Notes on nursing : what it is, and what it is not

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THE LIBRARY

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THE UNIVERSITY

OF CALIFORNIA

LOS ANGELES

GIFT OF
DR. AND MRS. ELMER BELT

DONATION BY

DR. AND MRS. ELMER BELT

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NOTES ON NURSING:

vVHAT IT IS, AND WHAT IT IS NOT.

BY

FLORENCE NIGHTINGALE,

WITH SOME ACCOUNT OF HER LIFE,

BOSTON:
WILLIAM CAllTEIl, 5 WATER STREET

1860.

AC
B

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 wo-
man, 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. Ea- ery day sanitary knowl-
edge, 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 wliich
every one ought to have — distinct from medical knowl-
edge, 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

herself, and for this purpose I venture to give her some

hints.

(ui)

TABLE OF CONTENTS.

Florence Nightingale 1

Index ... 6

Ventilation and WARinNG 11

Health of Houses 19

Petty Management 27

Noise 34

Variety 44

Taking Food 48

What Food ? 53

Bed and Bedding 60

Light 64

Cleanliness of Rooms and Walls ... 66

Personal Cleanliness 70

Chattering Hopes and Advices ... 72

Observation op the Sick 79

Conclusion 95

Appendix . . 103

(iv)

FLORENCE NIGHTINGALE.

In the year 1820, in Florence, that lovely city,
" where earth and sky
Are picture both and poetry,"
was bom the younger of the two daughters of William Shore Night-
ingale, Esq. ; and, in memory of her birthplace, its beautiful name was
given to her who will be known to all time as Florence Nightingale.

Her father, William Shore Nightingale, son of William Shore, Esq.,
of Tapton, is a descendant of the ancient Derbyshire family of Shore
— of which Lord Teignmouth is the representative of another branch.
He assumed the name of Nightingale by the Prince Regent's sign man-
ual in 1815, in accordance with the will of his maternal uncle, Peter
Nightingale, whose niece and sole heiress his father had married. In
early life, in 1818, he married Frances, daughter of William Smith,
Esq., formerly M. P. for Norwich, a zealous laborer in the cause of
slave emancipation, and a benevolent, eaimest man. By inheritance,
Mr. Nightingale possessed large wealth, and the ample estates of Em-
bley Park, Hampshire, and the Lea Hurst, Derbyshire.

The e; rly youth of Florence Nightingale was passed under circum-
stances well calculated to foster an elegant mind and a tender heart.
The child of affluent and intellectual parents, surrounded by all that is
beautiful in nature and rich in art, and beloved by all who came in
contact with her, her heart and mind developed their rare qualities
together.

Under the guidance of her father, she attained considerable proficien-
cy in the classics, and in mathematics — studies which are rarely pur-
sued by ladies in these latter days. Nor were the more feminine ac-
complishments neglected by the ardent student. She became an excel-
lent musician, and conversant with most of the modern languages,
speaking French, Italian, and German with fluency and purity.

During the course of her studies she travelled extensively, visiting
most of the cities of Europe, and penetrating even to the remotest cat-
aract of the Nile. While in Egypt, it is said, she tended the sick
Arabs with whom she came in contact, and frequently, by judicious
counsel and advice, rendered them important services.

The favorite home of Miss Nightingale's childhood — Lea Hurst,
Derbyshire — is a most picturesque and romantic spot. The quiet
and secluded hamlet of Lea abounds in lovely scenery, and in interest-
ing historical and literary associations. Lea Hurst is beautifully situ-
ated on rising ground, " in one of the most charming and extensive of
the Derbyshire valleys, and surrounded with hills and mountains, rocks
and woods, of majestic and gigantic proportions, and watered by the
■winding Derwent and its tributary streams. "

From her earliest childhood, Florence Nightingale displayed a con-
stant and active sympathy with the suffering, the desolate, and the dis-
tressed among the poor around Lea Hurst and Embley. As a friend,
a benefactress and a consoler, she was daily welcomed in many a cot-
tage ; and to the alleviation of pains and sorrows she devoted her per-
sonal energies and her large fortune. She was for many years, as a
voluntary teacher, the principal support of the schools for the poor ia
the neighboring villages ; for she never wearied of well-doing.

1

FLORENCE NIGHTINGALE.

Having attained the age when yoimg ladies of birth and fortune
generally " come out" and partake of the brilliant gayeties of society,
riorence Nightingale visited London, But it was for the purpose of
frequentmg and studying the hospitals, schools and reformatory insti-
tutions of the metropolis, a self-imposed duty, which she performed
with untiring energy and diligence. Yet she did not neglect to fulfil
the more immediate duties of her station with grace and propriety,
even to a presentation at Court ; which proved that she was not one of
those who devote themselves to the cause of charity in order to avoid
the onerous claims of social life.

