Full text of "Notes on nursing : what it is, and what it is not"

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NOTES 

O UR8ING : 

WHAT IT IS, AND WHAT IT IS NOT. 

BY 

FLORESICE IIGHTIGALE. 

LONDON: 
]XARRISON, 59, PALL MALL, 
BOOKSELLER TO THE QUEEN. 

[ Tle right of Translation is reserved.] 



PRINTED BY HARRISON AD SONS» 
ST. IARTIN'S LANE» W.C. 



PREFACE. 

TttE following notes are by no meaus intended as a rule of 
thought by wlùch nurses cun teuch themselves to nurse» still less 
as a munuul to teach nurses to nurse. They are meant simply to 
give hiuts for thought to vomea who Imvc personal clmrge of 
the health of others. Every woma% or at lcast almost every 
wolnan in Englaud Ims ut ont time or another of ber lire, 
churgc of the personal health of somebody, vhether child or 
invalidqin other words, every womaa is a nurse. Every day 
sanitary knowlelge, or the knowledge of nursing, or in other 
words, of how to 1)ut the constitution in such a statc as that 
it will bave no diseuse» or that it can recover from disease 
takes a higher place. It is recognized as the knowledge which 
every one ought to havedistinct from mcdical knowledge, 
which only a profession can hure. 

If then every woman must, at some tlme or other of her 
llfe, become a nurse, i.e., havc charge of somebody's health, 
howimmense and how valuable would be the produce of ber 
unlted experience if every woman would thluk how to nurse. 

I do not pretend to teach ber hov, I ask ber to teach ber- 
self, and for this purposc I venture to glve ber some hlnts. 



TABLE OF CONTENTS. 

Vv.r,to D Wrmo ............ 
Hv«,a OF llovss ............ 
PT IANAGEtEN ................ 
los. .................... 
VARIET .................... 
TAKING Food ................ 
Watt Foo ? .................... 
AND ]EDDIN« ............ 
Loz .................... 
CLEANLINESS OF IOOMS AND WA_I, LS ........ 
IER$ONAI, (LEANLINESS ................ 
HATTER1NG lïOPES AND ADVICES ........ 
0BSERVATIO OF THE tCK ............ 
APPENDIX .................... 

8 
.... 14 
0 
.... 36 
59 
... 71 



NOTES ON UISING: 

WHAT IT IS, AND WHAT IT IS :NOT. 

S,L we begin by taking if as  general principle--that all 
disease, af sonm period or other of its course, is more or less a 
repoErative process, hot necessari|y accompauied with suffering: an 
efibrt of nature to remedy a process of poisoaing or of decay, wh|ch has 
taken place weeks, months, sometimes years beforehand, unnoticed, 
the ter,nination of the disease being then, while the antecedent 
process was going on, determined P 
If we accept this as a general principle we shall be immediately 
met with anecdotes and instances fo prove the contrary. Just so if 
we were fo take, as a principle--all the climates of the earth are 
meant fo be ruade habitable for man, by the efforts of man--the 
objection would be im,nediately raised,--Vill the top of Mont Blanc 
ever be made habitable? Our answer would be, if will be nmny 
thousands of years before we bave reached the bottom of [ont Blanc 
in making the earth healthy. Wait ti|l we have reached the bottom 
before we discuss the top. 
In watching disease, both in private bouses and in public hos- 
pitals, the thing -hich strikes the experienced observer most torcibly 
is this, that the symptoms or the sufferi,gs generally considered to 
be inevitable and incident fo the disease are ver often not symptoms 
of the disease af al|, but of something quite dfferent--of the want 
of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, 
or of punctuality and coEre in the administration of diet, of each or 
of ail of these. And this quite as much in private as in hosloital 
nursing. 
The reparatlve process wh|ch Nature ]ans instituted and wh|ch we 
call disease has been hindered by some want of knowledge or atten- 
tion, in one or in all of these thiugs, and pain, suffering, or interrup- 
tion of the whole process sers in. 

Disease a 
reparative 
process. 

Of the surfer- 
ings of disease, 
disease hot 
always the 



( OTES O URSITG. 

What nursing 
ought to do. 

Nursing the 
sick little 
understood. 

Nursing ought 
to assist the 
reparative 
process. 

lgursing the 
well 

Little under- 
utood. 

If a patient is cold, if a patient is feverish, if a patient is faint, if 
he is sick after aking food, if he bas a bed-sore, it is generally the 
fattlt hOt of the disease, but of the nursing. 
I use the word nursing for vant of' a better. It bas been limited fo 
signitv littlc more than the administration of medicines and the 
application of pou|tices. It ought to signify the proper use of fresh 
air, light, -armth, clcanliuess, quiet, and the proper selection and 
ad,,inistration of aller--ail at the least expense of vital power to the 
patient. 
It h:s been said and written scores of rimes, that everv woman 
makes a good nurse. I believe, on the contrary, that ihe verv 
elements of nursing are all but unlnown. 
:By this I do hot lneaa that the nurse is always fo blame. ]]ad 
sanitarv, bad architectural, and bad administrative arrangements 
ot'te 'ake it impossible to nurse. Blt the art of nursing ought fo 
iclude such arrangelnents as alone make what :[ understand by 
nursbg, possible. 
The art of nursing, as now practised, seems fo be expressly 
constituted fo unmake what God had ruade disease to be, riz., a 
reparative process. 
To recur fo the first objection. If we are asked, Is such or 
such a disease a reparative process ? Can such an illness ho unac- 
companied with sufl'ering ? Will anv care prevent such a patient 
from suffering this or that ?--I hun;bly say, I do hOt know. But 
when ),ou have done away with all that pail and suffering, which in 
patients are the symptoms hot of their disease, but of the absence of 
one or all of the above-mentioned essentials to the success of 
:Nature's reparative processes, we shall then know what are the 
symptoms of and the sufferings inseparable from the disease. 
Another and the comnomst exclamation which will be instantly 
ruade isWould you do nothi,g, then, in cholera, lever, &c. ?so 
deep-rooted and universal is the conviction that fo give medicine is 
fo be doing something, or rather everything; to give air, warmth, 
cleanlimss, &c., is to do nothing. The reply is, that in these and 
many other similar diseases the exact wflue of particular remedies 
and modes of treatment is bv no means ascertained, while there is 
universal experience as to the'extreme importance of careful nursing 
in determining the issue of the disease. 
II. The very elements of what constitutes good nursing are as 
little understood ibr the wel[ as for the sick. The saine laws of 
health or of nursing, for they are in reality the sanie, obtain among 
thc well as among the sick. The breaking of them produces only a 
less violent consequence among the former than among the latter,-- 
and this sometimes, not alvays. 
It is constantly objected,--" :But how can I obtain this medical 
knovledge? I ara not a doctor. I must leave this fo doctors." 
Oh, mothers of familles! You who say this, do you know that 
one in ever)" seven inthnts in this civilized land of England perishes 
before if is one year old ? That, in London, two in every rive die 
beibre they are rive years old ? And, in the other great cities of 



NOTES ON NURSING. 

England, nearly one out of two ?* "The life duration of tender 
babies" (as some Saturn, turned analytical chemist, says) "is the 
most delicate test" of sanitarv conditions. Is all this premature 
suffering and death necessary . Or did ature intend mothers to 
be always accompanied by doctors ? Or is it better fo learn the 
piano-forte than to learn the laws which subserve the preservation of 
offspring ? 
]Iaeaulay somewhere says, that if is extraordinary that, whereas 
the laws of the motions of the heavenly bodies, far removed as 
taey are from us, are perfeetly well understood, the laws of the 
human mind, whieh are under out observation all day and every 
day, are no better understood than they were two thousand years ago. 
But how mueh more extraordinary is if that, whereas what we 
might eall the eoxeombries of edueation--e.g., the elements of astro- 
nony--are now taught fo every school-girl, neither lnothers of families 
of tny class, nor school-mistresses of any elass, nor nurses of ehildren, 
no nurses of hospitals, are taught anythiag about those laws whieh 
Got bas assigned fo the relations of out bodies with the world in 
vhieh He bas put them. In other words, the laws whieh make 
thee bodies, into whieh He has put out minds, healthy or un- 
hea]thy organs of those minds, are ail but unlearnt. :Not but that 
the,e laws--the laws of lifeare in a certain measure understood, 
but not even mothers think it worth their while to study them 
to s;udy how to give their children healthy existences. They call if 
medical or physiological knowledge, fit only for doctors. 
Another objection. 
We are constantly told,--" But the circumstances which govern 
our children's healths are beyond our control. What can we do 
witl winds ? There is the east wind. ][ost people can tell before 
they get up in the morning whether the wind is in the east." 

* Upon this fact the most wonderful deductions bave been strung. For a 
longtime an announcement something like the following bas been going the 
round of the papers :--" More than 25,000 children die eveD" year in London 
under 10 years of age ; therefore we want a Children's Hospital." This spring 
ther¢ was a prospectus issued, and divers other means taken to this eflct:-- 
"There is a great want of sanitary knowledge in women; therefore we want a 
Worren's Hospital." Iqow. both the above facts are too sadly true. But what is 
the deduction? The causes of the enormous child mortality are pelfectly well 
knon; they are chiefly want of cleanliness, want of ventilation, want of white- 
washing; in one word, defective hosehold hygiene. The remedies are just as 
well known: and among them is certainly hot the establishment of a Child's 
Hospital. This may be a want ; just as there may be a want of hospital room for 
adules. But the Registrar-General would certainly never think of giving us as 
a cause for the high rate of child mortality in (say) Liverpool that there was hot 
sufficient hospital room for children; nor would he urge upon us, as a remedy, to 
round a hospital for them. 
Again, women, and the best ,-omen, are wofully deficient in sanitary know- 
ledge; although if is to women that we must look, first and last, for ifs appli- 
cation, as far as household hygiene is concerned. But who would ever think of 
citing the institution of a Women's Hospital as the way fo cure this want ? 
We bave it, indeed, upon very high authority that there is some fear lest 
hospitals, as they bave been hitherto, may hot bave generally increaseds rather 
than diminished, the rate of mortality--especially of child mortatity. 

Curious deduc 
tions from an 
excessive 
death rate. 



8 lçOTES Ol IURSItG. 

To this one can answer with more certainty than fo the former 
objections. Who is if who knows when the wind is in the east ? 
Igot the Highland drover, certainly, exposed fo the east wind, but 
the young lady who is worn out with the want of exposure to fresh 
air, fo sunligllt, &c. Put the latter under as good sanitary circum- 
stances as the former, and she too will hot know when the wind is 
in the east. 

I. VENTILATION AND WAR:5IIIG. 

First rule of 
nursing, to 
keep the air 
within as pure 
as the air 
without. 

The very first canon of nursing, the first and the last thing up»n 
which a aurse's attention must be fixed, the first essential to the 
patient, without which all tle rest you can do for him is as nothing, 
with which l had ahnost s:tid you may leave all the rest alone, is ttis: 
0 KEEP TIIE AIR IIE BRE,kTHES AS PURE AS THE EXTERAL 
WITIIOUT CIIILLING IIIM. _'et what is so little attended to? N, en 
whcre t is thoug|t of st all. tbe most extraordinary misconceptions 
reigu about if. Even ia admitting air into the patient's roor or 
ward, few people ever thiik, where that air cornes t¥om. It nav 
corne from a corridor into x hich other wards are ventilated, from a all, 
always mmired, always full ot the fmnes of gas, dinner, of valious 
kinds of mustiness; from an underground kitchen, sink, washhcuse, 
water-closet, or even, as I myself bave had sorrowiul experience, kom 
open sewers loaded with filth; and with this the patient's roon or 
ward is aired, as if is calledpoisoned, if should rather be raid. 
Always air from the air without, and that, too, through taose 
windows, through which the air cornes freshest. From a cbsed 
court, especially if the ind do hot blow that way, air may cone as 
stagnant as any from a hall or corridor. 
Again, a thing I have often seen both in private bouses and insti- 
tutions. A room remains uninhabited; the tire place is care['ully 
fastened up with a board ; the windows are never opened ; pro]cably 
the shutters are kept always shut; perhaps some kind of sores are 
kept in the room ; no breath of fresh air can by possibility enter 
into that room, nor anv ray of suu. The air is as stagnant, musty, 
and corrupt as it can by possibility be ruade. It is quite ripe to 
breed small-pox, scarlet lever, diphtheria, or anything else you 
please.* 
Yet the mrsery, ward, or sick room adjoining will positively be 
aired (?) by having the door opened into that room. Or children will 
be pu$ into that room, without previous preparation, to sleep. 
A short time ago a man walked into a back-kitchen in Queen 

Why are unin-  The common idea as to uninhabited rooms is, that they may safely be left 
habited rooms with doors, windows, shutters, and chimney board, all closed--hermetically sealed 
if possible--to keep out the dust. it is said ; and that no harm will happen if the 
shut up  
room is but opened a short hour before the inmates are put in. I bave often been 
asked the question for uninhabited rooms--But when ought the windows to be 
opened ? The answer is--When ought they to be shut? 



VENTIL£I01 £D WARMIG. .Q 

square, and eut the throat of a poor consumptive creature, sitting bv 
the tire. The murderer did hot deny the act, but simply said, 
" It's all right." Of course he was mad. 
:But in our case, the extraordinary thing is that the victlm says, 
« It's ail right," and that we are not mad. Yet, although we "nose" 
the murderers, in the musty unaired unsunned room, the scarlet lever 
which is behind the door, or the fever and hospital gangrene which 
are stalking among the crowded beds of a hospital ward, we sa)', 
"It's ail right." 
With a proper supply of windows, and a proper supply of fuel 
in open tire places, fresh air is comparatively easy to secure when 
your patient or patients are in bed. Never be afraid of open windows 
then. People don't catch cold in bed. This is a popular fallacy. 
With proper bed-clothes and hot bottles, if necessary, you can 
alwavs keep a patient warm in bed, and well ventilate him at the 
same time. 
But a care]ess nurse, be her rank and education what it m,y, 
will stop up every crannv and keep a hot-bouse heat when ber 
patieat is in bed,--and, if'he is able to get up, leave him compara- 
tively unprotected. The time when people take cold (and there are 
manv ways of taking cold, besides a cold in the nose,) is when they 
first'get up after the two-fold exhaastion of dressing and of having 
had the skin relaxed by maay hours, perhaps days, in bed, aud there- 
by rendered more incapable of re-action. Then the saine tempera- 
ture which refreshes the patient in bed mav destroy the patient just 
risen. And common sense will point out tiret, while purity of air is 
essential, a temperature must be secured -hich shall hot chill the 
patient. Otherwise the best that can be expected will be a feverish 
re-action. 
To bave the air within as pure as the air without, it is hot 
necessary, as often appears to be thought, to nmke it as cold. 
In the afternoon again, without care, the patient whose vital 
powers bave then risen often finds the room as close and oppressive 
as he found i cold in the morning. Yet the nurse will be 
terrified, if a window is opened% 
I know an intelligent humane bouse surgeon who makes a 
practice of keeping the ward windows open. The physicians and 
surgeons invariably close them while going their rounds; and the 
house surgeon ver)- properly as invariably opens them whenever the 
doctors bave turned their backs. 
In a little book on nursing, published a short rime ago, we are 
told, that "with proper care it s very seldom that the windows 
cannot be opened for a few minutes twice in the day to adroit iesh 

Without chill. 

Open windows. 

* It is very desirable that the windows in a sick room should be such as 
that the patient shall, if he can more about, be able to open and shut them easily 
himself. In fact the sick room is very seldom kept aired if this îs not the case-- 
so very few people have any perception of what is a healthy atmosphcre for the 
sick. The sick man often says, "" This room where I spend 22 hom out of the 
24 is fresher than the other where I only spend 2. Because here I can manage 
the windows myself." ±knd is true. 



]0 OTES ON IUISIN('4. 

What klnd of 
warmth 
desirable. 

Bcdriims 
almost, univer- 
ally foul. 

An air-test of 
essential 
consequence. 

air from without." I should think hot; nor twice in tbe hour either. 
It onl, shows how little the sub]ect bas been considered. 
of all methods of keeping ptients warm the very worst certainly 
ls to depend for heat on the breath and bodies of the sick. I bave 
known a medical officer keep his ward windows hermetically closed, 
thus exposing the sick fo all the dangers of an iufected atmosphere, 
because he as afraid that, by admitting fresh air, the temperature 
of the ward would be too much loweed. This is a destructive 
fallacy. 
To attempt fo keep a ward warm at the expense of making the 
sick repeatedly breathe their own hot, humid, putrescing atmosphere 
is a certain way fo delay recovery or fo destroy lire. 
Do you ever go into the bed-rooms of any persons of any class, 
whether they contain one, two, or twenty people, whether they 
hold sick or well, af night, or before the windows are opened in 
the morning, and over find the air anything but unwholesomely 
close and ibul? And why should if be so? And of how 
much importance itis that it should hot be so? During sleep, 
the human body, even -hen in health, is far more injnred by the 
influence of foui air than when awake. Whv can't you keep the air 
all night, then, as pure as the air without in the rooms you sleep in ? 
But ibr this, you must bave sufilcient ourlet for the impure air you 
make vourselves to go out; sufllcient inlet for the pure air from 
withou't to corne in. You must bave open chimneys, open windows, 
or ventilators; no close curta[ns round your beds; no shutters or 
curtains fo your windows, none of the contrivances by which vou 
undermine your own health or destroy the chances of recovery of y'our 
sick." 

« Dr. Angus Smi(h's air test, if if could be made of simpler apldication , would 
be invaluahle to use in every sleeping and sick room. Just as without the use of 
a thermometer no nurse should ever put a patient into a bath, so should no nurse, 
or mother, or superintcndent be without the air test in any ward, nursery, or 
slceping-room. If the main ïunction of a nurse is fo maintai the air within the 
room as fresh as the air without, withont lowering the temperaturc, then she should 
always be provided with a thermometer which indicates the temperature, with 
an air test which indicates the organic matter of the air. But to be used, the 
latter must be ruade as simple a little instiument as the former, and both should 
be self-registering. The senses of nurses and mothers become so dulled to foul 
air that they are perfectly unconscious of what an atmo_phcre they bave let their 
children, patients, or charges, sleep in. But if the tell-tale air-test were fo exhibit 
in the morning, both to nurses and patients and to the superior officer going round, 
what he amosphere bas been during the night, I question if any 8reater security 
could be afforded against a recurrence of the misdcmeanour. 
And oh ; the crowded national school ! where so many children's epidemics 
bave their origin, what a talc its air-test would tell ! We should bave parents 
saying, and saying rightly, "I will not send my child to that school, the air-test 
stan,-Is at ' Horrid.'" And the dormitories of our great boardin" schools ! Scarlet 
lever would be no more ascribed fo contagion, but toits right cause, the air-test 
standing at '" Foui." 
We should hear no longer of '" l[ysterious Dispensations," and of "' Plague and 
Pestilence," being "in God's hand.," when, so far as we know, He has put them into 
out own. The little air-test would both b.etray the cause of these "mysterious 
pestilences," and call upon us to remedy it. 



VExNTILATI0T ATD WARIIxN'G. 11 

A careful nurse will keep a constant watch over her sick, 
especially weak, protracted, and collapsed cases, to guard against the 
effects of the loss of vital heat bv he patient himself. In certain 
diseased states much less heat is produced than in health ; and there 
is a constant tendency fo the decline and ultimate extinction of the 
vital powers by the call lnade npon them to sustain the heat of the 
body. Cases where this occurs should be watched with the greatest 
care from hour to hour, I had almost said from luinute fo minute. 
The feet and legs should be examined by the hand from time to time, 
and whenever a tendency fo chilling is discovered, hot bottles, hot 
bricks, or warm flannels, with some warm drink, should be ruade use 
of until the temperature is restored. The tire should be, if necessary, 
replenished. Patients are frequently lost in the latter stages of 
disease from want of attention to such simple prccautions. The 
nurse mav be trusting fo the patient's diet, or to his medicine, or to 
the occas]onal dose of stimulant which she is directed to give him, 
while the patient is all the while sinking from want of a little 
external warmth. Such cases hal)pen at all rimes, even during the 
height of summer. This fatal chill is most apt to occur towards 
early morning at the period of the lowest temperature of the twenty- 
four hours, and at the rime when the effect of the preceding day's 
diets is exhausted. 
Geuerally speaking, you may expect that weak patients will 
surfer cold lnuch more in the morning than in the evening. The 
vital powcrs are much lower. If they are feverish at night, with 
bur.ning hands and feet, they are almost sure tobe chilly and shi- 
vermg in the morning. But nurses are very fond of heating the foot- 
warmer at night, and of neglecting it in the lnorning, when they are 
busy. I should reverse the matter. 
All these things require comlnon sense and care. Yet perhaps 
in no one single thing is so litle comnmn sense shewn, in all ranks, 
as in nursing.  
The extraordinary confusion between cold and ventilation, in 
the minds of even well educated people, illustrates this. To 
make a room cold is by no means necessarily to ventilate it. :Nor 
is it at all necessary, in order fo ventilate a room, to chill it. 
Yet, if a nurse tinds a room close, she will let out the tire, thereby 
making it closer, or she ill open the door into a cold room, without 
a tire, or an open window in it, by way of improving the ventilation. 

When warmth 
must be most 
carefully 
looked to. 

Cold air hot 
ventilation, 
nor fresh air a 
method of 
chill. 

* With private sick, I think, but certainly with hospital sick, the nurse should 
never be satisfied as to the freshness of their atmosphere, unlss she can feel the 
air gently inoving over her face, whcn still. 
But itis often observed that nurses who make the greatest outcry against 
open windos are those who take the least pains to prevent dangerous draughs. 
The door of the patients' room or ward n«st sometimes stand ope to allow of 
persons passing in and out, or heavy ihings being carried in and out. Tbe careful 
nurse will kecp the door shut while she shuts thc windows, and then, and hot 
before, set the door open, so that a patient may hOt be left sitting up in bed, 
perhaps in a profuse perspimtion, directly in the draught between the open door 
and window. :Neither, of course, should a patient, while being washed or in any 
way exposed, remain in the draught of an open window or door. 



NOTES ON NURSING. 

Air from the 
outside. 
Open your 
windows, shut 
your doors. 

Smoke. 

Airing damp 
things in a 
patient'sroom. 

The safes$ atmosphere of all for a patient is a goocl tire and an open 
winclow, excepting in extremes of temperature. (¥et no nurse can 
ever be ruade to understand this.) To ventilate a small room with- 
out draughts of course requires more care than fo ventilate a 
large one. 
Another extraorclinary fallacy is the dreacl of nigh$ air. Vhat 
air can we breathe af night but night air ? The choice is between 
pure night air from without and foul night air from within. 
people prefer the latter. An unaccountable choice. What will 
they say if if is proved to be true that fullv one-half of all the disease 
we surfer from is occasioned by people sÏeeping with their windows 
shut ? An open window most nights h the year can never hurt any 
one. This is not to say that light is hot necessary for recovery. In 
great cities, night air is oftcn the best and purest air to be had in the 
twenty-four hours. I could better unclerstand lu towns shutting the 
windows during the day than during the night, for the sake of the 
sick. The absence of smoke, the quiet, all tend fo making night the 
best time tbr airing the patients. One of our highest medical 
authorities on Consumption and Climate bas tokl me that the air 
in London is never so good as afer ten o'clock at night. 
Always air your room, then, from the outside air, if possible. 
Windows are nmde fo open ; doors are lnade to shut--a truth which 
seems extremely difilcult of apprehension. I bave seen a careful 
nurse airing ber patient's room through the door, near to which were 
two gaslights, (each of which consumes as nmch air as eleven men), 
a kitchen, a corridor, the composition of the atmosphere in which 
consisted of gŒEs, paint, tbul air, never changed, full of effiuvia, includ- 
ing a current of sewer air from an ill-placed sink, ascending in a con- 
tinual streatn by a well-staircase, and discharging themselves con- 
stantly into the patient's room. The window of the said room, if 
opened, was ail that u as desirable fo air if. Every room must be 
aired from without--e,ery passage from without. :But the fewer 
passages there are in a hospital the better. 
It" we are to preserve the air within as pure as the air without, it 
is needless to say that the chimney must hot smoke, flrllnost ail 
smoky chimneys can be cured--from the bottom, hot from the top. 
Ot'ten it is only necessary to bave an inlet for air to supply the tire, 
wbich is feeding itselt; ibr wat of this, from ifs own chimney. On 
the other hand, almost ail chimneys can be ruade to smoke by a 
careless nurse, who lets the tire get low and then overwhelms it with 
coal; not, as we verily believe, in order to spare herselï trouble, (for 
very rare is unkindness to the sick), but ti-om hot thiuking what 
she is about. 
In laying down the principle that the first object of the nurse 
must be to keep the air breathed by ber patient as pure as the air 
without, it must hot be forgotten that everything in the room which 
can give off efltuvia, besides the patient, evaporates itself into his 
air. And it follows that there ought to be nothing in the room, 
excepting him, which can give off efi]uvia or moisture. Oat of all 
damp towels, &c., which become dry in the room, he damp, of 



VENTILATION AND W&]IMING. 13 

course, goes into the patient's air. Yet this "of course" seems as 
little thought of, as if it were an obsolete fiction. How very seldom 
you see a nurse who acknowledges by ber practice that nothing af 
all ought fo be aired in the patient's room, th»ot nothing af all 
ought fo be cooked ai the patient's tire! Indeed the arrangements 
often make this rule impossible to observe. 
If the nurse be a very careful one, she will, when the patient 
leaves his bed, but hot his room, open the sheets wide, and throw the 
bed clothes back, in order fo air his bed. And she will spread the 
wet towels or flannels carefully out upon a horse, in urder fo dry 
them. :Now either these bed-clothes and towcls are hot dried and 
aired, or they dry and air themselves into the patient's air. And 
whether the damp and effiuvia do him most harm in his air or in his 
bed, I leave fo you fo determine, for I cannot. 
Even in health people cannot repeatedly breathe air in which 
they live with impunity, on account of its becoming charged with 
unwholesome nmtter from the lungs and skin. In disease where 
everything given off from the body is highly noxious and dangerous, 
hot only must there be plenty of ventilation fo carry off the effiuvia, 
but everything which the patient passes must be instantly removed 
away, as being more noxious than even the emanations from the sick. 
Of the fatal effects of the effiuvia from the excreta if would seem 
unnecessary fo speak, were they hot so constantly neglected. Con- 
cealing the utensils behind the vallance fo the bed seems all the 
precaution which is thought necessary for safety in private nursing. 
Did you but think tbr one moment of the atmosphere under that 
bed, the saturation of the under side of the mattress xvith the warm 
evaporations, you would be startled and frightened too ! 
The use of any chamber utensil wit]wut a lid* should be utterly 
abolished, whether among sick or well. You can easily convince 
yourself of the necessity of this absolute rule, by taking one with a 

Effiuvia from 
excreta. 

Chamber uten- 
sils without 
lids. 

• But never, never should the possession of this indispensable lid confirm you Don't make 
in the abominable practice of letting the chamber utensil remain in a patient's yoursick-room 
room unemptied, except once in the 24 hours, i.e., when the bed is ruade. Yes, into a sewer. 
impossible as it may appear, I bave known the best and most attentive nurses 
guilty of this; aye, and bave known, too, a patient affiicted with severe diarrhoea 
for ten days, and the nurse (a very good one) hOt know of it. because the chamber 
utensil (ont with a lid) was emptied only once in the 24 hours, and that by the 
housemaid who came in and ruade the patient's bed every evening. As well 
might you bave a sewer under the room, or think that in a »ater closet the plug 
need be pulled up but once a day. Also take care that your lid, as well as your 
utensil, be always thoroughly rinsed. 
If a nurse declines to do these kinds of things for ber patient, "because it is 
hot ber business," I should say that nursing was hOt ber calling. I bave seen 
surgical " sisters," women whose hands were worth to them two or three guineas 
a-week, clown upon their knees scouring a room or but, because they thought it 
otherwise not tir for their patients fo go into. I ara far from wishing nurses to 
scour. It is a waste of power. But I do say that these women had the true 
nurse-calling--the good of their sick first, and second only the consideration 
hat it was their "place" to do--and that women vho wait for the housemaid to 
do this, or for the charwoman to do that, when their patients are suffering, have 
hot the aking of a nurse in them. 



