the mass. The situation of the been thrown round the ministrations of the mass would lead me to conclude that it is not nurse in times of peace and war; she has an aneurism. While it is as large as we would ever been the ministering angel of the sick. expect from such a condition, it does not pre- room, and has brought joy and comfort alike sent the distinct pulsation we would recognize to the expectant mother, the fever-racked child, in an aneurism. The situation and size of the stricken hospital patient, and the wounded the mass lead me to believe that it is the left soldier upon the field of battle. kidney which is displaced and has become more or less fixed in this region, and that it is to this her distress is due. It is not the spleen, as the growth is not sufficiently large. It does not present its shape; nor do we believe it to be a growth of the descending colon. Before committing myself further, however, I take the precaution to turn the patient over on her left side, flexing the limbs well upon the abdomen, when we are enabled to run the hand beneath the rib and diaphragm, and to determine more definitely the character of any growth in that region; so that I am satisfied this is a displaced kidney. Such displacements are not unfrequently found in women who have undergone abdominal operations for removal of large growths, or in women who have become fleshy and subsequently lost it, so that the normal support of the parts is lost. Being situated near to the abdominal brain,—the solar plexus, -the dragging of the displaced kidney not unfrequently produces pain in the back and over the abdomen, with palpitation, sense of faintness, nausea, and vomiting. The history of the Civil War in America and of the Crimean and Franco-Prussian Wars in Europe teems with accounts of the heroism, self-sacrifice, and devotion of these noble women, the Sisters of Mercy and of Charity, who, for the glory of God and the honor of their sex, faced death itself in the discharge of their duty. Doubtless you all have heard of Florence Nightingale, the gentle, high-bred English woman, who, when the Crimean War was at its height, when the soldiers were dying like flies in the hospitals of Russia from neglect and ignorance, went out to the scenes of battle with a devoted band of followers to reduce the horrors of war. So devoted was her care of the sick and wounded that the gratitude of the English people found expression in a great public meeting, at which over $200,000 were subscribed as a testimonial to her. She refused to take it, but devoted the money to found "The Institution for the Care and Training of Nurses," at St. Thomas's Hospital, in London. And thus the first training-school for nurses was established in 1860. During the Civil War of this country Miss Clara Barton established the NURSING AS A PROFESSION FOR Society of the Red Cross, whose flag brought WOMEN.* By P. S. DONNELLAN, M.D., Lecturer on Physical Diagnosis, Medico-Chirurgical College; I PHILADELPHIA. THANK you for your kind attendance this evening, and congratulate you upon your entrance into what has come to be regarded as one of the noblest occupations of womankind. Before I proceed to the subject of my lecture, let me remind you that every woman has, at one time or another of her life, had charge of somebody else, whether a child or an invalid. In other words, every woman is a nurse. It is essentially a woman's occupation, because it calls forth the sweetest and noblest traits of * Opening address delivered at the Training-School for Nurses, Medico-Chirurgical Hospital, Philadelphia, November 17, 1894. peace and heaven-sent blessings to the poor fellows who fell wounded in their efforts to save the Union. But while sentiment gave birth to these humane impulses and developed heroines as well as heroes in war-time, hospital nursing in this country and in Europe was but little less than a disgrace to humanity. of "Martin Chuzzlewit," and been moved to Who has not read Charles Dickens's story tears at the treatment of the poor invalid by Sarah Gamp, who scolded the trembling patient, removed his pillows that her own sleep might be more comfortable, and took his nourishment, which she washed down with copious draughts of whisky from a black bottle, while complacent Betsy Prig looked on unconcerned! That this picture is not overdrawn, any one who has had experience | tinct liking for your calling, and not enter it of untrained nursing in hospital and private practice twenty years ago can testify. But the time had arrived, none too soon, when the old order of things must give way to the new, when the self-made nurses-the Sarah Gamps and Betsy Prigs-must yield to the intelligence, the education, and the training of women fitted for duties of the profession of nursing. Thanks to Florence Nightingale, the wave of reform spread rapidly from England to the continent of Europe, and reached this country, where, in 1872, the first training-school for nurses in America was established, at Bellevue Hos. pital, New York. Philadelphia was not slow to follow the good example, and inaugurated a number of training schools for nurses which are alike the pride and glory of a city ever celebrated for its philanthropy. The establishment of a training school for nurses at the Philadelphia Hospital, by the late Miss Alice Fisher, whose memory is to this day respected for the noble work she has accomplished, has been a positive blessing to the poor, and robbed hospital treatment of its terrors. In our institution it is particulary fitting that the good work should continue, and that it should be the pioneer in everything that can contribute to the scientific and humane care of those who are stricken by illness or injury. Trained nursing has become such a necessity to the rich and poor alike that one would no more think of taking a patient through a serious illness without a trained nurse than a captain of a ship would take his vessel through a dangerous channel without a pilot. It is rapidly becoming a profession for intelligent, well-bred, educated women who seek to be independent and have to earn their own living. It is not many years since the sphere of the average woman was to cook, wash, mend, darn and knit, to get married, and to raise a family. But a higher civilization and the asserted independence of the sex have opened up numerous occupations to women that were not dreamed of twenty years ago. Unquestionably, of all the pursuits open to women, nursing offers the greatest advantages, but, before adopting it as a profession, certain qualities are essential. In the first place you must have an aptness for nursing,-not that I mean that you must be "a born nurse"; every woman thinks she is; but you must have a dis solely as a means of livelihood. Do not imagine, because you hear of Miss Jones or Miss Smith making $500 a year as nurses and admire the