From London, Florence Nightingale went to Edinburgh, and to the
Continent, intent on perfecting herself for a high and holy mission,
and gathering up stores of knowledge for present as well as for future
use. In the memorable year 1851, when all Europe held festive holi-
day in honor of the Great Exhibition, when ''the highlands of Scot-
land, the lakes of Switzerland, and all the bright spots of the Conti-
nent were filled with parties of pleasure," Miss Nightingale — so well
fitted by birth and education to shine a star in her own proper sphere
— took up her abode in a hospital at Kaiserwerth on the Rhine, where
Protestant Sisters of Mercy are trained as nurses for the sick ; and for
three long months, within the walls of this institution, she remained
in daily and nightly attendance, unwearyingly expending her health
and strength in the cause of benevolence. Here she made herself
thoroughly acquainted with all the rules and regulations required in
the management of a hospital. The Pasteur Flieaner, director of the
establishment, affirmed that during the progress of the institution, no
one had ever passed so distinguished an examination or shown herself
so thoroughly mistress of all she had to learn, as the young, wealthy,
and graceful Englishwoman. With the institution she was so favora-
bly impressed that she afterwards returned to it, and subsequently pub-
lished a little book containing an account of its origin and manage-
ment.

From Germany, Miss Nightingale returned to the happiness of home,
the love of her parents and sister, and to the fresh, free air of Derby-
shire and Hampshire, in order to recruit her health. 13ut her sympa-
thy and energy were speedily enlisted on behalf of the Hospital for
Sick Governesses, established in Harley Street, London, which was
languishing for want of proper management and judicious support.
She was appealed to for aid. ^lost young and wealthy ladies in such
a case would have given a handsome donation to assist the institution.
With the heroism of pure benevolence Florence Nightingale gave —
herself.

She took the active and entire superintendence of the Sanatorium,
devoting herself with indefatigable energy to place it on a firm basis.
Derbyshire and Hampshire were exchanged for the narrow, dreary es-
tablishment in Harley Street, to which she devoted all her time and
fortune. " While her friends missed her at assemblies, lectures, con-
certs, exhibitions and all the entertainments for taste and intellect
with which London, in its season, abounds," says one writer, "she,
whose powers could have best appreciated them, was sitting beside the
bed, and soothing the last complaints of some poor, dying, homeless,
querulous governess. The homelessness might, not improbably, result
from that very quc-rulousness ; but this is too frequently fomented, if
not created, by the hard, unreflecting folly which regards fellow-crea-
tures intrusted with forming the minds and dispositions of its children

ii

FLORENCE NIGHTINGALE.

as ingenious, disagreeable machines, needing, like the steam-engine,
sustenance and covering, but, like it, quite beyond or beneath all sym-
pathy, passions, or affections. Miss Nightuigale tiiought otherwise,
and found pleasure in tending those poor, destitute governesses, in
their infirmities, their deaths, or their recoveries. She was seldom seen
outside the walls of the institution, and the few friends whom she ad-
mitted found her in the midst of nurses, letters, prescriptions, accounts,
and interruptions. Her health sank under the heavy pressure, but a
little Hampshire fresh air restored her, and the failing institution was
saved.

About this time, 1854, Florence Nightingale also took an active in-
terest in the Ragged Training Schools, and several similar institutions.
She felt, with Hannah More, that "the care of the poor is the profes-
sion of women," and all her talents were unceasingly employed in the
amelioration of their miseries.

13ut while Miss Nightingale was recruiting her health and spirits in
her beautiful home at Embley, a cry of dire distress and bitterest agony
came from the East, piercing England nearly to the heart. It arose
from our wounded brethren, huddled together, languishing in their
rough beds, destitute of comforts or even necessary accommodations,
crushed by the cold, unfeeling, iron heel of Routine, and by the heavy,
murderous hand of Mismanagement. An enthusiastic desire to re-
spond to it instantly sprang up in the breasts of all who heard it ; and
suggestions were offered from all quarters by warm and willing hearts.
Undisciplined zeal, however, could do little towards supplying the
wants of those dying heroes who were uttering the mournful cry for
help ; and it was feared lest the ardent feelings which had been roused
might flag or be misdirected for lack of some systematic arrangement.
Wealth was poured forth to aid, and food, clothing, medicines, and
other necessaries were shipped in abundance ; but something more was
needed. A proposition, originated by Lady Maria Forester, to form a
band of female nurses, to be despatched to the seat of war, w^as started,
and found favor with the government and the majority of the public.

The idea being propounded, the chief difficulty was to carry it out ;
and there was a fear " lest a noble impulse should fail for the Avant of
a head, a hand, and a heart to direct it." But, having engaged three
nurses. Lady Maria Forester waited on Miss Nightingale, and entreated
her to take the direction and entire control of the nursing establishment
for our sick and wounded soldiers and sailors on the distant shores of
the Levant. Lady J*Iaria's request, earnestly seconded by that of the
Right Hon. Sidney Herbert, then secretary-at-war, induced ^liss Night-
ingale to yield a generous consent to undertake the management of the
expedition. It is, indeed, affirmed by some, that, by a strange coinci-
dence, the noble woman had herself written to Mr. Herbert on the
very same day, volunteering her services where they were so direfully
needed.

Immediately on her intention becoming known, horror thrilled the
souls of those humane and wise Gradgrinds Avho, comprehending no
•' facts " but those which had undoubted precedents, had lau<?hed aloud
when Elizabeth Fry proposed to cleanse Newgate, and had coldly
sneer id when Hannah More hinted at Sunday schools. But, upheld
by her noble and compassionate heart, and resolved to follow humbly
and reverentially in the footsteps of Oxe who had suffered from evil
tongues, Florence Nightingale calmly held on her way up the steep
and rocky road, nor heeded the discordant cries which would have
called her back.

iii

FLORENCE NIGHTINGALE.