14 

NOTIS ON IURSING. 

Abolish slop- 
pails. 

Fumigations 

lid, and examining the under side of that lid. If will be round 
always covered, whenever the utensil is net empty, by condensed 
offensive moisture. Where does that go, when there is no lid ? 
Earthenware, or if" there is auy wood, highly polished and 
varnished wood, are the only materiaIs fit ibr patients' utensils. The 
very lid of the old abolninable close-stool is cnough te breed a pesti- 
lence. If becomes saturated with offensive marrer, which scouring is 
only wanted te briug out. I prefer an earthenware lid as being always 
cleaner. ]ut there are various good new-fashioned arrangements. 
A slop-pail should never be brought into a sick room. If 
should be a rule invariable, rather more important in the private 
]muse than elsewhere, that the utensil should be carried directlv te 
the water-closet, emptied there, rinsed there, and brought bàck. 
There should alwavs be water and a cock in every water-closet for 
rinsing. ]ut ever if there is net. ¥ou must carry water there te rinse 
with. I have actually seen, in t]e private sick room, the utensils 
emptied into the foot-pan, and put back unrinsed under the bed. I 
can hardly say which is most abominable, whether te de this or te 
rinse the ntensil in the sick room. Iu the best hospitals if is new a 
rule that no slop-pail shall ever be brought into the wards, but that 
the ntensils shall be carried direct te be emptied and rinsed af the 
proper place. I would if were se in the private house. 
Let no one ever depcnd upon fumigations, "disinfectants," and 
the like, for purit)ing the air. The offensive thing, net ifs smell, 
must be removed. A celebrated medical lecturer began one day 
"Fumigations, gentlemen, are of essential importance. They make 
such an abominable smell that they compel you te open the window." 
I wish ail the disinfecting fluids invented made such an "abominable 
smell" that they forced you te admit ïresh air. That would be a 
useful invention. 

II.--ttEALTH OF ttOUSES. " 

Health of There are 
bouses. Five bouses :- 
points essen- 
tial. 

Health of 
carriages. 

rive essential points in securmg the health of 

1. Pure air. 
2. Pure water. 
8. Efficient drainage. 
4. Cleanliness. 
5. Light. 
« The health of carriages, especially close carriages, is net of suflïcient uni- 
versal importance te mention here, otherwise than cursorily. Children, who are 
always the most delicate test of sanitary conditions, generally cannot enter a close 
carriage without being sick--and very lucky for them that it is se. A close car- 
riage, with the horse-hair cushions and linings always saturated with organic 
matter, if te this be added the windows up, is one of the nost unhealthy of human 
receptacles, q?he idea of taking an airbg in it is something preposterous. Dr. 
çngus Smith bas shown that a crowded railway carriage, which goes at the rate 
of 80 toiles an heur, is as unwholeson¢ as the strong smell of a sewer, or as a 
back yard in one of the most unhealthy courts off one of the naost unhealthy 
stl'eets in hIanchester. 



HEALTH OF HOUSES. 15 

Without these, no house can be healthy. And if will be uahealthy 
just in proportioa as they are deficieat. 
1. To have pure air, your house must be so coastructed as that the 
outer atmosphere shall iind its way with ease to every corner of it. 
House architects hardly ever consider this. The object in building 
bouse is to obtain the largest interest for the money, hot to save 
doctors' bills to the tenants. But, if tenants should ever becone so 
wise as to refuse to occupy unhealthily constructed bouses, and if 
Insurance Companies should ever corne to understand their interest 
so thoroughly as fo pay a Sanitary Surveyor to look after the bouses 
where their clients lire, speculative architects would speedily be 
brought to their senses. As it is, they build what pays best. And 
there are always people foolish enough to take the bouses they build. 
And if in the course of tinm the families die off; as is so often the 
case, nobody ever thinks of bliming any but Providence * for the 
result. Ill-informed medical men aid in sustaining the delusion, by 
laying the blame on "current contagions." Badly constructed houses 
do for the healthy what badly constructed hospitals do for the sick. 
Once insure that the air in a house is stagnant, and sickness is 
certain to follow. 
2. Pure water is more generally introduced into bouses than it 
used to be, thanks to the exertions of the sanitary reformers. 
Within the last tbw years, a large part of London was in the daily 
habit of using water polluted by the drainage of its sewers and 
water closets. This bas happily been remedied. But, in many 
parts of the country, well water of a very impure kind is used tbr 
domestic purposes. And when epidemic diaease shows itselt; person 
using such water are almost sure to surfer. 
3. It woutd be curious to ascertain by inspection, ho many 
bouses in London are really well drained. Many people wou]d say, 
surely ail or most of them. But many people have no idea in what 
good drainage consists. They think that a sewer in the street, and 
a pipe leading to it ri-oto the bouse is good drainage. All the while 
the sewer mav. be nothing but a laboratory front which epidemic 
disease and ill health is being distilled into the house. 1No bouse 
with any untrapped drain pipe cÇmmunicating immediately with a 
sewer, whether it be from water closet, sink, or gully-grate, can ever 
be healtlay. An untrapped sink may af any rime spread lever 
or pyoemia among the inmates of a palace. 
ïhe ordinary oblong sink is an abomination. That great surface 
of stone, which is always left wet, is alwa)-s exhaling into the air. 
bave known whole bouses and hospitals smell of the sink. I bave 
met just as strong a stream of sewer air coming up the back 8tair- 
case of a grand London bouse ii»om the sink, as I bave ever met af 
* God lays down certain physical laws. Upon His carrying out such laws 
depends our responsibility (that much abused word), for how could we bave any 
responsibility for actions, the results of which we could hot foresee--which would 
be the case if the caxrying out of His laws were hot certain. Yet we seem to be 
continually expecting that He will work a rni-acle-i, e. break His own lawz 
expre»sly to rclieve us of responsibility. 

Pure air. 

Pure wate. 

Drainage. 

Sieks. 



l(J OTES O IURSYN. 

Cleanliness. 

Liht. 

Three common 
errors in 
managing the 
health of 
house 

Scutari; and I have seen the rooms in that bouse a.ll ventilated by 
the open doors, and the passages all unventilated by the closed 
windows, in order that as much of the sewer air as possible might 
be conducted into and retained in the bed-rooms. It is wonderful. 
Anothcr great evil i bouse construction is carrying drains 
underneath the bouse. Such drains are never sale. Ail bouse 
drains should begin and end outside the walls. :Mauy people will 
readily admit, as a theory, the importance of these things. But how 
few are tbere who can intelligently trace disease in their households 
fo such causes ! Is if hot a thct, that when scarlet fever, measles, or 
small-p.ox appear among the children, the very first thought which 
occurs lS, "where" the children can have " caught" the disease ? 
And the parents immediately run over in their minds a]l the familles 
with whom they may bave been. Tbey never think of looking at 
home for the source of the mischief. If a neghbour's child is seized 
vith small pox, the first question which occurs is vhether if had 
becn vaccinated. :No one would undervalue vaccination; but it 
becomcs of doubtful bcnefit fo society when if leads people to look 
abroad ibr the source of evils which exist at home. 
4,. Without c]eafliness, withiu and without your bouse, ventila- 
tion s comparatively useless. In certain foul districts of London, 
poor people used to object fo open their windows and doors because 
of the foul smells tha cme in. Rich people like fo have their 
stables and dunghill near their houses. ]3ut does if ever occur to 
them that with many arrangements of this kind if would be saler 
to keep the windows shut than open ? You cannot bave the air 
of the house pure with dung heaps under the windows. These are 
common all over London. And yet people are surprised tbat their 
children, brought up in large " well-aired" nurseries and bed-rooms 
surfer from children's epidemcs. If they studied :Nature's laws in 
the matter of cbildren's health, they would hot be so surprised. 
There are other wavs of having filth inside a bouse besides having 
dirt in heaps. Old p,pered -alls of years' standing, dirty carpets, 
uncleansed thrniture, are just as ready sources of impurity to the air 
as if there were a dung-heap in the basement. People are so unac- 
customed from education and habits to consider how to make a home 
healthy, that tbey either never think of it af ail, and take every 
disease as a matter of course, fo be "resigned fo" when if comes 
" as from the hand of Providence ;" or if they ever cntertain the 
idea of preserving the health of their household as a duty, they are 
ver), apt to commit all kinds of "negligences and ignorances" in 
perfonning it. 
5. A dark house is always an unhealthy bouse, always an ill-aired 
bouse, always a dirty bouse. Want of light stops growth, and pro- 
motes scrofitla, rickets, &c., among the cl,ildren. 
People lose their health in a dark houle, and if they get il] they 
cannot get well again in it. :More will be said about this ihrther on. 
Three out of many "negligences and ignoraces" in managing the 
health of bouses generally, 1 will here mention as specimensl. That 
the fema]e head in charge of any building does hot think it necessary to 



IEALT[ OF ]OUSES. i? 

visit every hole and corner of it every day. How can she expect those 
who are under ber to be more careful to maintain ber ]muse in a 
healthy condition than she vho is in charge of if ?--2. That if is no 
considered essential to air, fo sun, aud to clean rooms vhile unin- 
habitcd; which is simply ignoring the first elementarv notion of 
sanitary things, and laying the ground ready for ail kinds of 
diseases.--3. Tha the vindow, and one window, is considered 
enough fo air a room. Have you never observed that any room 
withou a tire-place is always close ? A n d, if you bave a tire-place, 
vould you cram it up hot only with a chimney-board, but perhaps 
vith a great wisp of brown paper, in the throat of the chimney 
fo prevent the soot i¥om coming down, you say ? If vour chimney 
i ibul, sveep it ; but don't expect that you can ever air a room with 
only one aperture; don't suppose that to shut u I) a room is the way 
to keep if clean. If is the best way to foul the room and all that is 
in if. Don't imagine that if you, who are in charge, don't look fo 
ail these things yourself, those under you will be more careful tha 
vou are. It appears as ifthe part of a mistrcss nov is to complain 
f her servants, and to accept their excuses--hOt fo show them how 
there need be neither complaints marie nor excuses. 
:But again, to look fo ail these things yourself does not mean to 
do them yourself. "I ahvavs open the windows," the head in 
charge often says. If you d'o it, if is by so much the better, cer- 
tainly, than if it were hot donc at all. :Bnt can you hot insure that 
it is donc when hot donc by yourself? Caa you insure that it is 
not undone when your back is turned? This is vhat being "in 
charge" means. And a very important meaning if is, too. The 
former only implies that just what you can do vith your own banals 
is doue. The latter that what ought to be donc is ahvays donc. 
And now, you think these things trifles, or af least exaggerated. 
:But what you "think" or what I "think" matters little. Let us 
sec what God thinks of them. God alwavs justifies I-Ils ways. things so 
While we are thinking, I-Ie bas been teaching. I have known seriously 
cases of hospital pyœemia quite as severe in handsome private bouses 
as in any of the worst hospitals, and from the saine cause, riz., foul air. 
Xet nobody learnt the lesson. Nobody learnt anpt]tiny a all from 
it. They went on t]tinlciy--thinking that the sufferer had scratched 
his thumb, or that if was singular that "all the servants" had 
"whitlows," or that something was "much about this year; there 
is always siclness in our house." This is a ihvourite mode of 
thongbt--leading wt fo inquire what is the uniform cause of these 
general « whitlows," but fo stifle all inquiry. In what sense is 
"sickness" being " always there," a justification of its being "there" 
af all ? 
I will tell you what was the cause of this hospital pyoemia being 
in that large private bouse. If was that the sewer air from an ill- 
placed sink was careftd]y conducted into all the rooms by sedulously 
opening aH the doors; and closing all the passage windows. It was 
that the slops were emptied into the foot pans ;--if was that the 
tensils were never properly rinsed;--it -as that the chamber 

Hcad in chargc 
must sec fo 
House Hy- 
giene, hot da 
it hcrself. 

ttow does He 
carry out His 
laws ? 

Does Goal 
think of these 



I OTES O UIISIhG. 

How does 
teach 
laws? 

Physical dege- 
neration in 
families. Its 
causes. 

Scrvant' 
rooms. 

crockery was rinsed wifh dirty wter;--it was thar the beds were 
never properly shaken, aired, pieked fo pieces, or ehnnged. If was 
that the earpets and curtains were always musty ;--it was that the 
furniture was always dusty ; if was that the papered walls were satu- 
rated with dirf ;--if was that the floors were never eleaned ;--if was 
that the uuinhabited rooms were never sunned, or eleaned, or aired ; 
--if was that the eupboards were always reservoirs of foul air 
was that the xvindows xvere always tight shuf up at night ;--if was 
that no window was evcr systematieally opened, even in the day, or 
that the right window was hOt opened. A person gasping for air 
might open  window for himself. But the servants were hot taughf 
to open the windows, fo shut the doors ; or fhey opened the windows 
upon a dank w«.ll bctween high walls, no upon the altier eourf; 
or fhey opcned the room doors into the unaired halls and passages, 
by way of airing the rooms. :Now all this is hOt iancy, but faef. 
In thaf handsome house I have known in one summer three 
cases of hospital pyœemia, che of phlebitis, two of consumptive 
cougb : M1 the immedia[e products of foul air. AVhen, in temperate 
climates, a house is more unhealthy in summer than in winter, if 
is a certain sign of somethlng wrong. Yef nobodv learns the lesson. 
Yes, God alwavs justifies His ways. He is teahing while vou are 
hot learning. his poor body loses his tlnger, thaf one Ioses is lire. 
And all from the most easily preventible causes.* 
The houses of the grandmothers and great grandmothers of this 
generation, af leasf the country bouses, with iront door and back 
door always standing open, vinter and summer, and a thorough 
draught always blowing through--with all the scrubbing, and clean-- 
ing, and polishing, and scouring which used fo go on, the grand- 
mothers, and still more the great grandmothers, alwavs out of doors 
and never with a bonnet on excepf fo go fo churc'h, these things 
entirely accourir for the facf so often seen of a g-reaf grandmother, 
who was a tower of physical vigour descending into a grandmother 
perhaps a little less vigorous but still soimd as a bell and healfhv 
fo the core, into  mother languid and confmed fo ber carriage anal 
bouse, aud lastly into a daughter sickly and confined fo her bed. 
:For, remember, even with a general decrease of mortality you may 
offert find a race thus degenerating and still oftener a family. You 
mav see poor ]ittle feeble washed-out rags, children of a noble stock, 
sufring morally and physically, throughout their useless, degenerate 
* I must say a word about scrvants' bed-rooms. From the way they are built, 
but oftener from the way thcy are kept, and from no intelligent inspection what- 
ever being execised over them, they are almost invariably dens of foul air, and the 
"' servants' health" suffers in an "unaccountable" (.) way, even in the country. 
For I am by no means speaking only of London houses, where too often servants 
are put fo lire under the ground and over the roof. But in a country "mansiob'" 
which was really a "mansion," (hot after the fashion of advertisements), I have 
known tllree maids who slept in the saine room ill of scarlet fever. " How catching 
if is," was of course the rcmark. One look af the room, one smell of the room, was 
quite enough. If was no longer "unaccountable." The room was hot a small 
one ; it was up stairs, and if had two large windows--but nearly every one of the 
neglects emunerated above was thcre. 



XLT or ovss. 19 

lires, and yet people who are golng to marry and to bring more such 
into the world, will consult nothing but their own convenience as to 
where they are to lire, or how they are to lire. 
1Vith regard to the health of bouses 'here there is a sick person, Don't make 
it offert happens that the sick room is ruade a ventilating shaft for the your sick- 
rest of the house. For while the house is kept as close, unaired, room into a 
ventilating 
and dirty as usual, the window of the sick room is kept a little open shaft for the 
always, and the door occasionally. :Now, there are certain sacrifices whole house. 
'hich a bouse with one sick person in it does make fo that sick 
person: itries up ifs knocker; it lays straw before it iu the street. 
Vhy can't it keep itself thoroughly clean and unusuallv well aired, 
in deference to the sick person ? 
We must hot ibrget what, in ordinary language, is called Infection. 
" Infection ;" v--a thing of which people are generally so ai'raid that 
thev frequently follow the very practice in regard to it which they 
ouht to avoid, lothing used to be considered so infectious or 
coutagious as small pox; and people hot very long ago used to cover 
up patients with heavy bed clothes, while they kept up lar,ge rires 
and shat the windows. Small pox, of course, under this regime, is 
very "iufectious." leople are somewhat wiser now in their manage- 
ment of this disease. They have venttred to cover the patients 
lightly aud fo keep the windows opeu; and we hear much less of 
the " infection" of small pox than we used to do. But do peop]e 
in our days act with more wisdom on the subjec of" infection" in 
fevers--scarlet fever, measles, &c.--than their forefatheru did with 
small pox ? ]3oes hot the popular idea of "infection" involve that 
people should take greater care of themselves than of the parieur ? 
that, for insta.nce, it is saler hot to be too much with the patient, 
hot to attend too much fo his wants ? lerhaps the best illustration 
of the urger absurdity ofthis view of duty in attending on "infectious" 
diseases is afforded by what was very recently the practice, if it is 
v Is it hot living in  continual mistake to look upon diseases, as we do noir, Diseases are 
as separate entities, vhich must exist, like cats and dogs ? instead of looking upon hot individuals 
thcm as conditions, like a dirty and a clcan condition, and just as much under armnged in 
our oa control ; or mther as ihe reactions of kindly nature, against the condi- classes, like 
tions in 'hich we have placed ourselves, cats and dogs, 
I was brought up, both by scientific men and ignorant -omen, distinctly fo but conditions 
bclieve that small-pox, for instance, vas a thing of which there was once a first growing out of 
specimen in the world, which went on propagating itself, in a perpetual chain of ont another. 
descent, just as much as that there 'as a fit dog, (or a first pair of dogs), and 
that small-pox would hot begin itself any more than u new dog would begin 
without there lmving been a parant dog. 
Since then I bave seen with my eyes and smclt with my nose small-pox grow- 
ing up in tiret specimens, either in close rooms or in overcrowded wards, where 
it could hot by any possibility have been "caught," but must have begun. 
l-oEv, more, I have seen diseases begin, grow up, aud pass into one another. 
ow. dogs do hot pass into cats. 
I have seen. for instance, 'ith a little overcrowding, continued fever gv up ; 
and with a little more, typhoid ïever; and with a little more, typhus, and ail in 
the saine val'd or hut. 
Would it hot be far better, truer, and more pmctical, if we looked upon 
disease in this light ? 
'or diseases, as all experience shows, are adjectivcs, hOt noun substantivcs. 
c2 



Why nmst 
children hure 
measles, &c. ? 

hOt so even now, in some of the :European lazarets--ln whlch the 
plague-patient used to be condemned to the horrors of filth, over- 
crowding, and want of ventilation, while the medical attendaut was 
ordered to examine the patient's fougue through an opera-glass and 
fo toss him a lancer to open his abscesses with ! 
True nursing ignores iufection, except fo prevent if. Cleanliness 
and fresh air from open windows, with uuremitting attention fo the 
patient, are the only defence a true nurse either asks or needs. 
]Vise and humane management of the patient is the best safe- 
guard against infection. 
Thcre are hot a few popular opinions, in regard fo which if is 
usehfi af rimes fo ask a question or two. For example, if is com- 
monlv thought that children must bave what are commonly called 
"chidren's epidemics," "currcnt contagions," &c., in other words, 
that they are born to bave measles, hooping-congh, perhaps eçen 
scarlet lever, just as they are born to cut their teeth, if they lire. 
Now, do tell us, why must a child bave measles ? 
Oh because, you say, we cannot leep it from infection--other 
childrcn have measles--and if must takc thcm---and it is saler that 
if slmuld. 
But why must othcr children have measlcs ? And if they ]mve, 
whv must vours bave them too ? 
• :If you elieved in aud observed the laws for preservlng tbe health 
of houses which inculcate cleanliness, ventilation, wbite-washing, and 
other means, and which, by the çay, are laws, as implicitly as vou 
believe in the popular opinion, for if is nothing more than an opinion, 
that your child must bave children's cpidemics, don't you think that 
u»on the whole your child would be more likely to escape altogether? 

Petty 
munagcment, 

III. PETTY I]:ANAGESIENT. 

AI1 the results of good nursing, as detailed in these notes, may 
be spoiled or utterly negatived bv oue defect, riz. : in pettv manae- 
ment. or, in other words, by hot "knowing how to manage "that 
vou do when you are there, shall be doue when you are hot there. 
rhe most devoted friend or nurse cannot be always there. 
desirable that she should. And she may gi-e up her health, all her 
other duties, and yet, for waut of a little management, be hot one-half 
so ecient as another who is hot one-half so devoted, but who bas 
this art of multiplying herselftbat is fo say, the patient of the 
first will not really be so well cared for, as the patient of the second. 
It is as impossible in a book to teach a person in charge of sick 
how fo aage, as if is fo teach her how fo nurse. Circumsta.nces 
must vary with each different case. :But if is possible fo press uport 
ber to think for herself: Now what does happen dtring my absence? 
I ara obliged to be a.way on Tuesday. :But fresh air, or punctualitv 
is hot less important to my patient on Tuesday than iV was oh 



:Ionday. Or : Af 10 ,.r. I am never wih my patient ; but quiet is 
of no less consequence fo him af 10 than if was af 5 minutes to 10. 
Curious as if may seem, this very obvious consideration occurs 
¢omparatively fo few, or, if if does occur, if is only to cause the 
devoted friend or nurse fo be absent fewer hours or fewer minutes 
from her patient--hOt fo arrange so as that no minute and no hour 
shall be for her patient without the essentials of her nursing. 
A very few instances will be suttlcient, hot as precepts, but as 
illustrations. 
A strange washerwoman, comlng late a.t night for the "things," 
vill burst in by mistake fo the patient's sîck-room, after he has 
fallen into his first doze, giving him a shock, the effects of which are 
irremediable, though he himself laughs af the cause, and probably 
never even mentions if. The nnrse ho is, and is quite right fo be, 
af ber supper, has not provided that the washerwoman shall hot lose 
hcr  ay and go into the wrong room. 
The patient's room mav always have the window open. ]3ut the Sick room 
passage outside the patients room, though provided with several large aring the 
vindows, may never bave one open. Because if is hOt understood whole bouse. 
that the charge of the sick-room extends to the charge of the passage. 
_And thus, as often happens, the nurse makes if ber business fo turn 
the patient's room into a ventilating shatb for the foul air of the 
vhole bouse. 
An uninhabited room, a newlv painted room,* an uncleaned Uninhabited 
eloset or cupboard, may often beconîe a reservoir of foul air for the room fouling 
n-hole bouse, because the person in charge never thinks of arranging the whole 
- bouse. 
that these places shall be alwavs aired, alwavs cleaned; she merely 
vpens the window herself "vhén she goes in." 
An agitating letter or message may be delivered, or an important Delivery and 
non-deliverv 
letter or message wt delivered ; a visitor whom it was of consequence 
of letters ad 
to see, may be refused, or one vhom if was of still more consequence messages. 
vwt to see may be admitted--because tho person in charge bas never 
asked herself this question, Vhat is done when I m hot there ? f 
Af all events, one may safely say, a nurse cannot be with the 
« That excellcnt paper, the Builder, mentions the lingering if the smell of 
paint for a month about a bouse as a proof of want of ventilation. Cer«inly-- 
and. vhere there are amplc 'indows to open, and these are never opened to get 
rid of the smell of paint, i is a proof of want of management in using the means 
of ventilation. Of course the smell will then remain for months. Why should it go ? 
•  Vhy should you let your patient ever be surprised, except by thieves? i do Why let your 
hot know. In England, people do not corne down the chimney, or through the patient ever 
windo', unless they are thieves. They corne in by the door, and somcbody must be surpriscd 
open the door to them. The '" somebody" charged with opening the door is one of 
two, three, or at most four persons, lVhy cannot these, at most, four persons be 
lu in charge as to what is to be done whcn there is a ring at the door bell? 
The sentry at a post is changed much oftener than any servant at a private 
bouse or institution can possibly be. But what should we think of such an excuse 
as this : that the enemy had entered such a post because A and not B had been 
on guard. Yet I bave eonstantly heard such an excuse ruade in the private 
bouse or institution and accepted: riz., that such a person had been "let in" or 
ot "' let in," and such a parcel had been wrongly delivered or lost because A 
and not B had opened the door ! 

Illustrations ot 
the want of it. 
Strangers 
coming into 
the sick room. 

Lingering 
smell of paint 
a want of care. 



22 

OTES O NUltSING. 

Partial mca- 
surcs such as 
"' bcing always 
in thc way" 
yoursclf, in- 
crcasc instcad 
of saving thc paticnt's 
anxic T. Bc- 
cause they 
must bc only 
partial. 

What is thc 
cause of half 
thc accidents 
which 
happen ? 

patient, open the door, eat ber meals, take a message, all af one and 
the saine rime. Nevertheless the person in charge never seems fo 
look the impossibility in the ikce. 
Add fo this that the atte»lting this impossibility does more fo 
increase the poor Patient's hurry and nervousness thaa anything else. 
It is nevcr thought that the pttient remcmbers thesc things if 
you do uot. He has not only to think whcther the visit or letter 
may arrive, but uhcthcr you will be in the way af the particular day 
and hour when if nmy arrive. So that your partial measures for 
'" being in the way" yourself, only increase the necessity for his 
thoght. Whereas, if you could but arrange that thc thig shouid 
always be donc whcther you are there or hot, he nced never think 
at al! about it. 
]?or the bove reasons, whatever a patient ca do for hilnself, if 
is better, i.e. lcss anxiety, ibr hiln to do for h[mself, unless the 
person in charge has the spirit of managelnent. 
it is evidently much less exertion tbr a patient fo arlswer a letter 
for hlmself by return of post, than to have tbur conversations, wait 
rive days, havc six anxieties before it is off his mind, before th 
person who is fo answer it has done so. 
Apprehension, unccrtainty, waitiug, expectation, fear of surprise, 
do a patient more harm than any exertion. Remember, he is face 
to face with his enemy all the time, internally wrestling with him, 
having long ilnagimry couversations vith hiln. ¥ou are thinking of 
something else. ":Rid him of his adversary quickly," is a 'st rule 
'ith the sick. : 
:For the saine rcasons, always tell a patient and tell him before- 
hand when you arc going out and when vou will be back, whether it 
is for a day, an hour, or ten minutes. ou ihncy perhaps that if is 
better for him if he does hot fiud out your going af ail, better for 
him if you do hot make yotrself" of too nmch importance" to him; 
or else you iinnot bear t.o give him the pain or the anxiety of the 
temporary separation. 
N'o such thig. ¥ou o«g£t to go, we will suppose. Health or duty 
requires if. Then say so to the 1)atient openly. If you go vithout his 
lnowing if, and he finds it out, he never will feel secure again that 
the things which depend upon you will be done when you are away, 
raid in nine cases out often he will be right. Ifyou go out without 
telling hin when you will be back, he eau take no mcasures nor 
precauions as to the things which concern you both, or which you 
do for him. 
If you look into the reports of trials or accidents, ,and especially 
of suicides, or into the medical history of tatal cases, if is ahnost 
incredible how often the whole thing turns upon something wh:ch 

« Thcre are many physical opcrations whcrc coeteris paribus thc danger is in 
a dircct ratio to the rime thc operation lasts; and coeteris pari5us thc operator's 
success will be in direct ratio fo his quickness, low flmrc arc many mental opc- 
rations wherc cxactly the saine rule holds good with thc sick ; coeteris paribu. 
thcir capability of bearing such operatious depends dircctly on thc quickncss 
without hurry, with which fley can bc got through. 



bas happened because "he," or still oftener "she," "was hot there." 
But i is still more incredible how often, how almost alwçs this is 
accepted as a sufficient reason, a justification; why, the very fac of 
the thing having happened is the proof of it.s hot being a justification. 
The person in charge was quite righ hot tobe "t]wre," he -as called 
away for quite sufficient reason, or he was away for a daily recurring 
and unavoidable cause: yct no provisioa was made to supply his 
absence. The faul vas hot in his "being away," but in there being 
no management to supple,_nent his " being away." When the sun is 
under a total eclipse or during his nightly absence, u-e ligh c,ndles. 
But it would seem as if i did no occm' to us that -e must also 
SUpl)lement the person in charge of sick or of children, whether 
under an occasional eclipse or during a regular absence. 
In institutions where nmny lires would be lost and the effec 
of such vant of management  ould be terrible and patent, thcre is 
less of it than in the private house.  

