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

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'■^INGAtE 



?,< 'IVi |l/rr«lj 




THE LIBRARY 

OF 

THE UNIVERSITY 

OF CALIFORNIA 

LOS ANGELES 

GIFT OF 



DR. AND MRS. ELMER BELT 



/■'- 




The Story of This Reprint 

To make available the first book on nursing 
by the founder of all modern nursing, Florence 
Nightingale, the original English edition of 
"Notes on Nursing: What It Is and What It Is 
Not" has been reproduced in facsimile in 1946, 
eighty-seven years after its first issuance. 

Its basic discussion of bedside ntirsing, its 
sprightly comment, its common-sense evaltia- 
tions, all preserve a distinguished background 
to ntirsing and will be read and made a valti- 
able part of any nurse's armamentarium. 

The appearance of this facsimile reprint is the 
cidmination of an initial stiggestion from Helen 
G. McClelland, Director of Nursing of the 
Pennsylvania Hospital, plus the present scar- 
city of the first edition, which appeared in Lon- 
don over the Harrison imprint in 1859. The first 
available American edition followed in i860 
over the imprint of D. Appleton and Company. 

This facsimile has been reproduced from the copy in 
the Rare Book Room of the Library of Congress, Wash- 
ington, D. C, and the original date and other details 
have been checked with the Library of the British Museum 
in London. 




Philadelphia London Montreal 

J. B. LIPPINCOTT COMPANY 



Foreword 

The timeliness of the revival of "Notes on Nurs- 
ing," the plan and purpose of which is so clearly 
stated in Miss Nightingale's preface, cannot be ques- 
tioned. 

Nearly a century has passed since this woman of 
great vision and wide experience, as her last contri- 
bution to humanity, epitomized in terse, sometimes 
caustic, btit always convincing language, a message 
to the womanhood of the world. 

It is a book which shotild be owned not only by 
every member of the nursing profession, but which 
should find its place in every home, not to replace 
the ever-increasing body of knowledge relating to 
the development of that priceless possession of every 
nation, its child-life, but because it interprets in 
simple terms the age-old principle of healthy living. 

It should be noted that Florence Nightingale 
makes very clear the distinction between persons 
professionally qualified for the practice of nursing 
and the knowledge essential for every woman to 
whom may come at any time a call to render nursing 
service in some form. 

Though the message of this little book is for all, 
to none shotdd its appeal be stronger than to the 
American nurses of the twentieth centtiry who, as 
teachers, as citizens, and ofttimes as mothers, have, 
through their acquired knowledge, the responsi- 
bilities that citizenship in a democracy implies. It is 
a tragic fact that, despite almost phenomenal ad- 
vances in the art and science of living, ignorance, 
poverty and disease still obtain in great degree. Let 
us hope that this little book will, in this present 
edition, continue its career of usefidness. 

Annie W. Goodrich. 



NOTES ON NURSING: 



WHAT IT IS, AND WHAT IT IS NOT. 



BY 



FLORENCE NIGHTINGALE. 



LONDON: 
HAERISON, 59, PALL MALL, 

BOOKSELLER TO THE QUEEN. 

[The right of Translation is reserved.] 



FBDITED BY HARBISON AMD SONS, 

ST, martin's lane, w.o. 



Facsimile of 

the First Edition, printed in London, 1859. 

Reproduced by offset in /g^6 by 

Edward Stern & Company, Inc., 

Philadelphia Pennsylvania 



PREFACE. 



The following notes are by no means intended as a rule of 
thought by which nurses can teach themselves to nurse, still less 
as a manual to teach nurses to nurse. They are meant simply to 
give hints for thought to women who have personal charge of 
the health of others. Every woman, or at least almost every 
woman, in England has, at one time or another of her life, 
charge of the personal health of somebody, whether child or 
invalid, — in other words, every woman is a nurse. Every day 
sanitary knowledge, or the knowledge of nursing, or in other 
words, of how to put the constitution in such a state as that 
it will have no disease, or that it can recover from disease, 
takes a higher place. It is recognized as the knowledge which 
every one ought to have— distinct from medical knowledge, 
which only a profession can have. 

If, then, every woman must, at some time or other of her 
life, become a nurse, i.e., have charge of somebody's health, 
how immense and how valuable would be the produce of her 
united experience if every woman would think how to nurse. 

I do not pretend to teach her how, I ask her to teach her- 
self, and for this purpose I venture to give her some hints. 



i^^wv\?A 



RApC 
TABLE OF CONTENTS. 



Ventilation and Warming .... .... ... 8 

Health op Houses .... .... ..•• .... 14 

Petty Management .... .... .... ... 20 

Noise .... .... .... .... .... ... 25 

Variety .... .... .... .... .... 33 

Taking Food .... .... .... .... .... 36 

What Food ?.... .... .... .... ... 39 

Bed and Bedding .... .... .... .... 45 

Light .... .... ... .... .... 47 

Cleanliness of Rooms and Walls .... .... .... 49 

Personal Cleanliness .... .... .... .... 52 

Chattering Hopes and Advices .... .... .... 64 

Observation of the Sick .... .... .... 59 

Conclusion .... .... .... •.• ... 71 

Appendix .... .... .... ... — 77 



NOTES ON NUESING: 

WHAT IT IS, AND WHAT IT IS NOT. 



Shall we begin by taking it as a general principle — that all Disease a 
disease, at some period or other of its course, is more or less a reparative 
reparative process, not necessarily accompanied with suffering : an P™<^®^* 
effort of nature to remedy a process of poisoning or of decay, which has 
taken place weeks, months, sometimes years beforehand, unnoticed, 
the termination of the disease being then, while the antecedent 
process was going on, determined ? 

If we accept this as a general principle we shall be immediately 
met with anecdotes and instances to prove the contrary. Just so if 
we were to take, as a principle — all the climates of the earth are 
meant to be made habitable for man, by the efforts of man — the 
objection would be immediately raised, — Will the top of Mont Blanc 
ever be made habitable ? Our answer would be, it will be many 
thousands of years before we have reached the bottom of Mont Blanc 
in making the earth healthy. Wait till we have reached the bottom 
before we discuss the top. 

In watching disease, both in private houses and in public hos- of the suffer- 
pitals, the thing which strikes the experienced observer most forcibly ings of disease, 
is this, that the symptoms or the sufferings generally considered to disease not 
be inevitable and incident to the disease are very often not symptoms ^l^^^ys the 
of the disease at all, but of something quite different — of the want *^"^' 
of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, 
or of punctuality and care in the administration of diet, of each or 
of aU of these. And this quite as much in private as in hospital 
nursing. 

The reparative process which Nature has instituted and which we 
call disease has been hindered by some want of knowledge or atten- 
tion, in one or in all of these things, and pain, suffering, or interrup- 
tion of the whole process sets in. 



6 



NOTES OK NUESING. 



What nursing 
ought to do. 



Nursing the 
sick little 
understood. 



I reparauve 
! process. 



If a patient is cold, if a patient is feverish, if a patient is faint, if 
he is sick after taking food, if he has a bed-sore, it is generally the 
fault not of the disease, but of the nursing. 

I use the word nursing for want of a better. It has been limited to 
signify little more than the administration of medicines and the 
application of poultices. It ought to signify the proper use of fresh 
air, light, warmth, cleanliness, quiet, and the proper selection and 
administration of diet — all at the least expense of vital power to the 
patient. 

It has been said and written scores of time^ that^very woman 
makes a good nurse. I believe, on the contrary, that the vefF 
elements of nursing are all but unknown. 

By this I do not mean that the nurse is always to blame. Bad 
sanitary, bad architectural, and bad administrative arrangements 
often make it impossible to nurse. But the art of nursing ought to 
include such arrangements as alone make what 1 understand by 
nursing, possible. 

The art of nursing, as now practised, seems to be expressly 
constituted to unmake what God had made disease to be, viz., a 
reparative process. i 

Nursing ought/ To recur to the first objection. If we are asked. Is such or I 
to assist the |such a disease a reparative process ? Can such an illness be unac-/ 
companied with suffering ? Will any care prevent such a patient 
from suffering this or that ? — I humbly say, I do not know. But 
when you have done away with all that pain and suffering, which in 
patients are the symptoms not 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 commonest exclamation which will be instantly 
made is — Would you do nothing, then, in cholera, fever, &c. ? — so 
deep-rooted and universal is the conviction that to give medicine is 
to be doing something, or rather everything ; to give air, warmth, 
cleanliness, &c., is to do nothing. The reply is, that in these and 
many other similar diseases the exact value of particular remedies 
and modes of treatment is by 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 for the well as for the sick. The same laws of 

; health or of nursing, for they are in reality the same, obtain among 

j the 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 always. 

It is constantly objected, — " But how can I obtain this medical 
knowledge ? I am not a doctor. I must leave this to doctors." 

Oh, mothers of families! Ton who say this, do you know that 
one in every seven infants in this civilized land of England perishes 
before it is one year old ? That, in London, two in every five die 
before they are five years old ? And, in the other great cities of 



Nursing the 
well 



Little under- 
stood. 



KOTES ON IffUaStNG. 7 

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 sanitary conditions. Is all this premature 
suffering and death necessary ? Or did Nature intend mothers to 
be always accompanied by doctors ? Or is it better to learn the 
piano-forte than to learn the laws which subserve the preservation of 
offspring ? 

Macaulay somewhere says, that it is extraordinary that, whereas 
the laws of the motions of the heavenly bodies, lar removed as 
they are from us, are perfectly well understood, the laws of the 
human mind, which are under our observation all day and every 
day, are no better understood than they were two thousand years ago. 

But how much more extraordinary is it that, whereas what we 
might call the coxcombries of education — e.g., the elements of astro- 
nomy — are now taught to every school-girl, neither motliers of families 
of any class, nor school-mistresses of any class, nor nurses of children, 
l^or nurses of hospitals, are taught anything about those laws which 
lOod has assigned to thewrelations of our bodies with the world in 
Ifhich He has put themy In other words, the laws which make 
these bodies, into which He has put our minds, healthy or un- 
healthy organs of those minds, are all but unlearnt. Not but that 
these laws — the laws of life — are in a certain measure understood, 
but not even mothers think it worth their while to study them — 
to study how to give their children healtliy existences. They call it 
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 
with winds ? There is the east wind. Most people can tell before 
they get up in the morning whether the wind is in the east." 

• Upon this fact the most wonderful deductions have been strung. For a Curious deduc- 
long time an announcement something like the following has been going the tions from an- 
round of the papers: — "More than 25,000 children die every year in London excessive 
under 10 years of age; therefore we want a Children's Hospital." This spring death rate, 
there was a prospectus issued, and divers other means taken to this eflFect: — 
" There is a great want of sanitary knowledge in women ; therefore we want a 
Women's Hospital." Now, both the above facts are* too sadly true. But what is 
the deduction ? The causes of the enormous child mortality are peifectly well 
known ; they are chiefly want of cleanliness, want of ventilation, want of white- 
washing; in one word, defective household hygiene. The remedies are just as 
well known ; and among them is certainly not the establishment of a Child's 
Hospital. This may be a want; just as there may be a want of hospital room for 
adults. But the Registrar-General would certainly never think of giving us as 
a cause for the high rate of child mortality in (gay) Liverpool that there was not 
sufficient hospital room for children; nor would he urge upon us, as a remedy, to 
found a hospital for them. 

Again, women, and the best women, are wofully deficient in sanitary know- 
ledge ; although it is to women that we must look, first and last, for its 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 to cure this want 1 

We have it, indeed, upon very high authority that there is some fear lest 
hospitals, as they have been hitherto, may not have generally increased^ rather 
than diminished, the rate of mortality — especially of child mortality. 



O NOTES ON NUESING. 

To this one can answer with more certainty than to the former 
objections. Who is it who knows when the wind is in the east ? 
Not the Highland drover, certainly, exposed to the east wind, but 
the young lady who is worn out with the want of exposure to fresh 
air, to sunlight, &c. Put the latter under as good sanitary circum- 
stances as the former, and she too will not know when the wind is 
in the east. 



I. VENTILATION AND WAEMING. 

First rule of The yery first canon of nursing, the first and the last thing upon 

t^'^^th' *° which a nurse's attention must be fixed, the first essential to the 
within ^*pure P^^i^^^^, without which all the rest you can do for him is as nothing, 
as the air with which I had almost said you may leave all the rest alone, is this: 

without. To KEEP THE AIB HE BREATHES AS PUEE AS THE EXTERNAL AIB, 

WITHOUT CHILLIN& HIM. Yet what is SO little attended to 1 Even 
where it is thought of at all, the most extraordinary misconceptions 
reign about it. Even in admitting air into the patient's room or 
ward, few people ever think, where that air comes from. It may 
come from a corridor into which other wards are ventilated, from a hall, 
always unaired, always full ot the fumes of gas, dinner, of various 
kinds of mustiness ; from an underground kitchen, sink, washhouse, 
water-closet, or even, as I myself have had sorrowful experience, from 
open sewers loaded with filth ; and with this the patient's room or 
ward is aired, as it is called — poisoned, it should rather be said. 
Always air from the air without, and that, too, through those 
windows, through which the air comes freshest. From a closed 
court, especially if the wind do not blow that way, air may come as 
stagnant as any from a hall or corridor. 

Again, a thing I have often seen both in private houses and insti- 
tutions. A room remains uninhabited ; the fire place is carefully 
fastened up with a board ; the windows are never opened ; probably 
the shutters are kept always shut ; perhaps some kind of stores are 
kept in the room ; no breath of fresh air can by possibility enter 
into that room, nor any ray of sun. The air is as stagnant, musty, 
and corrupt as it can by possibility be made. It is quite ripe to 
breed smaU-pox, scarlet fever, diphtheria, or anything else you 
please.* 

Yet the nursery, ward, or sick room adjoining will positively be 
aired (?) by having the door opened into that room. Or children will 
be put into that room, without previous preparation, to sleep. 

A short time ago a man walked into a back-kitchen in Queen 

VThy are unin- * '^^^ 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 

shut up ] ^^ possible — to keep out the dust, it is said ; and that no harm will happen if the 

room is but opened a short hour before the inmates are put in. I have often been 

asked the question for uninhabited rooms — But when ought the windows to be 

opened 1 The answer is — When ought they to be shut ? 



TEKTILATIOK AJfD WARMING. 9 

square, and cut the throat of a poor consumptive creature, sitting by 
the fire. The murderer did not 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 victim says, 
*' It's all right," and that we are not mad. Yet, although we " nose" 
the murderers, in the musty unaired unsunned room, the scarlet fever 
which is behind the door, or the fever and hospital gangrene which 
are stalking among the crowded beds of a hospital ward, we say, 
"It's all right." 

With a proper supply of windows, and a proper supply of fuel Without chill, 
in open fire 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 
always keep a patient warm in bed, and well ventilate him at the 
same time. 

But a careless nurse, be her rank and education what it may, 
will stop up every cranny and keep a hot-house heat when her 
patient 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 
many ways of taking cold, besides a cold in the nose,) is when they 
first get up after the two-fold exhaustion of dressing and of having 
had the skin relaxed by many hours, perhaps days, in bed, and there- 
by rendered more incapable of re-action. Then the same tempera- 
ture which refreshes the patient in bed may destroy the patient just 
risen. And common sense will point out that, while purity of air is 
essential, a temperature must be secured which shall not chill the 
patient. Otherwise the best that can be expected will be a feverish 
re-action. 

To have the air within as pure as the air without, it is not 
necessary, as often appears to be thought, to make it as cold. 

In the afternoon again, without care, the patient whose vital 
powers have then risen often finds the room as close and oppressive 
as he fouud it cold in the morning. Yet the nurse will be 
terrified, if a window is opened*. 

I know an intelligent humane house surgeon who makes a Open windowg. 
practice of keeping the ward windows open. The physicians and 
surgeons invariably close them while going their rounds ; and the 
house surgeon very properly as invariably opens them whenever the 
doctors have turned their backs. 

In a little book on nursing, published a short time ago, we are 
told, that " with proper care it is very seldom that the windows 
cannot be opened for a few minutes twice in the day to admit fresh 

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



10 NOTES ON NUHSINO. 

air from without." I should think not ; nor twice in the hour either. 

It only shows how little the subject has been considered. 

What kind of Of all methods of keeping patients warm the very worst certainly 

warmth jg ^q depend for heat on the breath and bodies of the sick. I have 

aesira e. known a medical oflBcer keep his ward windows hermetically closed, 

thus exposing the sick to all the dangers of an infected atmosphere, 

because he was afraid that, by admitting fresh air, the temperature 

of the ward would be too much lowered. This is a destructive 

fallacy. 

To attempt to keep a ward warm at the expense of making the 
sick repeatedly breathe their own hot, humid, putrescing atmosphere 
is a certain way to delay recovery or to destroy life. 
Bedrooms Do you ever go into the bed-rooms of any persons of any class, 

almost univer- whether they contain one, two, or twenty people, whether they 
nilj foul. JjqI^j gjg^ Qj, well, at night, or before the windows are opened in 
the morning, and ever find the air anything but unwholesomely 
close and foul ? And why should it be so ? And of how 
much importance it is that it should not be so ? During sleep, 
the human body, even when in health, is far more injured by the 
influence of foul air than when awake. Why can't you keep the air 
all night, then, as pure as the air without in the rooms you sleep in ? 
But for this, you must have sufficient outlet for the impure air you 
make yourselves to go out ; sufiicient inlet for the pure air from 
without to come in. Tou must have open chimneys, open windows, 
or ventilators ; no close curtains round your beds ; no shutters or 
curtains to your windows, none of the contrivances by which you 
undermine your own health or destroy the chances of recovery of your 
sick.* 

An air-test of * ^^- A-ngus Smith's air test, if it could be made of simpler ap]ilication, would 

essential ^^ invaluable to use in every sleeping and sick room. Just as without the use of 

consequence. * thermometer no nurse should ever put a patient into a bath, so should no nurse, 
or mother, or superintendent be without the air test in any ward, nursery, or 
sleeping-room. If the main function of a nurse is to maintain the air within the 
room as fresh as the air without, without lowering the temperature, 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 made as simple a little instrument 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 atmosphere they have let their 
children, patients, or charges, sleep in. But if the tell-tale air-test were to exhibit 
in the morning, both to nurses and patients and to the superior oflBcer going round, 
what the atmosphere has been during the night, I question if any greater security 
could be afforded against a recurrence of the misdemeanour. 

And oh ; the crowded national school ! where so many children's epidemics 
have their origin, what a tale its air-test would tell ! We should have parents 
saying, and saying rightly, " I will not send my child to that school, the air-test 
stands at ' Horrid.' " And the dormitories of our great boarding schools ! Scarlet 
fever would be no more ascribed to contagion, but to its right cause, the air-test 
standing at "Foul." 

We should hear no longer of " Mysterious Dispensations," and of " Plague and 
Pestilence," being " in God's hands," when, so far as we know, He has put them into 
our own. The little air-test would both betray the cause of these " mysterious 
pestilences," and call upon us to remedy it. 



VENTIIiATIOir AND WABMIKG. 11 

A careful nurse will keep a constant watch over her sick, When warmth 
especially weak, protracted, and collapsed cases, to guard against the ™"8* ^^ ™°^^ 
effects of the loss of vital heat by the patient himself. In certain ^^1^^^ ^^ 
diseased states much less heat is produced than in health ; and there 
is a constant tendency to the decline and ultimate extinction of the 
vital powers by the call made upon 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 minute to minute. 
The feet and legs should be examined by the hand from time to time, 
and whenever a tendency to chilling is discovered, hot bottles, hot 
bricks, or warm flannels, with some warm drink, should be made use 
of until the temperature is restored. The fire should be, if necessary, 
replenished. Patients are frequently lost in the latter stages of 
disease from want of attention to such simple precautions. The 
nurse may be trusting to the patient's diet, or to bis medicine, or to 
the occasional 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 happen at all times, 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 time when the efiect of the preceding day's 
diets is exhausted. 

Generally speaking, you may expect that weak patients will 
suffer cold much more in the morning than in the evening. The 
vital powers are much lower. If they are feverish at night, with 
burning hands and feet, they are almost sure to be chilly and shi- 
vering in the morning. But nurses are very fond of heating the foot- 
warmer at night, and of neglecting it in the morning, when they are 
busy. I should reverse the matter. 

All these things require common sense and care. Yet perhaps 
in no one single thing is so little common sense shewn, in all ranks, 
as in nursing.* 

The extraordinary confusion between cold and ventilation, in Cold air not 
the minds of even well educated people, illustrates this. To ventilation, 
make a room cold is by no means necessarily to ventilate it. Nor ^^^ ^^^ s.i'" * 
is it at all necessary, in order to ventilate a room, to chill it. ™^*|^0" of 
Yet, if a nurse finds a room close, she wiU let out the fire, thereby 
making it closer, or she wiU open the door into a cold room, without 
a fire, or an open window in it, by way of improving the ventilation. 

* With private sick, I think, but certainly with hospital sick, the nurse should 
never be satisfied as to the freshness of their atmosphere, unless she can feel the 
air gently moving over her face, when still. 

But it is often observed that nurses who make the greatest outcry against 
open windows are those who take the least pains to prevent dangerous draughts. 
The door of the patients' room or ward must sometimes stand open to allow of 
persons posing in and out, or heavy things being carried in and out. The careful 
nurse will keep the door shut while she shuts the windows, and then, and not 
before, set the door open, so that a patient may not be left sitting up in bed, 
perhaps in a profuse perspiration, 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. 



12 



NOTES ON NUESING. 



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



The safest atmosphere of all for a patient is a good fire and an open 
window, excepting in extremes of temperature. (Yet no nurse can 
ever be made to understand this.) To ventilate a small room with- 
out draughts of course requires more care than to ventilate a 
large one. 
Night air. Another extraordinary fallacy is the dread of night air. What 

air can we breathe at night but night air ? The choice is between 
pure night air from without and foul night air from within. Most 
people prefer the latter. An unaccountable choice. What will 
they say if it is proved to be true that fully one-half of all the disease 
we suffer from is occasioned by people sleeping with their windows 
shut ? An open window most nights in the year can never hurt any 
one. This is not to say that light is not necessary for recovery. In 
great cities, night air is often the best and purest air to be had in the 
twenty-four hours. I could better understand in 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 to making night the 
best time for airing the patients. One of our highest medical 
authorities on Consumption and Climate has told me that the air 
in London is never so good as after ten o'clock at night. 

Always air your room, then, from the outside air, if possible. 
Windows are made to open ; doors are made to shut — a truth which 
seems extremely difficult of apprehension. I have seen a careful 
nurse airing her patient's room through the door, near to which were 
two gaslights, (each of which consumes as much air as eleven men), 
a kitchen, a corridor, the composition of the atmosphere in which 
consisted of gas, paint, foul air, never changed, full of effluvia, includ- 
ing a current of sewer air from an ill-placed sink, ascending in a con- 
tinual stream by a well-staircase, and discharging t'lemselves con- 
stantly into the patient's room. The window of the said room, if 
opened, was all that was desirable to air it. Every room must be 
aired from without — every passage from without. But the fewer 
passages there are in a hospital the better. 
Smoke. If we are to preserve the air within as pure as the air without, it 

is needless to say that the chimney must not smoke. Almost all 
smoky chimneys can be cured — from the bottom, not from the top. 
Often it is only necessary to have an inlet for air to supply the fire, 
which is feeding itself, for want of this, from its own chimney. On 
the other hand, almost all chimneys can be made to smoke by a 
careless nurse, who lets the fire get low and then overwhelms it with 
coal ; not, as we verily believe, in order to spare herself trouble, (for 
very rare is unkindness to the sick), but from not thinking what 
she is about. 
Airing damp In laying down the principle that the first object of the nurse 

things in a must be to keep the air breathed by her patient as pure as the air 
patient'sroom. without, it must not be forgotten that everything in the room which 
can give ofi" effluvia, 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 effluvia or moisture. Out of all 
damp towels, &c., which become dry in the room, the damp, of 



VENTILATION AND WABMING. 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 her practice that nothing at 
all ought to be aired in the patient's room, that nothing at all 
ought to be cooked at the patient's fire! 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 not his room, open the sheets wide, and throw the 
bed clothes back, in order to air his bed. And she will spread the 
wet towels or flannels carefully out upon a horse, in order to dry 
them. Now either these bed-clothes and towels are not dried and 
aired, or they dry and air themselves into the patient's air. And 
whether the damp and efiluvia do him most harm in his air or in his 
bed, I leave to you to determine, for I cannot. 

Even in health people cannot repeatedly breathe air in which Eflauviafrom 
they live with impunity, on account of its becoming charged with excreta, 
unwholesome matter from the lungs and skin. In disease where 
everything given off from the body is highly noxious and dangerous, 
not only must there be plenty of ventilation to carry off the effluvia, 
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 eff'ects of the effluvia from the excreta it would seem 
unnecessary to speak, were they not so constantly neglected. Con- 
cealing the utensils behind the vallance to the bed seems all the 
precaution which is thought necessary for safety in private nursing. 
Did you but think for one moment of the atmosphere under that 
bed, the saturation of the under side of the mattress with the warm 
evaporations, you would be startled and frightened too ! 