Not a tnomcnt was lost in unnecessary delay, or in preliminary
preparations. Miss Nightingale formed, from some hundreds who
offered, a band of«thirty- seven nurses — many of them, like herself,
volunteers from the higher ranks of life, gentle ladies, accustomed to
ease and luxury, but not unused to tend the suffering or the dying,
nor to lead lives of charity and self-denial. Twelve nuns from the
Convent at Norwood, under charge of their superioress, an Irish lady,
proffered their services, and were gladly included in the noble corps ;
for the holy leader of the band was no narrow-minded bigot, and did
not doubt but that a basin of gruel, a glass of wine, or a cup of med-
icine, might perhaps be administered as tenderly by a hand which
claspejcl a missal as by one which touched a Testament. When every
thing was ready, Florence Nightingale bade farewell to her fond par-
ents and her affectionate sister, renounced her friendships and her
intellectual pleasures, and quitted the comforts of her home, the quiet
liberty of dear old England, for a perilous journey to a land teeming
with danger and disease.

She and her sister-laborers, prompted by the most sincere, charit^le,
and religious feelings which can inspire the human heart, \id fin-
daunted by the length of the voyage, the strange and distant cou -itry
before them, the awful scenes they would encounter, or the privations
they Avould have to endure, started for their destination on Tuesday,
the 24th of October, 1854. Surely, if there was heroism in dashing
up the heights of Alma, seeking glory at the cannon's mouth in defi-
ance of death and of all mortal opposition, amid the shouts of the vic-
tors and the cries of the vanquished, there was heroism unparalleled
in calmly volunteering to minister to the fever-stricken and the dying
in a place reeking with deadly disease and polluted air, where '* wounds
almost refused to heal, and M'here the heavy smell of pestilence could
be perceived outside the very walls," and surrounded by sights and
sounds calculated to appall the stoutest hearts.

They were accompanied by Mr. and !Mrs. Bracebridge, a clergyman,
and a courier. On their arrival at Boulogne, the self-devoted band
was hailed with demonstrations of sympathy and respect by a crowd
which assembled to welcome them on their way, and bid them " God
speed." In passing through France, they were received with the utmost
enthusiasm ; hotel-keepers refusing payment for their accommodation,
servants declining the customary fees, all emulating to evince achnira-
tion and sympathy. One of the Paris journals, on Miss Nightmgale's
passing through the French metropolis, observed of her that "her toi-
lette was charming, and she was almost as graceful as a Parisienne."
On the 27th, they sailed from Marseilles, in the Vectis steamer, for
Constantinople.

On the oth of November, Miss Nightingale, accompanied by Mr.
and Mrs, Bracebridge, and her nurses, arrived at Constantinople ; and
the whole party was speedily established at their new quarters in the
Barrack Hospital at Scutari. This was a handsome building, capable
of holding an immense number of soldiers ; the court-yard alone being
sufficiently large to afford space for exercising twelve thousand men,
and the corridors, running the whole length of the barrack, being esti-
mated to comprise four miles in extent. On three sides of the building
were galleries, in which were ranged in double rows the beds of the
patients. Five rooms, which had been set apart for wounded general
officers, were happily vacant ; and these were assigned to Miss Night-
ingale and her friends.

FLORENCE NIGHTINGALE.

The appearance of the delicate, tender, thoughtful nurses was hailed
with delight and raptures of gratitude by the objects of their sympathy
and devotion. One poor fellow burst into tears, and exclaimed, "I
can't help crying when I see them. Only think of Englishwomen
coming out here to nurse us ; it is so homely and comfortable ! " The
heavy cares and duties which awaited them were terribly increased,
within a few hours of their coming, by the arrival of six hundred
wounded, sent down after the battle of Inkerman. The over- worked
surgeons, "one and all," acknowledged that their services, at such a
juncture, were invaluable; even the most <* hard-headed old Scotch
"- , geons," whom some of the croakers had feared would be constantly
resenting raps from the scented fan of Miss Nightingale, admitted that
the tender nurses ♦' were not in the way except to do good."

"Miss Nightingale," says one letter, in November, "appears emi-
nently qualified for the noble work she has undertaken. Her labors
will spare the clergy many a sad sight of men sinking for want of
proper nursing, and because food cannot be administered often enough.
This is impossible, with only the hospital orderlies ; but with the
nurses, all who need will be supplied." But food, clothing, medicines,
and extra medical aid were wanting ; and the men were constantly
sinking through exhaustion, when, if it had been at hand, a timely
stir ulant administered might have saved them.

Linen, flannels, stockings, and other necessary articles of clothing,
were not to be obtained ; the vast freights which had hcen sent from
England were either rotting under the snow at Balaklava, or hidden in
the mud outside the custom-house at Constantmople. The strength
with which Miss Nightingale supported the difficulties and duties of
her position surpassed even the expectations of those who were best
acquainted with her character and the resources of her nature. Every
day brought some new complication of misery to be unravelled. " Each
day," observes a qualified witness, " had its own peculiar trial to one
who had taken such a load of responsibility in an untried field, and
with a staff of her own sex all new to it. She has frequently been
known to stand twenty hours, on the arrival of fresh detachments of
sick, apportioning quarters, distributing stores, directing the labors of
her corps, assisting at the most painful operations where her presence
might soothe or support, and spending hours over men dying of chol-
era or fever. Indeed, the more awful to every sense any particular
case might be, the more certainly might be seen her slight form bending
over him, administering to his ease by every means in her power, and
seldom quitting his side until death released him."