* So truc is this that I could mention two cases of women of vcry high posi- 
tion, both of whom died in thc mme way of thc consequences of a surgical 
operation. And in both cases. I was told by the highest authority that the/htal 
result would hot have happencd in a London hospital. 
But, as far as regards the art of pctty management in hospitals, all thc mili- 
tary hospitals I know must be excluded. Upon my own experience I stand, and 
I solemnly declarc that I have seen or knon of £ttal accidents, such as suicides 
in delirium tre»wns, bleedings to death, dying patients dragged out of bed by 
drunken ]Iedical Staff Corps men, and many other thingsless patent and striking, 
vhich would hot bave happened in London civil hospitals nurscd by women. The 
medical officers should be absolved from all blame in these accidents. How can 
 medical officer mourir guard all day md ail xight over  patient (say) in deli- 
ri.tm trees ? The fault lies in there being no organized system of attendance. 
Werc a trustworthy »tan in charge of each ward, or set of wards, hot as office 
clerk, but as head nurse, (aad head nurse the best hospital seeant, or ward mas- 
ter, is hot now and cannot be, from dcfault of the propcr regulations), the thin 
would hot, in all probability, havc happened. But were a trustworthy woman in 
charge of the ward, or set of wards, the thing would hot, in all certaint.y, have 
happened, lu other words, it does hot happen whcre a trustworthy woman is 
really in charge. And, in these remarks, I by no means rcfcr only to exceptional 
times of great emergency in war hospitals, but also, and quite as ranch, to the 
ordimry run of military hospitals ai home, in time of peace ; or to a rime in war 
when our mmy was actually more healthy than ai home in peace, and thc pres- 
sure on our hospitals consequently ranch less. 
It is often sid that, in regimental hospitals, patients ought fo "nurse each 
other," because the number of sick altogether being, say, but thirty, and out 
of these one only perhaps being seriously ill, and the other twenty-nine having 
littIe the matter vith them, and nothing to do, thcy should be set to nurse the 
one ; also, that soldiers are so trained to obcy, that they will be the most 
obedient, and thcrefore the best of nurses, add to which they are always kind to 
their comrades. 
iow, have those who say this, considered that, in ordcr to obey, you must 
know ltow to obey, and that these soldiers certainly do hot know how to obey in 
nursing. I have seen these "kind" fellows [and how kind they a-e no one 
kuows so well as myself) mo'e a comrade so that, in one case at least, the man 
died in the act. I bave seen the comrades' "kindness" produce abundance of 
spirits, to be druuk in secret. Let no one understand by this that fcmale nurses 
ought to, or could be introduced in regimental hospitals. It would be most 
nudesirable, even wcre it hot impossible. But the head nurseship of a hospital 

Petty manage- 
ment better 
understood in 
istitutions 
than in private 
houses. 
What institu- 
tions are the 
exception ! 

Nursing in 
Regimental 
Hospitals. 



2 IOTES ON 

WhaL if is to 
be ' iii 
charge." 

But in both, let whoever is in charge keep th]s simple question in 
hcr hcad (hot, how can I always do this right thing myself, but) how 
can I provide for this right thing to be alwavs donc ? 
Then, vhen anything rong bas actually'happened in consequence 
o hcr absence, vhich absence we will suppose fo lmve been quite 
right, let her question still be (hot, how can I provide against anr 
more of such abseces ? which is neithcr possible nor desiroEble, bu) 
how cau I provide against any thing wrong arising out of lny 
absence ? 
l[ow few men, or even women, understand, either in great or in 
little things, what if is the being " in charge "--I mean, know how to 
carry out a "charge." From the lnost colossal calamities, down to the 
most trifling accidents, results are oten traced (or rather hot troEced) 
to such want of some oe "in clmrge" or of his knowing how to be 
"in charge." A short time ago the bursting of a fimnel-casing oa 
board the finest and stronges ship that ever was buil, on her trial 
trip, destroyed several lires ald put several hundreds in jeopoErdy-- 
hot from any uudetected flaw in her new and untried works--but 
ff'oto a al) being closed which ought hot to have been closed from 
hat cvcry child knows would make ifs mother's teoE-kettle burst. 
And this siml)ly because no one seemed to know what if is to be "i 
charge," or wlo was in charge. Nay more, the jury at the inquest 
actually altogether ignored the saine, and apparently considered the 
tap "in charge," for thcy gave as a verdict " accident death." 
This is the meaning of the word, on a large scale. On a much 
snmller scale, if hoEppencd, a shor rime ago, that an insane persou 
burnt herself slowly and inteutionally to death, while in ber doctor's 
charge and almost in her nurse's presence. Yet neither woEs consi- 
dered "af all to blame." The very ihct of the accident halpening 
proves its own case. There is nothing more fo be said. Either 
thev did not know their business or they did not know how to 
1)erbrm if. 
OEo be "in charge " is certainly hot only fo coErry out the proper 
measm-es yonrself buç o sec that every one else does so too ; to sec 
that no one either wilful]y or ignorantly hwarts or prevents such 
measures. If is neither fo do everything yourself nor fo appoint a 
number of people o each duty, but fo ensure thoEt each does that 
d,aty fo -hich he is appointed. This is the lneaning hich must be 
attached to the word by (above ail) those" in charge" of sick, whether 
of numbers or of individua|s, (and indeed I think it is 'ith individual 
sick that it is least understood. One sick person is often waiîed 
ou by ibur with less precision, and is really less cared for than ten 
who are -aited on by one; or af ]east than 40 who are waited o1 
by ; and all for want of this one person" in charge.)" 

seleant is the more essential, the more important, Ihe more inexperienced the 
nurses. Undoubtedly, a London hospital '" sister" does sometimes set relays of 
patients to watch a critical case ; but, undoubted]y a]so, always under ber own 
superintendence; and she is called fo whenever there is something to be donc, 
and she knows how to do it. The patients are not ]eft to do it of thcir own 
unassised genius, however "kind" and willing they may be. 



IOISF, o ri5 

If is often said that tlaere are tbw good servants now : I say there 
are Ib, w good mistresses now. As the jury seems to have though 
the tap was in charge of the ship's safety, so mistresses now seem 
to think the bouse, is in charge of itself. They neither know how fo 
give orders, nor how fo teach their smwants to obey orders--i, e. fo 
obey intelligently, which is the re, al meaning of all discipline. 
Agail people who are in charge often seem fo have  pride in feel- 
ing that they will be "missed," that no one, can mderstand or carry 
on their arrmlgements, their system, books, accounts, &c., but them- 
elves. If seems fo me, that tlm pride is rather in carrying ou a 
systeln, in keeping stores, closets, books, accounts, &c., so that anv 
bodv can understand and carry them on--so that, in case of absenc'e 
or illlmss, one can deliver every thing up fo others and know that ail 
will go on as usual, and that one shall noyer be, missed. 

'o.--It is offert complained, that professional nurses, brought into private Why hired 
familles, in case of sickness, make themsdves intolerable by "ordering about" the nurses give so 
cther servants, under plca of hOt ncglceting the patient. Both things are truc ; the much trouble. 
patient is often neglected, and the servants are often unfairly "put upon." But 
the fault is genendly in the want of management of the head in charge. If is 
surely for ber to arrange both that the nurse's place is, when necessary, supple- 
mentcd, and that the patient is never neglected--things with a little manage- 
ment quite compatible, and indeed only attainable together. If is certainly hot 
for the nurse to "order about" the servants. 

IV. NOISE. 

Unnecessary noise, or noise that creates an expeeation in the 
mind, is that which hmoEs a patient. It is rarely the loudness of tho 
noise, the efibct upon the organ of the ear itself, which appears to 
afibct the sick. t[ow well a patient will generally bear, e.y., the 
putting up of a scaffolding close fo the bouse, when ho cannot bear 
the talking, still less the whispering, especially if if be of a familiar 
voice, outside his door. 
There are ceoEain patients, no doubt, especially where there is 
slight concussion or other disturbance of the brain, who are affected 
by more noise. :But intermittent noise, or sudden and sharp noise, 
in these as in al] other cases, affects fir more than continuous 
noise--noise with jar far more than noise without. Of one thing 
you may be ceoEain, that anything hich wakes a patient suddenly 
out of his sloop wfil invariably pu him into a state of greater 
excitement, do him more sericus, we, and lasting mischief, than mly 
continuous noise, however ]oud. 
ever fo allow a patient tobe waked, intentionaily or accident- 
al]y, is a sine ç.uâ non of all good nursing. If" ho is roused out of his 
first sleep, ho is ahnost certain fo bave no more sleep. Itis a curions 
but quine intelligible fact that, if a patient is waked aîter a few 
bours' instead of a few minutes' sloop, ho is much more likely fo 
sleep again. :Because pain, like irritability of brain, perpetuates 
and intensifies itself. ïf you have gained a respire of either in sloop 

Unnccessary 
noise. 

ever let a 
ptient be 
waked out of 
his first sloop. 



NOTES O IURSING. 

5Zoise which 
excites expcc- 
tation. 

Whispered 
conversation 
in thc room 

Or just out- 
side the door. 

5Zoiseoffemale 
dress. 

you bave gained lnore than the mere respite. Both the probability 
of recurrence and of the saine intensity will be diminished ; whereas 
both xvill be terribly increased by want of sleep. TMs is the reason 
why sleep is so all-importanto This is the reason why a patient 
waked in the early part of his sleep loses hot only his sleep, but his 
power to sleep. A healthy person who allows himself to sleep during 
the day will lose his sleep at night. :But itis exactly the reverse 
with the sick genera]ly; the more they sleep, the better will they 
be able to sleep. 
I have oi'ten been surprised at the thoughtlessness, (resulting 
in cruelty, quite unintentionally) of friends or of doctors who xvill 
hold a long conversation just in the room or passage adjoining fo 
the roon of the patient, who is either every moment expecting 
them to corne in, or vho bas just seen them, and knows they are 
talking about him. If he is an amiable patient, he will try fo 
occupy his attention elsewhere and hot fo listen--and this makes 
matters worse--fvr the strain upon his attention and the effort he 
makes are so great that it is well if he is hot worse for hours 
after. If it is a xvhispered conversation in the same room, then 
if is absolutely cruel ; for if is impossible that the patient's attention 
shodd hot be involuntarily strained to hear. Walking on tip-toe, 
doing any thing iu the room very slowly, are injurious, for exactly the 
saine reasons. A firm light quick step, a steady quick hand are the 
desiderata ; hot the slow, lingering, shuffting foot, the timid, uncertab2 
touch. Slowness is hot gentleness, though it is often mistaken for 
such; quickness, lightness, and gentleness are quite compatible. 
Again, if friends and doctors did but watch, as nurses can and 
should watch, the features sharpening, the eyes growing a]most xvfld, 
of fever patients who are listening for the entrauce from the 
corridor of the persons vhose voices they are hearing there, these 
would never run the risk again of creating such expectation or 
irritation of mind.--Such unnecessary noise bas undoubtedly induced 
or aggravated delirium in many cases. I have known suchin one 
case death ensued. It is but fair to say that this death xvas attri- 
bnted to fright. It was the result of a long whispered conversation, 
xvithin sight of the patient, about an impending operation ; but any 
one who bas known the lnore than stoicism, the cheerful coolness, wïth 
vhich the certainty of an operation will be accepted by any patient, 
capable of bearing an operation af all, if it is properly communi- 
cated fo him, will hesitate fo believe that it was mere fear xvhich pro- 
duced, as was averred, the fatal result in this instance. If was rather 
the uncertainty, the strained expectation as to what was fo be decided 
UpOl. 
I need hardly say that the other common cause, nanely, for a 
doctor or friend to leave the patient and comnmnicate his opinion 
on the result of his visit to the friendsjust outside the patient's door, 
or in the adjoining room, after the visit, but within hearing or know- 
ledge of the patient is, if possible, worst of all. 
It is, I think, alarming, peculiarly ai this time, when the female 
ink-bottles are perpetually impressing upon us "woman's" "parti- 



OISE. 27 

cular worth and generai missioniriness," to see that the dress of 
women is daily more and more unfitting them for any "mission," or 
usefulness af all. If is equally unfitted for all poetic and all domestic 
purposes. A man is now a more handy and far less objectionable 
belng in a sick-room than a wonmn. Compelled by her dress, every 
woman now either shuffies or waddlcs--only anmn can cross 
the floor of a sick-room without shaking it! What is become of 
'oman's light step ?--the firm, light, quick step we have been 
asking for ? 
Unnecessary noise, then, is the most cruel absence of care which 
can be inflicted either on sick or vell. :For, in all these remarks, 
the sick are only mentioned as suffering in a greater proportion 
than the well from precisely the smne causes. 
Unuecessary (although slight) noise injures a slck person much 
more than necessary noise (of a much greater amount). 
Ail docrines about mysterious afiiuities and aversions will be 
ïound to resolve themselves very much, if no entirely, into presence 
or absence of care in these things. 
A nurse who rustles (I ara speaking of nurses professional and 
unprofessional) is the horror of a patient, though perhaps he does 
hot know why. 
The fidget of silk and of crinoline, the rattling ofkeys, the creaking 
of stays and of shoes, will do a patient more harm than all the medi- 
cines in the world -ill do him good. 
The noiseless step of woman, the noiseless drapery of -oman, 
are mere figures of speech in this day. Her skirts (and well if they 
do not throw down some piece of furnim-e) will af least brush 
against every article iii the room as she moves. " 
Again, one nurse cannot open the door without making 
everything rattle. Or she opens the door unnecessarilv often, 
tbr want of remembering all the articles tha might be brouht in af 
once. 
A good nurse will always make sure that no door or 'indow in 
ber patient's room shall rattle or creak; that no blind or curtain 
shall, by any change of wind through the open window, be ruade to 
flap--especially vilI uhe be careful of all this before she leaves ber 
patients for the night. If you wait till your patients tell you, or 
remind you of these things, where is the use of their having a nurse ? 
There are more shy than esacting patients, in all classes; and many 

Patient's re- 
pulsion to 
nurses who 
rustle. 

* Fortunate if is if hcr skirts do not catch tire--and if the nurse does hot give 
herself up a sacrifice togethcr with ber patSent, fo be burnt in ber own petticoats. 
I wish the legistrar-General would tell us the exact number of deaths by burning 
occasioned by this absurd and hideous custom. But if people will be stupid, let 
them take measures fo protect themselves from their own stupidity--measures 
which every chemist knows, such as putting alum into starch, which prevents 
starched articles of dress from blazing up. 
I wish too that people who wear crinoline could see the indecency of their 
ow dress as other people see it. A respectable elderly woman stooping for- 
ward, invested in crinoline, exposes quite as much of her own person to the patient 
lying in the room as any opera-dancer does on the stage. But no one will ever 
tell ber this unpleasant trath. 

Burning of the 
crinolines. 

Indecency of 
the crinolines. 



28 

OTES O UISI3-G. 

Iffurry pecu- 
liarly hurtful 
to sick. 

tIow to visit 
¢he sick and 
hot hurt thern. 

qhese things 
hot fancy. 

Interruption 
damaging to 
sick 

a patienç passes a bad night, rime afçer rime, rather than remind 
hls nurse every nighç of all the things she has forgotten. 
If there are blinds fo your windows, always take care fo bave 
thcm well up, when they are noç being used. A little piece slipping 
down, and flapping with everv draught, will distract a patient. 
All hurry or bustle is pecu'liarly painftfl to the sick. And when a 
patient has compulsory occupations to engage him, instead of lmving 
imply to amuse himse]f, it becomes doublv injurious. The friend 
vho rcmains standing and fidgetting tbouç while a patienç is talking 
business to him, or the friend ho sits and proses, the one from a 
Jdea of hot letting the patient talk, the other from an idea of aumsing 
him,--each is equally iuconsiderate. Always sit down when a sick 
person is talking business to vou, show no signs of hurry, give 
complete atteution and full cosideration if your advice is wanted, 
and go awa.v thc momeut the subjccç is endcd. 
Always sit ithin the patient's view, so that v:hen you speak to 
him he bas noç painful]y to turn his head round in order to look aç 
vou. :Evcrybody involuntarily looks at the person speaking. If vou 
uale this act a wearisome one on the part of the patient you are 
doing him harm. So also if by continuing to stand you nmke him 
continuously raise his eyes to sec vou. ]3e as motionless as possible, 
and nevcr gesticulate in speaking "to the sick. 
Nevcr make a patient repeat a nmssage or request, especially if it 
be some rime after. Occupied patients are often accused of doing 
too much of their own business. Thev are instinctively righç. :l:[ow 
often you hear the person, charged ith the request of gîving the 
message or vriting the letter, say half an hour afterwards to the 
patient, " Did you appoint 12 o'clock .9,, or, "What did you sav was 
the address .9" or ask perhaps some much more agitating quest'ion-- 
thus causing the patienç the effort of memory, or worse still, of 
decision, all over again. Jt is really less exertion to him to write his 
letters himself. OEhis is the ahnost universal experience of occupied 
invalids. 
This briugs us fo another caution. :h-ever speak fo an invalid 
from behind, nor from the door, nor from any distance from him, 
nor -hen he is doing anything. 
The oflàcial politeness of servants in these things is so grateful to 
invalids, that many prefer, vithout knowing why, having none but 
servauts about them. 
These thiugs are hot fancy. If we consider that, with sick as 
with well, every thought decomposes some newous matter,--tbat 
decomposition as well as re-composition of nervous marrer is alwavs 
going on, and more quickly vith the sick than with the well,that, o 
obtrude abruptly another thoughç upon the brain while it is in 
thc act of destroying nervous matter by thinking, is calling upon it 
to make a new exertion,--if we consider these things, which are 
facts, hot fancies, we shall remember that we are doing positive 
inju W by interrupting, by "startling a fnciful" person, as if is 
called. Alas ! it is no fancy. 
If the invalid is torced, by his avocations, to continue occupations 



requiring nmeh thinking, the injury is doubly great. In feeding a 
patient suflring under delirium or stupor you may suflbeate hiin, 
by giving him his food suddenly, but if you tub his lips gently 
with a spoon and thus attraet his attention, he will swallow the food 
uneonseiotusly, but with perlier safety. Thus itis with the brain. 
If you offer ita thought, espeeially one requiring a deeision, abruptly, 
, vou doit a real not thneiful injury. Never speak toa sick person 
suddenly ; but, st the saine rime, do not keep his expeetation on tlm 
tiptoe. 
This rule, indeed, applies fo the well quite as mueh as to the siek. And to well. 
I bave never known persons who exposed themselves for years fo 
constant interruption who did hOt muddle away their intelleets by i 
st last. The proeess with them may be aeeomplished without pain. 
With the siek, pain gives warning of the injury. 
I)o hot meet or overtake a patient who is Inoving about in order Keeping . 
fo speak fo hiin, or fo give hiin any message or letter. You might patient 
just as well give hiin a box on the car. I bave seen a patient thll standing. 
fiat on the ground who was standing when his nurse came into the 
room. This was au accident which Inight have happened to the 
most careful nurse. But the other is donc with intention. _k 
patient in such a state is not going fo the East Indies. If vou would 
wait ten seconds, or walk ten yards further, any promenadè he could 
make xxould be over. OEou do not know the efibrt itis toa patient 
fo reinain standing for even a quarter of a minute fo listen to you. 
If I had not seen the thing donc bv the kindest nurses and ti'iends, 
I should have thought this caution luite superfluous.* 
Patients are oïten accused of being able to "do Inuch more when Patients drea 
nobody is by." Itis quite truc that they can. Unless nurses cau surprise. 
be brought fo attend to considerations of the kind of which we bave 
given here but a few specimens, a verv weak patient finds it really 
much less exertiou to do things for ]iinself than to ask tbr them. 
And he will, in order to do them, (very innocently and from 
instinct) calculate the rime his nurse is like]y to be absent, froin , 
fear of her " coming  upon" hiin or speaking fo him, just at the 
Inoinent when he finds it quite as much as he can do to crawl from 
his bed to his chair, or froln one rooin fo another, or down stairs, or 
out of doors for a few minutes. Some extra call ruade upon his 
attention st that moment will quite upset hiin. In these cases you 
mav be sure that a patient in the state we have described does not 
mak-e such exertions more than once or twice a-day, and probably 
* It is absolutely essential that a nurse should lay this down as a positive rule 
fo herself, never to spcak to any patient who is standing or moving, as lng as 
zhe exercises so little observation as not fo know when a patient cannot bear it. 
I am satisficd that many of the accidents which happen from feeble patients tumb- 
ling" down stairs, fainting after getting up, &c., happen solely from the nurse pop- 
ping out of a door fo speak fo the patient just at that moment ; or from his fearing" 
that she will do so. And that if the patient were even left fo himself, till he can 
sit down, such accidents would much seldomer occur. If thc nurse accompanics 
the patient let ber not call upon him fo speak. If is incredible that nurses tan- 
hot picture to thcmselves the strain upon the heart, the lung, and the brain 
which the net of moving la to any feeble patient. 

Never speak 
patient in 
the act of 
moving. 



30 IOTES ON I'URSI'G. 

Effccts of over- 
excrtion on 
sick. 

Difference 
between real 
and fancy 
patients. 

much about the saine hour every day. And if is hard, indeed, if 
nurse and friends cannot calculate so as to let him make them 
undisturbed. :Remember, that many patients can walk who cannot 
stand or even sit up. Standing is, of all positions, the most trying 
fo a weak patient. 
Everything you do in a patient's room, after he is "put up" for 
the night, increases tenfold the risk of his having a bad night. 
]3ut, if' you rouse him up after he bas fallen asleep, you do hot risk, 
you secure him a bad night. 
One hint I would give to a]l who attend or visit the slck, fo 
all who have to pronounce an opinion upon sickness or ifs pro- 
gn'css. Corne back and look at vour patient after he lins had 
an hour's animated conversation w]th vou. Itis the best test of 
his real state we know. But never pronounce upon him from 
mere]y seeing what he does, or how he looks, during such a conver- 
sation. Learn also «arefully and exactly, if you can, how he passed 
thc n]ght after if. 
:People rarely, f ever, fifint while making an exertlon. I- is after 
if is over. Indeed, ahnost every effect of over-exertion appears 
,nfter, not during such exertion. Itis the highest folly to judge of 
the sick, as is so often done, when you see them merely during a 
period of excitement. People bave very offert died of that which, if 
has been proclaimed at the rime, bas " done them no barre. ''v 
:Remember never fo ]enn against, sit upon, or unnecessarily 
shake, or even touch the bed in which a patient lies. This is inva- 
riably a painful annoyance. If you shake the chair on which he 
sits, he bas a point by which fo steady himself, in his feet. But on 
a bed or sofa, he is entirely at your mercy, and he ïeels every jar 
you give him all through him. 
In all that we bave said, both here and elsewhere, let it be 
distinctly understood that we are hot speaking of hypochondriacs. 
To distinguish between real and fancied disease forms an important 
branch of the education of a nurse. To manage fancy patients forms 
an important branch of her duties. But the nursing which rem and 
that which f,nncied patients require is of different, or rather of 
opposite, character. And the latter will hot be spoken of here. 
:Indeed, many of the symptoms which are here mentioned are those 
which distinguish rcal from fancied disease. 

Careless obscr- 
vntion of the 
results of care- 
lcss visits. 

 As an old experienced nurse, I do most earnesfly deprecate all such careless 
woMs. I have known patients delirious ail night, after seeing a visitor who 
called them "better," thought thcy "only wanted a little amusement," and who 
came again, saying, "I hope you wcre hot the worse for my visit," neither wait- 
ing for an answer, nor even looking af the case. 1o real patient will ever say, 
"Ycs, but I was a great deal the worse." 
It is hot, however, either dcath or delirium of which, in these cases, there is 
most danger fo thc patient. Unperceived consequences are far more likely to 
ensue. :Fou will have impunity--the poor patient will hot. That is, the patient 
will surfer, although neither he uor the inflictor of the injury will attribute it to 
its real cause. It will not be directly tmceable, except by a very careful 
observant nurse. The patient will often hot even mention whŒt bas done him 
most harm, 



If is true that hypochondriacs very often do that behind a nurse's 
back which they would hOt do before her face. Many such I have 
had as patients who scarcelv are anything af their regular meals; 
but if you concealed food fo]: them in a drawer, they would take if 
at night or in secret. But this is il'oto quite a different motive. 
They do if from the wish fo conceal. Whereas the real patient 
will often boast to his nurse or doctor, if these do hOt shake their 
heads at him, of how much he has doue, or eaten, or walked. To 
return fo real disease. 
Conciseness and decision are, above all things, necessary with the 
sick. Let your thought expressed to them be concisely and decidedly 
expressed. What doubt and hesitation there may be in your own 
mind lnust never be communicated fo theirs, hOt even (I would 
rather say especiMly hOt) in little things. Let your doubt be fo 
yourself, your decision to them. Pêople who think outside their 
Ïmads, the whole process of whose thought appears, like Homer's, in 
the act of secretion, who tel1 everything that led theln towards this 
conclusion and away from that, ought never fo be with the sick. 
Irresolution is what all patients most dread. :Rather than meet 
this in others, they will collêct all their data, and make up thei' minds 
for themselves. A change of mind in others, whether it is re'qrding 
an operation, or re«vriting a letter, alwavs, injures the patient 
more than the being called upon fo make up his mind fo the most 
dreaded or dif6cult decision. Farther than this, in very many cases, 
the imagination in disease is far more active and vivid than if is in 
health. If you propose fo the patient change of air to one place 
one hour, and fo another the next, he has, in each case, immediately 
constituted himself in imagination the tenant of the place, gone over 
the whole prêmises in idea, and you have tired him as much bv 
displacing his imagination, as if you had actually carried him over 
both places. 
Above all leave the sick room quickly and corne into if quickly, 
hOt suddenly, hOt with a rush. But don't let the patient be wem-ily 
waiting for when you vill be out of the room or when you will be in 
if. Conciseness and decision in your movements, as well as your 
words, are necessary in the sick room, as necessary as absence of 
hurry and bustle. To possess yourself entirely will ensure you from 
either failing--either loitering or hurrying. 
If a patient bas fo see, hot only to his own but also fo his nurse's 
punctuality, or perseverance, or readiness, or calmness, fo any or all 
of these things, he is far better without that nnrse than with hêr-- 
however valuable and handy her services may otherwise be to him, 
and however incapable he may be of rendering them fo himself. 
With regard fo reading aloud in the sick room, my experience 
is, tlmt when the sick are too ill fo rend fo themselves, they can 
seldom bear fo be rend to. Children, eye-patients, and uneducated 
persons are exceptions, or where there is any mechanical difflculty 
in readiug. People who like to be rend to, have generally hOt much 
the matter with them ; while in fevers, or where there is much irri- 
tability of brain, the effort of listeni_ug to reading aloud has often 

Conclseness 
necessury with 
Sick. 

Irresolution 
most painful 
to them. 

Wh: a patient 
must not have 
to sec fo. 

Reuding 
aloud. 