The use of any chamber utensil without a lid* should be utterly Chamber uten- 
abolished, whether among sick or well. You can easily convince eils without 
yourself of the necessity of this absolute rule, by taking one with a ^'^^• 

* 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 your sick-room 
room unemptied, except once in the 24 hours, i.e., when the bed is made. Yes, into a sewer. 
impossible as it may appear, I have known the best and most attentive nurses 
guilty of this ; aye, and have known, too, a patient aflBicted with severe diarrhoea 
for ten days, and the nurse (a veiy good one) not know of it, because the chamber 
utensil (one with a lid) was emptied only once in the 24 hours, and that by the 
housemaid who came in and made the patient's bed every evening. As well 
might you have a sewer under the room, or think that in a water closet the plug 
need be pulled up but onco 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 her patient, " because it is 
not her business,' I should say that nursing was not her calling. I have seen 
surgical " sisters," women whose hands were worth to them two or three guineas 
a-week, down upon their knees scouring a room or hut, because they thought it 
otherwise not fit for their patients to go into. I am 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 
what it was iheir "place" to do— and that women who wait for the housemaid to 
do this, or for the charwoman to do that, when their patients are suffering, have 
not the making of a nurae in them. 



14 



NOTES ON NURSING. 



lid, and examining the under side of that lid. It will be found 
always covered, whenever the utensil is not empty, by condensed 
offensive moisture. Where does that go, when there is no lid ? 

Earthenware, or if there is any wood, highly polished and 
varnished wood, are the only materials fit for patients' utensils. The 
very lid of the old abominable close-stool is enough to breed a pesti- 
lence. It becomes saturated with offensive matter, which scouring is 
only wanted to bring out. I prefer an earthenware lid as being always 
cleaner. But there are various good new-fashioned arrangements. 
Abolish slop- A slop-pail should never be brought into a sick room. It 

pails. should be a rule invariable, rather more important in the private 

house than elsewhere, that the utensil should be carried directly to 
the water-closet, emptied there, rinsed there, and brought back. 
There should always be water and a cock in every water-closet for 
rinsing. But even if there is not, you must carry water there to rinse 
with. I have actually seen, in the 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 to do this or to 
rinse the utensil in the sick room. In the best hospitals it is now a 
rule that no slop-pail shall ever be brought into the wards, but that 
the utensils shall be carried direct to be emptied and rinsed at the 
proper place. I would it were so in the private house. 
Fumigations Let no one ever depend upon fumigations, " disinfectants," and 

the like, for purifying the air. The offensive thing, not its 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 to open the window." 
I wish all the disinfecting fluids invented made such an " abominable 
smell" that they forced you to admit fresh air. That would be a 
useful invention. 



Health of 
houses. Five 
points essen- 
tial. 



Health of 
carriages. 



II.— HEALTH or HOUSES.* 

There are five essential points in securing the health of 
houses : — 

1. Pure air. 

2. Pure water. 

3. Eflicient drainage. 

4. Cleanliness. 

5. Light. 

• The health of carriages, especially close carriages, is not of sufficient uni- 
versal importance to 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 so. A close car- 
riage, with the horsehair cushions and linings always saturated with organic 
matter, if to this be added the windows up, is one of the most unhealthy of human 
receptacles. The idea of taking an airing in it is something preposterous. Dr. 
Angus Smith has shown that a crowded railway carriage, which goes at the rate 
of 30 miles an hour, is as unwholesome as the strong smell of a sewer, or as a 
back yard in one of the most unhealthy courts off one of the most unhealthy 
streets in Manchester. 



HEALTH OF HOUSES. 15 

Without these, no house can be healthy. And it will be unhealthy 
just in proportion as they are deficient. 

1. To have pure air, your house must be so constructed as that the Pure air. 
outer atmosphere shall find its way with ease to every corner of it. 
House architects hardly ever consider this. The object in building a 
house is to obtain the largest interest for the money, not to save 
doctors' bills to the tenants. But, if tenants should ever become so 

wise as to refuse to occupy unhealthily constructed hovises, and if 
Insurance Companies should ever come to understand their interest 
so thoroughly as to pay a Sanitary Surveyor to look after the houses 
where their clients live, 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 houses they build. 
And if in the course of time the families die off, as is so often the 
case, nobody ever thinks of blaming 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 houses than it Pure water, 
used to be, thanks to the exertions of the sanitary reformers. 
Within the last few 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 has happily been remedied. But, in many 
parts of the country, well water of a very impure kind is used for 
domestic purposes. And when epidemic disease shows itself, persons 
using such water are almost sure to suffer. 

3. It would be curious to ascertain by inspection, how many Drainage, 
houses in London are really well drained. Many people would say, 

surely all or most of them. But many people have no idea in what 
good drainage consists. They thiuk that a sewer in the street, and 
a pipe leading to it from the house is good drainage. All the while 
the sewer may be nothing but a laboratory from which epidemic 
disease and ill health is being distilled into the house. No house 
with any untrapped drain pipe communicating immediately with a 
sewer, whether it be from water closet, sink, or gully-grate, can ever 
be healthy. An untrapped sink may at any time spread fever 
or pyaemia among the inmates of a palace. 

The ordinary oblong sink is an abomination. That great surface Sinka. 
of stone, which is always left wet, is always exhaling into the air. I 
have known whole houses and hospitals smell of the sink. I have 
met just as strong a stream of sewer air coming up the back stair- 
case of a grand London house from the sink, as I have ever met at 

" God lays down certain physical laws. Upon His carrying out such laws 
depends our responsibility (that much abused word), for how could we have any 
responsibility for actions, the results of which we could not foresee — which would 
be the case if the carrying out of His laws were not certain. Yet we seem to be 
continually expecting that He will work a miracle -i. e. break His own laws 
expressly to relieve us of responsibility. 



16 NOTES ON NUESING. 

Scutari ; and I have seen tlie rooms in that house all ventilated bj 
the open doors, and the passages all «?2ventilated 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. 

Another great evil in house construction is carrying drains 
underneath the house. Such drains are never safe. All house 
drains should begin and end outside the walls. Many people will 
readily admit, as a theory, the importance of these things. But how 
few are there who can intelligently trace disease in their households 
to such causes ! Is it not a fact, that w^hen scarlet fever, measles, or 
small-pox appear among the children, the very first thought which 
occurs is, "where" the children can have "caught" the disease? 
And the parents immediately run over in their minds all the families 
with whom they may have been. They never think of lookihg at 
home for the source of the mischief If a neighbour's child is seized 
with small pox, the first question which occurs is whether it had 
been vaccinated. No one would undervalue vaccination ; but it 
becomes of doubtful benefit to society when it leads people to look 
abroad for the source of evils which exist at home. 
Cleanliness. 4. "Without cleanliness, within and without your house, ventila- 
tion is comparatively useless. In certain foul districts of London, 
poor people used to object to open their windows and doors because 
of the foul smells that came in. Bich people like to have their 
stables and dunghill near their houses. But does it ever occur to 
them that with many arrangements of this kind it would be safer 
to keep the windows shut than open ? You cannot have the air 
of the house pure with dung heaps under the windows. These are 
common all over London. And yet people are surprised that their 
children, brought up in large " well-aired" nurseries and bed-rooms 
suffer from children's epidemics. If they studied Nature's laws in 
the matter of children's health, they would not be so surprised. 

There are other ways of having filth inside a house besides having 
dirt in heaps. Old papered walls of years' standing, dirty carpets, 
uncleansed furniture, 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 they either never think of it at all, and take every 
disease as a matter of course, to be " resigned to" when it comes 
" as from the hand of Providence ;" or if they ever entertain the 
idea of preserving the health of their household as a duty, they are 
very apt to commit all kinds of " negligences and ignorances" in 
performing it. 
j^iglit. 5. A dark house is always an unhealthy house, always an ill-aired 

house, always a dirty house. Want of light stops growth, and pro- 
motes scrofula, rickets, &c., among the children. 

People lose their health in a dark house, and if they get ill they 
cannot get well again in it. More will be said about this farther on. 
Three common Three out of many " negligences and ignorances " in managing the 
errors in health of houses generally, 1 will here mention as specimens — 1. That 

r^U^h ^T ^^^ *^® female head in charge of any building does not think it necessary to 
houses. 



HEALTH OF HOUSES. 17 

visit every hole and corner of it every day. How can she expect those 
who are under her to be more careful to maintain her house in a 
healthy condition than she who is in charge of it ? — 2. That it is not 
considered essential to air, to sun, and to clean rooms while unin- 
habited ; which is simply ignoring the first elementary notion of 
sanitary things, and laying the ground ready for all kinds of 
diseases. — 3. That the window, and one window, is considered 
enough to air a room. Have you never observed that any room 
without a fire-place is always close? And, if you have a fire-place, 
would you cram it up not only with a chimney-board, but perhaps 
with a great wisp of brown paper, in the throat of the chimney — 
to prevent the soot from coming down, you say ? If your chimney 
is foul, sweep it ; but don't expect that you can ever air a room with 
only one aperture ; don't suppose that to shut up a room is the way 
to keep it clean. It is the best way to foul the room and all that is 
in it. Don't imagine that if you, who are in charge, don't look to 
all these things yourself, those under you will be more careful than 
you are. It appears as if the part of a mistress now is to complain 
of her servants, and to accept their excuses — not to show them how 
there need be neither complaints made nor excuses. 

But again, to look to all these things yourself does not mean to Headincharge 
do them yourself. " I always open the windows," the head in Ho^ge^Hy? 
charge often says. If you do it, it is by so much the better, cer- gjene, not do 
taiuly, than if it were not done at all. But can you not insure that it herself, 
it is done when not done by yourself? Can you insure that it is 
not undone when your back is turned ? This is what being " in 
charge" means. And a very important meaning it is, too. The 
former only implies that just what you can do with your own hands 
is done. The latter that what ought to be done is always done. 

And now, you think these things trifles, or at least exaggerated. Does God 
But what you " think " or what I " think " matters little. Let us ^'^\^^ of these 
Bee what God thinks of them. God always justifies His ways. '^^^gfY' 
While we are thinking. He has been teaching. I have known 
cases cf hospital pyaemia quite as severe in handsome private houses 
as in any of the worst hospitals, and from the same cause, viz., foul air. 
Yet nobody learnt the lesson. Nobody learnt anything at all from 
it. They went on thinking — thinking that the suflerer had scratched 
his thumb, or that it was singular that "all the servants" had 
"whitlows," or that something was "much about this year; there 
is always sickness in our house." This is a favourite mode of 
tliought — leading not to inquire what is the uniform cause of these 
general " whitlows," but to stifle all inquiry. In what sense is 
" sickness" being " always there," a justification of its being " there" 
at all ] 

I will tell you what was the cause of this hospital pyaemia being How does He 
in that large private house. It was that the sewer air from an ill- carry out His 
placed sink was carefuUy conducted into all the rooms by sedulously laws? 
opening all the doors, and closing all the passage windows. It was 
that the slops were emptied into the foot pans ; — it was that the 
itensils were never properly rinsed ; — it was that the chamber 





18 



>'OTES O'S XUESIKG. 



How does He 
teach His 
laws? 



Physical dege- 
neration in 
families. Its 
causes. 



Senanta' 
rooms. 



crockery was rinsed wiih dirty water; — it was that the beds were 
never properly shaken, aired, picked to pieces, or changed. It was 
that the carpets and curtains were always musty ; — it was that the 
furniture was always dusty ; it was that the papered walls were satu- 
rated with dirt ; — it was that the floors were never cleaned ; — it was 
that the uninhabited rooms were never sunned, or cleaned, or aired ; 
— it was that the cupboards were always reservoirs of foul air; — it 
was that the windows were always tight shut up at night; — it was 
that no window was ever systematically opened, even in the day, or 
that the right window was not opened. A person gasping for air 
might open a window for himself. But the servants were not taught 
to open the windows, to shut the doors ; or they opened the windows 
upon a dank well between high walls, not upon the airier court ; 
or they opened the room doors into the unaired halls and passages, 
by way of airing the rooms. Now all this is not fancy, but fact. 
In that handsome house I have known in one summer three 
cases of hospital pyaemia, one of phlebitis, two of consumptive 
cough : all the immediate products of foul air. When, in temperate 
climates, a house is more unhealthy in summer tlian in winter, it 
is a certain sign of something wrong. Yet nobody learns the lesson. 
Yes, God always justifies His ways. He is teaching while you are 
not learning. This poor body loses his finger, that one loses his life. 
And all from the most easily preventible causes.* 

The houses of the grandmothers and great grandmothers of this 
generation, at least the country houses, with front door and back 
door always standing open, winter and summer, and a thorough 
draught always blowing through — with all the scrubbing, and clean- 
ing, and polishing, and scouring which used to go on, the grand- 
mothers, and still more the ^eat grandmothers, always out of doors 
and never with a bonnet on except to go to church, these things 
entirely account for the fact so often seen of a great grandmother, 
who was a tower of physical vigour descending into a grandmother 
perhaps a little less vigorous but still sound as a bell and healthy 
to the core, into a mother languid and confined to her carriage and 
house, and lastly into a daughter sickly and confined to her bed. 
For, remember, even with a general decrease of mortality you may 
often find a race thus degenerating and still oftener a family. You 
may see poor little feeble washed-out rags, children of a noble stock, 
suffering morally and physically, throughout their useless, degenerate 

* I must say a word about servants' bedrooms. From the way they are built, 
but oftener from the way they are kept, and from no intelligent inspection what- 
ever being exercised 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 to live under the ground and over the roof. But in a country " mannion," 
which was really a " mansion," (not after the fashion of advertisements), I have 
known three maids who slept in the same room ill of scarlet fever. " How catching 
it is," was of course the remark. One look at the room, one smell of the room, was 
quite enough. It was no longer " unaccountable." The room was not a small 
one ; it was up stairs, and it had two large windows — but nearly every one of the 
neglects enumerated above was there. 



HEALTH OF HOUSES. 19 

lives, and yet people who are going to marry and to bring more such 
into the world, will consult nothing but their own convenience as to 
where they are to live, or how they are to live. 

With regard to the health of houses where there is a sick person, Don't make 
it often happens that the sick room is made a ventilating sliaft for the your sick- 
rest of the house. For while tlie house is kept as close, unaired, '■^°™ ^"^.^-o ^ 
and dirty as usual, the window of the sick room is kept a little open ^^"ft'f^'^h 
always, and the door occasionally. Now, there are certain sacrifices ^yjujie house, 
which a house with one sick person in it does make to that sick 
person: it ties up its knocker; it lays straw before it in the street. 
Why can't it keep itself thoroughly clean and unusually well aired, 
in deference to the sick person ? 

We must not forget what, in ordinary language, is called Infection. 
" Infection;"* — a thing of which people are generally so afraid that 
they frequently follow the very practice in regard to it which they 
ought to avoid. Nothing used to be considered so infectious or 
contagious as small pox; and people not very long ago used to cover 
up patients with heavy bed clothes, while they kept up large fires 
and shut the windows. Small pox, of course, under this regime, is 
very " infectious." People are somewhat wiser now in their manage- 
ment of this disease. They have ventured to cover the patients 
lightly and to keep the windows open; and we hear much less of 
the " infection" of small pox than we used to do. But do people 
in our days act with more wisdom on the subject of " infection " in 
fevers — scarlet fever, measles, &c. — than their forefathers did with 
small pox ? Does not the popular idea of "infection" involve that 
people should take greater care of themselves than of the patient ? 
that, for instance, it is safer not to be too much with the patient, 
not to attend too much to his wants ? Perhaps the best illustration 
of the utter absurdity of this view of duty in attending on "infectious" 
diseases is afforded by what was very recently the practice, if it is 

* Is it not living in a continual mistake to look upon diseases, as we do now, Diseases are 
as separate entities, which must exist, like cats and dogs 1 instead of looking upon not individuals 
them as conditions, like a dirty and a clean condition, and just as much under arranged in 
our own control ; or rather as the reactions of kindly nature, against the condi- classes, like 
tions in which we have placed ourselves. cats and doers, 

I was brought up, both by scientific men and ignorant women, distinctly to but conditions 
believe that small-pox, for instance, was 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 one another, 
descent, just as much as that there was a first dog, (or a first pair of dogs), and 
that small-pox would not begin itself any more than a new dog would begin 
without there having been a parent dog. 

Since then I have seen with my eyes and smelt with my nose small-pox grow- 
ing up in first specimens, either in clo.se rooms or in overcrowded wards, where 
it coidd not by any possibility have been " caught," but must have begun. 

Nay, more, I have seen diseases begin, grow up, and pass into one another. 
Now, dogs do not pass into cats. 

I have seen, for instance, with a little overcrowding, continued fever grow up ; 
and with a little more, typhoid fever ; and with a little more, typhus, and all in 
the same ward or hut. 

Would it not be far better, truer, and more practical, if we looked upon 
disease in this light] 

For diseases, as all experience shows, are adjectives, not noun substantives. 

c 2 



20 



NOTES OK NUBSINQ. 



not 80 even now, in some of the European lazarets — In which the 
plague-patient used to be condemned to the horrors of filth, over- 
crowding, and want of ventilation, while the medical attendant was 
ordered to examine the patient's tongue through an opera-glass and 
to toss him a lancet to open his abscesses with ! 

True nursing ignores infection, except to prevent it. Cleanliness 
and fresh air from open windows, with unremitting attention to the 
patient, are the only defence a true nurse either asks or needs. 

Wise and humane management of the patient is the best safe- 
guard against infection. 
"Why must There are not a few popular opinions, in regard to which it is 

children have useful at times to ask a question or two. For example, it is cora- 
measles, &c. 1 monly thought that children must have what are commonly called 
" children's epidemics," " current contagions," &c., in other words, 
that they are born to have measles, hooping-cough, perhaps even 
scarlet fever, just as they are born to cut their teeth, if they live. 

Now, do tell us, why must a child have measles ? 

Oh because, you say, we cannot keep it from infection — other 
children have measles — and it must take them — and it is safer that 
it should. 

But why must other children have measles ? And if they have, 
why must yours have them too ? 

If you believed in and observed the laws for preserving the health 
of houses which iiiculcate cleanliness, ventilation, white-washing, and 
other means, and which, by the way, are laws, as implicitly as you 
believe in the popular opinion, for it is nothing more than an opinion, 
that your child must have children's epidemics, don't you think that 
upon the whole your child would be more likely to escape altogether? 



III. PETTY MANAGEMENT. 



Petty 
management. 



All the results of good nursing, as detailed in these notes, may 
be spoiled or utterly negatived by one defect, viz. : in petty manage- 
ment, or, in other words, by not knowing how to manage that what 
you do when you are there, shall be done when you are not there. 
The most devoted friend or nurse cannot be always there. Nor is it 
desirable that she should. And she may give up her health, all her 
other duties, and yet, for want of a little management, be not one-half 
so efficient as another who is not one-half so devoted, but who has 
this art of multiplying herself — that is to 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 to manage, as it is to teach her how to nurse. Circumstances 
must vary with each different case. But it is possible to press upon 
her to think for herself : Now what does happen during my absence ? 
I am obliged to be away on Tuesday. But fresh air, or punctuality 
is not less important to my patient on Tuesday than it was on 



PETTY MANAGEMENT. 21 

Monday. Or : At 10 p.m. I am never with my patient ; but quiet is 
of no less consequence to him at 10 than it was at 5 minutes to 10. 

Curious as it may seem, this very obvious consideration occurs 
comparatively to few, or, if it does occur, it is only to cause the 
devoted friend or nurse to be absent fewer hours or fewer minutes 
from her patient — not to 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 sufficient, not as precepts, but as Illustrations of 
iUustrations. ^ the want of it. 

A strange washerwoman, coming late at night for the "things," Strangera 
will burst in by mistake to the patient's sick-room, after he has coming into 
fallen into his first doze, giving him a shock, the effects of which are 
irremediable, though he himself laughs at the cause, and probably 
never even mentions it. The nurse who is, and is quite right to be, 
at her supper, has not provided that the washerwoman shall not lose 
her way and go into the wrong room. 

The patient's room may always have the window open. But the Sjck room 
passage outside the patient's room, though provided with several large ^'^^^f ^^^ 
windows, may never have one open. Because it is not understood 
that the charge of the sick-room extends to the charge of the passage. 
And thus, as often happens, the nurse makes it her business to turn 
the patient's room into a ventilating shaft for the foul air of the 
whole house. 

An uninhabited room, a newly painted room,* an uncleaned Uninhabited 
closet or cupboard, may often become a reservoir of foul air for the ^°®°^ fouling 
whole house, because the person in charge never thinks of arranging jj^^gg 
that these places shall be always aired, always cleaned ; she merely 
opens the window herself " when she goes in." 

An agitating letter or message may be delivered, or an important QQQ.jg[^*^ 
letter or message not delivered ; a visitor whom it was of consequence ^^ letters and 
to see, may be refused, or one whom it was of still more consequence messages. 
not to see may be admitted — because the person in charge has never 
asked herself this question, What is done when I am not there ? t 

At ail events, one may safely say, a nurse cannot be with the 

• That excellent paper, the Builder, mentions the lingering of the smell of Lingering 
paint for a month about a house as a proof of want of ventilation. Certainly — smell of paint 
and, where there are ample windows to open, and these are never opened to get a want of care, 
rid of the smell of paint, it 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 1 

f Why should you let your patient ever be surprised, except by thieves'? I do Why let your 
not know. In England, people do not come down the chimney, or through the patient ever 
window, unless they are thieves. They come in by the door, and somebody must be surprised i 
open the door to them. The " somebody" charged with opening the door is one of 
two, three, or at most four persons. Why cannot these, at most, four persons be 
put in charge as to what is to be done when there is a ring at the door bell 1 

The sentry at a post is changed much oftener than any servant at a private 
house or institution can possibly be. But what should we think of such an excuse 
a3 this : that the enemy had entered such a post because A and not B had been 
on guard ? Yet I have constantly heard such an excuse made in the private 
house or institution and accepted: viz., that such a person had been "let in" or 
not " let in," and such a parcel had been wrongly delivered or lost because A 
and not B had opened the door ! 



22 



NOTES ON NURSING. 



Partial mea- 
sures such as 
" being always 
ia the way" 
yourself, in- 
crease instead 
of saving the 
patient's 
anxiety. Be- 
cause they 
must be only 
partial. 



What is the 
cause of half 
the accidents 
which 
happen ? 



patient, open the door, eat her meals, take a message, all at one and 
the same time. Nevertheless the person in charge never seems to 
look the impossibility in the face. 

Add to this that the attempting this impossibility does more to 
increase the poor Patient's hurry and nervousness than anything else. 

It is never thought that tbe patient remembers these things if 
you do not. He has not only to think whether the visit or letter 
may arrive, but whether you will be in the way at the particular day 
and hour when it may arrive. So that your partial measures for 
"being in the way" yourself, only increase the necessity for his 
thought. "Whereas, if you could but arrange that the thing should 
always be done whether you are there or not, he need never think 
at all about it. 

Tor the above reasons, whatever a patient can do for himself, it 
is better, i.e. less anxiety, for him to do for himself, unless the 
person in charge has the spirit of management. 

It is evidently much less exertion for a patient to answer a letter 
for himself by return of post, than to have four conversations, wait 
five days, have six anxieties before it is oflf his mind, before the 
person who is to answer it has done so. 

Apprehension, uncertainty, waiting, 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 imaginary conversations wich him. Tou are thinking of 
something else. "Rid him of his adversary quickly," is a first rule 
with the sick.* 

Tor the same reasons, always tell a patient and tell him before- 
hand when you are going out and when you will be back, whether it 
is for a day, an hour, or ten minutes. Tou fancy perhaps that it is 
better for him if he does not find out your going at all, better for 
him if you do not make yourself " of too much importance " to him ; 
or else you cannot bear to give him the pain or the anxiety of the 
temporary separation. 

No such thing. You ought to go, we will suppose. Health or duty 
requires it. Then say so to the patient openly. If you go without his 
knowing it, 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, 
and in nine cases out of ten he will be right. If you go out without 
telling him when you will be back, he can take no measures nor 
precautions 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 fatal cases, it is almost 
incredible how often the whole thing turns upon something which 

• There are many physical operations where caeteris paribus the danger is in 
a direct ratio to the time the operation lasts; and cceterie paribus the operator's 
success will be in direct ratio to his quickness. Now there are many mental ope- 
rations where exactly the same rule holds good with the sick ; coeteris jmribus 
their capability of bearing such operations depends directly on the quickness, 
without hurry, with which they can be got through. 



PETTY MANAGEMENT. 23 

has happened because "he," or still offcener "she," "was not there." 
But it is still more incredible how often, how almost always this is 
accepted as a sufficient reason, a justification ; why, the very fact of 
the thing having happened is the proof of its not being a justification. 
The person in charge was quite right not to be " there,'' he Mas called 
away for quite sufficient reason, or he was away for a daily recurring 
and unavoidable cause : yet no provision was made to supply his 
absence. The fault was not in his " being away," but in there being 
no management to supplement his " being away." When the sun is 
under a total eclipse or during his nightly absence, we light candles. 
But it would seem as if it did not occur to us that we must also 
supplement the person in charge of sick or of children, whether 
under an occasional eclipse or during a regular absence. 