Yet the difficulties of Florence Nightingale's position were increased
tenfold by the continual struggles which she was obliged to undergo
with System and the prejudices of individuals. By petty, daily con-
tests, she was compelled to extort from the authorities a scanty allow-
ance of the necessary materials required by her and her band of nurses.
Etiquette and "service" regulations impeded her movements at every
step; "indolence, indifference, and hicapacity " combined to clog her
exertions; for "no one would take 'responsibility' upon himself,
even to save the lives of hundreds." Happily, the presence and able co-
operation of Mr. Macdonald, the distributor of " The Times Fund,"
enabled her at length to lay in stores, to institute proper culinary and
washing departments, and to introduce some order and comfort. Had
it not been for their mutual exertions, a large proportion of the poor
prostrate sufferers must have been condemned to wear the tattered,

V

FLORENCE NIGHTINGALE.

filtiiV rags, in -which they Avere brought down from the Crimea. A
washing contract had, it is true, existed ; but it -was totally inoperative,
and the beds and habiliments of the men had been in a condition loath-
some and fold beyond description. A house, well supplied with water,
close to the Barrack Hospital, was engaged at the charge of the fund,
and here the clothing supplied by Miss Nightingale was washed and
dried. In ten days after her arrival an impromptu kitchen was fitted
up, from Avhich eight hundred men were daily supplied with well-
cooked food and other necessary culinary comforts in abundance —
beef-tea, chicken-broth, rice-pudding, jelly, chickens, and numerous
delicacies. Heretofore the cookery, performed by soldiers, without
any superintendence, and of course without any system, had been most
detestable, when the sickly, fastidious appetite of a fevered or consump-
tive patient is considered. Meat and vegetables had been boiled in
one large copper, the separate portions enclosed in nets, and served up
either done to rags or half raw ; and the delivery had been as devoid
of system as the cookery. Sometimes it would be six or seven o'clock
in the evening before, in individual cases, things ordered could be sup-
plied, and then the means of cooking would be at an end. In subor-
dinate as well as in leading points of arrangement, the same feminine,
directing hand was now to be traced.

With rare thoughtfulness, the nurses were employed in making up
needful articles of bedding or surgical requisites, stump pillows for
amputation cases, and other things of a like nature.

One "rule of the ser\ice" was in existence which alone exemplifies
the system bearing so heavily upon the helpless mvalids, and which it
required all the tact and firmness of Miss Nightingale to stand against ;
it demanded that all articles needed even for present use should be
procured from home through the commissariat ; and there was likewise
a regulation appointing that a "board" must judge stores already
landed, before they could be given out. On one occasion, the "board"
not having completed its arrangements, and the men languishing for
the stores sent from England, Miss Nightingale insisted that they
should be at once dispensed. Red Tape, shocked at the audacity of
such a singular proposition, interposed ; woe betide the man amenable
to martial law who should dare to touch even the cordage of one box !
The noble-spirited woman, conscious that determination must effect
what entreaty had failed to do, had the store-house broken open, on
her own responsibility, and its contents distributed through their
proper channels. But, on all other occasions, she paid the most scru-
pulous deference to the existing laws. Her name and angelic minis-
terings Avere the theme of frequent grateful praise among the men in
the trenches ; and it was remarked that she made the Barrack Hospital
so comfortable, that the convalescents began to display a decided re-
luctance to leave it.

Not only in the scene of her arduous labors, but at home, was the
self- dedicated Samaritan assailed by jealousies and suspicions. The
circumstance of her having accepted the services of some Sisters of
Charity from the nunnery at Norwood, and from St. Stephen's Hospi-
tal, Dublin, drew down upon her, in December, so invidious an attack
from a clergyman of the Established Church, that the Hon ]SIrs. Sidney
Herbert was' obliged to step forward and defend her absent friend, and
show " how cruel and unjust" were the aspersions thrown upon her.

"It is melancholy to think," she wrote to the wife of the Rev. gen-
tleman, " that in England no one can undertake any thing without the

vi

FLORENCE NIGHTINGALE.

most tincharitable and sectarian attacks ; and, had you not told me, I
should scarcely have believed that a clergyman of the Established
Church would have been the mouthpiece of slander. Miss Nightingale
is a member of the Established Church of England, and what is called
rather Low Church."

The Hon. and Rev. Sydney Godolphin Osborne adds his testimony
to the pure religion of the object of these animadversions : " I found
her myself to be, in her every word and action, a Christian ; I thought
this quite enough. It would have been, in my opinion, the most cruel
impertinence to scrutinize her words and acts to discover to which of
the many bodies of true Christians she belonged. I have conversed
•with her several times on the deaths of those whom I had \'isited min-
isterially in the hospitals, with whom she had been when they died. I
never heard one word from her lips that would not have been just what
I should have expected from the lips of those whom I have known to
be the most experienced and devout of our common faith. Her work
ought to answer for her faith ; at least, none should dare to call that
faith in question, in opposition to such w^ork, on grounds so weak and
trivial as those I have seen urged. ... If there is blame in look-
ing for a Roman Catholic priest to attend a dying Romanist, let me
share it with her — I did it again and again."