OTES O URSIG. 

brought on delirium. :[ speak with great ditdence; because there 
is an ahnost universal impression that if is s_pariff the sick fo read 
aloud to them. But two things are certain 
l/ead aloud (1.) If there is some marrer which mtst be read fo a sick 
slowly, 
distinct.ly, and person, do it slowly. People often think that tlae way fo get 
seadilv to the over with least fatigue fo him is to get if over in least rime. Th .y 
sick. gabble; thcy plunge and gallop through the reading. There never 
as a greater mistake. oudin, the conjuror, says that the wav to 
make a story seem short is to tell if sloly. o if is with realinff 
fo the sick. [ bave often hcard a patient say to such a mistake,a 
reader, " Don't read 
aware that this will regulate the plunging, the reading with unequal 
l»aces, slmTing over one part, instead of leaving if out altogether, 
if it is uuimportant, and mmubling another. If the reader lets his 
own attention wander, and thon stops fo read up to himself, or finds 
he has rcad the wrong bit, thon if is ail over with the poor patieut's 
chance of hot suffering. Very few people know how to read to the 
sick; ver)" few read aloud as pleasantly even as they speak. 
reading they sing, tlacy hcsitate, they stammer, they hurry, they 
mumble ; when i speaking they do noue of these things. Readinff 
aloud fo the sick ought always to be rather slow, and exceedingly 
distinct, but hot mouthing--rather monotonous, but not sing song 
--rather loud, but hot noisyand, above all, hot too long. Be ver:( 
sure of what your patient can bear. 
:Noyer read (2.) The extraordinary habit of reading fo oneself in a sick room, 
aloud by fits and reading aloud fo the patient anv bits which will amuse hin or 
and starts to 
the ick. more often the reader, is unaccountbly thoughtless. Vhat do you 
think the patient is thinling of during your gaps of non-reading ? 
Do vou think tha he amuses himse]f upon what you bave re.ad for 
predisely the rime it pleases you to go on reading to yourself, and 
that lais attention is ready for something else 
pleases you to begin reading again ? Whether the person thus read 
to be sick or well, whether he be doing nothing or doing something 
else while being thus read fo, the self-absorption and want of obser- 
vation of the person who does it, is equally di{ficult to understand 
although very often the readee is too amiable fo say how much 
disturbs him. 
People One thing more :--From the flimsy manner in which most moderr 
overhed, houses are built, here every step on the stairs, and along the 
toors, is felt all over the bouse; the higher the story, the greater 
the vibration. If is iuconceivable how nmch the sick suflbr by 
having anybody overhead. In the solidly built old bouses, whiclî, 
fortunately, most hospitals are, the noise and shaking is comparatively 
trifling. But it is a. serious cause of sufibring, in ]ightly built bouses, 
and with the irritability peculiar to some diseuses. ]3etter far put 
stch patients af the top of the bouse, even with the additional 
fatigue of stairs, if you cannot secure the room above them being 
The sick wou]d 
rather be told a * Sick childn, if hot too shy fo spcak, will always express this wish. They 
thingtha hoEve invariably prefcr a story to be told to them, rather than read to t!xem. 
iV read to îhem. 



VXT. 33 

untenanted; you may otherwise bring on a state of restlessness which 
no opium will subdue. Do hot neglect the warning, when a patient 
tells you that he "Feels every step above him to cross his heart." 
:Remember that every noise a patient caanot sec partakes of the 
character of suddenness fo him; and I mn )ersuaded ha.t patients 
with these peculi:arly irritable nerves, are po'sitively less injured by 
having persons m the saine room with them than overhead, or 
separated by only a rhin compartment. Anv sacrifice to secure silence 
br these cases is worth while, because no air, however good, no 
attendaace, howevcr careful, will do anything for such cases without 
quiet. 

:NOTE.--The effect of music npon the sick has been scarcely at all noticed. 
In fact, its expensiveness, as it is now, makes any gencral application of it quite 
out of the question. I will only remark here, that wind instruments, including 
the human voice, and stringed instruments, capable of continuous sound, have 
generally a beneficent effect--whilc thc piano-forte, with such instruments as have 
o continuity of sound, h just the revcrse. The fines piano-forte playin will 
damage the sick. whi|c an air. like "Home, sweet homc," or "Assisa a pi d'un 
salice," on the most ordinary griuding organ will sensibly soothc them--aad this 
quite independent of association. 

1Kusic. 

¥. YXRIETY. 

To any but an old nurse, or an old patient, the degree would be 
quite inconceivable fo viich the nerves of the sick suflbr from seeing 
the saine walls, the saine ceiling, the saine surroundings during a 
long confinement to one or two rooms. 
The superior cheerfalness of persons suffering severe paroxysms 
of pain over that of persons suffe-ing from nervous debility has often 
been remarked upon, and attributed fo the enjoyment of the former 
of their intervals of respire. I incline to think that the majrity of 
cheerful cases is to be round among those patients who are hot cou- 
fined fo one room, xvhatever their suffering, and that the majority of 
depresscd cases xvill be seen among those subjected toa long 
monotony of objects about them. 
The nervoas frame really suffers as much from thls as the diges- 
tive organs from long monotony of diet, as e.9. the soldier from Ms 
twenty-one years' "boiled bee£" 
The effcct in sickness of beautifal objects, of variety of objects, 
and especially of brilliancv of colour is hardlv at all appreciated. 
Such cravings are usually called the "thnëies" of patients. And 
often doubtless patients have "fancies," as, e.y. when they desire 
txvo contradictions. :But much more ofen, their (so called)"lhncies" 
are the most valuabl indications of what is necessaïv for their 
recovery. And it would be xvell if nurses would watc these (se 
called) "fancies" closel¥. 
I have seen, in feve:s (and felt, xvhen I -as a fever patient myself) 
the most acute suffering produced ff'oto the patient (in a hut) noç 
being able fo sec out of xvindow, and the knots in the xvoçd 
D 

Yariety  
mcans or" 
recovcry- 

Colour and 
form means of 
rccovcry. 



'OOEES ON çrSIN6. 

This is no 
fancy. 

Flox crs. 

Effcct of body 
on mind. 

Sick surfer fo 
cxcess from 
mcntal as well 
as bodily pain. 

being the onlv view. I sha.ll never forger the rapture of fever 
patients over a'bunch of bright-coloured flowers. I remember (in 
my own case) a noscgay of wild flowers being sent me, and from 
that moment recoverv becoming more rapid. 
People say the ei:tbct is only on the mind. It is no such thing. 
The eflbct is on the body, too. Little as -e know about the way in 
xvhich we are aficted by form, by colour, and light, we do know this, 
that they have an actual physical effect. 
Variety of form and brilliancy of colour in the objects presented 
to patients are actual means of recovery. 
But it must be slow variety, e..q., if you shew a patient ten or 
twelve engravings successivcly, ten-to-one that he does not become 
cold and ihint, or tbverish, or cven sick; but bang one up opposite 
him, one on cach successive d , or week, or montb, and he will revel 
in the variety. 
The iblly and inorance which re]gn too often supreme over the 
sick-room, cannot be betfer exemplified than by this. rbile the 
nurse will leave thc patient stewing in a corrupting atmosphere, 
the best ingredicnt of which is carbonic acid; she xvill deny him, on 
the plea of unhcalthiness, a glass of cut-flowers, or a growing plant. 
Now, no ont evcr saw " overcrowàing" by plants in a room or ward. 
And the carbnic acid they give off at nights wou}d hot poison a fly. 
/x',y, i, overcrowded rooms, they actually absorb carbonic acid and 
give off oxygen. Cut-flowers also decompose water and produce 
oxygen gas. I is true there are certain flowers, e.tT., lilies, the smell 
of which is said to depress the nervous system. These are easily 
known by the smell, and can be avoided. 
Volumes are now vritten and spoken upon the effect of the mlnd 
upon the body. l%iuch of it is true. But I wish a little more was 
thought of the effect of the body on the mind. You who believe 
vourselves overwhelmed with anxieties, but are able every day fo 
valk up :Regent-street, or out in the country, fo take your meals xvith 
others in other rooms, &c., &c., you little know how much your 
anxietics are thereby lightened ; you little know how intensified they 
become to those who can have no change ;* how the very walls of 
their sick rooms seem lmng with theh' cares; how the ghosts of 
lheir troubles hatmt their beds; how impossible if is ibr them to 
cscape from a pursuing thought without some help from varietv. 
A patient can just as lnuch more his leg when it is fractt[red as 
change his thoughts 'hen no external help from variety is given 
him. This is, indeed, one of the main sufferings of siclness ; just 
* It is a marier of painful wondcr fo tbe sick /hemselves how much painful 
ideas predoninate over pleasurable ones i,, their impressions ; they reason with 
themselves ; they/hink themselves ungrateful ; it is all of no use. The fact is, 
that thesc painful imloreions are far better dismied by a real laugh, if you can 
excite one by books or conversation, than by any direct reasoning; or if the 
patient is too weak to laugh, some knpreson from nature is what he wants. I 
bave mentioned thc cruelty of letting him stare at a dead wall. Ia many 
diseases, esloccially in convalescence from fevcr, that wall will appear to make all 
sor/s of faces at him; now flowers never do this. Form, colour, will free your 
patient from his painful ideas better than any argument. 



as the fixed posture is one of the 
limb. 
Ig is an ever recurring wonder fo see educated people, who 
call themselves nurses, acting thus. Thev var r their own objects, 
their own emp]oyments many rimes a d,y; ad while nursig (!) 
some bed-ridden sufferer, they let him lie there staring at a dead 
wall, without any change of object to enable him fo vary his thoughts ; 
and if never even occurs fo them, af least to more his bed so that he 
can look out of vindow. To, the bed is to be always left in the 
darkest, dullest, remotest, part of the room. v 
I thiak if is a very common error among the well to think that 
"' with a little more self-control" the sick might, if they choose, 
"' dismiss painfid thoughts" which "aggravate their disease," &c. 
Believe me, almosg an!/ sick person, who behaves decently well, 
exercises more self-control every moment of his day thmz you will 
ever know till you are sick voursel£ Ahnost every step that crosses 
his room is pahful fo hinç; ahnost cvery thouht that crosses his 
brain is painthI fo him; and if he eau speak without beiug savage, 
and look wihout being unpleasant, he is exereising selgeontrol. 
Suppose you bave been np all night, and instead of being allowed 
to bave your eup of tea, 3-ou "«-ere to be told that you ought to 
'" exereise self-eontrot," what should you sa.)" ? Now, the nerves of 
the sick are always in the state that yours are in after you have been 
ni» all night. 
We wfll suppose the diet of the siek to be cared for. Then, this 
state of nerves is most frequently fo be relieved by care in afibrding 
them a lleasant view, a judicious variety as fo flowers,J- and pretty 
hings. Light by itself will often relieve if. The craving for "the 
return of dw," which the sick so constantly evnce, is generally 
nothing but the desire for light, fhe remembrance of the refief which 
a variety of objects before the eye affords fo the harassed sick mind. 
Again, every man and every womn has some amount of manual 
employment, excepting a few fine ladies, who do hot even dress 
themselves, and vho are virtually in the saine category, as fo nerves, 
as the sick. -ow, you can have no idea of the relief which manual 
labour is to you--of the degree fo which the deprivation of manual 
* I remember  case in point. A man reccived an injury to the spine, from 
an accident, which after a long confinêment endcd in death. He was a workman 
--had not in his composition a singlc groin of what is called "enthusiasm for 
nature,"--but he was despcrate to "'sec once more out of window." His nnrse 
actually got him on ber back, and managed to perch him up af thc window for an 
i,;stant, "to sec out." The consequence to the poor nurse was a serious illness, 
which nearly proved tatl. The man never knew it ; but  grcat many other 
people did. Yet the consequencc in none of their minds, so far as I know, was 
the conviction that thc eraving for variety in thc starving cyc, is just as desperatc 
as that for food in thc starving stomach, and tcmpts the famishing creature in 
either csc to steal for its satisfaction, h'o other word will express it but "des- 
peration." And it sets the seal of ignorance and stupidity just as much on the 
governors and attendants of the sick if they do hot provide the sick-bcd with a 
"view" of some kind, as if they did hot provide the hospital with a k]tchen. 
 No ont who has wached thc sick can donbt the fact, that somc fcel stimulus 
from looking at sc,rlet fiowcrs, cxhaustion from Iooking at deep blue, &c. 
»2 

mtin sufferings of the broken 
Hclp thc slck 
to vary their 
thoughts. 

Supply to the 
sick the dcfect 
of manual 
labour. 

Desperate de- 
sire in the 
sick to "sec 
out of win- 
dow.'" 

]Physical cffcct 
of colonr. 



36 

IOTES O NURSING. 

employment increases the peculiar irrltability from which maay sick 
surfer. 
A little needle-work, a little writing, a little cleaning, would be the 
greatest relief the sick could hure, if they could do if ; these e«re the 
greatest relief fo you, tbough you do hOt know if. Reading, though 
if is often the only thing the sick can do, is hOt this relief. Bearing 
this in milld, bearing in miud that you have all these varicties of 
emptoymeut which the sick cannot bave, bear also in mind fo obtain 
for them all the varieties which thev eau enjoy. 
I need hardly say that I ara well aware that excess in needle-work, 
in writi,g, in any other continuous cmployment, will produce the 
saine irritability that defect in manual employment (as one cause) 
produces in the sick. 

Want of atten- 
tion to hours 
t,f taking food. 

Lifc often 
hangs upon 
ininutes in 
taking food. 

¥I. TAKING FOOD. 

:Every careSfi observer of the sick will agree in this that 
thousands of patients are annually starved in the midst of plenty, 
from want of attention to tbe ways which alone make if possible for 
them fo take food. This want of attention is as remarkable in those 
who nrge npon the sick to do wbat is quite impossible to them, as in 
the sick themselves who will hot make the effort to do what is per- 
fectly possible to them. 
For instance, to the large majority of verv weak patients if is 
quite impossible fo take any solid food before "11 x._., nor then, if 
tbeir strength is still further exhausted bv fasting till that hour. 
l%r weak patients have generally feverish ni,hts and, in the morning, 
drv mouths ; and. if they could eut with those dry mouths, if would 
be" tlm worse for them. A spoouful of beef-tea, of arrowroot and 
wine, of egg flip, every hour, will give them the requ.site nourish- 
ment, and prevent tbem from being too much exhausted to take af a 
luter hour the solid food, which is necessary for their recoverr. An(i 
every patient wbo eau swallow af all can swallow these liquid things, 
if he chooses. :But how often do we heur a mutton-chop, an egg, a 
bi of bacon, ordered to a patient for breakthst, to whom (as a 
moment's consideration would show us) if must be quite impossible 
to masticate such things at that hour. 
Again, a nurse is ordered fo give a patient a tea-cup ïull of some 
article of food every three hours. The patient's stomach rejects if;. 
If so, trv a table-spoon full every hour ; if this will hot do, a tea-spoon 
full eve:y quarter of an hour. 
I ara bound fo say, that I thlnk more patients are lost by want of 
cure and ingenuity in these momentous minuti,'e in private nursing 
than in public hospitals. And I think there is more of the etente 
cordiale fo assist one another's hands between the doctor and his heacl 
nurse in the latter institutions, than between the doctor and the 
patient's friends in the private bouse. 
If we did but know the consequences which may ensue, in very 
weak patients, from ten minutes' fasting or repletion, (I call it repletion 



OEAKING 'OOD. 7 

vheu they are obliged fo let too small an inter'al elapse between 
taking food and some other exertion, owing fo tbe nurse's unpunctu- 
• r x 
allt. , we should be more careful never fo let this occur. In very 
weak patients there is offert a nervous difl]cultv of swallowing, which 
is so much increased by any other call upou tlïeir strength that, un- 
less they have their ibod punctually at the minute, which minute 
agaiu must be arranged so as to thll in with no other minute's occu- 
pation, thev can take nothing till the next respire occursso 
that an ulçpunctuality or delay of ten minutes may very well turn 
out fo be one of two or three hours. _And why is if hot as easy 
fo be punctual to a minute ? Lire often literally hangs upon these 
.minutes. 
I,t acute cases, where lire or death is fo be determined in a few 
hours, these matters are very generatly attended fo, especiatly iu 
ttospitals ; and the number of cases is large where the patient is, as 
it wcre, brought back fo life by exceeding care on the par of ghe 
Doctor or N'urse, or boh, in ordering and giving nourishmen wih 
ninute selecion and punctualiy. 
But, in cbronic cases, lasting over months and years, where the Patients ofen 
fatal issue is offert determined at last by mere protracted starvation, starved fo 
I 1,ad raflmr hot enumerate the instances which I bave known where death in 
a little ingenuity, and a great deal of perseverance, might, in ail chronic cases° 
probability, bave averted the result. The consulting the hours when 
ghe patieng tan take food, the observation of ghe rimes, offert varying, 
wben he is lnost faint, the alering seasons of taking food, in order to 
.anticipate and prevent, such timesall this, which requires observa- 
ion, ingenuity, and perseverance (and hese reatly constitute the good 
Nurse), might save more lires than we wo of. 
To leave the patient's untasted food by his side, from meal fo Food neverto 
meal, in hopes that he will eat it in the interral, is si,nply fo prevent be lef by the 
him from taking any food af all. I bave known patients literally patient's side. 
incapacitated t¥om taking one article of food afer another, by his 
piece of ignorance. Let file food corne a the righ rime, and be 
taken away, eaten or uneaten, at the right time; but never let a 
patient have " something always standing" by him, if you don't wish 
to disgust hilu of everything. 
On the other hand, I bave known a patient's life saved (he was 
sinking for want of food) by the simple question, pat to him by the 
doctor, " :But is there no hour when vou feel you could eat?" " Oh, 
yes," he said, " I could always take omething at -- o'clock and -- 
o'clock." The thing was tried and succeeded. :Patients very 
seldom, however, can tell this ; it is for you fo watch and find it out. 
A patient should, if possible, not see or smell either the food of Patient had 
others, or a greater amount of food than he himself can consume at better hot see 
olle rime, or even hear food talked about or see it in the raw state, more food than 
his own. 
:[ know of no exception fo the above rule. The breaking of i always 
induces a greater or less incapacity of taking food. 
In hospital wards it is of course impossible fo observe all this ; 
and in single wards, where a patient must be continuously and closely 
watched, i is frequently impossible to relieve the attendant, so thar 



35 

-OTFS ON UItSIG. 

YOU canner be 
too careful as 
te quality in 
sick diet 

his or her own meals can be taken out of the ward. But itis net the 
lcss true that, in such cases, even vhere the patient is net himself 
aware of il, his possibility of taking fool is limited by seeing the 
attendant eating meals uuder his observation. In seine cases the 
sick are aware of it, anal complain. A case where the patient was 
supposed te bc insensible, but complained as soon as able te speak, 
is new present te mv recollection. 
:Remember, howêver, that the extreme punctuality in xvell-ordered 
hospitals, the rule that nothing shall be doue in the ward while the 
patients are having their meals, go £r te counterbalance wht un- 
avoidable evil there is in having patients together. I have often seen 
the private nurse go on dusting or fidgeting about in a sick room all 
the while the patient is eating, or trying te eut. 
That the more alonc art invalid can be when taking food, the 
better, is unquestionable; and, even if he must be fed, the nurse 
should net allow hin te talk, or talk te him, espccially about food, 
vhile eating. 
Vhen a person is compelled, by the pressure of occupation, te 
continue his business while sick, it ought te be a rule 
xco WEVR, that no oue shall bring business te him or 
talk te him -hile he is taking food, ner go on t«fiking te him on lute- 
resting subjects up te the last moment beIbre his meals, ner make an 
engagement with him immediately after, se that there be any hurry 
of mind while tking them. 
Upon the observance of these rules, especially the first, offert 
depends the patient's capability of taking tbod at all, or, if he 
amiable and forces himself te take food, of deriving any nourishment 
frein if. 
A nurse should never put before a patient milk that is sour, neat 
or soup that is turned, an egg that is bad, or vegetables underdone. 
Yet often I bave seen these things brought in te the sick in a state 
perfectly perceptible te every nose or eye except the nurse's. If is 
here that the clever nurse appears ; she will net bring in the peccant 
article, but, lOt te disappoint the patient, she will -hip up something 
else in a few minutes. :Remember that sick cookery should half de 
the work of your por patient's weak digestion. But if y_ou fltrther 
impair if ith your bad articles, I know net xvhat is te become of 
him or of 
If the nurse is an intelligent being, and net a mere carrier of 
diets te and frein the patient, let ber exercise her intelligence in 
these things. :How often we bave known a patient eut nothing af 
all in the day, because one meal was left untasted (af that time he 
was incapable of eating), af another the milk was sour, the third was 
spofled by seine other accident. And if never occurred te the nurse 
te extemporize seine expedient,--it never occurred te her that as he 
had had no solid food that da-y, he might eut a bit of toast (say) 
with his tea in the evening, or he rnight bave seine meal an heur 
earlier. A patient who canner touch his dinner af two, will offert 
accept if gladly, if brought te hiln at seven. But somehow nurses never 
"thi_uk of these things." One would imagine they did net consider 



wuoE :ooD ? 39 

themselves bound to exercise their judgment; they leave it to the 
patient. Now I mu quite sure that it is better for a patient rather 
to suffor these neglects than to try to teach his nurse to nurse him, 
if she does hot know how. If ruffies him, and if he is ill he is in 
no condition fo teach, especlally upon himself. The above remarks 
apply much more to private nursing than to hospitals. 
I would say fo the nurse, bave a rule of thought about your 
patient's diet ; consider, remembcr how much he bas had, and how 
much he ought to bave to-day. Gcnerally, the only rule of the 
private patient's diet is what the nurse has to give. It is truc she 
cannot give him what she has hot got ; bat his stomach does hot wait 
for ber convenience, or cven ber necessity, v If it is used to having 
its stinmlus at one hour to-day, and to-morrow it does not bave 
it, because she bas ihilcd in getting if, he will surfer. She must 
be always exercising her ingenuity to supply defccts, and fo remedy 
accidents which will happcn among the best contriversi but ff'oto 
which the patient does hot surfer the less, because "thcy cannot be 
helped." 
One very minute cautlon,--take cure hot to spi]l into your 
patient's saucer, in other words, take cure that the oatside bottom 
rira of his cup shall be quite dry and clcan ; if, every rime he lifts his 
cup to his lips, he has to curry the saucer with if, or else to drop 
the liquid upon, and to soil his sheet, or his bed-gown, or pillow, or if 
he is sitting up, his dress, you have no idea what a dittbrence this 
minute want of cure on vour part makes fo his comtbrt and even fo 
his willingness for food 

urse 1]lus 
have some rule 
of thought 
about ber 
paticnt's diet. 

Keep your 
patient's cup 
dry under- 
neath. 

VIL WttAT FOOD ? 

I w;ll mention one or two of the most common errors among 
women in charge of sick respecting sick diet. One is the belief that 
beef tea is the most nutritive of all articles. Now, just try and 
boil down a lb. oi' beef into beef tea, evaporate vour beef tea, and 
sec what is left of your beef. You will find that tlïere is barely a tea- 
spoouful of solid nourishment fo halfa plat ofwater in beef tea;--never- 
thcless there is a certain rcpoErative quality in it, we do hot know 
v:hat, as there is in tea ;--but if nmy safely bc givcn in ahnost any 
infiammatory diseuse, and is as little to be depended upon with the 
healthy or convalescent where much nourishment is required. Again, 
it is an ever ready saw that an egg is equivalent to a lb. of meat, 
whereas it is hot af all so. Also, it is seldom noticed with how mauy 

* Why, because the nurse has hot got some food to-day which the patient takes, 
can the patient wait four hours for food to..day, who could hot wait two hours yester- 
da)- ? Yet this is the only logic one geuerally hears. On the other hand, thc other 
logic, riz., of the nurse giving a patient a thing because she ]tas got if, is equally 
fatal. If she happens to have fresh jell3; or fresh fruit, she will frequently give 
it to the patient half-an-hour af ber his dinner, or at his dinner, when he oennot 
possibly eut that aud the broth too--or worse still leave it by his bed-side till he 
is so sickencd with thc sight of it, that he cannot eut it af ail. 

Common 
error in diet, 

Becf tca. 

]Nurse must 
hve Solne rule 
of time about 
the patient's 
diet. 



Eggs. 

)[eat without 
vegetables. 

A rrowroot. 

Iilk, butter, 
ceanl, &e. 

Intelligent 
crarings of 
particular sick 
for partieular 
articles of 
diet. 

pafienCs, particulnrly of nervous or bilious tempcrnmen, eggs dsugree. 
All puddhgs nmde wih eggs, are distas¢eçul fo them in consequence. 
An egg, wMpped up wih wine, is offen the only ibrm in hich they 
can tfle his kind onourishmen. A gain, if he pnien bas atained 
to eathg meat, i is supposcd tha fo give him men is the 
catir thing needil for his rccovery; vhereas scorbc sores bave 
bcgn acually nown ¢o appear among sick persons living in the 
mids of plenty iu England, which cold be traced ¢o no other source 
than tlfis, riz. : tlm the nurse, depending on mea nlone, had nllowed 
fle pafien fo be ithou vegcables ibr a consderable rime, flmse 
latter bcilg so bndly cookcd tlmt he alwnvs lef thcm untouched. 
Arrowroot is another grand dependence or / the nurse. As a vehicle 
for wine, and as a restorative quiekly prcpared, it is all very well. 
]ut it is nothing but tareh and vater. Flour is both more nutri- 
tive, and less liable to tbrlnent, and is preferable wherever it tan be 
used. 
Again. milk and the prcparations from milk, are a mos important 
article of tbod tbr the siek. Butter is he lightest kind of mlimal fat, 
and though it wants the sugar and some of the other elements whieh 
thcre are in milk, yet it is lnOSt valuable both in itself and in enabling 
the patient to eat more bread. Flour, oats, groats, barley, and their 
kind, are as we have already said. pretbrable in all their preparations 
to all the preparations of arrow roof, sagq, tapioca, and their kind. 
Cream, in many long chronic diseases, s quite irreplaceable by 
any othcr article whatever. It seems to act in the saine manner 
as beef tea, and fo most i is much casier of digestion than milk. 
In lhct, it seldom disagrecs. Cheese is not usuallv digestible bv the 
sick, but it is pure nourishment tbr repairing wate; and l'bave 
seen sick, and hot a few either, whose craving tbr eheese shewed how 
lnuch i was needed by them.* 
But, ift?esh milk is so valuable a food for the slek, the leas chauge 
or sourness in it, nmkes t of a]l articles, perhaps, the most injurious ; 
diarrhoea is a eommon resulg of fl'esh milk allowed to beeome at 
sour. The nurse therefore ought to exereise her utmost eare in this. 
]n large institutions for the siek, even the poorest, he utmost eare is 
exercised. Wenhmn Lake ice is used tbr this express purpose eveT 
summer, hile the private patient, perhaps, never fastes a drop of 
milk that is hot sour, all through the hot weather, so little does the 
privatc nurse undertand the neeessity of sueh tare. Ye, if you 
consider tha the only drop of real nourishment in your patient's tea 
is the drop of milk, and how mueh almos all English patients depend 
* In tbe diseases produeed by bad food, sueh as seorbutie dysentery and 
diarrhoea, the patient's stomaeh offen eraves tbr and digests things, some of whieh 
eertainly would be laid down in no dietary that ever was invented tbr siek, and 
espeeially hOt for sueh siek. ïhese are fruit, piekles, jams, gingerbread, fat of 
haro or of baeon, suet., eheese, butter, milk. OEhese eaaes I have seen hOt by ones, 
nor by tens, but by lmndreds. And {he paticnt's stomaeh was right and fle book 
was wrong. The aieles eraved tbr, in these cases, might have been principally 
arranged under the two heads of tt and vegetable aeids. 
There is offen a mafl;ed diflbrcnee between men and women in this marrer 
of siek teding. Women's digestion is generally s]ower. 



upou their tea, you xvill see the great importance of hot depriving 
your patient of this drop of nfilk. Buttermilk, a totally different 
thing, is oit.en very useful, especially in tbvers. 
In laying down rules of diet, by the amounts of "solid nutri-8'eet thiDgs. 
nent" in different ldnds of tbod, if is constantly lost sight of what 
the patient requires to repair his waste, xvhat he can take and what 
he can't. ou cannot diet a patient from a book, you cannot make 
np the human body as yoa would lnake up a prescription,--so many 
parts '" carboniferous," so many parts "nitrogenous " xvill consti- 
tttte a perfect diet for the patient. The narse's observation here 
ill materially assist the doctor--the patient's "iancies" will 
materially assist the nurse. For instance, sugar is one of the most 
nutritive of all articles, being pure carbon, and is particularly recon» 
mended in some books. But the vast majority of al_[ patients in 
EnglalM, young and old, nmle and female, rich and poor, hospital and 
private, dislike sweet things,--and while I have never known a person 
take fo sweets when he was iii who disliked theln when he xvas well, 
I bave knon lnany fond ofthem when in health, who in sickness would 
leave off anything sweet, even to sugar in tea,--swêet puddings, 
sweet drinks, are their aversion; the furred tongue almost always 
likes -hat is sharp or pungent. Scorbutic patients are an exception, 
thev offert crave tbr sweetmeats and jams. 
"Jelly is another article of diet in great favour with nurses and Jelly. 
friends of the sick; even ff it could be eaten solid, if would hot 
nourish, but if is shnply the height of folly fo take  oz. of gelatine 
and make if into a certain bulk by dissolving it in water and then to 
give if fo the sick, as if the mere bulk represented nourishment. If 
s now known that jelly does hot nourish, that if has a tendency to 
produce diarrhoea,--and to trust fo if to repair the waste of a diseased 
constitution is silnply to starve the sick under the guise of t?edil:g 
them. If 100 spoonthls ofjelly were given in the course of the da)-, 
you would bave given one spoonful of gelatine, hich spoonful has 
no nutritive power whatever. 
And, nevertheless, gelatine eontains a large quintity of nitrogen, 
hich is one of the most powerflfl elements in nutrition; on the 
other hand, beef tes mav be chosen as an illustration of -eat nutrient 
power in sickness, co-ëxisfing vith a very small amount of solid 
nitrogenous marrer. 
[Dr. Christison says that "everv one will be struck with the readi- Beef tes. 
ness ith which" certain classes o'f "patients will often take diluted 
lneat juice or beef tes repeatedly, when they refuse all other kinds of 
food." This is particularly remarkable in "cases of gastric tver, 
in hich," he says, "little or nothing else besides beef tes or dfluted 
meat juice" bas been taken for weeks or even months, "and yet a 
pint of beef tes contains scarcely ¼ oz. of alything but water,"--the 
result is so striking that he asks what îs ifs mode of action ? "2-ot, 
simply nutrient-- oz. of the most nutritive material cannot nearly 
replace the dafly wear and tear of the tissues in any circumstances. 
Possibly," he says, "if belongs fo a new denomination of remedies." 
It has been observed that a small quantity of beef tea added fo 



-/2 

OTE S OT 

Observation, 
hot chemistr; 
must decide 
sick diet. 

ttome-made 
bread. 