In institutions where many lives would be lost and the effect 
of such want of management would be terrible and patent, there is 
less of it than in the private house.* 

Petty manage- 
* So true is this that I could mention two cases of women of very high posi- ment better 
tion, both of whom died in the same way of the consequences of a surgical understood in 
operation. And in both car-es, I was told by the highest authority that the fatal institutions 
result would not have happened in a London hospital. than in private 

But, as far as regards the art of petty management in hospitals, all the mili- houses, 
tary hospitals I know must be excluded. Upon my own experience I stand, and ^ . 
I solemnly declare that I have seen or known of fatal accidents, such as suicides . institu- 
in delirium tremens, bleedings to death, dying patients dragged out of bed by "°iis are the 
drunken Medical Stafl' Corps men, and many other things less patent and striking, exception, 
which would not have happened in London civil hospitals nursed by women. The 
medical officers should be absolved from all blame in these accidents. How can 
a medical officer mount guard all day and all night over a patient (say) in deli- 
rium tremens ? The fault lies in there being no organized system of attendance. 
Were a trustworthy man in charge of each ward, or set of wards, not as office 
clerk, but as head nurse, (and head nurse the best hospital Serjeant, or ward mas- 
ter, is not now and cannot be, from default of the proper regulations), the thing 
would not, in all probability, have happened. But were a trustworthy woman in 
charge of the ward, or set of wards, the thing would not, in all certainty, have 
happened. In other words, it does not happen where a trustworthy woman is 
really in cnarge. And, in these remarks, I by no means refer only to exceptional 
times of great emergency in war hospitals, but also, and quite as much, to the 
ordinary run of military hospitals at home, in time of peace ; or to a time in war 
when our army was actually more healthy than at hoille in peace, and the pres- 
sure on our hospitals consequently much less. 

It is often said that, in regimental hospitals, patients ought to " nurse each Kursing in 
other," because the number of sick altogether being, say, but thirty, and out Regimental, 
of these one only perhaps being seriously ill, and the other twenty-nine having Hospitals, 
little the matter with them, and nothing to do, they should be set to nurse the 
one ; also, that soldiers are so trained to obey, that they will be the most 
obedient, and therefore the best of nurses, add to which they are always kind to 
their comrades. 

Now, have those who say this, considered that, in order to obey, you must 
know how to obey, and that these soldiers certainly do not know how to obey in 
nursing. I have seen these " kind " fellows (and how kind they are no one 
knows so well as myself) move a comrade so that, in one case at least, the man 
died in the act. I have seen the comrades' " kindness " produce abundance of 
spirits, to be drunk in secret. Let no one understand by this that female nurses 
ought to, or could be introduced in regimental hospitals. It would be most 
undesirable, even were it not impossible. But the head nurseship of a hospital 



24 NOTES ON NUnSIKG. 

But in both, let whoever is in charge keep this simple question in 
her head {not, how can I always do this right thing myself, but) how 
can I provide for this right thing to be always done ? 

Then, when anything wrong has actually happened in consequence 
of her absence, which absence we will suppose to have been quite 
right, let her question stiU be {not, how can I provide against any 
more of such absences ? which is neither possible nor desirable, but) 
how can I provide against any thing wrong arising out of my 
absence ? 
What it is to How few men, or even women, understand, either in great or in 

^^ "^^„ little things, what it is the being " in charge " — I mean, know how to 

carry out a " charge." From the most colossal calamities, down to the 
most trifling accidents, results are often traced (or rather not traced) 
to such want of some one " in charge " or of his knowing how to be 
"in charge." A short time ago the bursting of a funnel-casing on 
board the finest and strongest ship that ever was built, on her trial 
trip, destroyed several lives and put several hundreds in jeopardy — 
not from any undetected flaw in her new and untried works— ^but 
from a tap being closed which ought not to have been closed — from 
what every child knows would make its mother's tea-kettle burst. 
And this simply because no one seemed to know what it is to' be " in 
charge," or who was in charge. Nay more, the jury at the inquest 
actually altogether ignored the same, and apparently considered the 
tap "in charge," for they gave as a verdict " accidental death." 

This is the meaning of the word, on a large scale. On a much 
smaller scale, it happened, a short time ago, that an insane person 
burnt herself slowly and intentionally to death, while in her doctor's 
charge and almost in her nurse's presence. Yet neither was consi- 
dered " at aU to blame." The very fact of the accident happening 
proves its own case. There is nothing more to be said. Either 
they did not know their business or they did not know how to 
perform it. 

To be "in charge " is certainly not only to carry out the proper 
measm'es yourself but to see that every one else does so too ; to see 
that no one either wilfully or ignorantly thwarts or prevents such 
measures. It is neither to do everything yourself nor to appoint a 
number of people to each duty, but to ensure that each does that 
duty to which he is appointed. This is the meaning which must be 
attached to the word by (above all) those " in charge " of sick, whether 
of numbers or of individuals, (and indeed I think it is with individual 
sick that it is least understood. One sick person is often waited 
on by four with less precision, and is really less cared for than ten 
who are waited on by one ; or at least than 40 who are waited on 
by 4; and all for want of this one person " in charge.)" 

Serjeant is the more essential, the more important, the more inexperienced the 
nurses. Undoubtedly, a London hospital " sister " does sometimes set relays of 
patients to watch a critical case ; but, undoubtedly also, always under her own 
superintendence ; and she is called to whenever there is something to be done, 
and she knows how to do it. The patients are not left to do it of their own 
unassisted genius, however " kind " and willing they may be. 



NOISE. 25 

It is often said that there are few good servants now : I say there 
are few good mistresses now. As the jury seems to have thought 
the tap was in charge of the ship's safety, so mistresses now seem 
to think the house is in charge of itself. They neither know how to 
give orders, nor how to teach their servants to obey orders — i. e. to 
obey intelligently, which is the real meaning of all discipline. 

Again, people who are in charge often seem to have a pride in feel- 
ing that they will be "missed," that no one can understand or carry 
on their arrangements, their system, books, accounts, &c., but them- 
selves. It seems to me that the pride is rather in carrying on a 
system, in keeping stores, closets, books, accounts, &c., so that any 
body can understand and carry them on — so that, in case of absence 
or illness, one can deliver every thing up to others and know that all 
will go on as usual, and that one shall never be missed. 

Note. — It is often complained, that professional nurses, brought into private Why hired 
families, in case of sickness, make themselves intolerable by "ordering about" the nurses give 80 
other servants, under plea ofnot neglecting the patient. Both things are true; the much trouble. 
patient is often neglected, and the servants are often unfairly " put upon." But 
i\ie f:\ult is generally in the want of management of the head in charge. It is 
surely for her to arrange both that the nurse's place is, when necessaiy, supple- 
mented, and that the patient is never neglected — things with a little manage- 
ment quite compatible, and indeed only attainable together. It is certainly not 
for the nurse to " order about" the servants. 



lY. NOISE. 

Unnecessary noise, or noise that creates an expectation in the Unnecessary 
mind, is that which hurts a patient. It is rarely the loudness of the noise, 
noise, the effect upon the organ of the ear itself, which appears to 
affect the sick. How well a patient will generally bear, e.g., the 
putting up of a scaffolding close to the house, when he cannot bear 
the talking, still less the whispering, especially if it be of a familiar 
voice, outside his door. 

There are certain patients, no doubt, especially where there is 
slight concussion or other disturbance of the brain, who are affected 
by mere noise. But intermittent noise, or sudden and sharp noise, 
in these as in all other cases, affects far more than continuous 
noise — noise with jar far more than noise without. Of one thing 
you may be certain, that anything which wakes a patient suddenly 
out of his sleep will invariably put him into a state of greater 
excitement, do him more serious, aye, and lasting mischief, than any 
continuous noise, however loud. 

Never to allow a patient to be waked, intentionally or accident- Never let a 
ally, is a sine qua non of all good nursing. If he is roused out of his patient be 
first sleep, he is almost certain to have no more sleep. It is a curious waked out of 
but quite intelligible fact that, if a patient is waked after a few ^^ ^^^ &\qqv- 
hours' instead of a few minutes' sleep, he is much more likely to 
sleep again. Because pain, like irritability of brain, perpetuates 
and intensifies itself. If you have gained a respite of either in sleep 



26 



NOTES ON NUBSING. 



you have gained more than the mere respite. Both the probahility 
of recurrence and of the same intensity will be diminished ; whereas 
both will be terribly increased by want of sleep. This is the reason 
why sleep is so all-important. This is the reason why a patient 
waked in the early part of his sleep loses not 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 it is exactly the reverse 
with the sick generally ; the more they sleep, the better will they 
be able to sleep. 
Noise -which I have often been surprised at the thoughtlessness, (resulting 

excites expec- in cruelty, quite unintentionally) of friends or of doctors who will 
tation. hold a long conversation just in the room or passage adjoining to 

the room of the patient, who is either every moment expecting 
them to come in, or who has just seen them, and knows they are 
talking about him. If he is an amiable patient, he will try to 
occupy his attention elsewhere and not to listen — and this makes 
matters worse — for the strain upon his attention and the effort he 
•makes are so great that it is well if he is not worse for hours 
WhiBpered after. If it is a whispered conversation in the same room, then 
conversation it is absolutely cruel ; for it is impossible that the patient's attention 
in the room should not be involuntarily strained to hear. Walking on tip-toe, 
doing any thing in the room very slowly, are injurious, for exactly the 
same reasons. A firm light quick step, a steady quick hand are the 
desiderata; not the slow, lingering, shuffling foot, the timid, uncertain 
touch. Slowness is not 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 almost wild, 
of fever patients who are listening for the entrance from the 
corridor of the persons whose voices they are hearing there, these 
would never run the risk again of creating such expectation, or 
irritation of mind. — Such unnecessary noise has undoubtedly induced 
or aggravated delirium in many cases. I have known such — in one 
case death ensued. It is but fair to say that this death was attri- 
buted to fright. It was the result of a long whispered conversation, 
within sight of the patient, about an impending operation ; but any 
one who has known the more than stoicism, the cheerful coolness, with 
which the certainty of an operation will be accepted by any patient, 
capable of bearing an operation at all, if it is properly communi- 
cated to him, wiU hesitate to believe that it was mere fear which pro- 
duced, as was averred, the fatal result in this instance. It was rather 
the uncertainty, the strained expectation as to what was to be decided 
upon. 
Or just out- I need hardly say that the other common cause, namely, for a 

side the door, doctor or friend to leave the patient and communicate his opinion 
on the result of his visit to the friends just 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. 
Noiseof female It is, I think, alarming, peculiarly at this time, when the female 
dress. ink-bottles are perpetuaUy impressing upon us " woman's" " parti- 



NOISE. 27 

cular worth and general missionariness," to see that the dress of 
women is daily more and more unfitting them for any " mission," or 
usefulness at all. It is equally unfitted for all poetic and all domestic 
purposes. A man is now a more handy and far less objectionable 
being in a sick- room than a woman. Compelled by her dress, every 
woman now either shuffles or waddles — only a man can cross 
the floor of a sick-room without shaking it ! What is become of 
woman'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 well. For, in all these remarks, 
the sick are only mentioned as suffering in a greater proportion 
than the well from precisely the same causes. 

Unnecessary (although slight) noise injures a sick person much 
more than necessary noise (of a much greater amount). 

All doctrines about mysterious affinities and aversions will be Patient's re- 
found to resolve themselves very much, if not entirely, into presence Pulsion to 

u £■ • J.-I 1.1 ■ nurses who 

or absence ot care in these things. rustle 

A nurse who rustles (I am speaking of nurses professional and 
unprofessional) is the horror of a patient, though perhaps he does 
not know why. 

The fidget of silk and of crinoline, the rattling of keys, the creaking 
of stays and of shoes, will do a patient more harm than all the medi- 
cines in the world will do him good. 

The noiseless step of woman, the noiseless drapery of woman, 
are mere figures of speech in this day. Her skirts (and well if they 
do not throw down some piece of furniture) will at least brush 
against every article in the room as she moves.* 

Again, one nurse cannot open the door without making 
everything rattle. Or she opens the door unnecessarily often, 
for want of remembering all the articles that might be brought in at 
once. 

A good nurse will always make sure that no door or window in 
her patient's room shall rattle or creak ; that no blind or curtain 
shall, by any change of wind through the open window, be made to 
flap — especially will she be careful of all this before she leaves her 
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 exacting patients, in all classes ; and many 

* Fortunate it is if her skirts do not catch fire — and if the nurse does not give Burning of the 
herself up a sacrifice together with her patient, to be burnt in her own petticoats, crinolines, 
I wish the Registrar-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 to 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 Indecency of 
own dress as other people see it. A respectable elderly woman stooping for- the crinolines^ 
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 her this unpleasant truth. 



28 



NOTES ON NURSING. 



Hurry pecu- 
liarly hurtful 
to sick. 



How to visit 
the sick and 
not hurt them, 



These things 
not fancy. 



Interruption 
damaging to 
sick 



a patient passes a bad night, time after time, ratlier than remind 
his nurse every night of all the things she has forgotten. 

If there are blinds to your windows, always take care to have 
them well up, when they are not being used. A little piece slipping 
down, and flapping with every draught, will distract a patient. 

All hurry or bustle is peculiarly painful to the sick. And when a 
patient has compulsory occupations to engage him, instead of having 
simply to amuse himself, it becomes doubly injurious. The friend 
who remains standing and fidgetting about while a patient is talking 
business to him, or the friend who sits and proses, the one from an 
idea of not letting the patient talk, the other from an idea of amusing 
him, — each is equally inconsiderate. Always sit down when a sick 
person is talking business to you, show no signs of hurry, give 
complete attention and full consideration if your advice is wanted, 
and go away the moment the subject is ended. 

Always sit within the patient's view, so that when you speak to 
him he has not painfully to turn his head round in order to look at 
you. Everybody involuntarily looks at the person speaking. If you 
make this act a wearisome one on the part of the patient you are 
doing him harm. So also if by continuing to stand you make him 
continuously raise his eyes to see you. Be as motionless as possible, 
and never gesticulate in speaking to the sick. 

Never make a patient repeat a message or request, especially if it 
be some time after. Occupied patients are often accused of doing 
too much of their own business. They are instinctively right. How 
often you hear the person, charged with the request of giving the 
message or writing the letter, say half an hour afterwards to the 
patient, " Did you appoint 12 o'clock ?" or, " What did you say was 
the address ?" or ask perhaps some much more agitating question — 
thus causing the patient the effort of memory, or worse still, of 
decision, all over again. It is really less exertion to him to write his 
letters himself. This is the almost universal experience of occupied 
invalids. 

This brings us to another caution. Never speak to an invalid 
from behind, nor from the door, nor from any distance from him, 
nor when he is doing anything. 

The official politeness of servants in these things is so grateful to 
invalids, that many prefer, without knowing why, having none but 
servants about them. 

These things are not fancy. If we consider that, with sick as 
with well, every thought decomposes some nervous matter, — that 
decomposition as well as re-composition of nervous matter is always 
going on, and more quickly with the sick than with the well, — that, to 
obtrude abruptly another thought upon the brain while it is in 
the act of destroying nervous matter by thinking, is calling upon it 
to make a new exertion, — if we consider these things, which are 
facts, not fancies, we shall remember that we are doing positive 
injury by interrupting, by "startling a fanciful" person, as it is 
called. Alas ! it is no fancy. 

If the invalid is forced, by his avocations, to continue occupations 



NOISE. 29 

requiring much thinking, the injury is doubly great. In feeding a 
patient suffering under delirium or stupor you may suffocate him, 
by giving him his food suddenly, but if you rub his lips gently 
•with a spoon and thus attract his attention, he will swallow the food 
unconsciously, but with perfect safety. Thus it is with the brain. 
If you offer it a thought, especially one requiring a decision, abruptly, 
you do it a real not fanciful injury. Never speak to a sick person 
suddenly ; but, at the same time, do not keep his expectation on the 
tiptoe. 

This rule, indeed, applies to the well quite as much as to the sick. And to well. 
I have never known persons who exposed themselves for years to 
constant interruption who did not muddle away their intellects by it 
at last. The process with them may be accomplished without pain. 
With the sick, pain gives warning of the injury. 

Do not meet or overtake a patient who is moving about in order Keeping a 
to speak to him, or to give him any message or letter. You might patient 
just as well give him a box on the ear. I have seen a patient fall standing, 
flat on the ground who was standing when his nurse came into the 
room. This was an accident which might have happened to the 
most careful nurse. But the other is done with intention. A 
patient in such a state is not going to the East Indies. If you would 
wait ten seconds, or walk ten yards further, any promenade he could 
make would be over. You do not know the effort it is to a patient 
to remain standing for even a quarter of a minute to listen to you. 
If I had not seen the thing done by the kindest nurses and friends, 
I should have thought this caution quite superfluous.* 

Patients are often accused of being able to " do much more when Patients dread 
nobody is by." It is quite true that they can. Unless nurses can surprise, 
be brought to attend to considerations of the kind of which we have 
given here but a few specimens, a very weak patient finds it really 
much less exertion to do things for himself than to ask for them. 
And he will, in order to do them, (very innocently and from 
instinct) calculate the time his nurse is likely to be absent, from a 
fear of her " coming in upon" him or speaking to him, just at the 
moment when he finds it quite as much as he can do to crawl from 
his bed to his chair, or from one room to another, or down stairs, or 
out of doors for a few minutes. Some extra call made upon his 
attention at that moment will quite upset him. In these cases you 
may be sure that a patient in the state we have described does not 
make 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 Never speak to 
to herself, never to speak to any patient who is standing or movin'^, as long as a patient in 
she exercises so little observation as not to know when a patient cannot bear it. the act of 
I am satisfied that many of the accidents which happen from feeble patients tumb- moving, 
ling down stairs, fainting after getting up, &c., happen solely from the nurse pop- 
ping out of a door to speak to the patient just at that moment ; or from his fearing 
that she will do so. And that if the patient were even left to himself, till he can 
sit down, such accidents would much seldomer occur. If the nurse accompanies 
the patient let her not call upon him to speak. It is incredible that nurses can- 
not picture to themselves the strain upon the heart, the lungs, and the brain 
which the act of moving is to any feeble patient. 



30 



NOTES ON NUaSING. 



Effects of over- 
exertion on 
eick. 



Difference 
between real 
and fancy 
patients. 



much about the same hour every day. And it 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 
to 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. 
But, if you rouse him up after he has fallen asleep, you do not risk, 
you secure him a bad night. 

One hint I would give to all who attend or visit the sick, to 
all who have to pronounce an opinion upon sickness or its pro- 
gress. Come back and look at your patient after he has had 
an hour's animated conversation with you. It is the best test of 
his real state we know. But never pronounce upon him from 
merely seeing what he does, or how he looks, during such a conver- 
sation. Learn also carefully and exactly, if you can, how he passed 
the night after it. 

People rarely, if ever, faint while making an exertion. It is after 
it is over. Indeed, almost every effect of over-exertion appears 
after, not during such exertion. It is the highest folly to judge of 
the sick, as is so often done, when you see them merely during a 
period of excitement. People have very often died of that which, it 
has been proclaimed at the time, has " done them no harm."* 

Eemember never to lean against, sit upon, or unnecessarily 
shalie, 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 has a point by which to steady himself, in his feet. But on 
a bed or sofa, he is entirely at your mercy, and he feels every jar 
you give him all through him. 

In all that we have said, both here and elsewhere, let it be 
distinctly understood that we are not speaking of hypochondriacs. 
To distinguish between real and fancied disease forms an important 
branch of the education of a nurse. To manage fancy patients forma 
an important branch of her duties. But the nursing which real and 
that which fancied patients require is of diflferent, or rather of 
opposite, character. And the latter will not be spoken of here. 
Indeed, many of the symptoms which are here mentioned are those 
which distinguish real from fancied disease. 



Careless obser- * ^^ ^^ o^*^ experienced nurse, I do most earnestly deprecate all such careless 
vation of the 'w^ords. I have known patients delirious all night, after seeing a visitor who 
results of care- called them "better," thought they "only wanted a little amusement," and who 
less visits. came again, saying, " I hope you were not the worse for my visit," neither wait- 
ing for an answer, nor even looking at the case. No real patient will ever say, 
" Yes, but I was a great deal the worse." 

It is not, however, either death or delirium of which, in these cases, there is 
most danger to the patient. Unperceived consequences are far more likely to 
ensue. Ycm will have impunity — the poor patient will not. That is, the patient 
will suffer, although neither he nor the inflictor of the injury will attribute it to 
its real cause. It will not be directly traceable, except by a very careful 
observant nurse. The patient will often not even mention what has done him 
most harm< 



>"OISE. 31 

It is true that hypochondriacs very often do that behind a nurse's 
back which they would not do before her face. Many such I have 
had as patients who scarcely ate anything at their regular meals ; 
but if you concealed food for them in a drawer, they would take it 
at night or in secret. But this is from quite a different motive. 
They do it from the wish to conceal. Whereas the real patient 
will often boast to his nurse or doctor, if these do not shake their 
heads at him, of how much he has done, or eaten, or walked. To 
return to real disease. 

Conciseness and decision are, above all things, necessary with the Conciseness 
sick. Let your thought expressed to them be concisely and decidedly necessary with 
expressed. AVhat doubt and hesitation there may be in your own Sick. 
mind must never be communicated to theirs, not even (I would 
rather say especially not) in little things. Let your doubt be to 
yourself, your decision to them. People who think outside their 
heads, the whole process of whose thought appears, like Homer's, in 
the act of secretion, who tell everything that led them towards this 
conclusion and away from that, ought never to be with the sick. 

Irresolution is what all patients most dread. Eather than meet Irresolution 
this in others, they will collect all their data, and make up their minds most painful 
for themselves. A change of mind in others, whether it is regarding to them, 
an operation, or re-writing a letter, always injures the patient 
more than the being called upon to make up his mind to the most 
dreaded or dithcult decision. Farther than this, in very many cases, 
the imagination in disease is far more active and vivid than it is in 
health. If you propose to the patient change of air to one place 
one hour, and to another the next, he has, in each case, immediately 
constituted himself in imagination the tenant of the place, gone over 
the whole premises in idea, and you have tired him as much by 
displacing his imagination, as if you had actually carried him over 
both places. 

Above all leave the sick room quickly and come into it quickly, 
not suddenly, not with a rush. But don't let the patient be wearily 
waiting for when you will be out of the room or when you will be in 
it. 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 has to see, not only to his own but also to his nurse's What a patient 
punctuality, or perseverance, or readiness, or calmness, to any or all must not have 
of these things, he is far better without that nurse than with her — to see to. 
however valuable and handy her services may otherwise be to him, 
and however incapable he may be of rendering them to himself. 

With regard to reading aloud in the sick room, my experience Reading 
is, that when the sick are too ill to read to themselves, they can aloud, 
seldom bear to be read to. Children, eye-patients, and uneducated 
persons are exceptions, or where there is any mechanical difficulty 
m reading. People who like to be read to, have generally not much 
the matter with them ; while in fevers, or where there is much irri- 
tability of brain, the effort of listening to reading aloud has often 



32 



NOTES ON NUESING. 



Eead aloud 
slowly, 

distinctly, and 
steadily to the 
sick. 



Never read 
aloud by fits 
and starts to 
the sick. 



People 
OTerhead. 



The sick would 
rather be told a 
thing than have 
it read to them. 



brought on delirium. I speak witli great diffidence ; "because there 
is an ahnost universal impression that it is sparing the sick to read 
aloud to them. But two things are certain : — 

(1.) If there is some matter which must be read to a sick 
person, do it slowly. People often think that the way to get it 
over with least fatigue to him is to get it over in least time. They 
gabble ; they plunge and gallop through the reading. There never 
was a greater mistake. Houdin, the conjuror, says that the way to 
make a story seem short is to tell it slowly. So it is with reading 
to the sick. I have often heard a patient say to such a mistaken 
reader, " Don't read it to me ; tell it me."* Unconsciously he is 
aw^are that this will regulate the plunging, the reading with unequal 
paces, slurring over one part, instead of leaving it out altogether, 
if it is unimportant, and mumbling another. If the reader lets his 
own attention wander, and then stops to read up to himself, or finds 
he has read the wrong bit, then it is all over with the poor patient's 
chance of not suffering. Very few people know how to read to the 
sick ; very few read aloud as pleasantly even as they speak. In 
reading they sing, they hesitate, they stammer, they hurry, they 
mumble ; when in speaking they do none of these things. Reading 
aloud to the sick ought always to be rather slow, and exceedingly 
distinct, but not mouthing — rather monotonous, but not sing soug 
— rather loud, but not noisy — and, above all, not too long. Be very 
sure of what your patient can bear. 

(2.) The extraordinary habit of reading to oneself in a sick room, 
and reading aloud to the patient any bits which will amuse him or 
more often the reader, is unaccountably thoughtless. What do you 
think the patient is thinking of during your gaps of non-reading ? 
Do you think that he amuses himself upon what you have read for 
precisely the time it pleases you to go on reading to yourself, and 
that his attention is ready for something else at precisely the time it 
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 to, the self-absorption and want of obser- 
vation of the person who does it, is equally difficult to understand — 
although very often the readme is too amiable to say how much it 
disturbs him. 