Early in January, 1855, the executive strength at Miss Nightingale's
disposal was increased by the arrival of Miss Stanley, with fifty more
nurses, who were terribly needed, for there were then on the Bospho-
rus and Dardanelles no less than eight hospitals, containing an aggre-
gate of nearly five thousand sick and wounded, while there were eleven
hundred more on their way from the Crimea. In the Barrack Hospi-
tal alone there were about three thousand patients, all of them severe
cases.

But as Florence Nightingale was struggling against the disgraceful
jealousy of hospital officials, her heart was cheered and encouraged by
a glorious letter, filled with true English warmth and sjTnpathy, writ-
ten by Queen Victoria — "not a letter stifi" with gold thread and glit-
tering with gems," but womanly and queen-like, '* with nothing of the
ermine about it but its softness and purity."

" Would you tell Mrs. Herbert," wrote the Queen of England to
^Ir. Sidney Herbert, " that I beg she would let me see frequently the
accounts she receives from Miss Nightingale or Mrs. Bracebridge ; as
I hear no details of the wounded, though I see so many from officers,
&c., about the battle-field, and naturally the former must interest me
more than any one. Let Mrs. Herbert also know that I wish ^liss
Nightingale and the ladies would tell these poor, noble, wounded and
sick men that no one takes a warmer interest, or feels more for their
sufferings, or admires their courage and heroism more than their Queen.
Day and night she thinks of her beloved troops. So does the Prince.
Beg Mrs. Herbert to communicate these my words to those ladies, as
I know that our sympathy is much valued by these noble fellows."

It is easy to imagine that this letter, so gracious, kind, and tender,
must have strengthened the heart of the noble Florence Nightingale in
her arduous work. Touching and simple, those words of sympathy,
" spoken right nobly as a queen, right affectionately as a mother, right
eloquently as a woman," are worth a thousand times the brave speech-
es or heroism of any of the queens of " the jewel set in a golden sea."
But Her Majesty has proved by many good deeds that she can feci for
suffering and want, and has always evinced more especially a strong

vii

FLORENCE NIGHTINGALE.

interest in her wounded or disabled soldiers, visiting and cheering
them on many occasions.

By February, the great increase of fever was the chief point of re-
mark ; it raged destructively, and in less than a month it swept away
no fewer than seven surgeons, leaving eight more, and three of the
nurses, dangerously ill. Indeed, at that time there was but one medi-
cal attendant well enough to wait on the sick in the Barrack Hospital ;
and his services were required in no less than twenty-one wards. Drs.
Newton and Struthers were tended in their last moments, and had their
dying eyes closed, by Miss Nightingale. For "wherever there is dis-
ease in its most dangerous form," Avrote Mr. Macdonald, in February,
"and the hand of the despoiler distressingly nigh, there is that incom-
parable woman sure to be seen ; her benignant presence is an influence
for good comfort, even amid the struggles of expiring nature. She is
« a ministering angel,' without any exaggeration, in these hospitals ;
and, as her slender form glides quietly along each corridor, every poor
fellow's face softens with gratitude at the sight of her. "S\Tien all the
medical officers have retired for the night, and silence and darkness
have settled down upon those miles of prostrate sick, she may be ob-
served alone, with a little lamp in her hand, making her solitary
rounds. The popular instinct was not mistaken which, when she set
out from England on her mission of mercy, hailed her as a heroine ; I
trust that she may not earn her title to a higher, though sadder, appel-
lation. No one who has observed her fragile figiu-e and delicate health
can avoid misgivmgs lest she should fail. With the heart of a true
woman, and the manners of a lady, accomplished and refined beyond
most of her sex, she combines a surprising calmness of judgment with
promptitude and decision of character."

Of the sublime courage which must have supported her during these
solitary nocturnal rounds we may judge by the slight sketch given in
another place. Speaking of the frightful and sickening sounds and
sights in the wards and corridors, he says : " Duruag the day little of
this is heard ; but when all is silent, and sleep has settled down upon
the occupants of each ward and corridor, then rise at intervals upon
the ear sounds which go straight to the heart of the listener."

Merely to see her pass along was an inexpressible comfort to the
men. "She would speak to one," said a poor fellow, writing home,
" and nod and smile to a many more ; but she couldn't do it to all,
you know. "We lay there by hundreds ; but we could kiss her shadow
as it fell, and lay our heads on the pillow again, content." In her
rounds, to one she would administer words of consolation and hope, to
another teach resignation, now cheering with a smile or sjTupathizing
with a sigh — ministering to the necessities both of mind and body of
the sufferers, who, following her light, soft footsteps with their tear-
brimmed eyes, bent to "kiss her shadow as it fell." Such was her
uifluence, that when men, frenzied by their wounds and disease, had
worked themselves into a passionate refusal to submit to necessary op-
erations, a few calm sentences of hers seemed at once to allay the
storm ; and the men would submit willingly to the painful ordeal they
had to undergo.

Of Florence Nightingale's personal appearance the author of " Scu-
tari and its Hospitals " gives a most interesting description. "Miss
Nightingale," he says, " is jvist what you would expect in any other
well-bred woman, who may have seen, perhaps, rather more than
thirty years of life ; her manner and countenance are prepossessing,

viii

FLORENCE NIGHTINGALE.

and this without the possession of positive beauty ; it is a face not
easily forgotten, — pleasing in its smile, with an eye betokening great
self-possession, and giving, when she wishes, a quiet look of tirm deter-
mination to every feature. Her general demeanor is quiet, and rather
reserved ; still, I am much mistaken if she is not gifted with a very
lively sense of the ridiculous. In conversation, she speaks on matters
of business with a grave earnestness I should not expect from her
appearance. She has evidently a mind disciplined to restrain, under
the principles of the action of the moment, every feeling which would
interfere with it. She has trained herself to command, and learned
the value of conciliation towards others, and constraint over herself.
She seems to xmderstand business thoroughly. Her nerve is won-
derful. I have been with her at very severe operations ; she was more
than equal to the trial."