Sound obser- 
vation bas 
scarcely yet 
been brought 
to bear on sick 
diet. 

other articles of nutrition augments their power out of all proportion 
fo he adà;tional amount of solid marrer. 
The reason why jelly should be innutritious and beef tea nutrl- 
flous fo the sick, is i secret yet undiscovered, but if clearly shows 
that careful observation of the sick is the only clue to the best 
dietary. 
Chemistry bas as yet afforded little insight into the dieting of sick. 
All fhat chemistry can tell us is the amouut of "carboniferous" or 
"nitrogenous" elements discoverable in different dietetic articles. 
If bas given us lists OE dietetic substances, arranged in the order of 
their richness in one or other of these principles ; but that is all. In 
the great m:jority of cases, the stomach of the patient is guided by 
other principl_es of selectiou than merely the amount of carbon or 
nitrogen in the diet. :No doubt, in this as in other things, nature has 
very definite rules for ber guidance, but these rules can only be 
ascertained by thc most careful observation af fhe bed-side. She 
there tcaches us that living cbemistry, the chemistry of reparation, is 
something difibrent ff'ou the chemietry of the laborafory. Organic 
chenfistry is usefltl, as all knowledge is, when we corne face fo face 
vith nature; but it by no means ibllows that we should learn in the 
laboratory any one of the reparative processes going on in disease. 
Again, the nutritive power of milk and of the preparations from 
milk, is very much undervalued; there is nearly as auch nourish- 
ment in hall a pint of milk as there is in a quarter of a lb. of meat. 
But this is not the whole question or nearly the -hole. The main 
question is vhat the patient's stomach can assimilate or derive 
nourishment ff'oto, and of this the patient's stomach is the sole judge. 
Chemistry cannot tell this. The patient's stomach must be its own 
chemist. The diet which will keep the healthy man healthy, vill kill 
the sick one. The saine beef which is the most nutritive of all meat 
and which nourishes the healthv man, is the least nourishing of all 
food to the sick man, whose hal]-dead stomach can assimilate no part 
of if, that is, make no food out of if. On a diet of beef tea heaithy 
men on the other hand speedily lose their strength. 
I have known patients live for manv ronths vifhout touching 
bread, because they cotflà hot eat baker bread. These were mostly 
country patients, but not all. :Home-ruade bread or brown bread is 
a most important article, of diet for many patients. The use of 
aperienfs may be entirely superseded by if. Oat cake is another. 
To vatch for the opinions, tben, which the pafient's stomach gives, 
rather fhan to read "analyses of foods," is the business of all those 
vho have fo sertie what he patient is fo eat--perhaps file most 
important thing fo be provided tbr him after the air he is fo breathe. 
Now the medical man who sees the patient only once a day or even 
on]y once or twice a week, cannot possibly tel] thîs without the 
assistance of the patient himself, or of those who are in constant 
observation on the patient. The utmost the medical man can tell is 
whether the patient is weaker or stronger at this visit than he was af 
the last visit. I shou]d therefore say that incomparably the most 
impooEant oifice of the rira'se, after she has taken care of the patient's 



air, is fo take care fo observe the effect of his food, and report is to 
the medical attendant. 
It is quite incalculable the good that xvould certaiuly corne from 
such so«nd and close observation in this almost neglected branch ot 
nursing, or he help if would give fo the medical man. 
A great deal too much against tea:: is said by wise people, and a 
great deal too much of tea is given to the sick by ibolish people. 
When you see the natural aad ahnost universal crttving in English 
sick for their "tea," vou canuot but feel that nature knows what she 
is about. ]ut a litle tea or coffee resfores theln quite as much as 
a great deal, aud a great deal of fea and especiŒElly of coffee impairs 
the little power of digestion they havc. Yet a nurse because she 
sees how one or two cups of tea or coffee restores her patient, thinks 
that three or four cups will do twice as much. This is hot the case 
af all; if is however certain that there is nothing yet discovered 
which is a substifmte fo the English patient for his cup of tea ; he 
can take if when he can take nothing else, and he often can't take 
anything else if he has it not. I shofld be very glad if any of the 
abusers of tea would point out what fo give to an Euglish patient 
a'ter a sleepless night, instead of tea. If you give if af 5 or 6 o'clock 
in the morning, he may even sometimes fall asleep after if, and get 
perhaps lais on]y two or three hours' sleep during the twenty-four. 
At the saine time, you never should give ,t.ea or coffee to the sick, 
as a rule, after 5 o c[ock in the affernoon. Sleeplessness in the carly 
night is from excitement generally and is increased by tea or coffee ; 
sleeplessness which continues fo the ear!y morning is tom exhaustion 
often, and is relieved by tea. The ouly Euglish patients I bave ever 
known refuse tea, have been typhus cases, and fhe first sign of theie 
getting better was their craving again br tea. In general, fhe dry 
and dirfy tongue always prefers tea to coffee, and will quite decline 
milk, maless with tea. Cofie is a bctter restorative than tea, but a 

* It is ruade  frequent recommendation to persons about o incur grea ex- 
haustion, either from the nature of the service or from their being not in a state 
fit for it, to eat a piece of bread before they go. I wish the recommenders would 
thcmselves try the expcriment of sbstituting a piece of bread for a cup of tea or 
coffee or beef tea as a refresher. They would find it a very poor coInfort. When 
soldiers bave fo set out fasting on fatiguing duty, when nurses bave to go 
fasting" in o their patients, it is a ho restorative they wnt, and ought fo haï-e, 
before they go, not a cold bit of bread. And dreadful bave been the consequênces 
of neglecting" this. If thcy can take a bit of bread with the hot cup of tea, so 
much the bêtter, but hOt i,stead of it. The fact that there is more nourishInent 
in bread than in almost anything else bas probably induccd the mistake. That 
it is a fatal mistake there is no doubt. It seems, though ver)" little is known on 
the subject, that what "assimilates" itself directly and with the least trouble 
of digestion with the human body is the best for the above circumstances. Bread 
requires two or thrce processes of assimilation, beforc it becomes likc the huma 
body. 
The almost univêrsal testimony of English men and womcn who have un- 
dergone great fatiguc, such as riding long journeys without stopping, or sitting 
up for sêveral nights in succession, is that they could do it best upon an occasional 
eup of tea--nd nothing else. 
Let expericnce, not theory, decide upon this as upon all other things. 

and cofee. 



OTES O URSIG. 

Cocoa. 

Bulk. 

greater impairer of the digestion. Let the patient's taste decide. 
You will say that, in cases of great thirst, the patient's craving 
decidês that if will drink a 9reat deal of tea, and that you cannot help 
if. But in these cases be sure that the patient requires diluents for 
quite othcr purposes than queuching the thirst; he wants a great 
deal of some drink, hot only of tea, and the doctor will ortier what 
t:e is to lmve, barley water or lemonade, or soda water and milk, as 
the case nmy be. 
Lehluann, quoted by Dr. Christison, says that, anaon the well 
and active "the infusiou of 1 oz. of roasted coffce daily will diminish 
thc waste" going on in the body "by one-tburth," and Dr. Christison 
adds that tea has the salue property. Now this is actual experiment. 
Lchmalm weighs thc man and finds the tb.ct froln his weight. It is 
hot deduced from any " analysis" of food. All experience among 
the sick shows the saine thing.  
Cocoa is often rccommcnded fo the sick in lieu of tea or coffee. 
:But indepeudcntly of the tict that English sick verv generally dislike 
cocoa, it lins quine a differcnt cltct ri'oin tea or coifee. If is an oily 
starchv mit having no restorative power af all, but simply increasing 
lat. :[t is pure mockery of the sick, theretbre, fo call if a substitute 
for tea. or auy relmvating stimulus it has, you might just as well 
ofir thenl cheSllUts instead of tea. 
An ahnost universal error alnong nurses is in the bulk of the food 
and especially the drinks they offer to their patients Suppose a 
patient ordered -t oz. brandy duriug the day, how is he fo take this if 
you lnake it into four pints with diluting it ? The saine with tea and 
beef tea, with arrowroot, milk, &c. 3:ou have not increased the 
nourishlnent, you have not increased the renovating power of these 
articles, by increasingtheir bnlk,--you bave very likely diminished both 
by giving the patient's digestion more fo do, and most likely of all, 
the patient will leave hall of what he bas been ordered to take, 
bccause he cannot swallow the bulk with which you bave been pleased 
to invest if. If requires very nice observation and cure (and meets 
vith hardly any) to determine what will hot be too thick or strong 
ibr the patient to take, while giving him no more thau the bulk 
Mich he is able fo swallow. 
* In making coffee, it is absolutely nccessary to buy if in the berry and grind 
i af home. Otherwise you may reckon pon its containing a certain amoun of 
chicory, at least. This is hot a question of the taste or of the wholesomeness of 
chicory. It is that chicory bas nothing at all of the properties for which you 
give coffee. And therefore you may as well hot give it. 
Again, M1 laundresses, mistresses of dairy-farms, hcad nmes (I speak of the 
good old sort only--women who unite a good deal of hard manual labour with 
the head-work necessarv for arranging the day's business, so that noue of if shall 
tread upon the heels (f something else) set great value, I have observed, upon 
having a high-priced tea. This is called extravagant. But these women are 
"' cxtwg'ant" in nothing else. And thcy are right in this. ReM tea-leaf tea alone 
conains the restorative they want; which is hot to be found in sloe-leaf tea. 
The mistresses of houses, who cannot even go over their own house once 
a-day, are incapable of judg'ing for these women. For they are incapable them- 
selves, to .'tll appearance, of the spirit of arrangement (no small task) necessary 
for managing  large 'ard or dairy. 



BED AND BEDDING.  

VIII. BED AND BEDDING. 

A few words upon bedsteads and bedding; and principally as Feverishnes 
regards patients who are entirely, or almost entirely, confined to bed.  symptom of 
Feverishness is generally supposed to be a symptom of lever--- bedding. 
in nine cases out of ten it is a symptom of bedding.* The patien 
bas lmd re-introduced into the body the em,nations from himself 
which dav after day and week after week saturate lais unaired bed- 
ding. How eau it be otherwise ? Look at the ordinary bed in which 
a patient lies. 
:If :I were looking out for an example i order fo show whaç hot Uncleanliness 
fo do, I should take the specimen of au ordinary bed in a private ofordinary 
bouse : a woodeu bedstead, two or even three mattresses piled up fo bedding. 
above the height of a table; a vallance attached to the frame 
nothing but a miracle could ever thoroughly drv or ait- such a bed 
and bedding. The patient must iuevitztbly alernate between cold 
damp after his bed is ruade, and warm damp before, both saturated 
with organic matter,î" and this from the aime the mattresses are put 
under him till the time they are picked fo pieces, if this is ever done. 
If vou consider that an adull in health exhales by the lungs and 
s]in i the twentv-four hours three pints at least of moisturc, loaded 
vith organic matter ready to enter into putrefaction ; that in sickness 
the quantity is offert greatly increased, the quality is alwavs nmre 
noxiousjust ask vourself uext where does all this moisturè go to? 
Chieflv into the beldit)g, because it cannot go anywhere else. And le 
stars "there ; because, except perhaps a weekly change of sheets, 
scarcelv anv other airing is attempted. A nurse will be careful fo 
fidgeli(mss "about airing the cleau sheets froln clean damp, but airing 
the dirty sheets from noxious damp will ncver even occur to her. 
Besides tbis, the most dangcrous etfluvia we know of are ri'oto the 
excreta of the sick--these are placed, af least temporarily, where they 
must throw their effiuvia into the under side o" the bed, and the 
space under the bed is never aired ; it cannot be, with out arrange- 
ments. :Must hot such a bed be alwavs saturated, and be always 
the means of re-introducing into the system of the unfortunate 
patient who lies in iç, that excrementitious matter to eliminate which 
from the body nature had expressly appoiuted the disease ? 
[v heart always sinks withiu me when I hear the good house- 
wife, (f every class, say, ":I assure you the bed bas been well slept 
« I once told a "very good nurse" that the way in which her patient's room 
ws kept was quite enough to account for his sleeplessness; and she ŒEnswered 
quite good-humouredly she was hot at ail surprised ŒEt itas if the state of the 
room were, like the state of tlle weathel; entirely out of ber power. 1Vow in what 
sense was this woman to be called a "nurse." 
T For the saine reason if, after washing a poEtient, you must put the saine 
night-dress on him again, always give it a preliminary warm at the tire. The 
night-gown he has worn must be, to a certain extent, damp. It bas now got 
cold from haring been off him for a feue minutes. The tire will dry and at the 
samc aime air it. This is much more important than with clean things. 

Air your dirty 
sheets, hot 
only your 
clean one 

Nurses often 
do hot think 
the sick-room 
any business of 
theirs, but 
only the sick. 



6 

lqOTES ON lqURSI:hG. 

Iron spring 
bcdstead the 
best. 

Comfort and 
clcanliness of 
two bcds. 

Bcd not fo bo 
too wide 

13cd hot fo be 
too high. 

in," and I can onlv hope if is hot true. What ? is the bed already 
saturated with sonebody else's damp before my patient COlnes fo 
exhale into it his own damp ? Has if hot tmd , single ch,nce to be 
aired ? No, not one. "If bas been slept in every night." 
The only way of really nursing a real patient is to bave an iron 
be.dstead, with rheocline springs, which are permeable by the air up 
to the vcry mattress (no vallauce, of course), the mattress to be a 
rhin hmr one; the bed to be not above 3{ feet wide. If the patient 
be entirely confined fo his bed, here should bc wo such bedsteads ; 
each bed fo be "made" with mattress, sheets, blankets,'&c., complete 
--the patient fo pass twelve hours in each bed ; on no account to 
carry his sheets with him. The whole of the bedding fo be hung up 
fo air for each intermediate twelve hours. Of course there are many 
cases where this canuot be doue at all--many more v;here oulv an 
approach fo if can be m,de. I ara indicating the ideal of nursing, 
aud what I have actually had doue. But about the kind of bedstead 
therc can be no doubt, wh,'ther there be one or two provided. 
There is a prejudice iu favour of a wide bed[ believe if fo be 
a prejudice. All the refrcshment of nmving , patient from one side 
fo the other of his bed is far more effectually secured bv puttiug 
him into , fresh bed ; and a patient who is really very il[ does not 
stray far in bed. :But it is said there is no room to put a tray down 
on a narrow bed. ro good nurse will ever put a trav on  bed af all. 
]f the patient can turn on his side, he will eat more comfortably 
from , bed-side table; aud on no accourir whatever should a bed 
ever be higher than , sofa. Otherwise the patient feels hunself 
"out of humanity's reach"; he can get af nothing for himself: he can 
move nothing for 1,imself. If the patient cannot turn, a table over 
the bed is a better thing. I need hardly say that a patient's bed 
should never bave its side ,ngainst the wall. Tbe nurse must be 
able to get easily to both sides the bed, and to reach easily every 
part of the patient without stretching--a thing impossible if the bed 
be either too wide or too high. 
When I see a patient in a room aine or ten feet high upon a bed 
between ibur and rive feet high, with his head, when he is sitig up 
iu bed, actually within two or three feet of the ceiling, I ask myself, 
is this expressly planned to produce that peculiarly distcessing 
feeling common to the sick, riz., as if the v;,lls and ceiling were 
closing in upon them, and they becoming saudwiches between floor 
and ceiling, which imagination is hot, indeed, here so far from the 
truth ? If, over and above this, the v;indow stops short of the 
ceiliug, then the patienUs head mav literallv be raised ,qbove the 
stratum of fresh air, even when the w'indow is ôpen. Can human per- 
versity anv farther go, in unmaking the process of restoration which 
God bas ade ? The thct is, that the heads of sleepers or of sick 
should never be higher than the throat of the chimney, which ensures 
their being in the current of best air. And we will not suppose it 
possible that you haro closed your chimney with  chimney-board. 
If a bed is higher than a sofa, the difference of the fatigue of 
getting in ,nd out of bed will jus make the diflbrence, vez_-- often, to 



m. 47 

the patient (who can get in and out of bed af all) of being able fo 
take a few lninutes' exercise, either in the open air or in another 
room. If is so very odd that people never think of this, or of how 
manv more rimes a patient who is in bed for the twenty-four hours 
is olliged fo get in and out of bed than they are, who only, it is fo be 
hoped, get into bed once and out of bed once during the twenty-four 
hours. 
A patient's bed shou|d lwavs be in the lightest spot in the room ; 
and he should be able fo sec out of window. 
I need scarcely say that the old four-post bed with curtains is 
utter)y inadmissible, whether for sick or well. Hospital bedsteads 
are in many respects very much less objectionable than private 
ones. 
There is reason fo believe that hot a few of the apparently unac- 
countable cases of scrofllla among children proceed from the babil. 
of sleeping with the head under the bed clothes, and so inhaling air 
already brea.thed, which is thrher contaminated bv exhalations ff'oto 
the skin. Patients are sometimes given fo a sinilar habit, and 
often happens that the bed clothes are so disposed tht the patient 
mus necessarily breathe air more or less contaminated by exhala- 
tions from his skin. A good nurse will be careful fo attend fo his. 
I is an important part, so fo speak, of ventilation. 
If may be worth while to remark, that where there is any danger 
of bed-sores a bloEnket should never be placed under he patient. 
retains damp and acts like a poultice. 
Never use anything but light Witney blankets as bed covering 
for the sick. The heavy cotton impervious counterpue is bad, for 
Che very rcason that if keeps in the emanations f.'om the sick person, 
while the blanket allows them fo pass through. Weak patients are 
invariably distressed bv a great weight of bed-clothes, which offert 
prevents their getting any sound sleep whaever. 
l-o.--One word about pillows. Every weak patient, be his illness what it 
nay, suffers more or less from diculty in breathing. To ake the weight of the 
body off the poor ehest, which is hardly up fo its work as if is, ought thereîore to 
be the objec of the nurse in arranging his pillows. Now what does she do and 
what are the eonsequences ? She piles the pillows one a-top of the other like 
wall of bricks. The head is tl,rown upma the chest. And the shoulders are 
pushed forward, so as hot fo allow the lungs room fo expand. The pillows, in 
fat. lean upon the pxtient, hot the patient upon the pillows. If is impossible to 
give a rule for this, because if must vary with the figure of the patient. And tll 
patients surfer much more than short ones, because of the drag of the long limbs 
npon the waist. But the objec is fo support, with the pillows, the baek below 
the breathing" apparatus, to allow the shoulders room fo îall back, and fo support 
¢he head, without throwing if forward. The suffering of dying patients is im- 
nescly increased by nelect of these points. And many an invalid, too weak 
to drag about his pillows himself, slips his book or anything af hand behind the 
lower par of his back fo support if. 

Nor in a dark 
place. 
or a four 
poster with 
cmains. 

Scroîula offert 
a result of dis- 
position of 
bedclothes. 

Bed sores. 

Heavy and im- 
pervious bed- 
clothes. 

IX. LIG]KT. 
I is the unqualified resu]t of ail my exper,.'ence with the sick, Light esscntal 
to both health 
that second only fo their need of iesh air is their necd of light ; and recovery. 



Aspect, view, 
;md sunlight 
matters of first 
importance 
to the sick. 

that, after a close room, what hurts them most is a dark room. 
And that itis hot only light but direct sun-light they want. I had 
rather havc the power of carrying my patient about after the sun, 
according fo the aspect of the rooms, if circumstances permit, than 
let hiln linger in a room when the sun is off. People think the effect 
is upon the spirits only. This is by no means the case. The sun is 
not only a painter but a sculptor. You adroit that he does the 
photograph. Without going into any scientific exposition we must 
admi that light has quite as real and tangible effects upon the 
hnman bodv. ]3ut this is hot all. Who bas hot observed the 
purifying ebct of light, and especially of direct sunlight, upon the 
air of a room ? ]tere is an observation within everybody's expe- 
rience. Go into a room where the shutters are Mways shut, (in  
sick room or a bedroom there should never be shutters shut), and 
though the room be uninhabited, though the air has never been 
polluted by the breathing of hnman beings, you will observe a close, 
nmsiy smell of corrupt air, of air i. e. unpurified by the effect of the 
sun's ravs. Tbe nmstiness of dark rooms and corners, indeed, is 
provcrbiàl. The cheerthlness of a room, the usefulness of light in 
treating disease is ail-important. 
A very high authority in hospital construction has said that 
peoplc do hot enough consider the difference between wards and 
dormitories in planning their buildings. But I go thrther, and say, 
that bealthy people never remember the difference between bed- 
roons and sick-rooms, in making arrangements for the sick. To a 
sleeper in health it does hot signit wlmt the view is from his bed. 
He ought never fo be in it excepting when asleep, and at night. 
Aspect does hot very much signiy either (provided the sun reach 
his bed-room some time in every day, to puriIv the air), because he 
ought never fo be in his bed-room except during the hours wl:en 
there is no sun. But the case is exactly reversed with the sick, even 
should they be as many hours out of their beds as vou are in vours, 
which probably thev are hot. Therefore, that the should bë able, 
without raising theînselves or turning in bed, to sec out of window 
from their beds, fo see skv and sun-light af least, if you eau show 
them nothing else, I assert fo be, if not of the very first importauce 
tbr recovery, af least something very near it. And you should there- 
tbre look to the position of tbe beds of your sick one of the very first 
things. If they can see out of two windows instead of one, so much 
the better. Again. the morning sun and the mid-day sun--the hours 
when they are quite certain hOt to be up, are of more importance to 
them, if a choice must be ruade, than the afternoon sun. Perhaps 
yon can take them out of bed in the afternoon and set them br the 
window, where they can see the sure ]3ut the best rule "is, if 
possible, fo give them direct sun-light from the moment he rises till 
the lnoment he sers. 
Another gTeat difference between the bed-room and the sic]:'-room 
is, that the sleeper has a verv large balance of fresh air to begin with, 
when he begins the night, f his room bas been open all day as it 
ought fo be; the sic]c man bas not, because all day he has been 



CLEAxLI-ESS OF :ROG.-IS AID WALLS. 49 

breathing the air in the saine room, and dirt5ing it by the emanations 
I¥om himself. Far more care is therefore necessary fo keep up a 
constant change of air in the sick room. 
If is hardlv necessarv fo add th:lt there are acute cases, (particu- 
larlv a few ophthalmic cases, and diseases where the eye is morbidly 
sensitive), where a subdued light is necessarv. ]3ut a dark north 
room is inadmissible even br these. ]ou can" alwax, s moderate the 
light by blinds and curains. 
Heavy, thick, dark -indow or bed curtains should, however. 
hardly ever be used tbr any kind of sick in this country. A light 
white curtain at the head of the bed is, in general, all that is neces- 
sary, and a green blind fo the window, fo be drawn down only when 
necessarv. 
One bf the greatest observers of human things (hot physiological), 
savs, in another language, " Where there is sun there is thought." 
Ail physiology goes fo confirm this. Where is the hady side of 
teep v.lleys, thcre is cretinism. Where are cellars and the un- 
unned sides of narrow streets, there is the degeneracy and weakli- 
ness of the human race--mind and body equally degenerating. Put 
the pale withering plant and hmnan being into the sun, and, if hot 
too thr gone, each will recover health md spirit. 
It is a curious thing to observe how ahnost all patients lie with 
their faces turned to the light, exactiy as plants always make their 
way towards the light; a patient will even complain that if gives 
him pain "lying on that side." "Then why do you lie on that 
side ?" He does hot know,--but we do. If is because if is the side 
towards the window. A fashionable physician has recently published 
in a government report that he always turns his latients' thces from 
the light. Yes, but nature is stronger than fashionble physiciaus, and 
depend upon if she turns the faces back and towa,'ds such light as 
she can get. Walk through the wards of a hospital, remember the 
bed sides of private patients yoa bave seen, and count how many sick 
you ever saw lying with their taaces towards the wall. 

Without sun- 
light, we de- 
gencrate body 
and mind. 

Almost all 
patients fie 
with thcir 
faces to the 
light. 

X. CLEAILINESS OF ]00_IS AND WALLS. 

If cannot be necessarv to tell a nurse that she should be clean. 
or that she should keep ]mr patient clean,--seeing that the greater 
part of nursing consists in preserving cleanliness. Lo ventilation 
can freshen a room or ward where the most scrupulous cleanliness is 
hot observed. Unless the wind be blowing through the vindows at 
the rate of twenty mlles an hour, dustv carpets, dirty wainscots, 
lnust-curtains and furniture, will infalli'blv produce a close sine!l. 
I haî-e lived in a large and expensively fùrnished London bouse, 
where the only constant inmate in two very loïty rooms, with 
opposite widows, vas myselI; and yet, owing fo the abovementioned 
dirty circumstances, no Olening of windows could ever keep those 

Cleanliness of 
carpets and 
furniture. 