One thing more : — From the flimsy manner in which most modern 
houses are built, w^here every step on the stairs, and along the 
floors, is felt all over the house ; the higher the story, the greater 
the vibration. It is inconceivable how much the sick suffer by 
having anybody overhead. In the solidly built old houses, which, 
fortunately, most hospitals are, the noise and shaking is comparatively 
trifling. But it is a serious cause of suffering, in lightly built houses, 
and with the irritability peculiar to some diseases. Better far put 
such patients at the top of the house, even with the additional 
fatigue of stairs, if you cannot secure the room above them being 

* Sick children, if not too shy to speak, will always express this wish. They 
invariably prefer a story to be told to them, rather than re^ to them. 



TAKIETT. 33 

untenanted; you may otherwise bring on a state of restlessness which 
no opium will subdue. Do not neglect the warning, when a patient 
tells you that he " Feels every step above him to cross his heart." 
Eemember that every noise a patient cannot see partakes of the 
character of suddenness to him; and I am persuaded that patients 
with these peculiarly irritable nerves, are positively less injured by 
having persons in the same room with them than overhead, or 
separated by only a thin compartment. Any sacrifice to secure silence 
for these cases is worth while, because no air, however good, no 
attendance, however careful, will do anything for such cases without 
quiet. 

Note. — The effect of music upon the sick has been scarcely at all noticed. Music. 
In fact, its expensiveness, as it is now, makes any general 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 — while the piano-forte, with such instruments as have 
no continuity of sound, has just the reverse. The finest piano-forte playing will 
damage the sick, while an air, like "Home, sweet home," or "Assisa a piii d'un 
salice," on the most ordinary grinding m^gaa will sensibly soothe them — and this 
quite independent of association. 



V. VAEIETY. 

To any but an old nurse, or an old patient, the degree would be Variety a 
quite inconceivable to which the nerves of the sick sutler from seeing means ot 
the same walls, the same ceiling, the same surroundings during a r^^ov^^^T- 
long confinement to one or two rooms. 

The superior cheerfulness of persons sutfering severe paroxysms 
of pain over that of persons sutfering from nervous debility has often 
been remarked upon, and attributed to the enjoyment of the former 
of their intervals of respite. I incline to think that the majority of 
cheerful cases is to be found among those patients who are not con- 
fined to one room, whatever their suffering, and that the majority of 
depressed cases will be seen among those subjected to a long 
monotony of objects about them. 

The nerTOUs frame r eally suffers as much from this as the diges- 
tive orga"nsTroin long monotony of diet, as e.g. the soldier from his 
twenty-one years' " boiled beef" 

The etfect in sickness of beautiful objects, of variety of objects, Colour and 
and especially of brilliancy of colour is hardly at all appreciated. ^^'"^^ means of 

Such cravings are usually called the "fancies" of patients. And ^^'^^^'^^i* 
often doubtless patients have "fancies," as, e.g. when they desire 
two contradictions. But much more often, their (so called) "fancies" 
are the most valuable indications of what is necessary for their 
recovery. And it would be well if nurses would watch these (so 
called) "fancies" closely. 

I have seen, in fevers (and felt, when I was a fever patient myself) 
the most acute suffering produced from the patient (in a hut) not 
being able to see out of window, and the knots in the wood 






^^- 



34 NOTES ON NUESING. 

being the only view. I shall never forget the rapture of fever 
patients over a bunch of bright-coloured flowers. I remember (in 
my own case) a nosegay of wild flowers being sent me, and from 
that moment recovery becoming more rapid. 

This is no People say the effect is only on the mind. It is no such thing. 

fancy. ^jjg effect is on the body, too. Little as we know about the way in 

which we are affected 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.g., if you shew a patient ten or 
twelve engravings successively, ten-to-one that he does not become 
cold and faint, or feverish, or even sick ; but hang orie up opposite 
him, one on each successive day, or week, or month, and he will revel 
in the variety. 

Flowers. The folly and ignorance which reign too often supreme over the 

', sick-room, cannot be better exemplified than by this. While the 

I nurse will leave the patient stewing in a corrupting atmosphere, 

■V the best ingredient of which is carbonic acid ; she will deny him, on 

the plea of unhealthiness, a glass of cut-flowers, or a growing plant. 

Now, no one ever saw " overcrowding" by plants in a room or ward. 

And the carbonic acid they give off at nights would not poison a fly. 

Nay, in overcrowded rooms, they actually absorb carbonic acid and 

give off oxygen. Cut-flowers also decompose water and produce 

oxygen gas. It is true there are certain flowers, e.g., lilies, the smell 

of which is said to depress the nervous system. These are easily 

known by the smell, and can be avoided. 

Effect of body Volumes are now written and spoken upon the effect of the mind 

on mind. upon the body. Much of it is true. But I wish a little more was 

thought of the effect of the body on the mind. Tou who believe 
yourselves overwhelmed with anxieties, but are able every day to 
walk up Regent-street, or out in tho country, to take your meals with 
others in other rooms, &c., &c., you little know how much your 
anxieties 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 hung with their cares ; how the ghosts of 
their troubles haunt their beds ; how impossible it is for them to 
escape from a pursuing thought without some help from variety. 

A patient can just as much move his leg when it is fractured as 
change his thoughts when no external help from variety is given 
him. This is, indeed, one of the main sufferings of sickness ; just 

Sick suffer to * It is a matter of painful wonder to the sick themselves how much painful 

excess from ideas predominate over pleasurable ones in their impressions ; they reason with 

mental as well themselves ; they think themselves ungrateful ; it is all of no use. The fact is, 

as bodily pain, that these painful impressions are far better dismissed 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 impression from nature is what he wants. I 

have mentioned the cruelty of letting him stare at a dead wall. In many 

diseases, especially in convalescence from fever, that wall will appear to make all 

sorts of faces at him ; now flowers never do this. Form, colour, will free your 

patient from his painful ideas better than any argument. 



VABIETT. 35 

as the fixed posture is one of the main sufierings of the broken "^ 
limb. 

It is an ever recurring wonder to see educated people, who Help the sick 
call themselves nurses, acting thus. They vary their own objects, to vary their 
their own employments many times a day ; and while nursing (!) thoughts, 
some bed-ridden sufferer, they let him lie there staring at a dead 
wall, without any change of object to enable him to vary his thoughts ; 
and it never even occurs to them, at least to move his bed so that he 
can look out of window. No, the bed is to be always left in the 
darkest, dullest, remotest, part of the room.* 

I think it is a very common error among the well to think that 
"with a little more self-control" the sick might, if tliey choose, 
"dismiss painful thoughts" which "aggravate their disease," &c. 
Believe me, almost any sick person, who behaves decently well, 
exercises more self-control every moment of his day than you will 
ever know till you are sick yourself. Almost every step that crosses 
his room is painful to him ; almost every thought that crosses his 
brain is painful to him ; and if he can speak without being savage, 
and look without being unpleasant, he is exercising self-control. 

Suppose you have been up all night, and instead of being allowed 
to have your cup of tea, you were to be told that you ought to 
" exercise self-control," what should you say ? Now, the nerves of 
the sick are always in the state that yours are in after you have been 
up all night. 

We will suppose the diet of tMe sick to be cared for. Then, this Supply to the 
state of nerves is most frequently to be relieved by care in affording sick the defect 
them a pleasant view, a judicious variety as to flowers,t and pretty of manual 
things. Light by itself will often relieve it. The craving for " the l^^*'"'"- 
return of day," which the sick so constantly evince, is generally 
nothing but the desire for light, the remembrance of the relief which 
a variety of objects before the eye affords to the harassed sick mind. 

Again, every man and every woman has some amount of manual 
employment, excepting a few fine ladies, who do not even dress 
themsehes, and who are virtually in the same category, as to nerves, 
as the sick. Now, you can have no idea of the relief which manual 
labour is to you — of the degree to whicli the deprivation of manual 

* I remember a case in point. A man received an injury to the spine, from Desperate de- 
an accident, which after a long confinement ended in death. He was a workman gire in the 
— had not in his composition a single grain of what is called "enthusiasm for gick to "see 
nature," — but he was desperate to "see once more out of window." His nurge out of win- 
actually got him on her back, and managed to perch him up at the window for an dow." 
instant, " to see out." The consequence to the poor nurse was a serious illness, 
which nearly proved fatal. The man never knew it; but a great many other 
people did. Yet the consequence in none of their minds, so far as I know, was 
the conviction that the craving for variety in the starving eye, is just as desperate 
as that for food in the starving stomach, and tempts the famishing creature in 
either case to steal for its satisfaction. No 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 not provide the sick-bed with a 
"view" of some kind, as if they did not provide the hospital with a kitchen. 

+ No one who has watched the sick can doubt the fact, that some feel stimulus Physical effect 
from looking at scarlet flowers, exhaustion from looking at deep blue, &c. of colour. 

D 2 



30 



yOTES ON NUnSING. 



employment increases the peculiar irritability from which many sick 
suffer. 

A little needle-work, a little writing, a little cleaning, would be the 
greatest relief the sick could have, if they could do it ; these are the 
greatest relief to you, though you do not know it. Reading, though 
it is often the only thing the sick can do, is not this relief. Bearing 
this in mind, bearing in mind that you have all these varieties of 
employment which the sick cannot have, bear also in mind to obtain 
for them all the varieties which they can enjoy. 

I need liardly say that I am well aware that excess in needle-work, 
in writing, in any other continuous employment, will produce the 
same irritability that defect in manual employment (as one cause) 
produces in the sick. 



Want of atten- 
tion to hours 
of taking food. 



Life often 
hangs upon 
minntes in 
taking food. 



VI. TAKING JFOOD. 

Every careful 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 the ways which alone make it possible for 
them to take food. This want of attention is as remarkable in those 
who urge upon the sick to do what is quite impossible to them, as in 
the sick themselves who will not make the effort to do wliat is per- 
fectly possible to them. 

For instance, to the large majority of very weak patients it is 
quite impossible to take any solid food before 11 a.m., nor then, if 
their strength is still further exhausted by fasting till that hour. 
For weak patients have generally feverish nights and, in the morning, 
dry mouths ; and, if they could eat with those dry mouths, it would 
be tlie worse for them. A spoonful of beef-tea, of arrowroot and 
wine, of egg flip, every hour, will give them the requisite nourish- 
ment, and prevent them from being too much exhausted to take at a 
later hour the solid food, which is necessary for their recovery. And 
every patient who can swallow at all can swallow these liquid things, 
if he chooses. But how often do we hear a mutton-chop, an Qgo^^ a 
bit of bacon, ordered to a patient for breakfast, to whom (as a 
moment's consideration would show us) it must be quite impossible 
to masticate such things at that hour. 

Again, a nurse is ordered to give a patient a tea-cup full of some 
article of food every three hours. The patient's stomach rejects it. 
If so, try a table-spoon full every hour : if this will not do, a tea-spoon 
full every quarter of an hour. 

I am bound to say, that I think more patients are lost by want of 
care and ingenuity in these momentous minutiae in private nursing 
than in public hospitals. And I think there is more of the entente 
cordials to assist one another's hands between the doctor and his head 
nurse in the latter institutions, than between the doctor and the 
patient's friends in the private house. 

If we did but know the consequences which may ensue, in very 
weak patients, from ten minutes' fasting or repletion, (I call it repletion 



TAKING FOOD. 37 

vrlien they are obliged to let too small an interval elapse between 
taking food and some other exertion, owing to the nurse's unpunctu- 
alitv), we should be more careful Jiever to let this occur. In very 
weak patients there is often a nervous difficulty of swallowing, which 
is so much increased by any other call upon their strength that, un- 
less they have their food punctually at the minute, which minute 
again must be arranged so as to fall in with no other minute's occu- 
pation, they can take nothing till the next respite occurs — so 
that an unpunctuality or delay of ten minutes may very well turn 
out to be one of two or three hours. And why is it not as easy 
to be punctual to a minute ? Life often literally hangs upon these 
minutes. 

In acute cases, where life or death is to be determined in a few 
hours, these matters are very generally attended to, especially in 
Hospitals ; and the number of cases is large where the patient is, as 
it were, brought back to life by exceeding care on the part of the 
Doctor or Nurse, or both, in ordering' and giving nourishment with 
minute selection and punctuality. 

But, in chronic cases, lasting over months and years, where the patients often 
fatal issue is often determined at last by mere protracted starvation, starved to 
I had rather not enumerate the instances which I have known where death ia 
a little ingenuity, and a great deal of perseverance, might, in all chronic cases, 
probability, have averted the result. The consulting the hours when 
the patient can take food, the observation of the times, often varying, 
when he is most faint, the altering seasons of taking food, in order to 
anticipate and prevent such times — all this, which requires observa- 
tion, ingenuity, and perseverance (and these really constitute the good 
Nurse), might save more lives than we wot of. 

To leave the patient's untasted food by his side, from meal to pood never to 
meal, in hopes that he will eat it in the interval, is simply to prevent be left by the 
him from taking any food at all. I have known patients 'literally patient's side, 
incapacitated from taking one article of food after another, by this 
piece of ignorance. Let the food come at the right time, and be 
taken av. ay, 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 him of everything. 

On the other hand, I have known a patient's life saved (he was 
sinking for want of food) by the simple question, put to him by the 
doctor, " But is there no hour when you feel you could eat?" " Oh, 
yes," he said, " I could always take something at — o'clock and — 
o'clock." The thing was tried and succeeded. Patients very 
seldom, however, can tell this ; it is for you to 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 not see 
one time, or even hear food talked about or see it in the raw state. ™^'"® ^'^ ^ ^^ 
I know of no exception to the above rule. The breaking of it always 
induces a greater or less incapacity of taking food. 

In hospital wards it is of course impossible to observe all this ; 
and in single wards, where a patient must be continuously and closely 
watched, it is frequently impossible to relieve the attendant, so that 



38 NOTES ON NUESING. 

Lis or her own meals can be taken out of the ward. But it is not the 
less true that, in such cases, even where the patient is not himself 
aware of it, his possibility of taking food is limited by seeing the 
attendant eating meals under his observation. In some cases the 
sick are aware of it, and complain. A case where the patient was 
supposed to be insensible, but complained as soon as able to speak, 
is now present to my recollection. 

Remember, however, that the extreme punctuality in well-ordered 
hospitals, the rule that nothing shall be done in the ward while the 
patients are having their meals, go far to counterbalance what 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 to eat. 

That the more alone an invalid can be when taking food, the 
better, is unquestionable ; and, even if he must be fed, the nurse 
should not allow him to talk, or talk to him, especially about food, 
while eating. 

When a person is compelled, by the pressure of occupation, to 
continue his business while sick, it ought to be a rule wituout ant 
EXCEPTION WHATEVER, that uo One shall bring business to him or 
talk to him while he is taking food, nor go on talking to him on inte- 
resting subjects up to the last moment before his meals, nor make an 
engagement with him immediately after, so that there be any hurry 
of mind while taking them. 

Upon the observance of these rules, especially the first, often 

depends the patient's capability of taking food at all, or, if he is 

amiable and forces himself to take food, of deriving any nourishment 

from it. 

You cannot be ^ nurse should never put before a patient milk that is sour, meat 

too careful as ^j, gQ^p ^j^^j; jg turned, an egg that is bad, or vegetables underdone. 

„?„3"f:L^ ^^ Yet often I have seen these things brought in to the sick in a state 

perfectly perceptible to every nose or eye except the nurse's. It is 

here that the clever nurse appears ; she will not bring in the peccant 

article, but, not to disappoint the patient, she will whip up something 

else in a few minutes, liemember that sick cookery should half do 

the work of your poor patient's weak digestion. But if you further 

impair it with your bad articles, I know not what is to become of 

him or of it. 

If the nurse is an intelligent being, and not a mere carrier of 
diets to and from the patient, let her exercise her intelligence in 
these things. How often we have known a patient eat nothing at 
all in the day, because one meal was left untasted (at that time he 
was incapable of eating), at another the milk was sour, the third was 
spoiled by some other accident. And it never occurred to the nurse 
to extemporize some expedient, — it never occurred to her that as he 
had had no solid food that day, he might eat a bit of toast (say) 
with his tea in the evening, or he might have some meal an hour 
earlier. A patient who cannot touch his dinner at two, will often 
accept it gladly, if brought to him at seven. But somehow nurses never 
"think of these things." One would imagine they did not consider 



sick diet. 



WUAT FOOD ? 39 

themselves bound to exercise their judgment; they leave it to the 
patient. Now I am quite sure that it is better for a patient rather 
to sufier these neglects than to try to teach his nurse to nurse him, 
if she does not know how. It ruffles him, and if he is ill he is in 
no condition-to teach, especially upon himself. The above remarks 
apply much more to private nursing than to hospitals. 

I would say to the nurse, have a rule of thought about your Nurse must 
patient's diet ; consider, remember how much he has had, autl how ^^^e some rule 
much he ought to have to -day. Generally, the only rule of the °|^Q|)°"jf ''' 
private patient's diet is what the nurse has to give. It is true she pa^^gn^'g jjjet 
cannot give him what she has not got ; but his stomach does not wait 
for her convenience, or even her necessity.* If it is used to having 
its stimulus at one hour to-day, and to-morrow it does not have 
it, because she has failed in getting it, he will suffer. She must 
be always exercising her ingenuity to supply defects, and to remedy 
accidents which will happen among the best contrivers, but from 
which the patient does not suffer the less, because "they cannot be 
helped." 

One very minute caution, — take care not to spill into your Keep your 
patient's saucer, in other words, take care that the outside bottom patient's cup 
rim of his cup shall be quite dry and clean ; if, every time he litts his 'l^' under- 
cup to his lips, he has to carry tlie saucer with it, or else to drop ^^^^'i- 
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 dillereuce this 
minute want of care on your part makes to his comfort and even to 
his willin<rnes3 for food 



VII. WHAT F00D1 

I will mention one or two of the most common errors among Common 
women in charge of sick respecting sick diet. One is the belief that errors in diet, 
beef tea is the most nutritive of all articles. Now, just try and 
boil down a lb. of beef into beef tea, evaporate your beef tea, and Beef tea. 
see what is left of your beef. You will find that there is barely a tea- 
spoonful of solid nourishment to half a pint of water in beef tea; — never- 
theless there is a certain reparative quality in it, we do not know 
what, as there is in tea ; — but it may safely be given in almost any 
inflammatory disease, 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 not at all so. Also, it is seldom noticed with how many 

* Why, because the nurse has not got some food to-day which the patient takes, Nurse must 
can the patient wait four hours for food to-day, who could not wait two hours yester- havesomerule 
day 1 Yet this is the only logic one generally hears. On the other hand, the other of time about 
logic, viz., of the nurse giving a patient a thing because she has got it, is equally the patient's 
fatal. If she happois to have fresh jelly, or fresh fruit, she will frequently give diet. 
it to the patient halfan-hour after his dinner, or at his dinner, when he cannot 
possibly eat that and the broth too— or worse still leave it by his bed-side till he 
is so sickened with the sight of it, that he cannot eat it at all. 



40 



KOTZS ON NUESIXO. 



Eggs. 



Meat witliout 
vegetables. 



Arrowroot. 



Milk, butter, 
cream, &c. 



Intelligent 
cnivings of 
particular sick 
for particular 
articles of 
diet. 



patients, particularly of nervous or bilious temperament, eggs disagree. 
All puddings made with eggs, are distasteful to tliem in consequence. 
Au egg, whipped up with wine, is often the only form in which they 
can t-.ike this kind of nourishment. Again, if the patient has attaiiieJ 
to eating meat, it is supposed that to give him meat is the 
only thing needful for his recovery ; whereas scorbutic sores have 
been actually known to appear among sick persons living in the 
midst of plenty in England, which could be traced to no other source 
than this, viz.: that the nurse, depending on meat alone, had allowed 
the patient to be without vegetables for a considerable time, these 
latter being so badly cooked that he always left them untouched. 
Arrowroot is another grand dependence of the nurse. As a vehicle 
for wine, and as a restorative quickly prepared, it is all very well. 
But it is nothing but s-tarch and water. Flour is both more nutri- 
tive, and less liable to ferment, and is preferable wherever it can be 
used. 

Again, milk and the preparations from milk, are a most important 
article of food for the sick. Butter is the lightei^t kind of animal fat, 
and though it wants the sugar and some of the other elements whicli 
there are in milk, yet it is most 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, preferable in all their preparations 
to all the preparations of arrow root, sago, tapioca, and their kind. 
Cream, in many long chronic diseases, is quite irreplaceable by 
any other article whatever. It seems to act in the same manner 
ns heef tea, and to most it is much easier of digestion than milk. 
In fact, it seldoni disagrees. Cheese is not usually digestible by the 
sick, but it is pure nourishment for repairing waste; and I have 
seen sick, and not a few either, whose craving for cheese shewed how 
much it was needed by them.* 

But,iflresh milk is so valuable a food for the sick, the least change 
or sourness in it, makes it of all articles, perhaps, the most injurious ; 
diarrhoea is a common result of fresh milk allowed to become at all 
sour. The nurse therefore ought to ext-rcise her utmost care in this. 
In large institutions for the tsick, even the poorest, the utmost care is 
exercised. Wenham Lake ice is used for this express purpose every 
summer, while the private patient, perhaps, never tastes a drop of 
milk that is not sour, all through the hot Aveather, so little does the 
]irivate nurse understand the necessity of such care. Yet, if you 
consider that the only drop of real nourishment in your patient's tea 
is the drop of milk, and how much almost all English patients depend 

* In the diseases produced Ly bad food, Bucli as scorbutic dysentery and 
diarrlicca, the patient's stonjach often craves for and di^'csts things, some of whicli 
certainly would be lai<l down in no dietary that ever was invented for sick, and 
especially not for such sick. These arc fruit, pickles, jums, gingerbread, fat of 
ham or of bacon, suet, cheese, butter, milk. These cases 1 have seen not by ones, 
nor by tens, but by hundreds. And the patient's stomach «as right and the book 
was wrong. The articles craved for, in these cases, might have been principally 
arranged under the two heads of fat and vegetable acids. 

There is often a marked diflcrence between men and women in this matter 
of sick feeding. AV'omen's digestion is generally slower. 



M^ 



WHAT FOOD ? 41 

upon their tea, you -will see the great importance of not depriving 
your patient of this drop of milk. Buttermilk, a totally different 
thing, is often very useful, especially in fevers. 

In laying down rules of diet, by the amounts of " solid nutri- Sweet things, 
ment " in different kinds of food, it is constantly lost sight of what 
the patient requires to repair his waste, what he can take and what 
he can't. Tou cannot diet a patient from a book, you cannot make 
up the human body as you would make up a prescription,^80 many 
parts '-carboniferous," so many parts "nitrogenous" will consti- 
tute a perfect diet for the patient. The nurse's observation here 
will materially assist the doctor— the patient's "fancies" will 
materially assist the nurse. Tor instance, sugar is one of the most 
nutritive of all articles, being pure carbon, and is particularly recom- 
mended in some books. But the vast majority of all patients in 
England, young and old, male and female, rich and poor, hospital and 
private, dislike sweet things, — and while I have never known a person 
take to sweets when he was ill who disliked them when he was well, 
I have known many fond of them when in health, who in sickness would 
leave off anything sweet, even to sugar in tea, — sweet puddings, 
sweet drinks, are their aversion; the furred tongue almost always 
likes what is sharp or pungent. Scorbutic patients are an exception, 
they often crave for sweetmeats and jams. 

^ Jelly is another article of diet in great favour with nurses and Jelly, 
friends of the sick ; even if it could be eaten solid, it would not 
nourish, but it is simply the height of folly to take ^ oz. of gelatine 
and make it into a certain bulk by dissolving it in water and then to 
give it to the sick, as if the mere bulk represented nourishment. It 
is now known that jelly does not nourish, that it has a tendency to 
produce diarrhoea, — and to trust to it to repair the waste of a diseased 
constitution is simply to starve the sick under the guise of feeding 
them. If 100 spoonfuls of jelly were given in the course of the day, 
you would have given one spoonful of gelatine, which spoonful has 
no nutritive power whatever. 

And, nevertheless, gelatine contains a large quantity of nitrogen, 
which is one of the most powerful elements in nutrition ; on the 
other hand, beef tea may be chosen as an illustration of great nutrient 
power in sickness, co^existing with a very small amovint of solid t 
nitrogenous matter. 

Dr. Christison says that " every one will be struck with the readi- Beef tea. 
ness with which" certain classes of "patients will often take diluted 
meat juice or beef tea repeatedly, when they refuse aU other kinds of 
food." This is particularly remarkable in "cases of gastric fever, 
in which," he says, "little or nothing else besides beef tea or diluted 
meat juice " has been taken for weeks or even months, " and yet a 
pint of beef tea contains scarcely ^oz. of anything but water," — the 
result is so striking that he asks what is its mode of action ? " Not 
simply nutrient — ^ oz. of the most nutritive material cannot nearly 
replace the daily wear and tear of the tissues in any circumstances. 
Possibly," he says, "it belongs to a new denomination of remedies." 

It has been observed that a small quantity of beef tea added to ^ 



42 



NOTES ON NUESING. 



must decide 
Bick diet, 



other articles of nutrition augments their power out of all proportion 
to the additional amount of solid matter. 

The reason why jelly should be innutritions and beef tea nutri- 
tious to the sick, is a secret yet undiscovered, but it clearly shows 
that careful observation of the sick is the only clue to the best 
dietary. 