In April ^Miss Nightingale lost a very dear personal friend, one of
the nurses, a young and amiable lady named Miss Sniythc. This lady
had commenced her occupation as nurse at Scutari, but, being re-
quested to join ]Miss Bracebridge at Kululee, — which was on the
Asiatic side of the Bosphorus, five miles from Scutari, — she left for
that place, much regretted by Miss Nightingale, who said she hoped
that they would have labored together in the same hospital. Shortly
after her arrival she was attacked by fever, and died deeply mourned.

Miss Nightingale's firm, systematic, and energetic thoughtfulness at
length gained its w^ay, and she had the satisfaction of seeing that the
most important part of her work at Scutari w^as accomplished. She
accordingly repaired to Balaklava, with the view of inspecting its hos-
pitals, arriving there May 4, 1855. There she examined the general
state of aff'airs, had new huts erected, kitchens built, and vigorous
organization instituted ; but no sooner were all these matters arranged
than the long- continued arduous exertions which she had undergone
told on her system. Her delicate and fragile fiame was attacked by
Crimean fever ; and, completely prostrated, she was carried up to the
hut-hospital on the heights.

For a fortnight the fever continued its hold ; but at the end of that
time Florence Nightingale rose, weak, yet pronounced out of danger,
from her sick bed. She was earnestly entreated to return to England ;
but no persuasion could induce her to quit her post, or to proceed
further than Scutari. Too well she knew that her presence on that
sad spot was still urgently needed. She left Balaklava for Scutari,
June 6 ; Lord Ward placing his steam yacht at her disposal, that she
might have the advantage of change of air in sea excursions to recruit
her strength. So exhausted was she that she had to be carried down
to the vessel, tenderly and reverently in the arms of the men, amidst
their heartfelt prayers for her speedy recovery.

Miss Nightingale's efforts for the poor fellows in the hospitals did
not terminate with their death ; for on her return to Scutari she
originated a scheme for erecting a monument to the brave men who
had died during the winter. This memorial has been only recently
completed, and now towers in gloomy grandeur above the surrounding
graves of our British heroes. It is simple and massive ; a square base,
surmounted by four figures of angcLs with drooping wings, who sup-
port a tapering shaft, which rises towards the sky. In four difi'erent
languages on each side of the base is this inscription : —

"This Monument was erected by Queen Victokia and iier

People."

ix

FLORENCE NIGHTINGALE.

By December, 1855, the greater number of the hospitals were
closed ; the Barrack Hospital was again used for its original purpose ;
and all seemed hopeful and invigorated. Her Majesty, to mark her
warm appreciation of the inestimable services of Miss Nightingale,
presented her with a beautiful ornament, adapted to be worn as a
decoration of the most elegant and costly description. It was formed
of a St. George's Cross, in ruby-red enamel, on a white field, repre-
senting England ; this was encircled by a black band, typifying the
office of charity, on which was inscribed the legend, "Blessed are the
merciful." Tlie letters V. R., surmounted by a crown in diamonds,
were impressed upon the centre of the St. George's Cross, from which
emanated rays of gold. Y/ide- spreading branches of palm, in bright-
green enamel, tipped with gold, composed a framework for the shield,
their stems being banded with a ribbon of blue enamel, inscribed with,
the word "■Crimea." At the top three brilliant stars of diamonds
illustrated the idea of the light of heaven shed upon labors of mercy,
peace, and charity. On the back of the jewel there was an inscription
written by Her Majesty, recording it to be a gift in memory of services
rendered to her brave army by ^Nliss Nightingale. The ornament Avas
about three inches in depth by two and a half in width. This gift was
accompanied by an autograph letter full of deep feeling, and graceful,
queenly kindness.

The sultan also presented !Miss Nightingale with a superb bracelet,
set in brilliants, as "a mark of his estimation of her devotion."

At the close of 1855 it was resolved that an acceptable testimonial
of public gratitude should be offered to the generous Florence Night-
ingale ; and a " Nightingale fund " was immediately raised. But,
as the noble-hearted woman distinctly declined any purely personal
reward for her efforts, a resolution was passed at a meeting held in
Willis's Rooms, in December, that the fund raised should be invested
to establish "an institute for training, sustenance, and protection of
nurses and hospital attendants," to embrace the paid and the unpaid,
for whom a home was to be provided, and a retreat for old age.
Numerous meetings were held, over some of which presided a prince
of the blood royal, who had been a witness of Miss Nightingale's
labors in the East, and which were attended by men of the highest
and noblest reputation. One important meeting was held at the Man-
sion House, December 26, at which the lord mayor presided, and at
which the names of many of the most influential merchants, traders,
and manufacturers were announced as ha-\dng consented to become
members of a committee. A copy of the proceedings of the meeting
at "Willis's Rooms was sent .out to Miss Nightingale ; to this she re-
turned, in January, 1856, a letter most characteristic of her firm,
practical, and yet gracious, kindly disposition. "Exposed as I am,"
she says, "to be misinterpreted and misunderstood, in a field of action
in which the work is new, complicated, and distant from many who
sit in judgment on it, it is, indeed, an abiding sixpport to have such
sympathy and such appreciation brought home to me in the midst of
labors and difficulties all but overpowering. I must add, however,
that my present work is such as I would never desert for any other,
so long as I see room to believe that what 1 may do here is unfinished.
May I, then, beg you (Mrs. Herbert) to express to the committee that
I accept their proposal, provided I may do so on their understanding
of this great uncertainty, as to when it will be possible for me to carry
it out." This gift of gratitude was, in very truth, but giving its recip-