IOTES OH :NU:RSIG-o 

Dtls ll(ver 1-c I 
OEoved nOW. 

Floors. 

Papered, 
plastcred, oil- 
lainted walls. 

rooms free from closeness; but the carpet ancl curtains having 
been turned outof the rooms altogether, they became instantly as 
fresh as could be wishcd. If is pure nonsense to say that in 
London a room canno be kcp clean. SIany of our hospitals show 
the exact reverse. 
Butno 1)article of dust is ever or can ever be rcmoved or really 
go rid of by thc present system of dusting. Dusting in these days 
means nothig but flapping the dust from one part of a room on fo 
another with doors and windows closed. What you do i for I 
canno thinL You had much better leave the dust alone, if you 
are hot going to take if away altogether. :For from the rime  room 
begins fo be a room up to the rime when i ceases to be one, no one 
atom of dust evcr actually lcaves ifs precincts. Tidying a room 
means nothing now but removing a thing from one place, which if 
has kept cleau ibr itseli on fo another and a dirtier one.  :Flapping 
by way of cleaning is only admissible in the case of I)ictures, or 
• nythiag ruade of paper. The only way 1 know to remoce dust, the 
plague of all loyers of fresh air, is to wipe everything with a damp 
cloh. And all furniture otght to be so marie as that if may be 
wipcd with a damp cloth vthoutinjury fo itself, and so polished as 
that it may be damped withou injury to others. To dust, as if 
is now practised, truly means fo distribute dust more equally over a 
room. 
As to floors, the only really clean floor I know is the :Berlin 
lackered floor, which is wet rubbed and dry rabbed every morning 
fo remove the dust. The French pa.ruet is always more or less 
dusçy, although infinitely superior m poit of cleanliness and 
healthiness to our absorben floor. 
:For a sick room, a carpe is Ferhaps the wors£ expedient whlch 
could by any possibility bave been invented. If you must bave a 
carpet, the only safety is to take if up two or three rimes a year, 
instead of once. A dirty carpct literally infects the room. And if 
you consider the enormous quantity of organic marrer from the feet 
of pe.op.le coming in, which mus saturate if, this is by no means 
surprsmg. 
As for walls, the wors is the papered wall; the next worst is 
plaster. :But the plaster can be redeen:ed by frequent lime-washing; 
the paper requires frequent renewing. A glnzed paper gets rid of a 

Iow  room is 

« If you like to clcan your furniture by laying out your clcan clothes upon 
your dirty chairs or sofa, this is one way certainly of doing it. Having witnessed 
he morning precess called '" tidying the reom," for many ycam, and with ever- 
increasing astenishment, I can describe what it is. From the chairs, tables, or 
sofa, upon which the "things" have lain during the night, and hich are there- 
fore comparatively clean ri'oto dust or blacks, the poor "" thigs" having "caught'" 
it, they are remeved fo other chairs, tables, sofas, upon which vou could 
vrite yeur naine with your finger in the dust or blacks. The other ide of the 
"thinœes" is thereïere now evenly dirtied or dusted. ïhe housemaid thcn flaps 
every thing, or some things, hot out of her reach, with a thing called a duster 
the dust flics ep, then re-seltles more equa]ly than if lay beforc thc otcrafion. 
ŒEhe room bas ow been "put to rights." 



CLEAILINESS OF IIOOMS AND LLS. i 

good deal of the danger. But the ordinary bed-room paper is all 
that if ought eot fo be.* 
The close connection between ventilaf.io and cleanliness s 
shown in this. An ordinary light pal»er will last clean mach longer 
if there is an Arnott's ventilator in the chimney than it otherwiso 
would. 
The best vall now extant is oil paint. From this you carr wash 
the animal exuvioe.t 
These are what male a room musty. 
The best wall Ibr a sick-rooln or ward that could be ruade s 
pure white non-absorbent cernent or glass, or glazed files, if thev 
were ruade sightly enough. 
Air can be soiled just like water. If you blow into water 
you will soil it with the animal lnatter from vour breath. Soit is 
with air. Air is always soilcd in a room vhèrc walls and carpets 
are saturated with animal exhalations. 
-ant of cleafliness, then, in rooms and wards, wMch you have 
fo guard against, may arise in three ways. 
1. Dirty air coming in from without, soiled by sewer emanations, 
the evaporation from dirty streets, smoke, bits of unburnt fuel, bits 
of straw, bits of horse dung. 
If people would but cover the outside walls of their houses vith 
plain or encaustic tiles, what an incalculable improvement would 
there be in light, cleanliness, dryness, warmth, and consequently 
economy. The play of a fire-engine would then effectually wash the 
outide of a house. This kind of walli would stand next to paving 
in improving the health of towns. 
2. Dirty air coming from witMn, ri'oto dust, which you often 
displace, but never remove. And this recalls what ought tobe a 
sie «d wn. Have as few ledges in your room or ward as possible. 
And under no pretence bave auy ledge whatever out of sight. Dus 
accumulates there, and xvill never be wiped off: This is a certain 
way fo soil the air. Besides this, the animal exhalations ff'oto your 
inmates saturate your furniture. And if you never clean your 
furniture properly, how can vour rooms or wards be anything but 
mustv ? lentilate as you p'lease, the rooms will never be sweet. 
Besides this, there is a constant d«.qraclatio» as it is called, taking 
place from everything except polished or glazed articles--E. ,., in 
colouring certain green papers arsenic is tsed. Now in the very 
dust even, which is lying about in rooms hung with this kind of 
green paper, arsenic bas been distinctly detected. You see your 
dust is anythlng but harmless ; yet you will let such dust lie about 
your ledges for .months, your rooms ibr ever. 
« I m sure that a person who bas accustomed ber senses to compare atmo- 
spheres proper and improper, for the sick and for children, could tell, blindfold, 
the difference of he air in old painted and in old papered rooms, ccetersparibes. 
The latter will ahvays be musty, even with all the windows open. 
- If you like fo wipe your dirty door, or some portion of your dirCy wall, by 
hanging up your clean gown or shawl against it on a peg, this is one wav cer- 
tain;y, and the most usual way, and gencrally the ouly way of cleaning eithe; door 
or wall ina bed-room ! 
Z2 

Best kind of 
wall for a 
sick-room 

Dirty air from 
without. 

Best kind of 
wall for a 
bouse. 

Dirty air from 
within. 

Atmos-phere in 
puinted ud 
papered rooms 
quite distin- 
gaishable. 
How fo keep 
your wall clean 
ai the expence 
ofyour clothes. 



52 OTES O- UItSIbTG. 

Dirty air from 
thc carpet. 

Rcmcdics, 

Again, the tire fills the room with coal-]ust. 
3. Dirty air coming from the ca.rpet. Above all, take cure of the 
carpets, that the animal dirt left there by the feet of visitors 
does hot stay there. Floors, unless the grain is filled up and 
polished, are just as ba]. The smell from the floor of a school-room 
or ward, when any moisture brings out the orgauic lnatter by which 
if is saturated, might alone be enough to warn us of the mischief 
that is going on. 
The outer air, then, can onlv be kept clean by sanitary improve- 
ments, and by consuming smole. The expense in soap, which this 
singlc iml)rovement would sure, is quite incalculable. 
The inside air can only be kept clean by excessive cure in the 
ways mentioucd above---to rid the walls, carpets, furniture, ledges, 
&c., of the organic marrer and dust--dust consisting greatly of this 
organic matter--with which they become saturated, and which is 
what really makes the room lnusty. 
Without cleanliuess, you cannot have all the effect of ventilation ; 
without vetilation, you can have no thorough cleanliness. 
Yery few people, be they of what class they may, have any idea 
of the exquisite cleanliuess required in the sick-room. :For much of 
what I bave said applies less fo the hospital than to the private sick- 
room. The smoky chimney, the dusty furniture, the utensils 
emptied but once a day, often keep the air of the sick constantly 
dirtv in the best private bouses. 
he well have a curious habit of forgetting that what is to them 
but a trifling inconvenience, tobe patiently " put up " with, is to 
the sick a source of suffering, delaying recovery, if hot actually 
hastening death. The welI are scarcely ever more than eight hours, 
at most, in the saine room. Some change they can always make, if 
only for a bw minutes. Even during the supposed eight hours, they 
can change their posture or their position in the room. But the 
sick man, who never leaves his bed, who cannot change by anv 
movelnent of his own his air, or his light, or his warmth; who cannot 
obtain quiet, or get out of the smoke, or the smell, or the dust ; he is 
really poisoned or depressed by what is to you the merest trifle. 
" What can't be cured nmst be endured," is the very worst and 
most dangerous maxlrn for a nurse which ever was ruade. :Patience 
and resiguation in her are but ot-her words for carelessness or 
indifference---contenTtible , if in regard fo herself; culpable, if h 
regard to her sick. 

XI. PERSO:NAL CLEA:NLI:NESS. 

Poisoning_by 
the skin. 

In almost all diseases, the function of the skin is, more or less, 
disordered; and in many most ilnportant diseuses nature relieves 
hersclf ahnost entirely by the skin. This is particularly the case 
with children. :But the excretion, which cornes from the skin, is ]eft 
there, unless removed by washing or by the clothes. Every nurse 



PEIISONAL CLEAILIITE SS. 53 

should keep this fact constantly in mind,--for, if she allow her sick 
to remain unwashed, or their clothing o remain on thein after being 
satm'ated with perspiration or other excretion, she is interfering 
injuriously with the natural processes of health just as eflbctlally as 
if she were fo give the patient a dose of slow poison by the n.outh. 
Poisoning by the skin is no less certain than poisoning by the mouth 
--only itis slower in ifs operation. 
The amount of relief and comfort experienced bv sicl¢ after tlle Ventilation 
skin has been carefully washed and dried, is one of "the commonest andskin-clean- 
observations ruade ata sick bed. ]3ut it lnust hot be forgotten t]lat liness eqully 
the comfort and relief so obtained are hOt all. They are, in fact, essential. 
nothing more than , sign that the vital powers have been relieved by 
removing something that was oppressing them. Thc nurse, thcre- 
fore, must never put off attending to the persona! cleanliless of ber 
patient under the plea that all that is fo be gailled is t little relief, 
hich can be quite as well given 1,ter. 
I all well-regulated hospitals this ought tobe, and geller,lly is, 
attended fo. B,t itis vcry generally neglected -ith private sick. 
Just as if is necessary to renew the air round a sick person 
freqtently, fo carry off morbi eittuvia from the lungs and skin, by 
maintaining free ventilation, sois it necessary fo keep the pores of 
the skin free from all obstructiug excretions. The object, both of 
ventilation and of skin-cleanliness, is pretty much the same,--to wit, 
removing noxious matter from the system as rapidly as possible. 
Care should be taken in all these operations of sponging, -,shing, 
and cleansing the ski, hOt to expose too great a suribce af once, so 
as fo check the perspiration, which would renew the evil in another 
form. 
The wtrious ways of washing the sick need hot here be specified, 
--the less so as the doctors ought fo say which is fo be used. 
In several forms of diarrhcea, dysentery, Ac., vhere the skin is 
hard and harsh, the relief aflbrded by washing with a great deal of 
soft soap is incalculable. In other cases, sponging with tepid soap 
and water, then with tepid water and drying with a hot towel vill be 
ordered. 
Every nurse ought fo be careful fo wash her hands very fre- 
quently during the day. If her face too, so ranch the better. 
One word as fo cleanliness merely as cleanliness. 
Compare the dirtiness of the water in which you bave washed Steaming and 
when it is cold without soap, cold with soap, hot with soap. ¥ou rubbing the 
will find the first has hardly removed any dirt af ail, the second a skin. 
little more, the third a eat deal more. But hold your hand over a 
cup of hot water for a minute or two, and then, by merely rubbing 
with the finger, you will bring off flakes of dirt or dirty skin. Ai'ter " 
a vapour bath you nay peel your whole selfclean in this way. Ahat 
I mean is, that by simply washing or sponging with water you do hOt 
really clean your skin. Take a rough towel, clip one corner in very 
hot water,if a little spirit be added fo if if will be more effectual, 
and then rub as if you were rubbing the towel into your skin 
with your fingers. The black flakes which will corne off will convince 



you that you were not clean before, however much soap and water 
you bave use& These flakes are what. require removing. And vou 
can really keep yourself cleaner with a tumbler of hot water and a 
rough towel and rubbing, than with a whole apparatus of bath and 
soap and sponge, without rubbing. It is quite nonsese fo say that 
anybody need be dirty. :Patients have been kept as clean by these 
means on a long voyage, when a basin full of water could hOt be 
ailbrded, and when they eould hot be movcd out of their berths, as 
if al| the appurtenanees of home had been af hand. 
Washing, however, vith a large quantity of water has quite other 
efibets thau those of mere elcanliness. The sldn absorbs the water 
aud becomes softer and more perspirable. To wash ith soap and 
soft -ttter is, therefore, desirable f,'om other points of view than that 
of eleauliness. 

Advising the 
sick. 

Chattering 
hopes tlm bane 
of the sick. 

XII. CIIATTERING tIOPES AND ADVICES. 

The sick man fo his advisers. 
"My advisers! Thcir naine is legion, e e e 
Solnehow or other, if seems a provision of the universal destlnies, 
that every man, xvoman, and child should consider him, ber, or itself 
privileged especially to advise me. Why ? That is precisely what 
1 ant to know." And this is hat I have fo say fo them. I have 
been advised fo go to every place extant in and out of Inglandto 
îake every kind of exercise by every kind of cart, carriage--yes, 
and even swing (!) and dumb-bell (!) in existence; to imbibe every 
differeut kind of stimulus that ever bas been invente& And this 
-hen those best fitted to know, riz., medical mena, after long and 
close attendance, had declared any journey out of the question, had 
prohibited any kind of motion whatever, had closely laid dowr. the 
diet and drink. What would my advisers say, were they the medical 
attendants, and I the patient left their advice, and took the casual 
adviser's ? But the singularity in Legion's mind is this: if never 
occurs fo him that everybody else is doing the saine thing, and that 
I the patient must perforce say, in sheer self-defence, like tlosalind, 
" I could hot do with all." 
" Chattering tIopes" may seem an odd heading. But I really 
believc there is scarcelv u greater worry -hich invalids bave fo endure 
than the incurable boxes of their friends. There is no one practice 
against which I can speak more strongly from actual personal expe- 
rience, wide and long, of its effects during sickness observed both upon 
others and upon myself. I would appeal most seriouslv fo ail friends, 
visitors, and attendants of the sick fo leave off t'his practice of 
attempting fo "cheer" t.he sick by making light, of their danger and 
by exaggerating their probabilities of recoverv. 
Far more now than formerlv does the mëdical attendant te!l the 
truth to tlle sick who are rea.ily desirous fo hear it. about their own 
state. 



CIIATTERING IIOPES AN'I) AD¥ICES. 55 

]:OW intnse is te folly, then, te say the leastof if of the friend, 
be he cven a medical man, who thinks that his opinion, given ai'ter a 
cursory observation, will weigh with te patient, against te opinion 
of the medical attendant, given, perhaps, aftcr yeara of observation, 
after using eve]3T help te diagnosis afibrded by the stethoscope, the 
examination of pulse, tongue, &c. ; and certainly after much more 
observation than the friend can possibly bave had. 
Supposing the patient te be possessed of commo_ sense,--how 
can the "favourable" opinion, if L is te be ca]led a.n opinion at all, 
vf the casual visiter " cheer " him,when difirent frein that of the 
experienced attendant ? Unquestionably the latter ma.y, and often 
d.»es, turn out te be wrong. But which is most likelv te be 
wrong ? 
The fact is, that the patient * is net "cheered" aiall by these 
wdl-meaning, most tiresomc friends. On the contrary, he is de- 
pmssed and wearied, li on the one hand, he exerts himselfto tell 
ea-'h successive nember of this too numerous conspiracy, whose 
nane is legion, why he does net think as they do,--in what respect 
he is worse,what symptoms exist that they know nothing of,--he 
is fa.tigued instead of " cheercd," and his ,attention is fixed upon 
hinseIf. In general, patients who are real]y ill, de netwnnt te talk 
about themselvcs. .Eypochondriacs de, but again I say  e are net 
on he subject of hypochondrics. 
If, on the other hand, and which is much more frequent]y the case, 
the patient says nothing, but the Shakespearian "Oh !" "Ah!" "Go 
te!' and "n good sooth !" in order te escape frein the conversation 
about himself the sooner, he is depressed by want of sçmpathv, rie 
feeh isolated in the midst of friends. ]:[e feels what a'convenlence if 
wot:ld be, if there were any single person te whom he ceuld speal 
sina?ly and openly, without pulliaag t.he string upon himself of this 
 There are, of course cases, as in firsC confinements, when an assurancc frein Xbsurd statis- 
,he doctor or experienced nurse te the frightened suflring woman that therc is tical compari- 
nothing unusual in her case, tht she has nothing te fear but a few hours' pain, sons ruade in 
may cheer her most effectull-. This is advice of quite another order. If is the common con- 
:dvice of experieuce te utter inexperience. But the advice we bave been refer- versation by 
ring te is the advice of inexperience te bitter experieuce ; and, in general, the most sen- 
amounts te nothing more than this, tht you think I shall recover frein consump- sible people 
t_on, bec,use somebody knows somebody somewhere who h recovered frein for the benefit 
f¢ver, of the sick. 
I bave heard a doctor condemned whose ptient did net, alas ! recover, be- 
cause another doctor's patient of a diffèrent sex, of  different age, recovered 
fmm  different disease, in a dfferet place. Yes, this is really true. If people 
wo make these comparisons did but know (only they de net care te know), the 
care and preciseness with which such comparisons rcquire te be ruade, (and are 
]ade), in order te be of any value whatever, they would spare their tongues. In 
ccmparing the deaths of one hospital with those of another, any statistics are 
ustly considered absolutely valueless which de net give the ages, the sexes, and 
t[e diseases of all the cases. It does net seem necessary te mention this. It does 
n0t seem necessary te say t.hat there can bc no comparison between old men with 
dropsies nd young women with consumpions. Yet the cleverest men and the 
.clevercst women are often herd making such comparisons, ignoring eutirely sex, 
a$e, disease, place---in fact, (dl the conditions essential te the question. I is the 
mcrcst gossi). 

Patient does 
net want te 
talk of himsclf. 

Absurd conso- 
lations put 
forth for the 
benefit of the 
sick. 



6 OTES ON IURSIIG. 

Wonderfulpre- 
sumpion of 
he advisers of 
he sick. 

shower-b,th of silly hopes and encouragements; fo whom he could 
express his wishes and directions without that person persisting in 
saying "I hope that it will ple,se God yet fo give you twenty 
years," or, " ¥ou bave , long life of activity before you." How 
ot'ten we see at the end of biographies or of cases recorded in medical 
papers, ",fter a long illness A. died rather suddenly," or, "unex- 
pectedly both fo himself and fo others." "Unexpected]y" fo others, 
perhaps, ho did hot see, bec,use they did hot look; but by no 
mealS " unexpectedly to himself," as I feel entitled fo believe, both 
from the infernal evidence in such stories, and from watching similar 
cases: there was every reason to expect that A. would die, and 
knew it ; but he found if uscless fo insist upon his ovn knovledge 
to his friends. 
In these remarks I ara ,lluding neither fo acute cases whih 
terminate rapidly nor fo "nervous " cases. 
By the first much interest in their own danger is verv rarelç frit. 
In ritins of fiction, hether novels or biogïaphies, thes'c deatl-beds 
are generally depicted as ahnost seraphic in lucidity of intelligence. 
Sadly large has been my experience in death-beds, and I can oaly 
say that ] ]lave seldom or never seen such. Indifference, exceptJng 
with regard fo bodily suffering, or fo some duty the dying nan 
desires to pertbrm, is the ihr more usaal state. 
The "nervous case," on the other hand, delights in figuring to 
himself and others a fictitious danger. 
But the long chronic case, who knows too well himself, and -ho 
bas been told by lais physici,n that he will never enter active life 
again, who feels that every month he has to give up something he 
could do the month before--oh ! spare such suflbrers your chatte:ing 
hopes. You do not know how you worry and wear " them. uch 
real sufferers cannot bear to talk of themselves, stil less fo l_ope 
for what they cannot at all expect. 
So also as fo all the advice showered so profusely upon such sick, 
to leave off some occupation, fo trv some other doctor, some other 
bouse, climate, pill, powder, or specfic ; I say nothing of the incon. 
sistencyfor these advisers are sure to be thc s,me persons 
exhorted the sick man not fo believe his own doctor's prog- 
nostics, because "doctors are aln,vs mistaken," but fo believe soins 
other doctor, because "this doctcr" is alwavs righ." Sure also ara 
these advisers fo be the persons fo bring t'he sick man ïresh occup- 
tion, while exhorting him fo leave his own. 
Vonderful is the tce -ith which friends, lay and naedicd, 
wfll corne in and worry the patient with recommendations fo o 
something or other, havingjust as little knowledge as to ifs beixg 
feasible, or even sale for him, as if they were fo recommend 
man to t,'ke exercise, hot knowing he had broken his leg. Vht 
would the friend sa.y, if he were the medical attendant, and if 
the patient, because some otlze" friend had corne in, because some- 
body, anybody, nobody, had recommended something, anything, 
nothing, were to disregard his orders, and take th,t other body:s 
recommendation ? ]3u people never think of this. 



CH.TTER]:G HOIS ,ID AD¥IC:ES.  

A celebrated historical personage bas related the common- 
places which, v;hen on the eve of executing a remarkable reso- 
lution, were showered in r, early the saine words by everv one 
around successively ibr a period of six months. To thee the 
personage statcs that if was round least trouble always fo reply 
the saine thing, riz., that if could hot be supposed that such a 
resolution lmd been takea without sufilcient previous consideration. 
To piients enduring every day for years from every fi.iend or 
accluaintance , either by letter or vivâ voce, some forment of this kind, 
I 'ould suggest the saine answer. It would indeed be Sl»ared, 
if such friends and acquaintances would but consider for one 
moment, that it is probable the patient has heard such advice af 
least fifty rimes before, and that, had it beea practicable, t would 
have been practised long ago. But of such cosideritio there 
appears to be no chance. Strange, though true, that peolle should 
be just the smne in these things as they were a few hundrcd years 
ago ! 
To me these commonplaces, lcaving their smear upon the cheerful, 
single-hearted, constant devotion to duty, which is so often seen in 
the decline of such sufferers, recall the slimy trail left by the snail on 
the sunny southern garden-wall loaded with f-uit. 
zNo mockery in the world is so hollow as the advice showered 
upon the sick. Itis of no use ibr the sick fo sayanything, tbr what 
the adviser wants is, not *o know the truth about the state of the 
patient, but to turn whatever the sick may sav fo the support of his 
own argument, set forth, it must be repeated, without any inquiry 
-hatever into the patient's real condition. "But it would be im- 
pertinent or indecent in me to nmke such an inquiry," says the 
adviser. True; and how much more impertinent is if to give your 
advice when you can know nothing about the truth, and adroit vou 
could not inquire into it. 
To nurses I saythese are the -isitors who do your patient 
barre. Vhen you hear him told :--1. That he bas nothing the 
xaatter with him, and that he wants cheering. 2. That he is com- 
• uitting suicide, and that he wants preventing. 3. That he is the 
tool of somebody who makes use of him for a purpose. 4,. That he 
will listen to nobody, but is obstinately bent upon his own vay; 
and 5. That he ought to be called to the sense of duty, and is fiying 
in the face of Providence ;then know that your patient is receiving 
all the injury that he can receive from a visitor. 
:ttow little the real sufferings of illness are known or understood. 
:ttow little does any one in good health fancy him or even hersel[ into 
the lii'e of a sick person. 
Do, you v;ho re about the sick or who visit the sick, try and give 
them pleasure, remember to tell them what will do so. How often in 
such visits the sick person bas to do the whole conversation, exerting 
his own imagination and memory, while you would take the visitor, 
absorbed in his own anxieties, making no effort of memory or 
imagination, ibr the sick person. " Oh! mv dear, I bave so much fo 
think of, I real!y quite forgot to tell hiln tient ; besides, I thought he 

Advisers the 
Sl,lD.e D.OW aS 
two hundred 
 ears ago. 

]Iockery of 
the advice 
givea to sick. 

[eans of 
givingplca- 
sure to the 
sick. 



would know if," says the visitor fo another friend. :How could "he 
know it "? Depend upon if, the people n-ho say this are really those 
vho bave little " fo think oL" There are many buloEhened with 
business who alwavs manage to 1;eep a pigeon-hole in their minds, 
ïull of things to te]l the "invalid." 
I do hot sa3" , don't tell him your anxieties--J believe itis good 
for him and good for you too; bt if you tell him what is anxious, 
surely you can remember to tell him what is pleasant too. 
A sick person does so enjoy hearing good nen-s :--for instance, 
a love and courtship, while in progress to a good ending. If vou tell 
him only when the marriae takes place, he loses hall the lleasure, 
which God knows he has little enough of; and ten to one but you 
bave told him of some love-making nith a bad. ending. 
A sick person also intensely enjoys hearing of any «lc«terial good, 
any positive or practical success of the right, tte has so much of 
books .nd fiction, of princil)les , and precepts, and tbeories; do, in- 
stead of advising him with ad ice he has heard at le.st fifty rimes 
before, tell him of one benevolent act which bas really succeeded 
practically,it is like a d.y's health fo him.* 
You have no idea what the craviag of sick wit undiminished 
power of thinking, but little power of doing, is to hear of good 
practical action, 'hen they can no lotager partake in if. 
Do observe these things with the ick. Do remember how their 
life is to them disappointed and incomplete. ¥ou ee them lying 
there with miserable disappointments, f'roln which they can have no 
escape but death, and you can't remember to tell them of what would. 
give them so much pleasure, or at least an hour's variety. 
They don't Tant you to be lachrymose and whining with them, 
they like you to be i'esh and. active and interested, but they cannot 
bear absence of mind, and they are so tired of the advice and preach- 
ing they receive from every bod.y, no naatter whom iC is, they see. 
ŒEhere is no better ociety than bab_es and sick people tbr one 
.nother. Of course you must mariage this so that neither shall 
surfer from it, which is perfectly possible. If you think the "air of 
the sick room" bad t'or the baby, why it is bad for the invalid too, 
and, therefore, you will of course correct it for both. It freshens up 
a sick person's whole mental atmosphere to see " the baby." And 
very young child, if unpoiled, will generally adapt itself wonderfally 
o the ways of z sick pcrson, if the time they spend togecher is hot 
too long. 
If you lnew hÇw unreasonbly icl people uffer from rensonable 
causes of distress, ¥ott vould take more pains about all these things. 
.An iffant laid. tp¢;n the ick bed will do the sick person, thus oEer- 
mg, more good than all your logic. A piece of good news will d.o 
the saine, lerhaps you are ataid of "disturbing" him. ou say 
thcre is no comfort for hispresent cause of affliction. [t is perfectly 
« A small pet animal is often an excelle..t companion for the sick, for long 
ehronic cases especially. A pet bird in  cage is 8ometimes the only plesure of 
an invalid eonfined for years to the saine room. If he cn feed and clean the 
animal himself, he ought alwys to be encouraged to do 



OBSEI¥ATIO Ol TIE SICK. 59 

reasonable. The distincfion is this, if ]:e is obliged to act, do hot 
"disturb" hm with another subject of thought just yet; help him 
fo do what he wants fo do : but, if he ]tac done this, or if nothing 
can be done, then "disturb" him by all means. You will relieve, 
nmre effectually, unreasonable suffering from reasouable causes by 
telling him "the news," showing him "the babv," or giving hiln 
something new to think of" or to look at than by :qll the logic in the 
world. 
If has been very justly said that the sick are like children in this, 
that there is no proportion in events fo them. :Now it is your busi- 
ness as their visitor fo restore this right proportion for them--to 
shew them what the rest of the world is doing. How can they fiud 
if out otherwise ? You will final thenl far more open fo conviction 
than children in flis. And you will find that their unreasonable 
intensity of suffering groin unkindness, from want of sympathy, &c., 
will disappear with their freshened interest in the big world's events. 
But then  ou must be able to give them real interests, hot gossip. 

l-oE.--Therc are two classes of patients which are unfortunately becomin Two new 
norc common every day, especially among womcn of the richer orders, to whom classes of 
all thcse remarks are pre-emincntly inapplicable. 1. Those who make health an patients pecu- 
excuse for doing nothing, and af thc saine timc allcge that the bcing able to do liar fo this 
nothing is their only grief. 2. Those who bave brought upon themseles il-generation. 
health by over pursuit of amusement, which they and their friends have most 
unhappily called intellcctual activity. I scarcely know a greater injury that can 
be iuflicted than the advice too offert given to the first class "to vegetate " 
or than the admiration too often bestowed on the latter class for "pluck." 