Observation, Chemistry has as yet afforded little insight into the dieting of sick. 

not chemistrj', ^q ^^^^ chemistry can tell us is the amount of "carboniferous" or 
' nitrogenous elements . discoverable in dmerent dietetic articles. 
It has given us lists of dietetic substances, arranged in the order of 
their richness in one or other of these principles ; but that is all. In 
the great majority of cases, the stomach of the patient is guided by 
other principles of selection 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 her guidance, but these rules can only be 
ascertained by the most careftd observation at the bed-side. She 
there teaches us that living chemistry, the chemistry of reparation, is 
something diii'erent from the chemistry of the laboratory. Organic 
chemistry is useful, as all knowledge is, when we come face to face 
with nature ; but it by no means follows 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 much nourish- 
ment in half 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 whole. The main 
question is what the patient's stomach can assimilate or derive 
nourishment from, and of this the patient's stomach is the sole judge. 
Chemistrj' cannot tell this. The patient's stomach must be its own 
chemist. The diet which will keep the healthy man healthy, will kiU 
the sick one. The same beef which is the most nutritive of all meat 
and which nourishes the healthy man, is the least nourishing of all 
food to the sick man, whose half-dead stomach can assimilate no part 
of it, that is, make no food out of it. On a diet of beef tea healthy 
men on the other hand speedily lose their strength. 

I have known patients live for many months without touching 
bread, because they could not eat baker's bread. These were mostly 
country patients, but not all. Home-made bread or brown bread is 
a most important article of diet for many patients. The use of 
aperients may be entirely superseded by it. Oat cake is another. 

To watch for the opinions, then, which the patient's stomach gives, 
rather than to read "analyses of foods," is the business of all those 
, who have to settle what the patient is to eat — perhaps the most 
to bearon^sick iiiiportant thing to be provided for him after the air he is to breathe. 
digt_ Now the medical man who sees the patient only once a day or even 

only once or twice a week, cannot possibly tell this 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 at 
the last visit. I should therefore say that incomparably the most 
important office of the nurse, after she has taken care of the patient's 



Home-made 
bread. 



Sound obser- 
vation has 
Bcarcely yet 



■WHAT rooD ? 43 

air, is to take care to observe the effect of his food, and report it to 
the medical attendant. 

It is quite incalculable the good that would certainly come from 
such sound and close observation in this almost neglected branch ot 
nursing, or the help it would give to the medical man. 

A great deal too much against tea^'' is said by wise people, and a Tea and coffee, 
great deal too much of tea is given to the sick by foolish people. 
When you see the natural and almost universal craving in English 
sick for their " tea," you cannot but feel that nature knows what she 
is about. But a little tea or coffee restores tliem quite as much as 
a great deal, and a great deal of tea and especially of coffee impairs 
the little power of digestion they have. Yet a nurse because sho 
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 not the case 
at all ; it is however certain that there is nothing yet discovered 
which is a substitute to the English patient for his cup of tea ; he 
can take it when he can take nothing else, and he often .can't take 
anything else if he has it not. I should be very glad if any of the 
abusers of tea would point out what to give to an English patient 
after a sleepless night, instead of tea. If you give it at 5 or 6 o'clock 
in the morning, he may even sometimes fall asleep after it, and get 
perhaps his only two or three hours' sleep during the twenty-four. 
At the same time you never should give tea or coffee to the sick, 
as a rule, after 5 o'clock in the afternoon. Sleeplessness in the early 
night is from excitement generally and is increased by tea or coffee ; 
sleeplessness which continues to the early morning is from exhaustion 
often, and is relieved by tea. The only English patients I have ever 
known refuse tea, have been typhus cases, and the first sign of their 
getting better was their craving again for tea. In general, the dry 
and dirty tongue always prefers tea to coffee, and will quite decline 
milk, unless with tea. Coffee is a better restorative than tea, but a 

* It is made a frequent recommendation to persons about to incur great ex- 
haustion, 3ither from tlie 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 
themselves try the experiment of substituting a piece of bread for a cup of tea or 
coifee or beef tea as a refresher. They would find it a very poor comfort. When 
soldiers have to set out fasting on fatiguing duty, when nurses have to go 
fasting in to their patients, it is a hot restorative they want, and ought to have, 
before they go, not a cold bit of bread. And dreadful have been the consequences 
of neglecting this. If they can take a bit of bread ivith the hot cup of tea, so 
much the better, but not instead of it. The fact that there is more nourishment 
in bread than in almost anything else has probably induced the mistake. That 
it is a fatal mistake there is no doubt. It seems, though very 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 three processes of assimilation, before it becomes like the human 
body. 

The almost universal testimony of English men and women who have un- 
dergone great fatigue, such as riding, long journeys without stopping, or sitting 
up for several nights in succession, is that they could do it best upon an occasional 
cup of tea— and nothing else. 

Let experience, not theory, decide upon this as upon all other things. 



44 irOTES ON NUESING. 

greater impairer of the digestion. Let the patient's taste 'lecide. 
You will say that, in cases of great thirst, the patient's craving 
decides that it will drinlc a great deal of tea, and that you cannot help 
it. But in these cases be sure that the patient requires diluents for 
quite other purposes than quenching the thirst ; he wants a great 
deal of some drink, not only of tea, and the doctor will order what 
he is to have, barley water or lemonade, or soda water and milk, as 
the case may be. 

Lehmann, quoted by Dr. Christison, says that, among the well 
and active " the infusion of 1 oz. of roasted coffee daily will diminish 
the waste " going on in the body " by one-fourth," and Dr. Christison 
adds that tea has the same property. Now this is actual experiment. 
Lehmann weighs the man and finds the fact from his weight. It is 
not deduced from any "analysis" of food. All experience among 
the sick shows the same thing.* 

Cocoa. Cocoa is often recommended to the sick in lieu of tea or cofiee. 

But independently of the fact that English sick very generally dislike 
cocoa, it has quite a different effect from tea or coffee. It is an oily 
starchy nut having no restorative power at all, but simply increasing 
fat. It is pure mockery of the sick, therefore, to call it a substitute 
for tea. For any renovating stimulus it has, you might just as well 
offer them chesnuts instead of tea. 

^"^^ An almost universal error among nurses is in the bulk of the food 

and especially the drinks they offer to their patients Suppose a 
patient ordered 4 oz. brandy during the day, how is he to take this if 
you make it into four pints with diluting it ? The same with tea and 
beef tea, with arrowroot, milk, &c. You have not increased the 
nourishment, you have not increased the renovating power of these 
articles, by increasing their bulk, — you have very likely diminished both 
by giving Ihe patient's digestion more to do, and most likely of all, 
the patient will leave half of what he has been ordered to take, 
because he cannot swallow the bulk with which you have been pleased 
to invest it. It requires very nice observation and care (and meets 
with hardly any) to determine what will not be too thick or strong 
for the patient to take, whUe giving him no more than the bulk 
which he is able to swallow. 

* In making coffee, it is absolutely necessary to buy it in the berry and grind 
it at home. Otherwise you may reckon upon its containing a certain amount of 
chicory, at least. This is not a question of the taste or of the wholesomenesa of 
chicory. It is that chicory has nothing at all of the properties for which you 
give coffee. And therefore you may as well not give it. 

Again, all laundresses, mistresses of dairy-farms, head nurses (I speak of the 
good old sort only — women who unite a good deal of hard manual labour with 
the head-work necessary for arranging the day's business, so that none of it shall 
tread upon the heels of something else) set great value, I have observed, upon 
having a high-priced tea. This is called extravagant. But these women are 
" extravagant " in nothing else. And they are right in this. Real tea-leaf tea alone 
contains the restorative they want ; which is not 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 judging for these women. For they are incapable them- 
selves, to all appearance, of the fepirit of arrangement (no small task) necessary 
for managing a large ward or dairy. 



BED AND BEDDING. 45 



VIII. BED AND BEDDING. 

A few words upon bedsteads and bedding ; and principally as Feverishnesa 
regards patients who are entirely, or almost entirely, confined to bed. a symptom of 

Eeverishness is generally supposed to be a symptom of fever — bedding, 
in nine cases out of ten it is a symptom of bedding.* The patient 
has had re-introduced into the body the emanations from himself 
which day after day and week after week saturate his unaired bed- 
ding. How can it be otherwise ? Look at the ordinary bed in which 
a patient lies. 

If I were looking out for an example in order to show what not Uncleanlincss 
to do, I should take the specimen of an ordinary bed in a private of ordinary 
house : a wooden bedstead, two or even three mattresses piled up to bedding, 
above the height of a table ; a vallance attached to the frame — 
nothing but a miracle could ever thorouglily dry or air such a bed 
and bedding. The patient must inevitably alternate between cold 
damp after his bed is made, and warm damp before, both saturated 
■with organic matter,t and this from the time the mattresses are put 
under him till the time they are picked to pieces, if this is ever done. 

If you consider that an adult in health exhales by the lungs and Air your dirty 
skin in the twenty-four hours three pints at least of moisture, loaded sheets, not 
with organic matter ready to enter into putrefaction ; that in sickness °°'y ^^^ 
the quantity is often greatljr increased, the quality is always more *^^^^" ^^^^' 
noxious — ;iust ask yourself ne'xt where does all this moisture go to? 
Chiefly into the bedding, because it cannot go anywhere else. And it 
stays there ; because, except perhaps a weekly change of sheets 
scarcely any other airing is attempted. A nurse will be careful to 
fidgetiness about airing the clean sheets from clean damp, but airino' 
the dirty sheets from noxious damp will never even occur to her. 
Besides this, the most dangerous effluvia we know of are from the 
excreta of the sick — these are placed, at least temporarily, where they 
must throw their effluvia into the under side of the bed, and the 
space under the bed is never aired ; it cannot be, with our arrange- 
ments. Must not such a bed be always saturated, and be always 
the means of re-introducing into the system of the unfortunate 
patient who lies in it, that excrementitious matter to eliminate which 
from the body nature had expressly appointed the disease ? 

My heart always sinks within me when I hear the good house- 
wife, of every class, say, " I assure you the bed has been well slept 

* I once told a " yerj' good nurse" that the way in which her patient's room Nurses often 
was kept was quite enough to account for his sleeplessness; and she answered do not think 
quite good-humouredly she was not at all surprised at it— as if the state of the the sick-room 
room were, like the state of the weather, entirely out of her power. Jf ow in what any busineaa of 
sense was this woman to be called a " nurse'?" theirs but 

t For the same reason if, after washing a patient, you must put the same only the sick 
night-dress on him "again, always give it a preliminary warm at the fire. The 
night-gown he has worn must be, to a certain extent, damp. It has now got 
cold from having been oflf him for a few minutes. The fire will dry and at the 
same time air it. This is much more important than with clean things. 



46 



NOTES ON NUESINO. 



Iron spring 
bedstead the 
best. 

Comfort and 
cleanliness of 
tVH) beds. 



Bed not to be 
too wide. 



Bed not to be 
too high. 



in," and I can only hope it is not true, "What ? is the bed already 
saturated with somebody else's damp before my patient comes to 
exhale into it his own damp ? Has it not had a single chance to be 
aired ? No, not one. " It has been slept in every night." 

The only way of really nursing a real patient is to have an iron 
bedstead, with rheocline springs, which are permeable by the air up 
to the very mattress (no vallance, of course), the mattress to be a 
thin hair one ; the bed to be not above 3| feet wide. If the patient 
be entirely confined to his bed, there should be two such bedsteads ; 
each bed to be " made" with mattress, sheets, blankets, &c., complete 
— the patient to pass twelve hours in each bed ; on no account to 
carry his sheets with him. The whole of the bedding to be hung up 
to air for each intermediate twelve hours. Of course there are many 
cases where this cannot be done at all — many more where only an 
approach to it can be made. I am indicating the ideal of nursing, 
and what I have actually had done. But about the kind of bedstead 
there can be no doubt, whether there be one or two provided. 

There is a prejudice in favour of a wide bed — I believe it to be 
a prejudice. All the refreshment of moving a patient from one side 
to the other of his bed is far more effectually secured by putting 
him into a fresh bed ; and a patient who is really very ill does not 
stray far in bed. But it is said there is no room to put a tray down 
on a narrow bed. No good nurse will ever put a tray on a bed at all. 
If the patient can turn on his side, he will eat more comfortably 
from a bed-side table ; and on no account whatever should a bed 
ever be higher than a sofa. Otherwise the patient feels himself 
" out of humanity's reach"; he can get at nothing for himself: he can 
move nothing for himself. 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 have its side against the wall. The 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 
De either too wide or too high. 

"When I see a patient in a room nine or ten feet high upon a bed 
between four and five feet high, with his head, when he is sitting up 
in bed, actually within two or three feet of the ceiling, I ask myself, 
is this expressly planned to produce that peculiarly distressing 
feeling common to the sick, viz., as if the walls and ceiling were 
closing in upon them, and they becoming sandwiches between floor 
and ceiling, which imagination is not, indeed, here so far from the 
truth ? If, over and above this, the window stops short of the 
ceiling, then the patient's head may literally be raised above the 
stratum of fresh air, even when the window is open. Can human per- 
versity any farther go, in unmaking the process of restoration which 
God has made ? The fact 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 have closed your chimney with a chimney-board. 

If a bed is higher than a sofa, the difference of the fatigue of 
getting in and out of bed will just make the difference, very often, to 



r 



LIGHT. 47 

the patient (who can get in and out of bed at all) of being able to 
take a few minutes' exercise, either in the open air or in another 
room. It is so very odd that people never think of this, or of how 
many more times a patient who is in bed for the twenty-four hours 
is obliged to get in and out of bed than they are, who only, it is to be 
hoped, get into bed once and out of bed once during the twenty-four 
hours. 

A patient's bed should always be in the lightest spot in the room ; Nor in a dark 
and he should be able to see out of window. place. 

I need scarcely say that the old four-poet bed with curtains is Nor a four 
utterly inadmissible, whether for sick or well. Hospital bedsteads poster with 
are in many respects very much less objectionable than private ^^'^'^i'^^- 
ones. 

There is reason to believe that hot a few of the apparently unac- Scrofula often 
countable cases of scrofula among children proceed from the habit ^ result of dis- 
of sleeping with the head under the bed clothes, and so inhaling air u°^*w'i,°^ 
already breathed, which is farther contaminated by exhalations from ^ ^ ° ^^* 
the skin. Patients are sometimes given to a similar habit, and it 
often happens that the bed clothes are so disposed that the patient 
must necessanly breathe air more or less contaminated by exhala- 
tions from his skin, A good nurse will be careful to attend to this. 
Tt is an important part, so to speak, of ventilation. 

It may be worth while to remark, that where there is any danger Bed sores. 
Df bed-sores a blanket should never be placed under the patient. It 
retains damp and acts like a poultice. 

Never use anything but light Witney blankets as bed covering Heavy and im- 
for the sick. The heavy cotton impervious counterpane is bad, for pervious bed- 
the very reason that it keeps in the emanations from the sick person, dotlies. 
while the blanket allows them to pass through. Weak patients are 
invariably distressed by a great weight of bed-clothes, which often 
prevents their getting any sound sleep whatever. 

Note. — One word about pillows. Every weak patient, be his illness what it 
may, suffers more or less from difficulty in breathing. To take the weight of the 
body off the poor chest, which is hardly up to its work as it is, ought therefore to 
be the object of the nurse in arranging his pillows. Now what does she do and 
what are the consequences 1 She piles the pillows one a-top of the other like a 
wall of bricks. The head is thrown upon the chest. And the shoulders are 
pushed forward, so as not to allow the lungs room to expand. The pillows, in 
fact, lean upon the patient, not the patient upon the pillows. It is impossible to 
give a rule for this, because it must vary with the figure of the patient. And tall 
patients suffer much more than short ones, because of the drag of the long limbs 
upon the waist. But the object is to support, with the pillows, the back helow 
the breathing apparatus, to allow the shoulders room to fall back, and to support 
the head, without throwing it forward. The suffering of dying patients is im- 
mensely increased by neglect of these points. And many an invalid, too weak 
to drag about his pillows himself, slips his book or anything at hand behind the 
lower part of his back to support it. 

IX. LIGHT. 

It is the unqualified result of all my experience with the sick, Light essential 

that second only to their need of fresh air is their need of light ; *° ^^^ health 

and recovery. 



48 NOTES ON NUESINQ. 

that, after a close room, what hurts them most is a dark room. 
And that it is not only light but direct sun-light they want. I had 
rather have the power of carrying my patient about after the sun, 
according to the aspect of the rooms, if circumstances permit, than 
let him 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 admit that he does the 
photograph. Without going into any scientific exposition we must 
admit that light has quite as real and tangible effects upon the 
human body. But this is not aU. Who has not observed the 
purifying effect of light, and especially of direct sunlight, upon the 
air of a room ? Here is an observation within everybody's expe- 
rience. Go into a room where the shutters are always shut, (in a 
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 human beings, you will observe a close, 
musty smell of corrupt air, of air i. e. unpurified by the effect of the 
sun's rays. The mustiness of dark rooms and corners, indeed, is 
proverbial. The cheerfulness of a room, the usefulness of light in 
treating disease is all-important. 
Aspect view -^ ^^^J ^^S^ authority in hospital construction has said that 

andsonlight* people do not enough consider the difference between wards and 
matters of first dormitories in planning their buildings. But I go farther, and say, 
importance that healthy people never remember the difference between bed- 
to the sick. rooms and «c^-rooms, in making arrangements for the sick. To a 
sleeper in health it does not signify what the view is from his bed. 
He ought never to be in it excepting when asleep, and at night. 
Aspect does not very much signify either (provided the sun reach 
his bed-room some time in every day, to purify the air), because ho 
ought never to be in his bed-room except during the hours when 
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 you are in yours, 
which probably they are not. Therefore, that they should be able, 
without raising themselves or turning in bed, to see out of window 
from their beds, to see sky and sun-light at least, if you can show 
them nothing else, I assert to be, if not of the very first importance 
for recovery, at least something very near it. And you should there- 
fore look to the position of the 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 not to be up, are of more importance to 
them, if a choice must be made, than the afternoon sun. Perhaps 
you can take them out of bed in the afternoon and set them by the 
window, where they can see the sun. But the best rule is, if 
possible, to give them direct sun-light from the moment he rises till 
the moment ne sets. 

Another great difference between the bed-room and the sick-room 
is, that the sleeper has a very large balance of fresh air to begin with, 
when he begins the night, if his room has been open all day as it 
ought to be ; the sick man has not, because all day he has been 



CLEANLIKESS OF BOOMS AKD WALLS. 49 

breathing the air in the same room, and dirtying it by the emanations 
from himself. Far more care is therefore necessary to keep up a 
constant change of air in the sick room. 

It is hardly necessary to add that there are acute cases, (particu- 
larly a few ophthalmic cases, and diseases where the eye is morbidly 
sensitive), where a subdued light is necessary. But a dark north 
room is inadmissible even for these. You can always moderate the 
light by blinds and curtains. 

Heavy, thick, dark window or bed curtains should, however, 
hardly ever be used for 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 to the window, to be drawn down only when 
necessary. 

One of the greatest observers of human things (not physiological), Without sun- 
says, in another language, " Where there is sun there is thought." light, we de- 
All physiology goes to confirm this. Where is the ahady side of S^^^^}'^ ^^7 
deep valleys, there is cretinism. Where are cellars and the un- '^ naiid. 
sunned 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 human being into the sun, and, if not 
too far gone, each will recover health and spirit. 

It is a curious thing to observe how almost all patients lie with Almost all 
their faces turned to the light, exactly as plants always make their patients lie 
way towards the light ; a patient will even complain that it gives J^^^ '^^'J" 
him pain "lying on that side." "Then why do you lie on that [^^^^^ ^'^ *^® 
side?" He does not know, — but we do. It is because it is the side " 
towards the window. A fashionable physician has recently published 
in a government report that he always turns his patients' faces from 
the light. Yes, but nature is stronger than fashionable physicians, and 
depend upon it she turns the faces back and towards such light as 
she can get. Walk through the wards of a hospital, remember the 
bed sides of private patients you have seen, and count how many sick 
you ever saw lying with their faces towards the wall. 



X. CLEANLINESS OF EOOMS AND WALLS. 

It cannot be necessary to tell a nurse that she should be clean. Cleanliness of 
or that she should keep her patient clean, — seeing that the greater carpets and 
part of nursing consists in preserving cleanliness. No ventilation ^"r'^i'^ure. 
can freshen a room or ward where the most scrupulous cleanliness is 
not observed. Unless the wind be blowing through the windows at 
the rate of twenty miles an hour, dusty carpets, dirty wainscots, 
musty curtains and furniture, will infallibly produce a close smell. 
I have lived in a large and expensively furnished London house, 
where the only constant inmate in two very lofty rooms, with 
opposite windows, was myself, and yet, owing to the abovementioned 
dirty circumstances, no opening of windows could ever keep those 



50 



NOTES ON NUESINO. 



Du8t never re 
moved now. 



Floors. 



Papered, 
plastered, oil- 
painted walls. 

How a room is 
dusted. 



rooms free from closeness ; but the carpet and curtains having 
been turned out of the rooms altogether, they became instantly as 
fresh as could be wished. It is pure nonsense to say that in 
London a room cannot be kept clean. Many of our hospitals show 
the exact reverse. 

But no particle of dust is ever or can ever be removed or really 
got rid of by the present system of dusting. Dusting in these days 
means nothing but flapping the dust from one part of a room on to 
another with doors and Windows closed. What you do it for I 
cannot think. You had much better leave the dust alone, if you 
are not going to take it away altogether. For from the time a room 
begins to be a room up to the time when it ceases to be one, no one 
atom of dust ever actually leaves its precincts. Tidying a room 
means nothing now but removing a thing from one place, which it 
has kept clean for itself, on to another and a dirtier one.* Flapping 
by way of cleaning is only admissible in the case of pictures, or 
anything made of paper. The only way I know to remove dust, the 
plague of all lovers of fresh air, is to wipe everything with a damp 
cloth. And all furniture ought to be so made as that it may be 
wiped with a damp cloth without injury to itself, and so polished aa 
that it may be damped without injury to others. To dust, as it 
is now practised, truly means to 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 rubbed every morning 
to remove the dust. The French parquet is always more or less 
dusty, although infinitely superior in point of cleanliness aoid 
healthiness to our absorbent floor. 

For a sick room, a carpet is perhaps the worst expedient which 
could by any possibility have been invented. If you must have a 
carpet, the only safety is to take it up two or three times a year, 
instead of once. A dirty carpet literally infects the room. And if 
you consider the enormous quantity of organic matter from the feet 
of people coming in, which must saturate it, this is by no means 
surprising. 

As for walls, the worst is the papered wall ; the next worst is 
plaster. But the plaster can be redeemed by frequent lime- washing; 
the paper requires frequent renewing. A glazed paper gets rid of a 

If you like to clean your furniture by laying out yonr clean clothes upon 
your dirty chairs or sofa, this is one way certainly of doing it. Having witnessed 
the morning process called " tidying the room," for many years, and with ever- 
increasing astonishment, I can describe what it is. From the cbaira, tables, or 
sofa, upon which the "things" have lain during the night, and which are there- 
fore comparatively clean from dust or blacks, the poor " tilings" having "caught" 
it, they are removed to other chairs, tables, sofas, upon which you could 
write your name with your finger in the dust or blacks. The other aide of the 
" things" is therefore now evenly dirtied or dusted. The housemaid then flaps 
every thing, or some things, not out of her reach, with a thing called a duster — 
the dust flies op, then re-settles more equally than it lay before the operation. 
The room has now been " put to rights." 



CLEANLINESS OF BOOMS AND ^AXLS. 61 

good deal of the danger. But the ordinary bed-room paper is all 
that it ought 710^ to be.* 

The close connection between ventilation and cleanliness is 
shown in this. An ordinary light paper will last clean much longer 
if there is an Arnott's ventilator in the chimney than it otherwise 
would. 

The best wall now extant is oil paint. From this you can wash 
the animal exuviae. t 

These are what make a room musty. 

The best wall for a sick-room or ward that could be made is Best kind of 
pure white non-absorbent cement or glass, or glazed tiles, if they wall for a 
were made sightly enough. sick-room. 

Air can be soiled just like water. If you blow into water 
you will soil it with the animal matter from your breath. So it is 
with air. Air is always soiled iu a room where walls and carpets 
are saturated with animal exhalations. 

Want of cleanliness, then, in rooms and wards, which you have 
to guard against, may arise in three ways. 

1. Dirty air coming in from without, soiled by sewer emanations, Dirty air from 
the evaporation from dirty streets, smoke, bits of unburnt fuel, bits without. 

of straw, bits of horse dung. 

If people would but cover the outside walls of their houses with Best kind of 
plain or encaustic tiles, what an incalculable improvement would wall for a 
there be in light, cleanliness, dryness, warmth, and consequently house, 
economy. The play of a fire-engine would then effectually wash the 
outside of a house. This kind of walling would stand next to paving 
in improving the health of towns. 