X

FLORENCE NIGHTINGALE.

lent more -work to execute; jet, as her friend Mr. Sidney Herbert
observed, " Miss Nighting-ale looks to her reward from this country in
having a fresh field for her labors, and means of extending the good
that she has already begun, A compliment cannot be paid dearer to
her heart than in givmg her more -work to do."

In ^larch, 1856, !Miss Nightingale sustained a slight injury from
the upsetting of a vehicle, in which, with some of the nurses, she was
proceeding up to the fi-ont of Balaklava. Her back being hurt, she
was obliged to remain for a short time in the Castle Hospital, which
had been erected during the summer of 1855, in a lonely but healthy
spot at the mouth of Balaklava Harbor. During the spring, despite
her anxieties and responsibilities, she found time to attend to different
minor affairs ; through her exertions, *' a considerable quantity of school
materials, such as maps and slates, was supplied to the schools ; " she
advanced on her own respond- ibility a sufficient sum from *' T/ie limes'
Fund " to complete the erection of the Inkerman Cafe ; she aided the
active senior chaplain in establishing a library and schoolroom, and
warmly assisted him in organizing evening lectures for the men. She
took a kindly interest in the private affairs of the men, and forwarded
their savings to their families in England, at a time when there was no
provision for sending home small sums ; she wrote letters for the sick ;
she studied the comforts of those who were convalescent ; and from
the dying she took charge of bequests. She had a tent constructed, to
protect from the glaring heat of an eastern sun the invalids who were
permitted to enjoy the air, and endured the mortification of a refusal,
from the hospital authorities, to have the tent put up.

M. Alexis Soyer, in his " Culinary Campaign," relates the follo\A-ing
interestmg incident : —

" Before leaving the batterj^ I begged ISIiss Nightingale, as a favor,
to give me her hand, which she did. I then requested her to ascend
the stone rampart next the w^ooden gun carriage, and lastly to sit upon
the centre mortar, to which requests she very gracefully and kindly
acceded. I then boldly exclaimed, * Gentlemen, behoW this amiable
lady sitting fearlessly upon that terrible instrument of war. Behold
the heroic daughter of England, the soldier's fiiend ! ' All present
shouted, ' Bravo ! bravo ! Hurrah I hurrah ! Long live the daughter
of England ! ' "

At length Florence Nightingale's holy work of Christian charity
■was accomplished,* and she prepared to return to England. The period
of this event was kept a profound secret, for she ever carefully shunned
publicity ; and, desirous of maintaining the strictest incognito, she
declined the offer of a passage in a British man-of-war, and embarked
on board a French vessel. Passing through France by night, and
travellhig her own country unrecognized, she quietly arrived at Lea
Hurst, Derbyshire, Friday, August 15, 1856.*

In October, Her Majesty invited her to visit the royal residence at
Balmoral ; and, at a ball given there, she was seated wdth the royal
family and the court circle at one end of the hall. On this occasion,
it was noticed that her hair, which the severe attack of illness she had
suffered in the Crimea necessitated cutting off, was " quite short," but
a charming little cap made a very graceful head-dress.

* It is deeply interesting to Icaru that tlio apartments in the poiithern tower
of the IJarrack Hospital, formerly occupied by Miss iN'ighting^ale, uow remain,
even as regards the furniture they contain, precisely as they were during- her
residence there ; a touching relic, which we owe either to our late ambassador,
I/Pr4 Stratford, or to his successor, Sir Henry Bulwer.

xi

FLORENCE NIGHTINGALE.

A subscription being raised by the ^A-orkingmen of Sheffield to erect
a monninent in that town to the memory of their countrymen who liad
falk-n in tlie Crimea, a request was made, in October, to Miss Night-
ingale, througli her relative Miss Shore, of Meersbrook Hall, that she
Avould consent to lay the foundation stone. Miss Nightingale, in re-
fusing, sent a check for twenty pounds towards the object proposed,
but said, " It is with real pain that I feel compelled to decline the priv-
ilege, -which they offer me, of laying the first stone ; but I believe I
shall best honor the cause of those brave dead by abstaining from ap-
pearing to court that publicity which I consider to have been my great-
est impediment in the work I have engaged in for their sakes — imped-
ing it by arousing in some minds a care for worldly distinctions."