XIII. OBSERVATIOR  OF THE SICK. 

There is no more silly or universal question scarcely asked than 
his, "Is he better ?" Ask it of the medical attendant, ifyou please. 
But of whom else, if vou wish for a real answer fo your question, 
would you ask -;t ? ertainly not of the casual visitor; certainly 
hot of the nurse, while the nurse's observation is so httle exercised 
as if is now. What you want are ihcts, not opinions--for who can 
have any opinion of any value as fo whether the patient is better 
or worse, excepting the constant medical attendant, or the really 
observing nurse ? 
The most important practical lesson that can be given fo nurses 
is to teach them wbat fo observe--how fo observe--what symptoms 
indicate improvement--what the reverse--which are of importance 
--which are of none--which are the evidence of neglect--and of 
what kind of neglect. 
All this is what ought to make part, and an essential part, of the 
training of every nurse. Af psent how few there are, either pro 
fessional or unprofessional, who really -know af al] whether any sick 
person they may be with is better or worse. 
The vagueness and looseness of the information one receives in 
answer to that much abused question, "Is he better?" would be 

What is tbe 
use of the 
question, Is he 
better ? 



6O 

]OTES O :çqU:RSIxTG. 

ludicrous, if if were hOt painful. The onlv sensible answer (in the 
present state of knowledge about sickness) would be " How can I 
know ? I cannot tell how he was when i was hot with him." 
I can record but a very few specimens of the answers  which I 
have heard made bv friends and nurses, and accepted by physicians 
aud surgeons at tire very bed-side of the patient, who could have 
contradicted every word, but did not--sometimes from amiabilikv, 
often from shyness, oftenest from languor ! 
" Ilow often have the boels acted, nurse ?" "Once, sir." 
This generally means that the utensil has been emptied once, it 
having becn used perhaps seven or eight rimes. 
" L)o you think the patient is much weaker than he was six weeks 
ago ?" " Oh no, sir ; yoa know it is very long since he bas been up 
and dressed, and he can get across the room now." This means that 
the nurse has not observed that whereas six weeks ago he sat up 
and occupied hilnself i1 bed, he now lies still doing nothing ; that, 
although he can "get across the room," he cannot stand ibr rive 
seconds. 
Another patient who is cating well, recoverilg steadily, although 
slowly, from lever, but cannot ,xalk or stand, is represented fo the 
doctor as making no progress at all. 

 If is a much more difficult thing to speak the truth than people commonly 
imagine. Thcrc is the want of observation si»q»le, and the want of observation 
copouM, compo,ndcd, that is, with the imaginati'e faculty. Both may equally 
intend to speak the truth. The information of the first is simply deïective. That 
of thc second is much more dangerous. The first gives, in answer fo a question 
asked about a thing that bas been before his eyes perhaps for years, information 
exceedingly imperïcct, or says, he does hot know. t=le has never observed. And 
people simply think him stupid. 
The second bas observed just as litfle, but imaginntion immediatcly steps in, 
and he describes the whole thing from imagination merely, being perfectly 
convinced all the while that he bas seen or heard if ; or he will repeat a whole 
convcrsation, as if it were inïormation which had been addressed to him ; whereas 
if is merely what he bas himself said to somebody else. This is the commonest 
oï ail. OEhese people do hot even observe that they have wt observed nor re- 
mcmber that they bave forgotten. 
Courts of j,,stice seem to think that any body can speak "thc whole truth 
and nothing but the truth," if he docs but intend it. It requires many faculties 
combined of obscrvation and mcmor)" to speak "the whole truth" and to say 
" nothing but the truth." 
" I knows I fibs dreadful : bu bclieve me, ]Iiss, I never finds out I bave 
fibbed until they relis me so," was a remark aetually ruade. It s aiso one of 
much more extended application than most people have the least idea of. 
Concurrence of testimony, which is so often adduced as final prooï, may prove 
nothing more, as is wcll known to those accustomed to deal with the unobservant 
imainative, than that one person bas told his story a great many rimes 
I have heard thirteen persons "concur" in declaring that a fourteenth, who 
had never left his bed, went to a distant chapel every morning at seven o'clock. 
I bave heard persons in perfect good faith declare, that a man camc to dine 
cvery day at the house where they lived, who had never dined there once ; that a 
person had ncver taken the sacramcnt, by whose side they had twice at least 
knelt af Communion; that but one meal a day came out of a hospital kitchen, 
-hich for six weeks they had seen provide from three fo rive and six meals a 
day. Such instances might be multiplied ad ùfiaitum if necessary. 



OIISRVATIOI 0' ]IE SIClï. 61 

Questions, too, as asked now (but too generally) of or about 
patients, would obtain no information af ail about them, even if the 
person asked of had every information to give. The questiou is 
generally a leading question; and if is singular that people noyer 
think what must be the aaswer fo this question before they ask 
if: for instance, " Has he had a good night?" Now, one patient 
will think he bas a bad night if ho has hOt slept ten hours without 
waking. Another does hOt think he has a bad night if ho has had 
interval. of dosing occasionally. The saine answer has actually been 
giron as regarded two patientsone who had been entirely sleepless 
ibr rive rimes twenty-four hours, and died of if, and another who had 
hot slept the sleep of a regular night, without waking. Why cannot 
the question be asked, tlow many hours' sleep has  had ? and 
af what hours of the night ? " I lmve never closed my eyes all 
mght, an answer as frequently ruade when the speaker has had 
several hours' sleep as whcn ho has had noue, would then be less 
often said. Lies, intentional and uuitentional, are much seldomer 
told iu answer to precise than to leading questions. Another 
frequent error is fo inquire whether one cause remains, and hot 
whether the eflbct which may be produced by a great nmny different 
causes, hot inquired after, remains. As when it is asked: whether 
there was noise in the street last night; and if there were hot, the 
patient is reported, without nore ado, to have had a good night. 
Patients are completely taken aback by these kinds of leading ques- 
tions, and give only the exact amount of information asked ibr, even 
when they know it fo be completely misleading. The shyness of 
patients is seldom allowed for. 
How few thero are who, by rive or six pointed questions, can 
elicit the whole case and get accurately to know and to be able fo 
report wlere the patient is. 
1 knew a verv clever physician, of large dispensary and hospital 
practice, who in'ariably began his examination of each patient with 
"Put your finger where you be bad." That nmu would never waste 
his time with collecting inaccurate information from ntrse or patient. 
Leading questions always collect inaccurate information. 
Af a recent celebrated trial, the following leading question was 
put successively fo nine distinguished medical men. " Can you attri- 
bute these symptoms fo anything else but poison ?" And out of the 
nine, eight answered "No !" without any qualification whatever. If 
appeared, upon cross-examination :1. That none of them had ever 
seen a case of the kind of poisoning supposed. 2. That none ofthem 
had ever seen a case of the kind of disease fo which the death, if not 
to poison, vas attributable. 3. That none of them were even aware 

Leading ques- 
tions useless 
or misleading. 

[eans of 
obtainin 
iaaccurate 
information. 

 ŒEhis is important, because on this depends what the remedy will be. If  
patient slceps two or three hours early in the night, and then does hot sleep 
again at all, ten to one it is hOt a narcotic he wants, but food or stimulus, or 
perhaps only warmth. If on the other hand, he is restless and awake all night, 
and is drovsy in the morning, he probabiy wants sedatives, either quiet, coolness, 
or medicine, a lighter diet, or all four. Now the doctor should be told this, or 
how can he judge what to give ? 



62 

OT]S Oh" UItSITO. 

As to food 
patienç takes 
or does 
takc. 

of the main çact of the disease and condition to wMch the death 
was attributable. 
Surely nothing stronger can be adduced fo prove what use leadng 
questions are of, and what they lcad fo. 
I had rather hot say how many instances :[ bave known, where, 
owing to this svstem of leading questions, the patient has died, and 
the attendants'have been actually unaware of the principal feature 
of the case. 
It is usc]ess to go through all the particu],rs, besides s]eep,  
u-ldch people have a pecuAar talent for glean]ng inaccurate infor- 
mation. As to tbod, for inst,nce, I often think that most common 
question, ttow is your appetite ? can only be put because the ques- 
tioner believes the questioned bas real|y nothing the marrer vith him, 
which is very often tbe case. :But where there s the remark holds 
gcod which has becn nmde about sleep. The s,ïe answer will often 
be madc as regards a patient who cannot take two ounces of solid 
food per diem, and a patient who does hot enjoy rive meals a day as 
nuch as usual. 
Again, the question, :How is your appetite ? s often put when 
:How is your digestion ? is he question meant. No doubt the two 
things depend on ont another. But they are quite different. IM:any 
a patient can car, if you can onlr "tcmpt his apetite." The hult 
lies in your hot having got hi the thing that he fancies. :But 
many another patient does not care between grapes and turnps,-- 
everything is c¢]ualiy dstasteful to him. He vould trv to eat anv- 
thing vhich would do hhn good; but everytMng "makes'hm worse:" 
The hult here generally lies in the cooking. It is hot his "appetite" 
vhich requires temptm., it is his digestion u-hich requres sparing. 
And good sick cookery vill save the digestion lmlf its work. 
There may be four diffcrcnt causes, any one of which will produce 
the saine result, riz, the patient slowly starving fo death from vaat 
of nutrition : 
1. ]efcct in cookhg; 
2. Defect in choice of det; 
3. Defect in choice of hours for taking diet ; 
. Defect of appetite in patient. 
Yet all these are generally comprehended in the one sweepiag 
assertion that the patient has "no appetite." 
Surely many lires night be saved by drawing a closer dlstinct]on; 
for the remedies are as diverse as the causes. The renedy for the 
rst is, to cook better; for the second, to choose other articles of 
diet; for the third, to w,tch for the hours when the patient is in 
vant of food; for the fcurth, to show him vhat he likes, and some- 
times unexpectedly. :But no one of these remedies vi]l do tbr any 
other çf the defects hot corresponding vith it. 
I cannot too often rcpeat that parleurs are genera]ly either too 
languid to observe these things, or too shy fo speak about them; nor 
is it vell that they should be nmde to observe them, it fixes their 
attention upcn thenselves. 



OBSERVATION OF TIIE SlCK. 63 
Again, I say, what is the nurse or friencl there for except fo take 
note of these things, instead of the patient doing so pi: 
Again, the question is sometimes put, Is there diarrhoea ? And As to diar- 
the answer will be the saine, whether if is just merging into choiera, rhoea. 
whether itis a trifling degree brought on by somo trifling indiscre- 
tion, which will ceise the moment the cause is removed, or whether 
there is no diarrhoea at a.ll, but simply relaxed bowels. 
If is useless fo multiply instances of this kind. As long as 
observation is so littlo cultivaçed as it is now, I do belleve that itis 
botter for the physician hot fo sec the friends of the patient at ail. 
They wi[l oftener mislead him than hot. And as often by making 
the patient out worse as better than ho really is. 
In the case of infauts, everjHin must depend upon the accurate 
observation of the nurse or mother 'ho bas fo report. And how 
seldom is tMs condition of accuracy fulfilled. 
,4_ celebrated man, though celebrated onlv for foolish thngs, has 
told us that one of his main objects in the elucation of hs son, was 
to give him a ready habit of accurate observation, a certainty of per- 
ception, and that for this purpose one of his means was a month's 
course as follows :--ho took the boy rapidly past a toy-shop; the 
çather and son thon described to each other as many of the objects as 
they could, which they had seen in passing the  indows, noting them 
dvwn with pencil and paper, and returning aferwards to verity their 
own accuracy. The boy always succeeded best, e.., if the father 
descr]bed 30 objects, the boy did 40, and scarcely evcr ruade a 
mistake. 
I hve often thought how wise a piece of education this would be 
for much higher objects ; and in our calling of nurses the thing itself 
is essential. :For it nmy safely be said, hot that the habit of ready 
and correct observation will by itself make us useful nurses, but that 
without it we shall be useless with all our devotion. 
I bave known a nurse in charge of a set of wards who hot only 
carried in ber head all the little varieties in the diets which each 
patient was allowed to fix for himself, but also exactly hat each 
patient had taken during each day. I have known auother nurse in 
charge of one single patient, who took away his meals day after day 
all but untouched, and noyer knew it. 
If vou find it helps you fo note down such things on a bit of 
paper,' pencil, by all means do so. I think if more ofen lames 
than strengthens the memory and observation, ttt if you cannot 
get the habit of observation one way or other, you had botter give up 
the being a nurse, for it is hot your ca]ling, however kind and 
anxious you may be. 
 It is commonly supposed that the nurse is there fo spare the patient from [ore impor- 
aaking physical exertion for himself--I would rather sa that she ought to be there tnt fo spzre 
to spre him from taking thought for himself. And I am quite sure, that if the the patient 
patient were spred all thought for hmself, nd hot spared all physical exertion, thought than 
ho would be infinitely the gainer. The reverse is generally the case in the private physical exer- 
bouse. In the hospitl it is the relief from all anxiety, afforded by the rules of a tion. 
'ell-regulated institution, which has often such  benficial effect upon the 
patient. 

[eans of 
cultivating 
sound and 
redy observa- 
tion. 



13= IOTES ON I-URSING. 

Sound and 
rcady observa- 
tion essential 
tu a nurse. 

English 
womea bave 
great capacity 
of but little 
practice in 
close obscrva- 
tion. 

Surely you tan ]earn af least to judge with the eye how much an 
oz. of soli(1 ibod is, how much an oz. of liquid. You wi]l find this 
helps Four observation an(1 memory very much, FOU will then say to 
yoursel[" "A. took about an oz. of his meat to day ;" " B. took three 
rimes in 2J hours about ¼ pint of beef tea;" instead of saying " B. 
has taken nothing all day," or " I gave A. lais dinner as usual." 
I bave known several of our real old-thshioned hospital "sisters," 
who could, as accurately as a measuring glass, measure out all their 
paticnts' wine and medicine bv the eye, and never be wrong. I do 
hot recommend this, one nmst'be very sure of one's self to do if. I 
onlv mention it, bccause if a nurse can by practice measure medicine 
bv he eye, surely she is no nurse -ho cannot measure by the eye 
about how nmch food (in oz.) ber patient has taken.  In hospitals 
those -ho cut up thc dicts give with quite sutficient accuracy, fo each 
patient, his 12 oz. or his (i oz. of meat without weighing. Yet a 
nurse xvill often have paticnts loathing ail food and incapable of any 
will fo get well, who just tumble over the contents of the plate or dip 
the spoon in the cup fo deceive the nurse, and she will take if away 
without evet" seeing that there is just the saine quantity of ibod as 
when she brought it, and shc will tel] the doctor, too, that the patient 
 It may be too broad an assertion, and it certainly sounds like a paradox. 
But I lhink that in no country arc women to be round so deficient in ready and 
sound observation as in England, while peculiarly capable of bcing trained to it. 
The French or Irish woman is too quick of perception to be so sound an observer-- 
the Teuton is too slow to be so reaely an observer as the English woman might 
be. Yet English womcn lay thcmselves open to the charge so often ruade against 
thcm by men, riz., that they are hot to be trusted in handicrafts to which their 
strength is quite cqual, for want of a practised and steady observation. In 
counlries wherc women (with avcrage intelligence certainly hot supeior to that of 
Englishwomen) are employed, e. g., in dispensing, men responsible for what these 
women do (hot theorizing about man's and woman's "missions"), have stated that 
ihcy prefcrrcd the service of women to that of men, as being more exact, more 
careful, and incurring fcwer mistakes of inadvertence. 
low certaïnly Englishwomen are peculiarly capable of attaining to this. 
I remembcr when a child, hearing the story of an accident, related by some 
one ho sent two girls to fctch a "bottle of salvolatile from her room; .... Iar T 
eould not stir," she said, "Fanny van and fetched a bottle that was hot salvolatile, 
and that wa.s hot in my room." 
h%w this sort of thing pursues every one through life. A woman is asked 
to fetch a large new bouud rcd book, lying on the table by the window, and 
he fetches rive small old boarded brown books lying on the shelf by the tire. 
And this, though she has"put that room to rights" evcry day for a month 
perhaps, and must have observed the books every day, lFing in the saine placcs, 
for a month, if she had any observation. 
Habitual observation is the more necessary, when any sudden call avises. If 
"Fanny" had observed "the bottle of salvo!atile " in "the aunt's room," every 
da)" she was there, she would more probably havc round it when if was snddenly 
wanted. 
There are two causes for thcsc mistakes of inadvertence. 1. A want of ready 
attention; only part of the request is heard at all. 2. A want of the habit of 
observation. 
To a nurse I would add, take care that FOU always put the same things in the 
same placcs ; Sou don't know how suddenly FOU may be called on some day to 
find something, and may hot be able to rcmembcr in Four haste where you Four- 
self had put it, if Four memory is hot in thehabit of seeing the thing there always. 



has eaten all his diets as usual, when all she ought te bave meant is 
that she has taken away bis diets as usual. 
:New what kind of a lmrse is this ? 
I would eall attention te something else, in which nurses ri'e- 
quent]y rail in observation. There is a well-marked distinction 
between the excitable and what I will call the accumulative tempera- 
ment in patients. One will blaze up af once, under any shock or 
anxiety, and sleep very comfortably afer if ; another will seem quite 
ealm and even torpid, under the sanie shock, and people say, "He 
hardly felt if af all," yet you will find him seine rime after slowly 
sinking. The same relnark applies te the action of narcotics, of ape- 
rients, vhich, in the one, take effect directly, in the other net 
perhaps for twentv-four hours. A journey, a visit, an unwonted 
exertion, will affec the one ilnmediately, but he recovers after if ; the 
other bears if very well af the tilne, apparently, and dies or is pros- 
trated for lii'e by if. People often sav how difficult the excitable 
temperament is te tonnage. I say how "diiIicult is tbe accumulative 
temperament. Yrith the first you bave an out-break which you could 
anticipate, and if is all over. With the second you never know where 
you nreyou never know when the consequences are over. And it 
requires your closest observation te know what are the consequences 
of whatfor the consequent by no means follows ilnmediately upon 
the antecedent--and coarse observation is utterly af fault. 
Almost all superstitions are owing te bad observation, te the ïost 
oc, erre V«otter hec ; and bad observers are almost all superstitious. 
l'armers used te attribute disease among cattle te witchcraft ; wed- 
dings have been attributed te seeing one magpie, deaths te seeing 
three; and I bave heard the most highly educated now-a-days draw 
consequences for the sick closely resembling these. 
Another remark: although there is unquestionably a physl- 
ognomy of disease as well as of health ; of all parts of the body, the 
face is perhaps the one which tells the least te the common observer 
or the casual visiter. Because, of ail parts of the body, it is 
the one most exposed te other influences, besides hêalth. And 
people never, or carcelv ever, observe enough te know how te dis- 
tinguish between the effect of exposure, of robust health, of a tender 
skin, of a tendency te congestion, of suffusion, flushing, or many 
other things. Again, the face is offert the last te shew emaciation. 
I should say that the hand was a lnuch surer test than the thce, both 
as te flesh, co]our, circulation, &c., &c. It is true that there are 
seine diseases which are onlv betruyed at all by something in the 
face, e.., the eye or the tongue, as great irritability of brain bv 
the appearance of the pupil of the eye. But we are talking of casua], 
net minute, observation. And few minute observers will hestate 
t,» say tbat far more untruth than truth is conveved by the off 
repeated words, :He loo]cs -ell, or ill, or better or worse. 
Wonderful is the way in which people will go upon the slightest 
observation, or ofte upon no observation at all, or upon seine saw 
wbich tlm world's experience, if if had any» would have proounced 
utterly false long ago. 

Difference oI 
excitable and 
tempcra- 
ments. 

Superstition 
the fruit of 
bad observa- 
ion. 

Physiog- 
nomyofdisease 
litle shewt 
by the face. 



66 

çOTES OT çURSING. 

Peculiarities 
of patients. 

Nurse nust 
vserve for 
herself in- 
crease of 
patient's weak- 
ness, patient 
vill hot tell 
ber. 

I bave knoxvn patients dying of sheer pain, exhaustlon, and want 
of sleep, ri'oto one of the most lingering and painful diseuses known, 
preserve, till vithin a few days of death, hot only the healthy colour 
of the eheek, but the mottled appearance of a robust child. And 
scores of rimes bave I heard these unfortunate creatures assailed with, 
"I ara glad fo see you looking so vell." "I see uo reason whv you 
should hot lire till ninety years of age." " Whv don't you ake a 
little more exercise and amusement ?" vlth all he other common- 
places with which we are so familiar. 
There is, unquestionably, a physiognomy of diseuse. Let the 
nurse learn if. 
The experienced nurse c,n always tel] that a person bas taken  
narcotic the night before by the patchiness of the colour about the 
facc, 'hen the re-action of depression bas set in ; that very colour 
which the inexperienced will point fo as a proof of health. 
There is, again, , fidntness. vhich does not betray itself by the 
colour af all, or in wMch the patient becomes brovn instead of white. 
There is a aintness of another kfid -hich, it ]s true, can always be 
seen by the paleness. 
But the nurse seldom dlstingulshes. She vill talk fo the patient 
who is too faint to more, vithout the least scruple, unless he is pale 
and unless, luckily for him, the muscles of the throat are affected and 
he loses his voice. 
Yet these two fahtnesses are perfectly distinguishable, by the 
mere countenance of the patient. 
Again, the nurse must distinguish between the diosyncracles o 
patients. One likes to surfer out all his suffering alone, to be as little 
looked after as possible. Another likes fo be perpetually ruade much 
of and pitied, and to have some one alvavs bv him. ]3oth these 
peculiarities might be observed and indulge] much more than they 
are. :For quite as often does t happen that a busv attendance is 
forced upon the first patient, vho vishes for nothing'but fo be "let 
alone," as that the second is ]eft fo think h]mself neglected. 
Again, I think that few things press so heavily on one suffering 
from long and incurable illness, as the necessity of recording in 
words from rime fo rime, for the infonuation of the nurse, vho vill 
hot otherwise see, that he cannot do this or that, vhich he could do 
a month or a year ago. hat is ŒE nurse there for if she cannot 
observe these things for herself? Yet I bave known--and known 
too mnong those--aud c]doE.g among those--whom money and 
position put in possession of everything vMch monev and position 
could give--I bave known, I say, more accidents, (ftal, slovly or 
rapidly,) arlsing from this want of observation amoug nurses than 
from almost anything else. Because a patient could get out of a 
warm-bath a]one a month ago--because a patient could walk as far 
as his bell a veek ago, the nurse concludes that he can do so now. 
She bas never observed the change; and the patient is lost from 
beug left in ŒE helpless state of exhaustion, till some one accidentally 
cornes in. And this hot from any unexpected apoplectic, paralytic, 
or iainting fit (though even these could be expected far more, af 



OBSErVaTION O THE ICo  

least, than they are now, if we did but observe). 
expected, or fo be expected, inevitable, visible, caleulable, uniuter- 
rupted inerease of weakness, which none need fitil fo observe. 
Again, a patient, hOt usutfily confined to bed, is eompelled bv an 
attaek of diarrhœea, vomiting, or other accident, to keep his bed for a 
few days; he gets up for the first rime, and the nurse legs him go 
into another room, without coming in, a few minutes afferwards, fo 
look afer him. If never oecurs o her that he is quite certain fo be 
faint, or eold, or fo wtmt something. 8he says, as her excuse, 
Oh, he does hOt like fo be fidgeted afer. Yes, he said so some 
weeks ago ; but he never said he did no like fo be "fidgetted armer," 
when he is in the state he is in now; and if he did, you ough fo 
make some excuse fo go in to him. [ore patients bave been lost in 
this way than is af ail generally known, riz., from relapses brought 
on by being let't for an hour or two faint, or cold, or hungry, afer 
getting up for the first rime. 
Yet if appears tlmt seareely any improvement in the faculey 
of observing is being lnade. Yast has been he inerease of know- 
ledge in pathology--that science whieh teaches us the final change 
produced by disease on the human framescarce any in the at of 
observing the simas of the change while in progress. Or, raher, is 
if hOt fo be feared that observation, as an essenial part of medieine, 
bas been deelining ? 
Whieh of us bas hot heard fifty 'imes, ri'oto one or another, a 
nurse, or a friend of the sick, aye, and a medietfl friend oo, the 
fo]lowing remark:"So A is worse, or ]3 is dead. I saw him 
he day belote; I thought him so much better; there eerainly 
was no appearanee from which one eould have expected so 
sudden (?) a change." I bave never heard anv one say, though 
one would think it the more natural thing, " There must have 
been corne appeamnee, which I should have seen if I had bu 
looked ; le me fa T and remember what there was, tha I mav observe 
another rime." No, this is no what people say. Thèy boldly 
assert that there was nothing fo observe, no tha their observation 
was at fault. 
Let people who bave fo observe sickness and death look back and 
try to register la their observation the appearances which have 
preceded relapse, attack, or death, anà hot assert that there were 
none, or that there were hot the riyht ones.  
A want of the habit of observing conàitions anà an inveterae 
habit of taking averages are each of them often equally misleading. 
* It falls fo few ever fo have had the opportunit.y of observing the different 
aspects which the human face puts on af the sudden approaeh of certain forms of 
death by violence ; and as it is a knowledge of little use I only mention it here 
as being the most startling example of what I mean. In the nervous tem- 
perament the face becomes pale (this is the only recognized effect); in the 
sanguine temperament purple; in the bilious yellow, or every manner of colour 
in patches. Now, if is generally supposed that palenes is the one indication 
of almost any violent change in the human being, whether from terror, disease, 
or anything else. There can be no more false observation. Granted, it is the 
one recognized liver; as I bave sad--de rigueur in novcls but nowhere else. 
r2 

o, from the 

Accidents 
arising from 
the nurse's 
want of obser- 
vation. 

Is the faculty 
of obsem-ing 
on the decline. 

Observation 
of general 
conditions. 
Approach of 
death, paleness 
by no means 
an ivariable 
effect, as we 
find in nove]s. 



( IOTES O NURSI. 