2. Dirty air coming from vdthin, from dust, which you often Dirty air from 
displace, but never remove. And this recalls what ought to be a within. 

sine qua non. Have as few ledges in your room or ward as possible. 
And under no pretence have any ledge whatever out of sight. Dust 
accumulates there, and will never be wiped off. This is a certain 
way to soil the air. Besides this, the animal exhalations from your 
inmates Siiturate your furniture. And if you never clean your 
furniture properly, how can your rooms or wards be anything but 
musty ? Ventilate as you please, the rooms will never be sweet. 
Besides this, there is a constant degradation, as it is called, taking 
place from everything except polished or glazed articles — E. g., in 
colouring certain green papers arsenic is used. Now in the very 
dust even, which is lying about in rooms hung with this kind of 
green paper, arsenic has been distinctly detected. You see your 
dust is anything but harmless ; yet you will let such dust lie about 
your ledges for months, your rooms for ever. 

* I am sure that a person who has accustomed her senses to compare atmo- -A^tmosphere m 
spheres proper and improper, for the sick and for children, could tell, blindfold, S^^j-edroo 
the difference of the air in old painted and in old papered rooms, coeteria paribus, quite (Jigtin- 
The latter will always be musty, even with all the windows open. gnishable. 

+ If you like to wipe your dirty door, or some portion of your dirty wall, by jjq^ ^o keep 
hanging up your clean gown or shawl against it on a peg, this is one way cer- your wall clean 
tainly, and the most usual way, and generally the only way of cleaning either door at the erpence 
or wall iu a bed-room I of your clothes. 

£ 2 



52 



NOTES ON NUESING. 



Dirty air from 
the carpet. 



Remedies, 



Again, the fire fills the room with coal-duat. 

3. Dirty air coming from the carpet. Above all, take care of the 
carpets, that the animal dirt left there by the feet of visitors 
does not stay there. Ploors, unless the grain is filled up and 
polished, are just as bad. The smell from the floor of a school-room 
or ward, when any moisture brings out the organic matter by which 
it is saturated, might alone be enough to warn us of the mischief 
that is going on. 

The outer air, then, can only be kept clean by sanitary improve- 
ments, and by consuming smoke. The expense in soap, which this 
single improvement would save, is quite incalculable. 

The inside air can only be kept clean by excessive care in the 
ways mentioned above — to rid the walls, carpets, furniture, ledges, 
&c., of the organic matter and dust — dust consisting greatly of this 
organic matter — with which they become saturated, and which is 
what really makes the room musty. 

Without cleanliness, you cannot have all the effect of ventilation ; 
without ventilation, you can have no thorough cleanliness. 

Very few people, be they of what class they may, have any idea 
of the exquisite cleanliness required in the sick-room. For much of 
what I have said applies less to 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 
dirty in the best private houses. 

The well have a curious habit of forgetting that what is to them 
but a trifling inconvenience, to be patiently " put up " with, is to 
the sick a source of suffering, delaying recovery, if not actually 
hastening death. The well are scarcely ever more than eight hours, 
at most, in the same room. Some change they can always make, if 
only for a few 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 any 
movement 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 must be endured," is the very worst and 
most dangerous maxim for a nurse which ever was made. Patience 
and resignation in her are but other words for carelessness or 
indifference — contemptible, if in regard to herself; culpable, if in 
regard to her sick. 



XI. PEESONAL CLEANLINESS. 



Poisoning by 
the skin. 



In almost all diseases, the function of the skin is, more or less, 
disordered ; and in many most important diseases nature relieves 
herself almost entirely by the skin. This is particularly the case 
with children. But the excretion, which comes from the skin, is left 
there, unless removed by washing or by the clothes. Every nurse 



FEBSOKAL CLXAITLIKESS. 53 

should keep this fact constantly in mind, — for, if she allow her sick 
to remain unwashed, or their clothing <"o remain on them after being 
saturated with perspiration or other excretion, she is interfering 
injuriously with the natural processes of health just as effectually as 
if she were to give the patient a dose of slow poison by the mouth. 
Poisoning by the skin is no less certain than poisoning by the mouth 
— only it is slower in its operation. 

The amount of relief and comfort experienced by sick after the Ventilation 
skin has been carefully washed and dried, is one of the commonest and skin-clean- 
observations made at a sick bed. But it must not be forgotten that liness equally 
the comfort and relief so obtained are not all. They are, in fact, essential, 
nothing more than a sign that the vital powers have been relieved by 
removing something that was oppressing them. The nurse, there- 
fore, must never put off attending to the personal cleanliness of her 
patient under the plea that all that is to De gained is a little relief, 
which can be quite as well given later. 

In all well-regulated hospitals this ought to be, and generally is, 
attended to. But it is very generally neglected with private sick. 

Just as it is necessary to renew the air round a sick person 
frequently, to carry off morbid eflBiuvia from the lungs and skin, by 
maintaining free ventilation, so is it necessary to keep the pores of 
the skin free from all obstructing 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, washing, 
and cleansing the skin, not to expose too great a surface at ouce, so 
as to check the perspiration, which would renew the evil in another 
form. 

The various ways of washing the sick need not here be specified, 
— the less so as the doctors ought to say which is to be used. 

In several forms of diarrhoea, dysentery, &c., where the skin is 
hard and harsh, the relief afforded 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 will be 
ordered. 

Every nurse ought to be careful to wash her hands very fre- 
quently during the day. If her face too, so much the better. 

One word as to cleanliness merely as cleanliness. 

Compare the dirtiness of the water in which you have washed Steaming and 
when it is cold without soap, cold with soap, hot with soap. Tou rubbing the 
will find the first has hardly removed any dirt at all, the second a stin. 
little more, the third a great 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. After 
a vapour bath you may peel your whole selfcleaninthis way. What 
I mean is, that by simply washing or sponging with water you do not 
really clean your skin. Take a rough towel, dip one corner in very 
hot water, — if a little spirit be added to it it 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 come off will convince 



54 



NOTES ON NURSING. 



you that you were not clean before, however much soap and water 
you have used. These flakes are what require removing. And you 
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 nonsense to 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 not be 
aftbrded, and when they could not be moved out of their berths, as 
if all the appurtenances of home had been at hand. 

Washing, however, with a large quantity of water has quite other 
effects than those of mere cleanliness. The skin absorbs the water 
and becomes softer and more perspirable. To wash with soap and 
soft water is, therefore, desirable from other points of view than that 
of cleanliness. 



XII. CHATTEEING HOPES AND ADVICES. 



Advising the The sick man to his advisers. 

sick. " My advisers ! Their name is legion. # * # 

Somehow or other, it seems a provision of the universal destinies, 
that every man, woman, and child should consider him, her, or itself 
privileged especially to advise me. Why ? That is precisely what 
I want to know." And this is what I have to say to them. I have 
been advised to go to every place extant in and out of England — to 
take every kind of exercise by every kind of cart, carriage — yes, 
and even swing (!) and dumb-bell (!) in existence ; to imbibe every 
different kind of stimulus that ever has been invented. And this 
when those hest fitted to know, viz , medical men, after long and 
close attendance, had declared any journey out of the question, had 
prohibited any kind of motion whatever, had closely laid down 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 : it never 
occurs to him that everybody else is doing the same thing, and that 
I the patient must perforce say, in sheer self-defence, like llosalind, 
" I could not do with all." 
Chattering " Chattering Hopes" may seem an odd heading. But I really 

hopes the bane believe there is scarcely a greater worry which invalids have to endure 
.f xi_ ^. ^]^^jj ^}jQ incurable hopes 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 seriously to all friends, 
visitors, and attendants of the sick to leave off this practice of 
attempting to " cheer " the sick by making light of their danger and 
by exaggerating their probabilities of recovery. 

Far more now than formerly does the medical attendant tell the 
truth to the sick who are really desirous to hear it about their own 
«tate. 



of the sick. 



OHATTEaUTG HOPES AKD ADVICES. 55 

How intense is the folly, then, to say the least of it, of the friend, 
be he even a medical man, who thinks that his opinion, given after a 
cursory observation, will weigh with the patient, ao'ainst the opinion 
of the medical attendant, given, perhaps, after yearo of observation, 
after using every help to diagnosis aftbrded by the stethoscope, the 
examination of pulse, tongue, &c. ; and certainly after much more 
observation than the friend can possibly have had. 

Supposing the patient to be possessed of common sense, — how 
can the "favourable" opinion, if it is to be called an opinion at all, 
of the casual \'i8itor " cheer " him, — when difterent from that of the 
experienced attendant ? Unquestionably the latter may, and often 
does, turn out to be wrong. But whi'^h is most likely to be 
wrong ? 

The fact is, that the patient* is not "cheered" at all by these Patient does 
well-meaning, most tiresome friends. On the contrary, he is de- not want to 
pressed and wearied. If, on the one hand, he exerts himself to tell talk of himself, 
each successive member of this too numerous conspiracy, whose 
name is legion, why he does not think as they do, — in what respect 
he is worse, — what symptoms exist that they know nothing of, — he 
is fatigued instead of " cheered," and his attention is fixed upon 
himself. In general, patients who are really ill, do hot want to talk 
about themselves. Hypochondriacs do, but again I say we are not 
on the subject of hypochondriacs. 

If, on the other hand, and which is much more frequently the case, Absurd conso- 
the patient says nothing, but the Shakespearian "Oh !" "Ah!" "Go lations put 
to!" and " In good sooth !" in order to escape from the conversation forth for the 
about himself the sooner, he is depressed by want of sympathy. He benefit of the 
feels isolated in the midst of friends. He feels what a convenience it ^'*^ ' 
would be, if there were any single person to whom he could speak 
simply and openly, without pulling the string upon himself of this 

* There are, of course cases, as in first confinements, when an assurance from Absurd statis- 
the doctor or experienced nurse to the frightened suffering woman that there is tical compari- 
DOthing unusual in her case, that she has nothing to fear but a few hours' pain, sons made in 
may cheer her most effectually. This is advice of quite another order. It is the common con- 
advice of experience to utter inexperience. But the advice we have been refer- versation by 
ring to is the advice of inexperience to bitter experience; and, in general, the most sen- 
amounts to nothing more than this, that you think / shall recover from consump- sible people 
tion, because somebody knows somebody somewhere who has recovered from for the benefit 
fever. of the sick. 

I have heard a doctor condemned whose patient did not, alas ! recover, be- 
cause another doctor's patient of a different sex, of a different age, recovered 
from a different disease, in a dfferent place. Yes, this is really true. If people 
who make these comparisons did but know (only they do not care to know), the 
care and preciseness with which such comparisons require to be made, (and are 
made), in order to be of any value whatever, they would spare their tongues. In 
comparing the deaths of one hospital with those of another, any statistics are 
justly considered absolutely valueless which do not give the ages, the sexes, and 
the diseases of all the cases. It does not seem necessary to mention this. It does 
not seem necessary to say that there can be i)o comparison between old men with 
dropsies and young women with consumptions. Yet the cleverest men and the 
cleverest women are often heard making such comparisons, ignoring entirely sex, 
age, disease, place — in fact, all the conditions essential to the question. It is the 
merest gossip. 



56 NOTES ON NUB8ING. 

shower-bath of silly hopes and encouragements; to whom he could 
express his wishes and directions without that person persisting in 
saying " I hope that it will please God yet to give you twenty 
years," or, " Tou have a long life of activity before you," How 
often we see at the end of biographies or of cases recorded in medical 
papers, " after a long illness A. died rather suddenly," or, " unex- 
pectedly both to himself and to others." " Unexpectedly " to others, 
perhaps, who did not see, because they did not look ; but by no 
means " unexpectedly to himself," as I feel entitled to believe, both 
from the internal evidence in such stories, and from watching similar 
cases: there was every reason to expect that A. would die, and he 
knew it ; but he found it useless to insist upon his own knowledge 
to his friends. 

In these remarks I am alluding neither to acute cases which 
terminate rapidly nor to "nervous " cases. 

By the first much interest in their own danger is very rarely felt. 
In writings of fiction, whether novels or biographies, these death-beds 
are generally depicted as almost seraphic in lucidity of intelligence. 
Sadly large has been my experience in death-beds, and I can only 
say that I have seldom or never seen such. Indifference, excepting 
with regard to bodily suffering, or to some duty the dying man 
desires to perform, is the far more usual 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 who 
has been told by his physician 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 sufferers your chattering 
hopes. Tou do not know how you worry and weary them. Such 
real sufferers cannot bear to talk of themselves, still less to hope 
for what they cannot at all expect. 

So also as to all the advice showered so profusely upon such sick, 
to leave off some occupation, to try some other doctor, some other 
house, climate, pill, powder, or specific ; I say nothing of the incon- 
sistency — for these advisers are sure to be the same persons who 
exhorted the sick man not to believe his own doctor's prog- 
nostics, because "doctors are always mistaken," but to believe some 
other doctor, because "this doctor is always right." Sure also are 
these advisers to be the persons to bring the sick man fresh occupa- 
tion, while exhorting him to leave his own. 
Wonderful pre- Wonderful is the face with which friends, lay and medical, 
sumption of will come in and worry the patient with recommendations to do 
the advisers of something or other, having just as little knowledge as to its being 
the sick. feasible, or even safe for him, as if they were to recommend a 

man to take exercise, not knowing he had broken his leg. What 
would the friend say, if he were the medical attendant, and if 
the patient, because some other friend had come in, because some- 
body, anybody, nobody, had recommended something, anything, 
nothing, were to disregard his orders, and take that other body's 
recommendation ? But people never thiuk of this. 



CHATTEEIKG HOPES AND ADTICES. 57 

A celebrated historical personage has related the common- Advisers the 
places which, when on the eve of executing a remarkable reso- same now as 
lution, were showered in nearly the same words by every one years a^o^^ 
around successively for a period of six months. To these the 
personage states that it was found least trouble always to reply 
the same thing, viz., that it could not be supposed that such a 
resolution had been taken without sufficient previous consideration. 
To patients enduring every day for years from every friend or 
acquaintance, either by letter or viva voce, some torment of this kind, 
I would suggest the same answer. It would indeed be spared, 
if such friends and acquaintances would but consider for one 
moment, that it is probable the patient has heard such advice at 
least fifty times before, and that, had it been practicable, it would 
have been practised long ago. But of such consideration there 
appears to be no chance. Strange, though true, that people should 
be just the same in these things as they were a few hundred years 
ago! 

To me these commonplaces, leaving their smear upon the cheerful, 
single-hearted, constant devotion to duty, which is so often seen in 
tlie decline of such suiFerers, recall the slimy trail left by the snail on 
the sunny southern garden-wall loaded with fruit. 

No mockery in the world is so hollow as the advice showered Mockery of 
upon the sick. It is of no use for the sick to say anything, for what „iy^^ to sick, 
the adviser wants is, not to know the truth about the state of the 
patient, but to turn whatever the sick may say to the support of his 
own argument, set forth, it must be repeated, without any inquiry 
whatever into the patient's real condition. "But it would be im- 
pertinent or indecent in me to make such an inquiry," says the 
adviser. True ; and how much more impertinent is it to give your 
advice when you can know nothing about the truth, and admit you 
could not inquire into it. 

To nurses I say — these are the visitors who do your patient 
harm. When you hear him told: — 1. That he has nothing the 
matter with him, and that he wants cheering. 2. That he is com- 
mitting 3uicide, 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 way; 
and 5. That he ought to be called to the sense of duty, and is flying 
in the face of Providence ; — then know that your patient is receiving 
all the injury that he can receive from a visitor. 

How little the real sufferings of illness are known or understood. 
How little does any one in good health fancy him or even herself into 
the life of a sick person. 

Do, you who are about the sick or who visit the sick, try and give Means of 
them pleasure, remember to tell them what will do so. How often in giving plca- 
such visits the sick person has to do the whole conversation, exerting ^P'? ^^ 
his own imagination and memory, while you would take the visitor, 
absorbed in his own anxieties, making no effort of memory or 
imagination, for the sick person. " Oh ! my dear, I have so much to 
think of, I really quite forgot to tell him that ; besides, I thought he 



58 NOTES ON NUESING. 

would know it," says the visitor to another friend. How could " he 
know it "? Depend upon it, the people who say this are really those 
who have little " to thiuk of." There are many burthened with 
business who alw'ays manage to keep a pigeon-hole in their minds, 
full of things to tell the " invalid." 

I do not say, don't tell him your anxieties — I believe it is good 
for him and good for you too; but 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 news : — for instance, of 
a love and courtship, while in progress to a good ending. If you tell 
him only when the marriage takes place, he loses half the pleasure, 
which God knows he has little enough of ; and ten to one but you 
have told him of some love-making with a bad ending. 

A sick person also intensely enjoys hearing of any material good, 
any positive or practical success of the right. He has so much of 
books and fiction, of principles, and precepts, and theories ; do, in- 
stead of advising him with advice he has heard at least fifty times 
before, tell him of one benevolent act which has really succeeded 
practically, — it is like a day's health to him.* 

You have no idea what the craving of sick with undiminished 
power of thinking, but little power of doing, is to hear of good 
practical action, when they can no longer partake in it. 

Do observe these things with the sick. Do remember how their 
life is to them disappointed and incomplete. Tou see them lying 
there with miserable disappointments, from 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 want you to be lachrymose and whining with them, 
they like you to be fresh 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 body, no matter whom it is, they see. 

There is no better society than babies and sick people for one 
another. Of course you must manage this so that neither shaU. 
suffer from it, which is perfectly possible. If you think the " air of 
the sick room" bad for 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 a 
very young child, if unspoiled, will generally adapt itself wonderfully 
to the ways of a sick person, if the time they spend together is not 
too long. 

If you knew how unreasonably sick people suffer from reasonable 
causes of distress, you would take more pains about all these things. 
Au infant laid upon the sick bed wiU do the sick person, thus suffer- 
ing, more good than all your logic. A piece of good news will do 
the same. Perhaps you are afraid of "disturbing" him. Tou say 
there is no comfort for his present cause of affliction. It is perfectly 

• A small pet animal is often an excellent companion for the sick, for long 
chronic cases especially. A pet bird in a cage is eoraetimes the only pleasure of 
an invalid confined for years to the same room. If he can feed and clean the 
animal himself, he ought always to be encouraged to do so. 



OBSEETATION OF THE SICK. 59 

reasonable. The di8tinc<"ioii is this, if he is obliged to act, do not 
"disturb" him with another subject of thought just yet; help him 
to do what he wants to do : but, if he has done this, or if nothing 
can be done, then " disturb " him by all means. Tou will relieve, 
more effectually, unreasonable suffering from reasonable causes by 
telling him "the news," showing him "the baby," or giving bim 
something new to think of or to look at than by all the logic in the 
world. 

It has been very justly said that the sick are like cbildren in this, 
that there is no lyroportion in events to them. Now it is your busi- 
ness as their visitor to restore this right proportion for them — to 
shew them what the rest of the world is doing. How can they find 
it out otherwise ? You will find them far more open to conviction 
than children in this. And you will find that their unreasonable 
intensity of suffering from unkindness, from want of sympathy, &c., 
will disappear with their freshened interest in the big world's events. 
But then you must be able to give them real interests, not gossip. 

Note. — There are two classes of patients which are unfortunately becoming Two new 
more common every day, especially among women of the richer orders, to whom classes of 
all these remarks are pre-eminently inapplicable. 1. Those who make health an patients pecu- 
excuse for doing nothing, and at the same time allege that the being able to do liar to this 
nothing is their only grief. 2. Those who have brought upon themselves ill- generation, 
health by over pursuit of amusement, which they and their friends have most 
nnhappily called intellectual activity. I scarcely know a greater injury that can 
be inflicted than the advice too often given to the first class " to vegetate " — 
or than the admiration too often bestowed on the latter class for "pluck." 



XIII. OBSEEYATIOX OF THE SICK. 

There is no more silly or universal question scarcely asked than What is the 
this, " Is he better ?" Ask it of the medical attendant, if you please, use of the 
But of whom else, if you wish for a real answer to your question, ^^^^*"'°' ^^ ^® 
would you ask it ? Certainly not of the casual visitor ; certainly ^ ^^ 
not of the nurse, while the nurse's observation is so little exercised 
as it is now. What you want are facts, not opinions — for who can 
have any opinion of' any value as to 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 to nurses 
is to teach them what to observe — how to 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. At present how few there are, either pro- 
fessional or unprofessional, who really know at all 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 



60 NOTES ON NURSIKG. 

ludicrous, if it were not painful. The only sensible answer (in the 
present state of knowledge about sickness) would be " How can I 
know ? I cannot teil how he was when I was not with him." 

I can record but a very few specimens of the answers* which I 
have heard made by friends and nurses, and accepted by physicians 
and surgeons at the very bed-side of the patient, who could have 
contradicted every word, but did not — sometimes from amiability, 
often from shyness, oftenest from languor ! 

"How often have the bowels acted, nurse?" "Once, sir." 
This generally means that the utensil has been emptied once, it 
having been used perhaps seven or eight times. 

" Do you think the patient is much weaker than he was six weeks 
ago ?" " Oh no, sir ; you know it is very long since he has 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 himself in bed, he now lies still doing nothing ; that, 
although he can "get across the room," he cannot stand for five 
seconds. 

Another patient who is eating well, recovering steadily, although 
slowly, from fever, but cannot walk or stand, is represented to the 
doctor as making no progress at all. 

* It is a much more difficult thing to speak the truth than people commonly 
imagine. There is the want of observation simple, and the want of observation 
compound, compounded, that is, with the imaginative faculty. Both may equally 
intend to speak the truth. The information of the first is simply defective. That 
of the second is much more dangerous. The first gives, in answer to a question 
asked about a thing that has been before his eyes perhaps for years, information 
exceedingly imperfect, or says, he does not know. He has never observed. And 
people simply think him stupid. 

The second has observed just as little, but imaginntion immediately steps in, 
and he describes the whole thing from imagination merely, being perfectly 
convinced all the while that he has seen or heard it ; or he will repeat a whole 
conversation, as if it were information which had been addressed to him ; whereas 
it is merely what he has himself said to somebody else. This is the commonest 
of all. These people do not even observe that they have not observed nor re- 
member that they have forgotten. 

Courts of justice seem to think that any body can speak "the whole truth 
and nothing but the truth," if he does but intend it. It requires many faculties 
combined of observation and memory to speak " the whole truth " and to say 
" nothing but the truth." 

" I knows I fibs dreadful : but believe me, Miss, I never finds out I have 
fibbed until they tells me so," was a remark actually made. It is also one of 
much more extended application than most people have the least idea of. 

Concurrence of testimony, which is so often adduced as final proof, may prove 
nothing more, as is well known to those accustomed to deal with the unobservant 
imaginative, than that one person has told his story a great many times 

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 have heard persons in perfect good faith declare, that a man came to dine 
every day at the house where they lived, who had never dined there once ; that a 
person had never taken the sacrament, by whose side they had twice at least 
knelt at Communion ; that but one meal a day came out of a hospital kitchen, 
which for six weeks they had seen provide from three to five and six meals a 
day. Such instances might be multiplied ad infinitum if necessary. 



OBSERVATION OF THE SICK. Gl 

Questions, too, as asked now (but too generally) of or about Leading qaes- 
patients, would obtain no information at all about them, even if the tions useless 
person asked of had every information to give. The question is °^ ^^ ®* ^"^' 
generally a leading question ; and it is singular that people never 
think what must be the answer to this question before they ask 
it: for instance, "Has he had a goodnight?" Now, one patient 
will think he has a bad night if he has not slept ten hours without 
waking. Another does not think he has a bad night if he has had 
intervals of dosing occasionally. The same answer has actually been 
given as regarded two patients — one who had been entirely sleepless 
for five times twenty-four hours, and died of it, and another who had 
not slept the sleep of a regular night, without waking. Why cannot 

the question be asked. How many hours' sleep has had ? and 

at what hours of the night ?* " I have never closed my eyes all 
night," an answer as frequently made when the speaker has had 
several hours' sleep as when he has had none, would then be less 
often said. Lies, intentional and unintentional, are much seldomer 
told in answer to precise than to leading questions. Another 
frequent error is to inquire whether one cause remains, and not 
whether the effect which may be produced by a great many difierent 
causes, not inquired after, remains. A.s when it is asked, whether 
there was noise in the street last night ; and if there were not, the 
patient is reported, without more 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 for, even 
when they know it to be completely misleading. The shyness of 
patients is seldom allowed for. 

How few there are who, by five or six pointed questions, can 
elicit the whole case and get accurately to know and to be able to 
report where the patient is. 

I knew a very clever physician, of large dispensary and hospital Means of 
practice, who invariably began his examination of each patient with obtaining 
" Put your finger where you be bad." That man would never waste Inaccurate 
his time with collecting inaccurate information from nurse or patient. ^^ **^°^* ^'^^ 
Leading questions always collect inaccurate information. 

At a recent celebrated trial, the following leading question was 
put successively to nine distinguished medical men. " Can you attri- 
bute these symptoms to anything else but poison ?" And out of the 
nine, eight answered "No!" without any qualification whatever. It 
appeared, upon cross-examination : — 1. That none of them had ever 
seen a case of the kind of poisoning supposed. 2. That none of them 
had ever seen a case of the kind of disease to which the death, if not 
to poison, was attributable. 3. That none of them were even aware 

* This is important, because on this depends what the remedy will be. If a 
patient sleeps tAvo or three hours early in the night, and then does not sleep 
again at all, ten to one it is not 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 drowsy in the morning, he probably 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 NOTES ON NUESINQ. 

of the main fact of the disease and condition to which the death 
was attributable. 