fine clothes they wear, that by spending a few months at a training-school, at the end of which you receive your diploma and the congratulations of your friends, your golden era has begun. No; the weary vigils by the bedside of some poor patient and the unpleasant duties you will be called upon to perform will test to the utmost your devotion to your chosen calling. As Dr. Weir Mitchell said, in speaking of the medical profession, "you cannot weigh or measure what you have to give," and the gratitude and thanks of your patients will be your only reward in many cases. Having considered aptness for your work as an essential qualification, not less necessary is good health. It is part of your stock in trade, and you must have an abundance of it, because by their very nature your duties are exhausting to mind and body. Close attention to duty, loss of sleep, the exactions of the sick-room or ward are all powerful factors in undermining your health if you let them do so. But, having good health to start with, see that you preserve it by daily exercise, walks in the open air, the proper amount of sleep and recreation, and regular meals. To a nurse of a sensitive, emotional nature, nursing the sick is a depressing occupation, and to those who are so constituted it makes them morbid; so that there should be diversion of mind by occasional visits to concerts or other places of amusement. Essential to good health is personal neatness. A nurse who is careless or untidy about her appearance can never hope to succeed. She must pay particular attention to bathing, to her hair, her teeth and finger-nails, and, what is sometimes overlooked by the nurses, but noticed by patients, her digestion must be kept in perfect order. She must be free from any defect of mind or body; her sight and hearing must be good, her skin in perfect condition. A woman who has the misfortune to be an epileptic or to suffer from any chronic nervous disease should never attempt to become a nurse, because her infirmities are noticed and magnified by her patients. The same may be said of those who suffer from nasal catarrh, asthma, or such dis tressing affections as make their presence dis- | the first place, trifling as it may appear, a agreeable in the sick room. So that too much stress cannot be laid upon the possession of a sound mind in a sound body as an essential qualification for a trained nurse. A good common-school education is necessary. The better the general education, the better the groundwork for the necessary study. Cultivate the knowledge you possess and add to it, because it will save you from contraction of mind and keep you out of gossiping tendencies, which are so undesirable in your profession. Cultivate a kindly, cheerful disposition if you are not fortunately the possessor of one, because a nurse who is like a gleam of sunshine in the sick-room chases away the shadows and brightens the patient by her very presence. She must be watchful against any exhibition of temper or irritation, no matter what the provocation is, because it reacts upon the patient and adds to his discomfort. Patients are like children in their likes and dislikes, and a nurse who is ever gentle, winning, and kind will earn the gratitude and respect of those whom she waits upon. She must not mind doing a certain amount of menial work if necessary. Indeed, it has been truly said that absolute cleanliness is a most essential factor in a patient's recovery; so that housemaid's work is a most important part of a nurse's training. If I were asked what I would regard as the most essential qualification to make a good nurse, I would say absolute fidelity in the discharge of her duties. She must carry out the directions of the doctor to the very letter. If medicines are ordered at certain hours they must be given at the moment; if pulse, temperature, and respiration are to be taken, it must be done. If the nurse should forget,and this word "forget" should have no place in the lexicon of a nurse,-she should have the integrity to acknowledge it, and not to try and cover up her lapse of memory by a false record, because it is to the nurse that the physician looks to aid him in the battle against disease. They are both engaged in a sacred duty, and each one must contribute to its faithful performance. We physicians have ample proof that without integrity in nursing the most eminent professional skill is unavailing. My experience has taught me that there are minor points which are apt to be lost sight of, and which are essential to good nursing. In great deal of unnecessary suffering is caused to patients who are very ill by the lack of "petty management," as Florence Nightingale appropriately terms it. A well-trained nurse should never be in a hurry, because the patient is kept, by the bustle and confusion, in a state of nervous tension. Again, there is that disagreeable feature of unnecessary noise about the sickroom. The rustling of heavily starched garments, the moving of furniture, and the jingling of glasses and cups brought to the bedside on metallic trays sound like the rattle of muskets to a sensitive patient. Again, there is the lack of tact displayed in admitting strangers unannounced to the sick room, just at the time, perhaps, when the patient, worn out by a long siege of pain, has fallen into a sound sleep; delivery or non delivery of letters or messages is another source of annoyance to a patient who is tortured with anxiety at not receiving an expected letter, which may be reposing upon the nurse's table. Do not be the herald of bad news, which comes to sick and well alike with startling suddenness. Nothing distresses sick people so much as whispered conversation, whether carried on in the patient's room or in the adjoining corridor. They are naturally deeply interested in everything connected with their illness, and whispering on the part of the nurses or attendants in their hearing only serves to arouse their suspicions unnecessarily. "Never let a patient be surprised except by thieves" is a maxim which has come to us from Florence Nightingale. Apprehension, uncertainty, fear of surprise, expectation of something going to happen, all do a patient more injury than a week of sickness. Attention to these details of petty management is therefore desirable in good nursing. Having touched upon the more essential qualifications of a good nurse, let me point out to you your position with regard to the physicians with whom you come in contact. Your attitude toward them should be invariably characterized by deference and courtesy, avoiding the extremes of familiarity and servility. It is not my intention to lecture to you upon etiquette; your own knowledge of what is expected of every refined, well-bred woman will be your best guide in your conduct toward the physician. I will only give you one hint, which may be of value to you: Do not feel |