Ien whose profession like that of med]cal men leads them to 
observe only, or chiefly, palpable and permanent organic changes are 
often just as wrong in their ol)inion of tbe result as those who do 
hot observe at all. For instance, there is a broken leg ; the surgeon 
bas only to look a it once fo kuow; i wiil hot be different if he 
sees i in the morning to what if would have been had he seen 
it in the evening. And in whatever conditions the patient is, or s 
likely fo be, tSere will still be the broken leg, until it is set, The 
saine with many organic diseuses. Au experienced physician has 
but fo fcel tbe puise once, and ho ktows that tbere is aneurism 
which will kill some rime or other. 
But with the grea majoriy of cases, there is nohlng of the kind ; 
and the l»ower of ibrmbg my correct opinion as fo the result must 
entirely depend upou an enquiry into all the conditions in which the 
patient lires. In a complicatd stte of society in large towns, 
dcath, as every one of grett experience knows, is far less often pro- 
duccd bv ay one organic diseuse tlan by some [lhess, after nmny other 
diseuses , producing just the sure of exlmustion necessary for deth. 
Tlmre is nothiug so absnrd, nothing so mislead[ng as the verdict one 
so ofen hears : 8o-and-so lins no organic disease,there is no reason 
'hy he should no live fo extreme old age; sometimes he clause 
is added, somethnes hot : Provdcd he bas quiet, good tbod, good 
&c., &c., &c. ; the verdict is repe,ted bv ignorant people wit]wut the 
latter clause; or there is no possib]lty of the conditions of the 
latter clause being obtained ; and this, the o///essential par of tle 
whole, is ruade of no effect. I bave heard a physicien, deservedly 
eminen, assure the friends of  patient of his recoverv. Why 
]3ecause he had now prescribed a course, every detail o" -hich the 
patient had followed for years. And because he had tbrbiddcn a 
course which the patient could hot by any possibility alter. « 
« I hve known two cses, the one of  man who intentionlly nd repeatedly 
displaced  dislocation, and ws kept and petted by ll the surgeons, the other 
of one who ws pronounced fo have nothing the mtter with him, there being 
no orginic change perceptible, but who died within the week. In both these 
cases, it was the nurse who, by accurately poining out what she had accurately 
observcd, to the doctors, saved the one case from persevering in a frud, the other 
from being discharged when actully in  dying state. 
I will evcn go furthcr and sy, that in diseases which hure their or]gin in the 
feeble or irregular action of some function, and hot in orgnic change, it is quite 
un accident il the doctor who sees the case only once a dy, and gencrally t the 
sme time, cn form ny but a negutive ide of its real condition. In the middle 
ofthc da3", when such  patient bus been refreshed by light nd air, by his tea, 
his bccf te, and his brandy, by hot bottles to his feet, by being wshed and by 
clean linen, you can scarcely believe that he is the saine person as lay with  rapid 
fluttering pulse, with puffed eye-lids, with short breath, cold limbs, nd unsteady 
hnds, this morning. ow wht is a nurse to do in such  case ? ot cry, "Lord 
bless you, air, why you'd hure thought he were  dying all night." This my be 
true, but it is hot the wuy to impress with the truth a doctor, more capable of form- 
ing  j udgmcnt from the facts, if he did but know them, than you are. Vhat he 
wants is hot your opinion, however respectfully given, but your facts. In all 
diseases it is important, but in diseases which do hot run  distinct nd tixed 
course, it is hot only important, it is essntial tht the fcts the nurse alone can 
observe, should be ccurtcly observed, and accuratcly reportcd to the doctor. 



OBSEEVATIOlq OF '£IIE SrCK. 6 

Undoubtedly a person of no scientific knowledge whatever but ot 
observation and experience in these kinds of conditions, will be able 
to arrive af a much truer guess as fo the probable duration of lire of 
melnbers of a thmily or inmates of a bouse, than the most scientific 
physician to whom the SalUe persons are brought to bave their pulse 
felt; no enquiry being ruade into their conditions. 
In Life lnsurance and such like societies, were they instead of 
having the persons examined by a medicM man, fo lmve the houses, 
conditions, vavs of lire, of these persons exalnined, af how much 
truer results :ould thev arrive! V. Slnith appears a fine hale man, 
but it might be knowu'that the next choler, epidenic he runs a ba4 
chance. Sir. and Sirs. J. are a strong bealtby couple, but it might 
be known that they lire in such a bouse, in such a part of London, 
so near the river that they will kill ibur-fifths of their children ; 
which of the children wilI be the ones to survive might also be 
known. 
Averages again seduce us awav from minute observation. 
"Aver:lge mortalities" merely tell that so many per cent. die in this 
town aud so mauy in that, per armure. But whether A or B will be 
among these, the "average rate" of course does hot tell. We know, 
sas-, that from 22 fo 2. per 1,000 vill die in London next year. But 
mnute enquiries into conditions enable tts to know that in such  
district, nay, in such , street,--or even on one side of that street, in 
such u particular bouse, or even on one floor of that particular 

I must direct the nme's attention to the extreme variation thcre is hot unfre- 
quently in the pulse of such patients during the dty. A very common case is 
this: Betwecn 3 and 4 ,.. the puise becomes quick, perhaps 130, and so 
thready it is hot like a pulse at ail, but like a string vibrating just underneath 
the skin. After this the patient gets no more sleep. About mid-day the puise 
bas corne down to 80 ; and though feeble and compressible is a ver 3- respectab!« 
puise. At night, if the putient has had a day of excitemeat, it is almost imper- 
ceptible. But, if the patient bas had a good day, it is stronger and steadier and 
hot quicker than af mid-day. This is a common history of , common l:ulse; 
and others, equally varying during the dy, might be given. :Now, in inflamma- 
tion, which may almost always be detected by the puise, in typhoid fever, which 
is accompanied by the low pulse that nothing will raise, there is no such great 
variation. And doctors and nurses become accustomcd hOt to look for it. The 
doctor indeed cannot. But the variation is in itse[f an important feature. 
Caes like the above often "go off rather suddenly," as if is called, from some 
trifling ailment of a few days, which just maKes up the sure of exhaustioa neccs- 
sary to produce death. And everybody crms, who would have thought it ? except 
the observing nurse, if there is one, who had al.ways expected the exhaustioa to 
corne, from which the would be no rally, because she knew the patient had no 
capital in strength on which to draw, if he failed for a few dys o make his 
barely daily income in sleep and nutrition. 
I bave offert seen really good nurses dstressed, because they co:ald no impress 
the doctor with the real danger of their patient; and quite provoked becanse 
the patient "would look," either "'so much better" or "so much worse" than 
he really is "whea thc doctor was there." The distress is verv legitimate, 
but it generally arises from the nurse hot having the power of layig clearly and 
shortly before the doctor the facts trom which she derives her opinion, or from 
the doctor being hasty and inexperienced, and hot capable of eliciting them. A 
man who really cares for his patients, will soon learn to ask for and appreciate the 
information of a nurse, who is at once a careful observer and a clear reporter. 

"' Average rate 
of mortality " 
tells us only 
that so many 
per cent. will 
die. Observa- 
tion must tell 
us which in the 
hundred they 
will be who 
will die. 



70 170TES ON 

What observa- 
tion is for. 

What a con- 
fidential nurse 
should be. 

bouse, will be the excess of mortality, that is, the person will die 
vho ought hot to bave died before old age. 
Now, vould it hot very materially alter the opinion of whoever 
were endeavouring to form one, if he knew that from that floor, of 
that house, of tlmt street the man came? 
IMuch more precise might be our observations evcn than this and 
much lnore correct out conclusions. 
It is well known that the saine names may be seen constantly 
recurring on vorkhouse books for generations. That is, the persons 
vere born and brought up, and will be born and brought up, genera- 
tion after generation, in the conditions vchich make paupers. Death 
and disease arc like the workhouse, they take from the saine family, 
the saine house, or in other words the saine conditions. Why will 
we hot observe a-hat they are ? 
The close observer nmy safely predict that such a family, whether 
its members marry or hot, a'ill become extinct; that such another 
vill degcuerate morally and physically. But who learns the lesson ? 
On the contrary, it may be wcll knoa-n that the children die in such 
a house af the rate of 8 out of 10 ; one vould think that nothing 
more need be said ; for how cofld Providence speak more distinctly ? 
yet nobody listens, the family goes on living there till it dies out, 
and then some other ihmily takes it. Neither vould they listen "if 
one rose from the dead." 
In dwelling upon the vital importance of sound observation, it 
must never be lost sight of what observation is for. If is not for the 
sake of piling up miscellaneous information or curious facts, but for 
the sake of saving lire and increasing health and comfort. The 
cautiou may seem useless, but it is quite surprising how many 
men (some women do it too), practically behave as if the scientific 
end v:ere the onlv one in view, or as if the sick body were but a 
reservoir for stoing medicines into, and the surgical disease 
only a curious case the sufferer bas ruade for the attendant's 
special information. This is really no exaggeration. You think, 
if" vou suspected your patient was being poisoned, say, by a copper 
letle, vou would instantly, as you ought, cut off all possible 
connectïon between him and the susp.ected source of injury, with- 
out regard to the fact that a curous mine oi observation is 
thereby lost. But it is hot everybody who does so, and it bas 
actually been lna.de a question of medical ethics, vhat should the 
medical man do if he suspected poisoning ? The answer see.ms a very 
simple one,--insist on a confidential nurse being placed "with th'e 
patient, or give up the case. 
And remember every nurse should be one vho is to be 
depended upon, in other vords, capable of being a "confidential" 
nurse. She does hot know how soon she may find herself placed 
in such a situation; she must be no gossip, no vain talker; she 
should never answer questions about ber sick except to those who 
bave a right to ask them; she must, I need hot say, be strictly 
sober and honest; but more than this she must be a religious 
and devoted n-oman; she must bave a respect for her own calling, 



conclusion. 71 

because God's precious glf of lire is offen literally placed in ber 
hands; she must be a souud, and close, and quick observer; and she 
must be a woman of delieate and decent feeling. 
To return fo the question of what observation is for :--It would 
really seem as if' some had considered it as its own end, as if detec- 
tion, hOt cure, was tlleir business ; nay more, in a recent celebrated 
trial, three medical men, according to their own account, suspeeted 
poison, prescribed for dysentery, and left the patient fo the poisoner. 
This is an extreme case. :But in a small way, the saine manner of 
acting fitlls uuder the cognizauce of us all. How offen the atendant.s 
of a case have stated that they knew perfectly well that the patient 
could hot get we]l in such an air, in such a room, or uuder such 
circumstances, yet bave gone ou dosing him with mediciue, and 
making no efibrt to remove the poison ff'oto him, or him fiom the 
poison which they knew was killiug him; nay, more, bave some- 
rimes hot so much as mentioned their conviction in the right quarter 
that is, to the only person who could act in the marrer. 

Observation is 
for practical 
purposes. 

CONCLUSION. 

The whole of the precediug remarks apply even more fo children 
and to puerperal wolnen than fo patients in gelleral. They also 
apply to the nursing of surgical, quite as much as to that of lnedical 
cases. Indeed, if it be possible, cases of external injury require such 
care even more thau sick. In surcal wards, one duty of every nurse 
certainly is îrevention. :Fever, or hospital gangrene, or pyoemia, or 
purulent discharge of some kind may else snpervene. I-[as she a case 
of compound fracture, of amputation, or of erysipelas, if lnay depend 
verv lnuch on how she looks upon the things enumerated in these 
notes, whether one or other of these hospital diseuses attacks lier 
patient or hot. Iï she allows ber ward to become filled wi.h the 
peculiar close foetid smell, so apt to be produced among surgical 
cases, especially wllere there is great suppuration and discharge, she 
mav sec a vigorous patient in the prime of lire gradually sink and die 
whêre, according to all human probability, he ought fo have recovered. 
ŒEhe surgical nurse must be ever on the watch, ever on ber guard, 
against want of cleanliness, foul air, want of light, and of warmth. 
:Nevertheless let no one think that because sanita?/nursing is the 
snbject of these notes, therefore, what may bc called the handicraft of 
nursing is to be uudervalued. A patient may be left to bleed to death 
in a sanitary palace. Another who cannot move himself lnay die of 
bed-sores, because the nurse does not know how fo change and 
clean hiln, while he bas every requisite of air, light, and quiet. :But 
nursing, as a handicraft, bas hot been treated of here br three 
rcasos: 1. that these notes do hot pretend to be a manual ibr 
nursing, any more than for cookiug for the sick; 2. that the wrier, 
wllo bas herself seen more of what mav be called surgical nursing, 
. e, practical manual nursing, than, )erhaps, any one in Europe, 

Sanitary 
nursing as 
essential in 
surgical as in 
medical cases, 
but not to 
persede surgi- 
cal nursing. 



72 

Children : 
their grcater 
susceptibility 
lo the saine 
things. 

honestly believes that if is impossible fo learn if from any book, and 
that if can only be thoroughly learnt in the -ards of a hospital ; and 
she also honestly believes that the perfection of surgical nursing may 
be seen 10ractised by the old-fashioned "Sister" of a London hospital, 
as if cau be seen nowhere else in Europe. 3. While thousauds die 
of foul air, &c., ho bave this surgical nursiug to perfection, the 
converse is comparatively rare. 
To revert to children. Thev are much more susceptible than grow 
people to all noxious influeîces. They are affected by the same 
tl.fings, but much more quickly and seriously, riz., by waut of tYesh 
air, of propcr warmth, want of cleanliness in house, clothes, bedding, 
or bodv,, by startling noises, iml»roper food, or want of puuctuality, 
by dulness and by -ant of light, by too much or too little coverin; 
in bed, or when up, by want of tho spirit of management generally 
in those in charge of them. One can, therefore, only press the im- 
portance, as being yet greater in the case of children, greatest in the 
case of sick children, of attending fo these things. 
That which, howcver, above all, is kno-n fo injure children 
seriouslv is tbul air, and most seriously at night. Keeping the rooms 
where tey sloop tight shut up, is destruction to them. _And, if the 
child's breathing be disordered by disease, a few hours only of such 
foul air may endanger ifs life, cven where no inconvenience is felt 
by grown-up persous in the saine room. 
The fbllowing passages, taken out of an excellent " Lecture 
Sudden Death in lni:ancy and Childhood," just published, show the 
vital importance of careful nursing of children. " In the great 
majority of instances, when death suddenlv befalls the infant or young 
child, it is an accidet; if is hot a necessàry, inevitable restflt of any 
disease from which it is suffering." 
]t may be here added, that it would be very desirable to know 
how often death is, with adults, "not a necessary, inevitable resu]t 
of any disease." Omit the -ord " sudden ;" (tbr sudden death is 
conparatively rare in nfiddle age ;) and the se¢tence is almost equally 
true for all ages. 
The followiug causes of " accidental" death in sick children are 
enumerated:--"Sudden noises, which startle--a rapid change of 
temperature, which chil]s the surface, though only tbr a moment 
a rude awakening from sloop--or even an over-hasty, or an over- 
full meal"" auy suddeu impression on the nervous system--any 
hasty alteration of posturein short, any cause hatever by hich 
the respiratory process nmy be disturbed." 
It may again be added, that, with ver¥ weak adult patients, these 
causes are also (hot often " suddenly fatal," it is true, but) very much 
oftener than is at all generally known, irreparable in their con- 
seUYlCeS. 
Both for children and for adults, both for slck and for well 
(although more certainly in the case of sick children than in any 
others), I would here again repeat, the most fi-equent and most 
ihtal cause of all is sleeping, for even a few hours, much more for 
-eels and months, in ibul air, a conditio -hich, more than auy 



cocLvso. 73 

other condition, disturbs the respiratory process, and tends fo pro- 
duce " accidental" death in diseuse. 
I need hardly here repeat the warning aga]nst any confusion of 
ideas between cold and fresh air. You may chi]l a ptient fatally 
uithout giving him fresh air at all. And you can qmte wcll, nay, 
mach better, give him fresh air vithout chilling him. This is the 
test of a good uurse. 
:In cases of long recto-ring faintnesses from dsease, for instance, 
especially diseuse which affects the organs of breathing, fresh air to 
the hmgs, warmth to the sm'ihce, and often (as soon as the patient 
can swallow) hot drink, these are the right remedies and the only 
ones. Yet, oftener than hot, you sec thc nurse or mother jus 
rcverslng this; shutting up every cranuy through which fresh air can 
enter, and leaving the body cold, or perhaps throwing a greater 
eight of clothes upou it, when alreadv it is generating too little heat. 
" Breathing carefully, auxiously," as though respiration were a 
fimction which requred all the attention ibr its performance," is 
cited as a hot unusual state in chi]dren, and as one ca!ling for cure 
in all the things enumerated above. That .breathing becomes an 
almost voluntary act, even in grown up patients who are very 
wcal, must often have been remarked. 
" Diseuse having interfered with the perfect accomplishment of 
the resph'atory function, some sudden demand ibr is complete excr- 
cise, issues in the sudden stand still of the whole machinery," is given 
as one process :" life goes out for want of ne-ous power to keep 
the vital functions in activitv," is given as another, by which "acci- 
dental" death is most often'brought to pass in infancv. 
Also in niddle age, both these processes mav be'seen ending in 
death, although generally hot suddenly. And  have seen, even in 
niddle age, the "sudde stand-st:l]" here mentioned, and i-om the 
saine causes. 
To sure up :--the answer fo two of the commonest objections Summary. 
urged, one by women themselves, the other by nmn, against the 
desirableness of sanitary knowledge for vomen, plt«s a caution, 
cou, prises the whole argument for the art of nursing.. 
(1.) It is often said by mon, that it is unwise to teach vomen Recklcss ama- 
anvthing about these laws of health, because they will take fo teur physick- 
phçsicking,--that there is a great deal too mach of amateur ph_-sick- ing by women. 
. " - Real know- 
ng as it is, which is indeed truc. One eminent physician told me ledge of the 
that he had known more calomel given, both af a pinch and for a laws of health 
continuance, by mothers, governesses, and nurses, o children than alone can 
]le had ever heard of a physician prescribing in all his experience, check this. 
Another says, that womea's only idea in medicine is calomel and 
aperients.. This is undeniably too often the case. There is nothing 
evcr seen m any professional practice likc lhe reckless physicking bv 
amateur females, v :But this is just what the rea]ly experienced anal 
* I have known many |adies 'ho, having once obtained a "blue pill" prescrip- Danger of phy- 
tion from  physician, gave and took it as a common aperient two or three times sicking by 
a week--with what efibct may be supposcd. In one case I happened to be the amateur 
person to inform the lohysician of it, who substituted for the prescription  coin- femles. 



What patho- 
logy teaches. 
What obser- 
vation alone 
teaches. What 
medicine does. 
What nature 
alonc docs. 

observlng nurse does qot do; she neither physics herself nor others. 
And fo cultivate in things pertaining fo health observation and expe- 
rience in women who are mothers, governesses or nurses, is just the 
way fo do away with amateur physicking, and if the doctors did but 
know if, fo make the nurses obedient to them,--helps to them 
instead of hindrances. Such education in women would indeed 
diminish the doctor's work--but no one really believes that 
doctors wish that there should be more illness, in order to bave more 
work. 
(2.) If is often said by women, that they cannot know anything of 
the laws of health, or wMt fo do fo preserve their children's health, 
because they can know nothing of "Pathology," or cannot "dissect," 
--a conflsion of ideas which i is hard fo attempt fo disentangle. 
Pathology teaches the harm that disease has done. :But it teaehes 
nothing more. We know nothing of the prineiple oï healtb, the 
positive or" whieh patbology is the negative, exeept from observation 
and experience. And nothing but observation and experienee will 
teach us the ways fo maintain or fo brmg baek the state of health. 
It is often thought tbat medicine is the curative process. If is no sueh 
thing ; medicine is the surgery of funetions, as surgery 1)roper is that 
of limbs and organs. _Neither can do anything but remove obstrue- 
tions ; neither can cure ; nature alone cures. 8urgery removes the 
parativcly harmless apcrient pill. The lad3, came to me and complained that it 
"did not suit hcr hall so well." 
If women will take or give physic, by far the safest plan is to send for "the 
doctor" every timefor I bave known ladies ho both gave and took physic, 
who would not take the pains to learn thc names of the commonest medicines, 
and confounded, e. g., colocynth with colchicum. This is lla3'ing with sharl 
cdged tools "with a vengeance." 
There arc excellent womcn who will writc to London to their lhysician that 
there is much sickncss in their neighbourhood in the country, and ask for some 
prescription from him, which thcy used to like themselves, and thon give it to all 
their fricnds and to ail their poorer neighbours who will take it. Iqow, instead 
of giving mcdicinc, of which you cannot possibly know the exact and propcr ap- 
plication, nor all its conscqucnces, would it not be botter if 3'ou were to persuade 
and hclp your poorer neighbours to reove the dung-hill from before the door, to 
put in a window which opens, or an Arnott's vcntilator, or to cleansc and lime-wash 
the cottages ? Of thcse things the bencfits are sure. Thc bcnefits of the inexpe- 
rienccd administration of mcdicines are by no means so sure. 
l-Iomccopath3' has introduced one essential amelioration in the practice of 
-physic by amateur females ; for ifs rules are excellent, its physicking compara- 
tivcly harmless--the "globule" is the ont grain of folly which appears to be ncces- 
aar3' to makc an3' good thing acccptable. Let then womcn, if they will give medi- 
cine, give homoeopathic medicine. It won't do an3, harm. 
An almost universal crror among womcn is the supposition that everybod3' 
o)ust bave the bowels opened once in every twenty-four hours or must fly imme- 
diatcly fo apcrients. The reverse is the conclusion of experience. 
This is a doctor's subject, and I will not enter more into it; but will simply 
rcpeat, do not go on taking or giving to your childrcn your abominable "courses of 
apcrients," without c«lling in the doctor. 
It is ver)- seldom indccd, that by choosing your diet,'you cannot rcgulate 
your own bowels; and evcry woman may watch hcrself to kno what kind of 
diet will do this ; I have known deficicncy of meat produce constipation, quite as 
often as deficiency of vegetables ; baker's bread much oftener than either. Home 
nade brown brcad will oftener cure it than anythmg else. 



C01CIUSI01% » o 

bullet out of the limb, which is an obstruction fo cure, but nature 
heals the wound. So if is with medicine ; tbe function of an organ 
becomes obstructed ; medicine, so lar as we know, assists nature fo 
remove the obstruction, but does nothing more. And what nursing 
has fo do in either case, is to put the patient in the best condition 
for nature fo act upon him. Generally, just the contrary is done. 
ïou think fresh air, and quiet and cleanliness extravagant, perhaps 
dangerous, luxuries, which should be given to the patient only whea 
quite convenient, and lnedicine the sie d wr, the panacea. If X 
bave succeeded in any measure in dispelling this illusion, and in 
showing what true nursing is, and what it is hot, my object will have 
been answered. 
l-Now for the caution :-- 
(3.) If seems a commonly received idea among men and eveu 
among women themselves that if requires nothing but a disappoint- 
ment in love, the want of an object, a. general disgust, or incapacity 
for other things, fo turn a woman into a good nnrsc. 
This rcminds one of the pa.rish where a stupid old man was set 
fo be schoohnaster because he was " past keeping the pigs." 
Apply the above receipt for making a good mu-se to making a 
good servant. And the receipt will be fotmd to fail. 
]:et popular novelists of recent days have invented ladles disap- 
pointed in love or fresh out of the drawing-room turning into the 
war-hospitals to find their wounded loyers, and wheu round, forthwith 
abandoning their sick-ward for their loyer, as might be expected. Yet 
in the estimation of the authors, these ladies were noue the worse 
for that, but on the contrary were heroines of nursing. 
Vhat cruel mistakes are sometimes ruade by benevolent men and 
women in matters of business about which they can know nothing 
and think they know a great deal. 
ïhe everyday management of a large ward, let alone of a hospital 
the knowing what are the laws of lire and death for men, and 
v-bat the laws of health for wards--(and wards are healthy or un- 
healthy, mainly according to the knowledge or ignorance of the 
nurse)--are not these matters of suiIicient importance and difflculty 
to require learning by experience and careful inquiL , just as much as 
auv other a.rt ? They do no corne by inspiration to the lady disap- 
ponted in love, nor to the poor vorkhouse drudge hard up for a 
livelihood. 
And terrible is the injury which has followed to the sick from 
such wild notions ! 
In this respect (and why is it so ?), in Roman Catholic comlh-ies, 
both writers and workers are, in theor)- at least, far beibre ours. 
They wotfld never thhk of such a beginning for a good working 
Superior or Sister of Charity. And many a Superior bas refused to 
adit a ,Fcstulat who appeared fo have no better "vocation " or 
reasons for offering herself than these. 
If is true we make "no vows." :But is a "vow" necessary fo 
convince us that the true spirit for learning any art, most especially 
an art of charity, aright;, is hot a dlsgust to everything or something 



G 'OTES ON UItSII'G. 

e]se ? :Do we rca]ly place the love of our kind (and of nurslng, as 
one branch of it,) so low as this ? Yhat would the Mère Aagélique 
of Port :Royal, 'hat would our own Mrs. Fry have said to this ? 

OTE.--I would earnestly ask my sisters fo keep clear of both thc jargons 
now current evc)-wherc (for thcy «re cqually jargons) ; of thc jargon, laamely, 
about the "rights" ofwomcn, which urges women to do all that men do, including 
the medical and other professions, mcrely becme men do i, and without regard 
to whether this is the best that women can do; and of the jargon which urges 
womcn fo do nothing that mcn do, merely because they are women, and shçld be 
"rccallcd to a sense of their duty as women," and because "this is women's work," 
and " that is men's," and "these arc things which women should not do," which is 
all assertion and nothing more. Surely woman should bring the bcst she has, 
zhatever that is, fo the work of God's world, without attcnding to either of these 
cries. For what m'e they, both of them, the one just as much as the othcr, but 
listening to the "what pcoplc will av. to opinion, to the "' voices from without?" 
And as a wise man bas said, no one bas ever done anything great or useful by 
listcning to the voices from without. 
You do hot want thc effect of your good things o be, " l=[ow wonderful for a 
coman !" nor would you bc deten'ed ff'oto good things, by hearing it said, "Yes, 
but she ought not to havc done this, becausc it is not suitable for a woman." But 
you want to do the thing that is good, whether it is "suitable for a woman'" 
or not. 
It does hot make a thing good, that it is remarkable that a woman shoul 
havc bcen ablc to do it. either does it make a thing bad, which wouid have 
been good had a man donc it, that it has been done by a woman. 
Oh, leave these jargons, and go your way stmight to God's work, in simpliclty 
and singlencss of hea. 



APPENDIX. 



7S 

• sA  pm 
"qluomuoI 



o. 79 

OTE AS TO THE I'IMBER OF WOIEN EMP]OY]D AS 
]çRSES i GREAT BRITAIN. 

25,466 were returned, at the census of 1851, as nurses by pro- 
fession, 39,139 nurses in domestic service, * aud 2,822 midwives. 
The numbers of different ages are shown in table A, and in table B 
their distribution over Great Britain. 
To increase the efficiency of this class, and fo make as many of 
them as possible the disciples of the true doctrines of health, would 
be a great national work. 
:For there the material exlsts, and will be used for nursing, 
whether the real " conclusion of the marrer" be fo nurse or fo poison 
the sick. A man, who stands perhaps at the head of our medical 
profession, once said to me, I send a nurse into a private tnfily to 
nurse the sick, but I know that it is only fo do them barre. 
:Now a nurse means any person in charge of the personal health 
of another. And, in the preceding notes, the terre #utrse is used 
indiscriminately for amateur and professional nurses. :For, besides 
nurses of the sick ad nurses of children, the numbers of whom are 
here given, there are friends or relations who take temporary charge 
of a sick person, there are mothers of familles. It appears as if 
these unprofessional nurses were just as much in want of kno-ledge 
of the laws of health as professional ones. 
Then there are the school-mistresses of all national and other 
schools throughout the kingdom, tt ow manv of children's epidemics 
originate in these! Then the proportion oi" girls in these schools, 
who become mothers or n}embers among the 6=t,600 nurses recorded 
above, or schoolmistresses in their turn. If the laws of health, as 
far as regards fresh air, cleanliness, light, &c., were taught to these, 
would this hot prevent some children being killed, some evil being 
perpetuated ? On women we must depend, first and last, for personal 
and household hygiene--for preventing the race from degenerating 
in s far as these things are concerned. Would hot the true wav of 
infusing the art of preserving its own health into the human racè be 
to teach the female part of it in schools and hospitals, both by 
practical teaching and by simple experiments, in as far as these filus- 
trate what may be calle the theory of it ? 

* A curious fact will be shown by Table A, riz., that 18,12 °. out of 39,139, or 
nearly one-half of all thc nurcs, in domestic sezvice, arc bctveen 5 and 20 years 
of age. 



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