Surely nothing stronger can be adduced to prove what use leading 
questions are of, and what they lead to. 

I had rather not say how many instances I have known, where, 
owing to this system of leading questions, the patient has died, and 
the attendants have been actually unaware of the principal feature 
of the case. 
As to food I* is useless to go through all the particulars, besides sleep, in 

patient takes which people have a peculiar talent for gleaning inaccurate infor- 
or does not mation. As to food, for instance, I often think that most common 
^^^' question, How is your appetite ? can only be put because the ques- 

tioner believes the questioned has really nothing the matter with him, 
which is very often the case. But where there is, the remark holda 
good which has been made about sleep. The same answer will often 
be made as regards a patient who cannot take two ounces of solid 
food per diem, and a patient who does not enjoy five meals a day as 
much as usual. 

Again, the question. How is your appetite ? is often put when 
How is your digestion ? is the question meant. No doubt the two 
things depend on one another. But they are quite different. Many 
a patient can eat, if you can only "tempt his appetite." The fault 
lies in your not having got him the thing that he fancies. But 
many another patient does not care between grapes and turnips, — 
everything is equally distasteful to him. He would try to eat any- 
thing which would do him good ; but everything " makes him worse." 
Tlie fault here generally lies in the cooking. It is not his " appetite " 
which requires " tempting," it is his digestion which requires sparing. 
And good sick cookery will save the digestion half its work. 

There may be four different causes, any one of which will produce 
the same result, viz., the patient slowly starving to death from want 
of nutrition : 

1. Defect in cooking; 

2. Defect in choice of diet ; 

3. Defect in choice of hours for taking diet ; 

4. Defect of appetite in patient. 

Yet , all these are generally comprehended in the one sweeping 
assertion that the patient has " no appetite." 

Surely many lives might be saved by drawing a closer distinction; 
for the remedies are as diverse as the causes. The remedy for the 
first is, to cook better ; for the second, to choose other articles of 
diet ; for the third, to watch for the hours when the patient is in 
want of food ; for the fourth, to show him what he likes, and some- 
times unexpectedly. But no one of these remedies will do for any 
other of the defects not corresponding with it. 

I cannot too often repeat that patients are generally either too 
languid to observe these things, or too shy to speak about them ; nor 
is it well that they should be made to observe them, it fixes their 
attention upon themselves. 



OBSEEVATION Or THE SICK. 63 

Again, I say, ■what is the nurse or friend there for except to take 
note of these things, instead of the patient doing so ?* 

Again, the question is sometimes put. Is there diarrhoea ? And As to diar- 
the answer will be the same, whether it, is just merging into cholera, racea. 
whether it is a trifling degree brought on by some trifling indiscre- 
tion, which will cease the moment the cause is removed, or whether 
there is no diarrhoea at all, but simply relaxed bowels. 

It is useless to rjultiply instances of this kind. As long as 
observation is so little cultivated as it is now, I do believe that it is 
better for the physician not to see the friends of the patient at ail. 
They will oftener mislead him than not. And as often by making 
the patient out worse as better than he really is. 

In the case of infants, everything must depend upon the accurate 
observation of the nurse or mother who has to report. And how 
seldom is this condition of accuracy fulfilled. 

A celebrated man, though celebrated only for foolish things, has Means of 
told us that one of his main objects in the education of his son, was cultivating 
to give him a ready habit of accurate observation, a certainty of per- sound and 
caption, and that for this purpose one of his means was a month's Jf**iy observa- 
course as follows : — he took the boy rapidly past a toy-shop ; the 
father and son then described to each other as many of the objects as 
they could, which they had seen in passing the windows, noting them 
down with pencil and paper, and returning afterwards to verify their 
own accuracy. The boy always succeeded best, e.g., if the father 
described 30 objects, the boy did 40, and scarcely ever made a 
mistake. 

I have 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 may safely be said, not tliat 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 have known a nurse in charge of a set of wards who not only 
carried in her head all the little varieties in the diets which each 
patient was allowed to fix for himself, but also exactly what each 
patient had taken during each day. I have known another nurse in 
charge of one single patient, who took away his meals day after day 
all but untouched, and never knew it. 

If you find it helps you to note down such things on a bit of 
paper, in pencil, by all means do so. I think it more often lames 
than strengthens the memory and observation. But if you cannot 
get the habit of observation one way or other, you had better give up 
the being a nurse, for it is not your calling, however kind and 
anxious you may be. 

* It is commonly supposed that the nurse is there to spare the patient from More impor- 
making physical exertion for himself — I would rather say that she ought to be there j^^q^ ^q spare 
to spare him from taking thought for himself. And I am quite sure, that if the ^jjg patient 
patient were spared all thought for himself, and not spared all physical exertion, tj^ought than 
he would be infinitely the gainer. The reverse is generally the case in the private physical exer- 
house. In the hospital it is the relief from all anxiety, afforded by the rules of a tJQQ^ 
well-regulated institution, which has often such a beneficial effect upon the 
patient. 



64 



NOTES ON NURSING. 



Surely you can learn at least to judge with the eye how much an 

oz. of solid food is, how much an oz. of liquid. Tou will find this 

helps your observation and memory very much, you will then say to 

yourself " A. took about an oz. of his meat to day ;" " B. took three 

times in 24 hours about ^ pint of beef tea;" instead of saying " B. 

has taken nothing all day," or " I gave A. his dinner as usual." 

Sound and I have known several of our real old-fashioned hospital " sisters," 

ready observa- who could, as acciu'ately as a measuring glass, measure out all their 

tion essential patients' wine and medicine by the eye, and never be wrong. I do 

lu a nurse. ^^^ recommend this, one must be very sure of one's self to do it. I 

only mention it, because if a niirse can by practice measure medicine 

by the eye, surely she is no nurse who cannot measure by the eye 

about how much food (in oz.) her patient has taken.* In hospitals 

those who cut up the diets give with quite sufficient accuracy, to each 

patient, his 12 oz. or his 6 oz. of meat without weighing. Tet a 

nurse will often have patients loathing all food and incapable of any 

will to get well, who just tumble over the contents of the plate or dip 

the spoon in the cup to deceive the nurse, and she will take it away 

without ever seeing that there is just the same quantity of food as 

when she brought it, and she will tell the doctor, too, that the patient 

English * It may be too broad an assertion, and it certainly sounds like a paradox. 

women have But I think that in no country are women to be found so deficient in ready and 

great capacity sound observation as in England, while peculiarly capable of being trained to it. 

of but little The French or Irish woman is too quick of perception to be so sound an observer — 

prastice in the Teuton is too slow to be so ready an observer as the English woman might 

close observa- be. Yet English women lay themselves open to the charge so often made against 

tion. them by men, viz., that they are not to be trusted in handicrafts to which their 

Btrength is quite equal, for want of a practised and steady observation. In 

countries where women (with average intelligence certainly not supeiior to that of 

Englishwomen) are employed, e. g., in dispensing, men responsible for what these 

women do (not theorizing about man's and woman's "missions'"), have stated that 

they preferred the service of women to that of men, as being more exact, more 

careful, and incurring fewer mistakes of inadvertence. 

Now certainly Englishwomen are peculiarly capable of attaining to this. 
I remember when a child, hearing the story of an accident, related by some 
one who sent two girls to fetch a " bottle of salvolatile from her room ;" " Mary 
could not stir," she said, " Fanny ran and fetched a bottle that was not salvolatile, 
and that was not in my room." 

Now this sort of thing pursues every one through life. A woman is asked 
to fetch a large new bound red book, lying on the table by the window, and 
she fetches five small old boarded brown books lying on the shelf by the fire. 
And this, though she has " put that room to rights " every day for a month 
perhaps, and must have observed the books every day, lying in the same places, 
for a month, if she had any observation. 

Habitual observation is the more necessary, when any sudden call arises. If 
" Fanny " had observed " the bottle of salvolatile " in " the aunt's room," every 
day she was there, she would more probably have found it when it was suddenly 
wanted. 

There are two causes for these 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 you always put the same things in the 
same places ; you don't know how suddenly you may be called on some day to 
find something, and may not be able to remember in your haste where you your- 
self had put it, if your memory is not in thehabit of seeing the thing there always. 



0B8EEYATI0N OF THE SICK. 65 

has. eaten all his diets as usual, "when all she ought to have meant is 
that she has taken away his diets as usual. 

Now what kind of a nurse is this ? 

I would call attention to something else, in which nurses fre- Difference of 
quently fail in observation. There is a well-marked distinction excitable and 
between the excitable and what I will call the accumulative tempera- f^^^""^"'^ '^'^ 
ment in patients. One will blaze up at once, under any shock or ments. 
anxiety, and sleep very comfortably after it ; another will seem quite 
calm and even torpid, under the same shock, and people say, " He 
hardly felt it at all," yet you wiU find him some time after slowly 
sinking. The same remark applies to the action of narcotics, of ape- 
rients, which, in the one, take effect directly, in the other not 
perhaps for twenty-four hours. A journey, a visit, an unwonted 
exertion, will affect the one immediately, but he recovers after it ; the 
other bears it very well at the time, apparently, and dies or is pros- 
trated for life by it. People often say how difficult the excitable 
temperament is to manage. I say how difficult is the accumulative 
temperament. "With the first you have an out-break which you could 
anticipate, and it is all over. With the second you never know where 
you are — you never know when the consequences are over. And it 
requires your closest observation to know what are the consequences 
of what — for the consequent by no means follows immediately upon 
the antecedent — and coarse observation is utterly at fault. 

Almost all superstitions are owing to bad observation, to the post Superstitioa 
hoc, ergo propter hoc ; and bad observers are almost all superstitious, t^^^ fruit of 
Farmers used to attribute disease among cattle to witchcraft ; wed- ^. observa- 
diugs have been attributed to seeing one magpie, deaths to seeing 
three ; and I have heard the most highly educated now-a-days draw 
consequences for the sick closely resembling these. 

Another remark : althougli there is unquestionably a physi- physio''- 
ognomy of disease as well as of health ; of all parts of the body, the nomy of disease 
face is perhaps the one which tells the least to the common observer little shewn 
or the casual visitor. Because, of all parts of the body, it is ^^ *'^^ ^^^^• 
the one most exposed to other influences, besides health. And 
people never, or scarcely ever, observe enough to know how to dis- 
tinguish between the effect of exposure, of robust health, of a tender 
skin, of a tendency to congestion, of suffusion, flushing, or many 
other things. Again, the face is often the last to shew emaciation. 
I should say that the hand was a much surer test than the face, both 
as to flesh, colour, circulation, &c., &c. It is true that there are 
some diseases which are only betrayed at all by something in the 
face, e.g., the eye or the tongue, as great irritability of brain by 
the appearance of the pupil of the eye. But we are talking of casual, 
not minute, observation. And few minute observers will hesitate 
to say that far more untruth than truth is conveyed by the oft 
repeated words, He looTcs well, or ill, or better or worse. 

Wonderful is the way in which people will go upon the slightest 
observation, or often upon no observation at all, or upon some saio 
which the world's experience, if it had any, would have pronounced 
utterly false long ago. 



66 



NOTES ON NTJESING. 



I liave known patients dying of sheer pain, exhaustion, and want 
of sleep, from one of the most lingering and painful diseases known, 
preserve, till within a few days of death, not only the healthy colour 
of the cheek, but the mottled appearance of a robust child. And 
scores of times have I heard these unfortunate creatures assailed with, 
" I am glad to see you looking so well." " I see no reason why y.ou 
should not live till ninety years of age." " Why don't you take a 
little more exercise and amusement ?" with all the other common- 
places with which we are so familiar. 

There is, unquestionably, a physiognomy of disease. Let the 
nurse learn it. 

The experienced nurse can always tell that a person has taken a 
narcotic the night before by the patchiness of the colour about the 
face, when the re-action of depression has set in ; that very colour 
which the inexperienced will point to as a proof of health. 

There is, again, a faintness, which does not betray itself by the 
colour at all, or in which the patient becomes brown instead of white. 
There is a faintness of another kind which, it is true, can always be 
seen by the paleness. 

But the nurse seldom distinguishes. She will talk to the patient 
who is too faint to move, without the least scruple, unless he is pale 
and unless, luckily for him, the muscles of the throat are affected and 
he loses his voice. 

Tet these two faintnesses are perfectly distinguishable, by the 
mere countenance of the patient. 

Again, the nurse must distinguish between the idiosyncracies oi 
patients. One likes to suffer out all his suffering alone, to be as little 
looked after as possible. Another likes to be perpetually made much 
of and pitied, and to have some one always by him. Both these 
peculiarities might be observed and indulged much more than they 
are. For quite as often does it happen that a busy attendance is 
forced upon the first patient, who wishes for nothing but to be " let 
alone," as that the second is left to think himself 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 time to time, for the information of the nurse, who will 

patient's weak- j^^j. otherwise see, that he cannot do this or that, which he could do 

^^n' ^t teU ^ naonth or a year ago. "What is a nurse there for if she cannot 

jjgj.^ observe these things for herself? Tet I have known — and known 

too among those— and chiefly among those — whom money and 

position put in possession of everything which money and position 

could give — I have known, I say, more accidents, (fatal, slowly or 

rapidly,) arising from this want of observation among nurses than 

from almost anything else. Because a patient could get out of a 

warm-bath alone a month ago — because a patient could walk as far 

as his bell a week ago, the nurse concludes that he can do so now. 

She has never observed the change ; and the patient is lost from 

being left in a helpless state of exhaustion, till some one accidentally 

comes in. And this not from any unexpected apoplectic, paralytic, 

or faulting fit (though even these could be expected far more, at 



Peculiarities 
of patients. 



Nurse must 
observe for 
herself in- 
crease of 



0B8EEVATI0N Or THE SICK. 67 

least, than they are now, if we did but observe). No, from the 
expected, or to be expected, inevitable, visible, calculable, uninter- 
rupted increase of weakness, which none need fail to observe. 

Again, a patient not usually confined to bed, is compelled by an Accidents 
attack of diarrhoea, vomiting, or other accident, to keep his bed for a arising from 
few days ; he gets up for the first time, and the nurse lets him go the nurse's 
into another room, without coming in, a few minutes afterwards, to ^^-i}' of obser- 
look after him. It never occurs to her that he is quite certain to be 
faint, or cold, or to want something. She says, as her excuse. 
Oh, he does not like to be fidgetted after. Yes, he said so some 
weeks ago ; but he never said he did not like to be " fidgetted after," 
when he is in the state he is in now ; and if he did, you ought to 
make some excuse to go in to him. More patients have been lost in 
this way than is at all generally known, viz., from relapses brought 
on by being left for an hour or two faiut, or cold, or hungry, after 
getting up for the first time. 

Yet it appears that scarcely any improvement in the faculty la the faculty 
of observing is being made. Vast has been the increase of know- of observing 
ledge in pathology — that science which teaches us the final change ^"^ *^® decline, 
produced by disease on the human frame — scarce any in the art of 
observing the signs of the change while in progress. Or, rather, is 
it not to be feared that observation, as an essential part of medicine, 
has been declining ? 

Which of us has not heard fifty times, from one or another, a 
nurse, or a friend of the sick, aye, and a medical friend too, the 
following remark : — " So A is worse, or B is dead. I saw him 
the day before ; I thought him so much better ; there certainly 
was no appearance from which one could have expected so 
sudden (?) a change." I have never heard any one say, though 
one woiild think it the more natural thing, " There rmist have 
been some appearance, which I should have seen if I had but 
looked ; let me try and remember what there was, that I may observe 
another time." No, this is not what people say. They boldly 
assert that there was nothing to observe, not that their observation 
was at fault. 

Let people who have to observe sickness and death look back and 
try to register in their observation the appearances which have 
preceded relapse, attack, or death, and not assert that there were 
none, or that there were not the right ones.* 

A want of the habit of observing conditions and an inveterate Observation 

habit of taking: averages are each of them often equally misleading:. ^,^?.^ 

no -i. J ts conditions. 

• It falls to few ever to have had the opportunity of observing the different Approach of 
aspects which the human face puts on at the sudden approach of certain forms of death, paleness 
death by violence ; and as it is a knowledge of little use I only mention it here by no means 
as being the most startling example of what I mean. In the nervous tern- an invariable 
perament the face becomes pale (this is the only recognized effect); in the effect, as we 
sanguine temperament purple ; in the bilious yellow, or every manner of colour find in novels, 
in patches. Now, it is generally supposed that paleness 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 livery, as I have said — de rigueur in novels, but nowhere else. 

r 2 



68 NOTES OK NUESING. 

Meu whose profession like that of medical men leads them to 
observe only, or chiefly, palpable and permanent organic changes are 
often just as wrong in their opinion of the result as those who do 
not observe at all. For instance, there is a broken leg ; the surgeon 
has only to look at it once to know ; it will not be different if he 
gees it in the morning to what it would have been had he seen 
it in the evening. And in whatever conditions the patient is, or is 
likely to be, there will still be the broken leg, until it is set. The 
same with many organic diseases. An experienced physician has 
but to feel the pulse once, and he knows that there is aneurism 
which will kill some time or other. 

But with the great majority of cases, there is nothing of the kind ; 
and the power of forming any correct opinion as to the result must 
entirely depend upon an enquiry into all the conditions in which the 
patient lives. In a complicated state of society in large towns, 
death, as every one of great experience knows, is far less often pro- 
duced by auy one organic disease than by some illness, after many other 
diseases, producing just the sum of exhaustion necessary for death. 
There is nothing so absurd, nothing so misleading as the verdict one 
so often hears : So-and-so has no organic disease, — there is no reason 
wliy he should not live to extreme old age ; sometimes the clause 
is added, sometimes not : Provided he has quiet, good food, good air, 
&c., &c., &c. ; the verdict is repeated by ignorant people without the 
latter clause ; or there is no possibility of the conditions of the 
latter clause being obtained ; and this, the onlij essential part of the 
whole, is made of no effect. I have heard a physician, deservedly 
eminent, assure the friends of a patient of his recovery. Why ? 
Because he had now prescribed a course, every detail of which the 
patient had followed for years. And because he had forbidden a 
course which the patient, could not by any possibility alter.* 

* I have known two cases, tlie one of a man who intentionally and repeatedly 
displaced a dislocation, and was kept and petted by all the surgeons, the other 
of one who was pronounced to have nothing the matter with him, there being 
no organic change perceptible, but who died within the week. In both these 
cases, it was the nurse who, by accurately pointing out what she had accurately 
observed, to the doctors, saved the one case from persevering in a fraud, the other 
from being discharged when actually in a dying state. 

I will even go further and say, that in diseases which have their origin in the 
feeble or irregular action of some function, and not in organic change, it is quite 
an accident if the doctor who sees the case only once a day, and generally at the 
same time, can form any but a negative idea of its real condition. In the middle 
of the day, when such a patient has been refreshed by light and air, by his tea, 
his beef tea, and his brandy, by hot bottles to his feet, by being washed and by 
clean linen, you can scarcely believe that he is the same person as lay with a rapid 
fluttering pulse, with puffed eye-lids, with short breath, cold limbs, and unsteady 
hands, this morning. Now what is a nurse to do in such a case % Not cry, " Lord 
bless you, sir, why you'd have thought he were a dying all night." This may be 
true, but it is not the way to impress with the truth a doctor, more capable of form- 
ing a judgment from the facts, if he did but know them, than you are. What he 
wants is not your opinion, however respectfully given, but your facts. In all 
diseases it is important, but in diseases which do not run a distinct and fi.xed 
course, it is not only important, it is essential that the facts the nurse alone can 
observe, should be accurately observed, and accurately reported to the doctor. 



OBSEEVATIOK OF THE SICK. 69 

Undoubtedly a persou of no scientific knowledge whatever but of 
observation and experience in these kinds of conditions, will be able 
to arrive at a much truer guess as to the probable duration of life of 
members of a family or inmates of a house, than the most scientific 
physician to whom the same persons are brought to have their pulse 
felt; no enquiry being made into their conditions. 

In Life Insurance and such like societies, were they instead of 
having the persons examined by a medical man, to have the houses, 
conditions, ways of life, of these persons examined, at how much 
truer results would they arrive ! W. Smith appears a fine hale man, 
but it might be known that the next cholera epidemic he runs a bad 
chance. Mr. and Mrs. J. are a strong healthy couple, but it might 
be known that they live in such a bouse, in such a part of London, 
so near the river that they will kill four-fifths of their children ; 
which of the children will be the ones to survive might also be 
known. 

Averages again seduce us away from minute observation. "Average rate 

" Average mortalities " merely tell that so many per cent, die in this of mortality " 

town and so many in that, per annum. But whether A or B will be *^^^^ "^ *^°^y 

among these, the " average rate " of course does not tell. We know, ^ cent^wm 

say, that from 22 to 21 per 1,000 will die in London next year. But die. Observa- 

minute enquiries into conditions enable us to know that in such a tion must tell 

district, nay, in such a street, — or even on one side of that street, in nawhich in the 

such a particular house, or even on one floor of that particular liundred they 

will be who 

I must direct the nurse's attention to the extreme variation there is not unfre- ^^^^ "^®* 
quently in the pulse of such patients during the day. A very common case is 
this: Between 3 and 4 a.m. the pulse becomes quick, perhaps 130, and so 
thready it is not like a pulse at all, but like a string vibrating just underneath 
the skin. After this the patient gets no more sleep. About mid-day the pulse 
has come down to 80 ; and though feeble and compressible is a very respectable 
pulse. At night, if the patient has had a day of excitement, it is almost imper- 
ceptible. But, if the patient has had a good day, it is stronger and steadier and 
not quicker than at mid-day. This is a common history of a common pulse; 
and others, equally varying during the day, might be given. Now, in inflamma- 
tion, which may almost always be detected by the pulse, 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 accustomed not to look for it. The 
doctor indeed cannot. But the variation is in itself an important feature. 

Cases like the above often "go off rather suddenly," as it is called, from some 
trifling ailment of a few days, whicli just makes up the sum of exhaustion neces- 
sary to produce death. And everybody cries, who would have thought it? except 
the observing nurse, if there is one, who had always expected the exhaustion to 
come, from which there would be no rally, because she knew the patient had no 
capital in strength on which to draw, if he failed for a few days to make his 
barely daily income in sleep and nutrition. 

I have often seen really good nurses distressed, because they could not impress 
the doctor with the real danger of their patient; and quite provoked because 
the patient "would look," either "so much better" or "so much worse" than 
he really is " when the doctor was there." The distress is very legitimate, 
but it generally arises from the nurse not having the power of laying clearly and 
shortly before the doctor the facts trom which she derives her opinion, or from 
the doctor being hasty and inexperienced, and not 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. 



70 NOTES ON NURSING. 

Louse, will be the excess of mortalit}", that is, the person will die 
who ought not to have died before old age. 

Now, would it not very materially alter the opinion of whoever 
were endeavouring to form one, if he knew that from that floor, of 
that house, of that street the man came ? 

Much more precise might be our observations even than this and 
much more correct our conclusions. 

It is well known that the same names may be seen constantly 
recurring on workhouse books for generations. That is, the persons 
were born and brought up, and will be born and brought up, genera- 
tion after generation, in the conditions which make paupers. Death 
and disease are like the workhouse, they take from the same family, 
the same house, or in other words the same conditions. Why will 
we not observe what they are ? 

The close observer may safely predict that such a family, whether 
its members marry or not, will become extinct ; that such another 
will degenerate morally and physically. But who learns the lesson ? 
On the contrary, it may be well known that the children die in such 
a house at the rate of 8 out of 10 ; one would think that nothing 
more need be said ; for how could Providence speak more distinctly ? 
yet nobody listens, the family goes on living there till it dies out, 
and then some other family takes it. Neither would they listen " if 
one rose from the dead." 
What observa- In dwelling upon the vital importance of sound observation, it 
tion is for, must never be lost sight of what observation is for. It is not for the 
sake of piling up miscellaneous information or curious facts, but for 
the sake of saving life and increasing health and comfort. The 
caution may seem useless, but it is quite surprising how many 
men (some women do it too), practically behave as if the scientific 
end were the only one in view, or as if the sick body were but a 
reservoir for stowing medicines into, and the surgical disease 
only a curious case the sufferer has made for the attendant's 
special information. This is really no exaggeration. Ton think, 
if you suspected your patient was being poisoned, say, by a copper 
kettle, you would instantly, as you ought, cut oif all possible 
connection between him and the suspected source of injury, with- 
out regard to the fact that a curious mine of observation is 
thereby lost. But it is not everybody who does so, and it has 
actually been made a question of medical ethics, what should the 
medical man do if he suspected poisoning ? The answer seems a very 
simple one, — insist on a confidential nurse being placed with the 
patient, or give up the case. 
What a con- And remember every nurse should be one who is to be 

fidential nurse depended upon, in other words, capable of being a " confidential " 
should be. nurse. She does not 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 her sick except to those who 
have a right to ask them ; she must, I need not say, be strictly 
sober and honest; but more than this, she must be a religious 
and devoted woman ; she must have a respect for her own calling, 



CONCLUSION. 71 

because God's precious gift of life is often literally placed in her 
hands ; she must be a sound, and close, and quick observer; and she 
must be a woman of delicate and decent feeling. 

To return to the question of what observation is for : — It would Observation is 
really seem as if some had considered it as its own end, as if detec- for practical 
tion, not cure, was their business ; nay more, in a recent celebrated purposes, 
trial, three medical men, according to their own account, suspected 
poison, prescribed for dysentery, and left the patient to the poisoner. 
This is an extreme case. But in a small way, the same manner of 
acting falls under the cognizance of us all. How often the attendants 
of a case have stated that they knew perfectly well that the patient 
could not get well in such an air, in such a room, or under such 
circumstances, yet have gone on dosing him with medicine, and 
making no effort to remove the poison from him, or him from the 
poison which they knew was killing him ; nay, more, have some- 
times not so much as mentioned their conviction in the right quarter 
— that is, to the ouly person who could act in the matter. 



CONCLUSION. 

The whole of the preceding remarks apply even more to children Sanitary 
and to puerperal women than to patients in general. They also nursing aa 
apply to the nursing of surgical, quite as much as to that of medical g^^gj^j^j g^g ^ 
cases. Indeed, if it be possible, cases of external injury require such medical cases 
care even more than sick. In surgical wards, one duty of every nurse but not to su- 
certainly is prevention. Fever, or hospital gangrene, or pyoemia, or persede surgi- 
purulent discharge of some kind may else supervene. Has she a case c^l nursing. 
of compound fracture, of amputation, or of erysipelas, it may depend, 
very much on how she looks upon the things enumerated in these 
notes, whether one or other of these hospital diseases attacks her 
patient or not. If she allows her ward to becom.e filled with the 
peculiar close foetid smell, so apt to be produced among surgical 
cases, especially where there is great suppuration and discharge, she 
may see a vigorous patient in the prime of life gradually sink and die 
where, according to all human probability, he ought to have recovered. 
The surgical nurse must be ever on the watch, ever on her guard, 
against want of cleanliness, foul air, want of light, and of warmth. 

Nevertheless let no one think that because sanitary nursing is the 
subject of these notes, therefore, what may be called the handicraft of 
nursing is to be undervalued. A patient may be left to bleed to death 
in a sanitary palace. Another who cannot move himself may die of 
bed-sores, because the nurse does not know how to change and 
clean him, while he has every requisite of air, light, and quiet. But 
nursing, as a handicraft, has not been treated of here for three 
reasons : 1. that these notes do not pretend to be a manual for 
nursing, any more than for cooking for the sick ; 2. that the writer, 
who has herself seen more of what may be called surgical nursing, 
i. e , practical manual nursing, than, perhaps, any one in Europe, 



72 



^'OTES ON NrBSING. 



Children 
their greater 



things. 



honestly believes that it is impossible to learn it from any book, and 
that it can only be thoroughly learnt in the wards of a liospital ; and 
she also honestly believes that the perfection of surgical nursing may 
be seen practised by the old-fashioned " Sister" of a London hospital, 
as it can be seen nowhere else in Europe. 3. While thousands die 
of foul air, &c., who have this surgical nursing to perfection, the 
converse is comparatively rare. 

To revert to children. They are much more susceptible than grown 
people to all noxious influences. They are affected by the same 
susceptibility things, but much more quickly and seriously, viz., by want of fresh 
to the same air, of proper warmth, want of cleanliness in house, clothes, bedding, 
or body, by startling noises, improper food, or want of punctuality, 
by dulness and by want of light, by too much or too little covering 
in bed, or when up, by want of the 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 to these things. 

That which, however, above all, is known to injure children 
seriously is foul air, and most seriously at night. Keeping the rooms 
where they sleep 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 its life, even where no inconvenience is felt 
by grown-up persons in the same room. 

The following passages, taken out of an excellent " Lecture on 
Sudden Death in Infancy and Childhood," just published, show the 
vital importance of careful nursing of children. " In the great 
majority of instances, when death suddenly befalls the infant or young 
child, it is an accident; it is not a necessary, inevitable result of any 
disease from which it is suffering." 

It may be here added, that it woidd be very desirable to know 
how often death is, with adults, " not a necessary, inevitable result 
of any disease." Omit the word " sudden ;" (for sudden death is 
comparatively rare in middle age ;) and the sentence is almost equally 
true for all ages. 

The following causes of " accidental" death in sick children are 
enumerated : — " Sudden noises, which startle — a rapid change of 
temperature, which chills the surlace, though only for a moment 
— a rude awakening from sleep — or even an over-hasty, or an over- 
full meal" — " any sudden impression on the nervous system — any 
hasty alteration of posture — in short, any cause whatever by which 
the respiratory process may be disturbed." 

It may again be added, that, with very weak adult patients, these 
causes are also (not often " suddenly fatal," it is true, but) very much 
oftener than is at all generally known, irreparable in their con- 
sequences. 

Both for children and for adults, both for sick and for well 
(although more certainly in the case of sick children than in any 
others), I would here again repeat, the most frequent and most 
fatal cause of all is sleeping, for even a few hours, much more for 
weeks and months, in foul air, a condition which, more than any 



CONCLUSION. 73 

other condition, disturbs the respiratory process, and tends to pro- 
duce " accidental" death in disease. 

I need hardly here repeat the -waming against any confusion of 
ideas between cold and fresh air. You may chill a patient fatally 
without giving him fresh air at all. And you can quite well, nay, 
much better, give him fresh air without chiUing him. This is the 
test of a good nurse. 

In cases of long recurring faintnessea from disease, for instance, 
especially disease which affects the organs of breathing, fresh air to 
the lungs, warmth to the surface, and often (as soon as the patient 
can swallow) hot drink, these are the right remedies and the only 
otfes. Tet, oftener than not, you see the nurse or mother just 
reversing this; shutting up every cranny through which fresh air can 
enter, and leaving the body cold, or perhaps throwing a greater 
weight of clothes upon it, when already it is generating too little heat. 

" Breathing carefully, anxiously,' as though respiration were _a 
function which required all the attention for its performance," is 
cited as a not unusual state in children, and as one calling for care 
in all the things enumerated above. That breathing becomes an 
almost voluntary act, even in grown up patients who are very 
weak, must often have been remarked. 

" Disease having interfered with the perfect accomplishment of 
the respiratory function, some sudden demand for its complete exer- 
cise, issues in the sudden stan'd still of the whole machinery," is given 
as one process : — " life goes out for want of nervous power to keep 
the vital functions in activity," is given as another, by which "acci- 
dental" death is most often brought to pass in infancy. 

Also in middle age, both these processes may be seen ending in 
death, although generally not suddenly. And 1 have seen, even in 
middle age, the " sudden stand-stiW here mentioned, and from the 
same causes. 

To sum up : — the answer to two of the commonest objections Summary, 
urged, one by women themselves, the other by men, against the 
desirableness of sanitary knowledge for women, plus a caution, 
compris'^s the whole argument for the art of nursing., 

(1.) It is often said by men, that it is unwise to teach women Reckless ama- 
anything about these laws of health, because they will take to teur physick- 
physicking, — that there is a great deal too much of amateur physick- ^^j know^^'^' 
ing as it is, which is indeed true. One eminent physician told mo i^^gg ^f ^jjg 
that he had known more calomel given, both at a pinch and for a laws of health 
continuance, by mothers, governesses, and nurses, to children than alone can 
lie had ever heard of a physician prescribing in all his experience, check this. 
Another says, that women's only idea in medicine is calomel and 
aperients. This is undeniably too often the case. There is nothing 
ever seen in any professional practice like the reckless physicking by 
amateur females.* But this is just what the really experienced and 

* I have known many ladies who, having once obtained a "blue pill" prescrip- Danger of phy- 
tion from a physician, gave and took it as a common aperient two or three times sicking by 
a week — with what effect may be supposed. In one case I happened to be the amateur 
person to inform the physician of it, who substituted for the prescription a com- females. 



74 NOTES OK NUHSING. 

observing nurse does not do; she neither physics herself nor others. 
And to cultivate in things pertaining to health observation and expe- 
rience in vs'omen who are mothers, governesses or nurses, ia just the 
way to do away with amateur physicking, and if the doctors did but 
know it, to 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 have more 
work. 
What patho- (2.) It is often said by women, that they cannot know anything of 

logy teaches, the laws of healtli, or what to do to preserve their children's health, 
What obser- because they can know nothing of " Pathology," or cannot " dissect," 
teaches What — ^ confusion of ideas which it is hard to attempt to disentangle, 
medicine does. Pathology teaches the harm that disease has done. But it teaches 
What nature nothing more. We know nothing of the principle of health, the 
alone does. positive of which pathology is the negative, except from observation 
and experience. And nothing but observation and experience will 
teach us the ways to maintain or to bnng back the state of health. 
It is often thought that medicine is the curative process. It is no such 
thing ; medicine is the surgery of functions, as surgery proper is that 
of limbs and organs. Neither can do anything but remove obstruc- 
tions ; neither can cure ; nature alone cures. Surgery removes the 

paratively harmless aperient pill. The lady came to me and complained that it 
"did not suit her half so well." 

If women will take or give physic, by far the safest plan is to send for "the 
doctor" every time — for I have known ladies who both gave and took physic, 
Avho would not take the pains to learn the names of the commonest medicines, 
and confounded, e. g., colocynth with colchicum. This is playing with sharp 
edged tools " with a vengeance." 

There are excellent women who will write to London to their physician that 
there is much sickness in their neighbourhood in the country, and ask for some 
prescription from him, which they used to like themselves, and then give it to all 
their friends and to all their poorer neighbours who will take it. Now, instead 
of giving medicine, of which you cannot possibly know the exact and proper ap- 
plication, nor all its consequences, would it not be better if you were to persuade 
and help your poorer neighbours to remove the dung-hill from before the door, to 
put in a window which opens, or an Arnoit's ventilator, or to cleanse and lime-wash 
the cottages 1 Of these things the benefits are sure. The benefits of the inexpe- 
rienced administration of medicines are by no means so sure. 

Homceopathy has introduced one essential amelioration in the practice of 
physic by amateur females ; for its rules are excellent, its physicking compara- 
tively harmless— the "globule" is the one grain of folly which appears to be neces- 
sary to make any good thing acceptable. Let then women, if they will give medi- 
cine, give homoeopathic medicine. It won't do any harm. 

An almost universal error among women is the supposition that everybody 
must have the bowels opened once in every twenty-four hours or must fly imme- 
diately to aperients. The reverse is the conclusion of experience. 

This is a doctor's subject, and I will not enter more into it ; but will simply 
repeat, do not go on taking or giving to your children your abominable "courses of 
aperients," without calling in the doctor. 

It is very seldom indeed, that by choosing your diet, you cannot regulate 
your own bowels; and every woman may watch herself to know what kind of 
diet will do this; I have known deficiency of meat produce constipation, quite as 
often as deficiency of vegetables ; baker's bread much oftener than either. Home 
made brown bread will oftener cure it than anythmg else. 



COKOEUSIOIT. 75 

bullet out of the limb, which ia an obstruction to cure, but nature 
heals the wound. So it is with medicine ; the function of an organ 
becomes obstructed ; medicine, so far as we know, assists nature to 
remove the obstruction, but does nothing more. And what nursing 
has to do in either case, is to put the patient in the best condition 
for nature to act upon him. Generally, just the contrary is done. 
Tou think fresh air, and quiet and cleanliness extravagant, perhaps 
dangerous, luxuries, which should be given to the patient only when 
quite convenient, and medicine the sine qua non, the panacea. If I 
have succeeded in any measure in dispelling this illusion, and in 
showing what true nursing is, and what it is not, my object will have 
been answered. 

Now for the caution : — 

(3.) It seems a commonly received idea among men and even 
among women themselves that it requires nothing but a disappoint- 
ment in love, the want of an object, a general disgust, or incapacity 
for other things, to turn a woman into a good nurse. 

This reminds one of the parish where a stupid old man was set 
to be schoolmaster because he was " past keeping the pigs." 

Apply the above receipt for making a good nurse to making a 
good servant. And the receipt will be found to fail. 

Yet popular novelists of recent days have invented ladies disap- 
pointed in love or fresh out of the drawing-room turning into the 
war-hospitals to find their wounded lovers, and when found, forthwith 
abandoning their sick-ward for their lover, as might be expected. Yet 
in the estimation of the authors, these ladies were none the worse 
for that, but on the contrary were heroines of nursing. 

What cruel mistakes are sometimes made by benevolent men and 
women in matters of business about which they can know nothing 
and think they know a great deal. 

The everj'day management of a large ward, let alone of a hospital 
— the knowing what are the laws of life and death for men, and 
what 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 sufficient importance and difficulty 
to require learning by experience and careful inquiry, just as much as 
any other art ? They do not come by inspiration to the lady disap- 

Eointed in love, nor to the poor workhouse drudge hard up for a 
velihood. 

And terrible is the injury which has followed to the sick from 
such wild notions ! 

In this respect (and why ia it so ?), in Eoman Catholic coiintries, 
both writers and workers are, in theory at least, far before ours. 
They would never think of such a beginning for a good working 
Superior or Sister of Charity. And many a Superior has refused to 
admit a Fostulant who appeared to have no better "vocation" or 
reasons for ofiering herself than these. 

It is true we make "no vows." But is a "vow" necessary to 
convince us that the true spirit for learning any art, most especially 
an art of charity, aright, is not a disgust to everything or something 



76 NOTES ON NUnSING. 

else ? Do we really place tlie love of our kind (and of nursing, as 
one branch of it,) so low as this ? What would the Mere Angelique 
of Port lioyal, what would our own Mrs. Fry have said to this ? 

Note. — I would earnestly ask my sisters to keep clear of both the jargons 
now current everywhere (for they are equally jargons) ; of the jargon, namely, 
about the "rights" of women, which urges women to do all that men do, including 
the medical and other professions, merely because men do it, and Avithout regard 
to whether this is the best that women can do; and of the jargon which urges 
women to do nothing that men do, merely because they are women, and should be 
"recalled to a sense of their duty as women," and because "this is women's work," 
and " that is men's," and " these are things which women should not do," which is 
all assertion and nothing more. Surely woman should bring the best she has, 
whatever that is, to the work of God's world, without attending to either of these 
cries. For what are they, both of them, the one just as much as the other, but 
listening to the "what people will say," to opinion, to the "voices from without 1" 
And as a wise man has said, no one has ever done anything great or useful by 
listening to the voices from witliout. 

You do not want the effect of your good things to be, " How wonderful for a 
woman!" nor would you be deterred from good things, by hearing it said, "Yes, 
but she ought not to have done this, because it is not suitable for a woman." But 
you want to do the thing that ia good, whether it is " suitable for a woman " 
or not. 

It does not make a thing good, that it is remarkable that a woman should 
have been able to do it. Neither does it make a thing bad, which would have 
been good had a man done it, that it has been done by a woman. 

Oh, leave these jargons, and go your way straight to God's work, in simplicity 
and singleness of heart. 



APPENDIX. 



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NOTE. 79 



Note as to the Numbeb of "Women employed as 
NuESES IN Geeat Beitain. 

25,466 were returned, at the census of 1851, as nurses by pro- 
fession, 39,139 nurses in domestic service,* and 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 to make as many of 
them as possible the disciples of the true doctrines of healtli, would 
be a great national work. 

For there the material exists, and will be used for nursing, 
•whether the real " conclusion of the matter" be to nurse or to 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 family to 
nurse the sick, but I know that it is only to do them harm. 

Now a nurse means any person in charge of the personal health 
of another. And, in the preceding notes, the term nurse is used 
indiscriminately for amateur and professional nurses. For, besides 
nurses of the sick and 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 families. It appears as if 
these unprofessional nurses were just as much in want of knowledge 
of the laws of health as professional ones. 

Then there are the school-mistresses of all national and other 
schools throughout the kingdom. How many of children's epidemics 
originate in these ! Then the proportion of girls in these schools, 
who become mothers or members among the 64,600 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 not 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 as far as these things are concerned. Would not the true way of 
infusing the art of preserving its own health into the human race 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 illus- 
trate what may be called the theory of it ? 

* A curious fact will be shown by Table A, viz., that 18,122 out of 39,139, or 
nearly one-half of all the nurses, in domestic service, are between 5 and 20 years 
of age. 



A SUMMER SEAECH FOR SIR JOHN FRANKLIN, 

with a Peep into the Polar Basin, by Commander E. A. Inglefleld, R.N. Demy 
8vo., 14s. 

FRENCH NAVAL TACTICS ; Translated from the French- 

by Augustus FhiUimore, Captain, R.N. Demy 8vo., lOs. 

DESPATCHES AND PAPERS RELATIVE TO CAM- 

pugn in Turkey, Asia Minor, and the Crimea in 1854 5-6, by Captain Sayer. 

DESPATCHES OF VISCOUNT HARDINGE, LORD 

Gough, and Sir Harry Smith. Demy 8vo., 6s. 

PRESENT STATE OF THE TURKISH EMPIRE, by 

Marshal Marmont, translated by General Sir P. Smith, K.H., P.R.S. Second 
Edition, post 8vo., 73. 6d. 

PASTORAL AND OTHER POEMS, by Mrs. aeorge Halse, 

Fcap. 8vo., 2s. 6d. cloth. 

THE LAUREL AND THE PALM, by Mrs. ChaUice, 

Cloth, 6s. 

EDA MORTON AND HER COUSINS. Fcap. 8vo., 6*. 
CAVENDISH, OR THE PATRICIAN AT SEA, by 

W. Johnson Neale. Fcap. 8vo., cloth. 28. 6d. 

CHOLLERTON, A TALE OF OUR OWN TIMES, 

Fcap. 8vo , 78. 6d. 

EVELINA, by Miss Burney. Fcap. 8vo., 3«. 



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Bookseller to the Queen. 



THE PAEISH CHOIE, OE CHUECH MUSIC BOOK, 

In 3 vols., 2l3. cloth. 

A PLAIN TRACT ON SINGLING IN PUBLIC WOE- 

ship. Id , or 7s. pei- 100. 

CONVEESATIONS ON THE CHOEAL SEE VICE, being 

au Examination of popular prejudices agiiinst Church Music. Fcap. 8vo., Is. 

BISHOP BLOMFIELD AND HIS TIMES, by the Eev. 

G. E. Biber, LL.D. 1 vol., postSvo , Ts. 6d. 

A PLAIN TEACT ON CHUECH ORNAMENTS, 1^., or 

78. per 100. 

HOW TO STOP AND WHEN TO STOP; Punctuation 

reduced to a System Fcap. 8vo., cloth. Is. 

ANTHEMS FOE PAEISH CHOIRS, collected and edited by 

the Bev. Sir W. H. Cope, Bait. 1 vol., 4to., 9s. 

GERMAN, IN PIFTY LESSONS, by Herr C. A. A. Bran, 

Fcap. 8vo., 5s. 6d. 

THE TUEKISH CAMPAIGNER'S YADE-MECUMOF THE 

Ottoman Colloquial Language, by J W. Redhouee, F.E.A.S. Pocket Edition, 4s. 
cloth. 

COMPAEATIVE GEAMMAE OF THE DR A VIDIAN 

or South-Indian I'amily of Languages, by the Rev. R. CaldweU, B.A. Demy 8to., 
cloth. 2l8. 



HARRISON, 59, PALL MALL, LONDON, S.W., 
Bookseller to the Queen. 



LONDON : HARRISON, BookseUer to the Queen, 59, PALL MALL. 

EASY anthems! 

For Four Yolces, with Organ or Piano Forte Accompaniments. 



O love the Lord GoLlwin 2(1. 

Praise the Lord .. Okeland 'id. 

For unto us a Cliild is Born.. .. Hastlton 2d. 

O Praise God in liN Tlolinoss .. Welaiiu 'id. 

Behold, now Praiso tlie Lor<l . . Rogers 2d. 



Deliver us, O Lord our God.. .. Batten 

Teacli me, O Lord Rogers 

O Praise the Lord Weldoii 

Veui, Creator Spirilus Tallis 

'Outof the Deep AUb-icli 



Id. 

2d. 

■A,\. 
6d. 



The above ANTHEMS, forming PART I, may also be had in Wrapper, 2s. 



O Praise the Lord Batten 2d. 

Plead Thou ;iiy Cau«e >, Glareauus 2d. 

Praise the Lord, O Jerusalem .. Scott id. 

My Soul Trulv Waiteth . . . . Batten 2d. 

If "Ye Love Me Tallis 2d. 

Thou Visitest the E.irth .. .. Greene 2d. 



O How Au'iiiide 1 Richai'd.sou 

Offertory .Vuthem AVhitbroke 

Not unto Us, O Lord Aldrich 

Hear my Prayer Batten 

Lord, Wlio shall ilu ell Pvo^ers 



}^ 



3d. 

3d. 

4d. 
Id. 



The above ANTHEMS, forming PART II, may also be had in Wrapper, 2s. 



Have mercy upon Me . . ' . . . . Gibbs 2d 

XN'herewi thai shall a Young Man. . Alcock 2d. 

I give vou a New Commandment . . Shepharil 3d. 

Holy, Holy, Holy Bishop 2d. 

Call to Remembrance Farnint 2d. 

'IVach Me Tliv War, O Lord . . Fex \ ., 

Bles>ed art Tliou, d Lord .. .. Weld.-u t ' 



O Israel, Trust in the Lord .. .. Crolt 2d 

Blessiu;,' and Glory . .^ .. .. Bovce 2d 

Lilt Up Your Heads Turner 2d 

Thou Knowest, Liird Purcell } ., . 

Set uji Thyself, () (;od Wise ( ~" 

Behold i:ow. Praise the Lord . . Creyghtou 2d 

Gloria in Excelsis S. Mai-k'siise 2d 



The above ANTHEMS, forming PART III, may also be had in Wrapper, 

The Three Parts, forming Vol. I of EAl^Y A]STHE3£S, vwv he had, neatly 

together in cloth, price 0.s'. 

2d. 

Id. 



O Praise the Lord . . 

() Give Thanlis 

Lord, AVe Beseech Thee 



Goldwh 
Rogers 
Bill en 



Ofl'eriorv .Anthems Monk 



(ilory be to God on Higli 
Loril, for Thv Tender Mercies 



Loosemore 
Farrant 



2d. 
4d. 

2d. 



O Lord, Grant th(^ King . . . . Child 

Behold How Good and Joyful .. Rogers 

Tlie Lord is King Ki»g 

Sing We Merrily Batten 

O I'rav for the Peace Rogers 



2s. 
hound 



2d. 
2d. 

•Id. 

4d. 



The above ANTHEMS, forming PART IV, may also be had in Wrapper, 2s. 



ANTHEMS FOR PARISH CHOIRS, 

By JEminent Composers of the English Church. 
Collected a:ut Eclited by the Kev. SIR WILLIAM H. C01>E, Bart., Minor Canon 

of St. Peter'.*, Westminster. 

No. I. ^Price 8d.) Contains : No. VI. (Price lOd.) Contains : 



Sing « e merrily 

Let my complaint 

I will not leave you comfortless 

No. II. (Price lOd.) 

O Clap your hands 

When the Lord turned again . . 
O Pray for the Peace of Jerusalem 
Hou long wilt Thou forget me , . 



Adrian Batten 

Ditto 
Dr. William I'-yrdc 

Contains : 

Dr. William Ciiild 
Adrian Batieii 
Dr. Benj. Rogers 
Ditto 



I'ra'se the Lord, O my soul 
Tn Thee, O Lord, have I put mj- 
trust 



Dr. John Blow 



William Evans 



No. III. (Price Is.j Contains: 

Oh: tliat the salvatinu .. .. Dr. Benj. Ki 
Praise the Lord, O my soui .. Ditto 

() Give thanks unto the Lord. . Ditto 

Save we; O God Ditto 

Behold how good and joyful .. Ditto 

No. IV. (Price 8d.) Contains : 

Bv the watevs of B.abylon 

Not Uiito us, (> Lord 

() jiraise the Lmil all ye h(;illicii 



Rev. Dr. K. Aldrich 
Thonia-. Ivelway 
John Goldwin 



No. V. (Price 8d.) Contains : 



I !ustcT!ie°,0 God, to deliver me 
■^'t liy art thou so heavy . . 
Ilehcild now prai:<e the Lord .. 



Adrian Batten 

Dr. Orlando Gibbons 

Rev. Dr. H. Aldricn 



No. VII. (Price 8d.) Contains : 

Unto Thee O Lord, will I lift 

\i\) Thomas Keiway 

The Lord is King William King 

In the beginning, O Lonl . . Matthew Lock 

No. VIII. (Price Is.) Contains : 

Let God arise .Matlliew Lock 

Sing unto the Lord a new song Ditto 

When the Son of Man shall coma Ditto 

Lord, we beseech Thee . . . . Adrian Batten 

No. IX. (Price 8d.j Contains : 

O Lord, I have ".oved the habi- 

talion Thomas Tomkins 

Great and marvellous .. .. Ditto 

He that Lath pity upon the poor Ditto 

No. X. (Price lOd.) Contains: 



O Lord God of our salvation 

Lord, who shall dwell 

O Praise the Lord : laud ye 



Rev. Dr. H, Aldrich 
Adrian Bat'.en 
Dr. William Child 



UNIVERSITY OF CALIFORNIA-LOS ANGELES 




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