As an instance of her large-hearted benevolence, we may cite an in-
cident which occurred on her return. In France there exists a chari-
table institution, — the " OEuvre de Notre Dame D'Orient," — under
the direction of I'Abbe Legendre, almoner of the hospital of Bour-
bonne-les-bains, a town to which large numbers of military men resort
annually for the benefit of the waters. A relief fund being set on foot
to aid infirm soldiers on their discharge from the hospital. Miss Night-
ingale forwarded a donation of one hundred francs, through Lady Fox
Strangvt'ays, widow of the general who fell at Inkerman. Accompa-
n}-ing this donation was a graceful letter, addressed to the Abb6. in
which she said, " I feel the warmest sympathy with you in the touch-
ing object of your work, and I ahi happy to join in it to the limited
extent which my own engagements allow. I received, too, from the ex-
cellent religious ladies who were attached to the French army in the
East, so many tokens of their friendship, — they gave me their assist-
ance with such entire self-denial, and lightened my hard task in the
hospital with so much devotedness, that I shall always seek any op-
portunity of showing my gratitude to France and to her brave chil-
dren, whom I have been taught by these ladies to love and respect."

A graceful and interesting incident, in connection y\-iih the Nightin-
gale Fund, occurred very recently. It will scarcely be forgotten
that Mr. and ISIadame Goldschmidt contributed more than two thou-
sand pounds to the fimd, being the proceeds of a grand concert given
at Exeter Hall for the piirpose, when the generous donors not only
performed gratuitously themselves, but insisted on defraying every ex-
pense connected Avith the concert. This munificence, showing that
true genius is at all times kindred and sympathetic, excited such ad-
miration, that several of those who took a deep interest in the success
of the Nightingale xindertaking resolved to present Mr. and Madam-e
Goldschmidt, as a testimony of their regard, a copy in marble of Dur-
ham's bust of Her Majesty. This desire was carried into effect at the
Mansion House on the 17th of last June, when the Lord Mayor, Lord
Monteagle, Mr. and Madame Bunsen, Mr. and Mrs. George Grote, Mr.
and ^Irs. S. C. Hall, Dr. Mackay, Mrs. and Miss Stanley, Mr. Brace-
bridge, and several other friends and subscribers, were pres nt. The
Lord Mayor offered the bust in the name of the subscribers, and truly-
remarked, in a very happy speech, that " gifted as Madame Gold-
schmidt u as with the divinest faculty of song, it has been and is her
greatest lionor that she has ever been prepared to devote a proportion
of the proceeds of her genius to the large purposes of charity."

One of the brightest, noblest names in the list of brave, heroic
women, is —

FLORENCE NIGHTINGALE,
xii

FLORENCE NIGHTINGALE.

Florexce Nightingale will be, tlii-ough all time to come, the
representative nurse par excellence. In her case it is a special calling,
in virtue of natural capacity, moral and intellectual at once. She did
not set out from any chosen starting point. She did not propose to
earn her own salvation by a life of good works. She was not incited
by visions of a religious life in a favored monastic community. She
did not aspire to take m hand a department of human misery, in order
to extinguish it, and then look about to see what particular misery it
should be. She does not appear to have had any plans relating to
herself at all. Nor was she overtaken by the plague in a village ; nor
did she overtake a fever in a village in the course of her travels, like
her representative sisters of an earlier time ; nor did she do the work
of the occasion, and reenter ordinary life as if nothuig had happened.
Her case is special and singular in every way.

Her childhood and youth Avere very much like those of little girls
who have wealthy parents, and carefully- chosen governesses, and good
masters, and much travel — in short, all facilities for intellectual culti-
vation by study and extended intercourse with society, at home and
abroad.

The peculiarity in the case of herself and her nearest relatives seems
to be their having been reared in an atmosphere of sincerity and free-
dom, — of reality, in fact, — which is more difficult to obtain than
might be thought. There was a certain force and sincerity of character
in the elder members on both sides of the house which could not but
affect the formation of the children's characters ; and in this case there
was a governess also whose lofty rectitude and immaculate trutlifuhiess
commanded the reverence of all Avho knew her.

In childhood a domestic incident disclosed to the honest-minded
little girl what her liking was, and she followed the lead of her natural
taste. She took care of all cuts and bruises, and nursed all illness
within her reach ; and there is always a good deal of these things
within the reach of country gentry who are Avealthy and benevolent.
For the usual term of young-lady life, Florence Nightingale did as
other young ladies. She saw Italy, and looked at its monuments ;
she once went to Egypt and Greece with the Bracebridges ; she visited
in society, and went to court. But her heart was not in the apparent
objects of her life — not in travel for amusement, nor in art. In liter-
ature, books Avhich disclosed life and its miseries, and character with
its sufferings, burnt themselves in upon her mind, and created much
of her future effort. She Avas never resorted to for sentiment. Senti-
mentalists ncA'cr had a chance Avith her. Besides that her character
was too strong, and its quality too real, for any sympathy Avith shal-
loAvness and egotism, she had tAvo characteristics* Avhich might avcU
daunt the sentimentalists — her reserve, and her capacity for ridicule.
Ill Avould they have fared Avho had come to her for responsiA'c sympa-
thies about sentiment, or even real woes in Avhich no practical help
was proposed ; and there is perhaps nothing uttered by her, from her
evidence before the Sanitary Commission for the Army to her recently-
published " Notes on Nursing," Avhich does not disclose powers of
irony Avhich self- regardant persons may Avell dread.

Such force and earnestness must find or make a career. She evi-
dentlv believes, as all persons of genius do, that she found it, while
1 (1)

2 FLOREXCE NIGiniNGALE,

others say she made it. Philosophy will hereafter reconcile the Uvo
in her case and many others. As a matter of fact, whil ^ otlier young
ladies were busy, and perhaps better cmployecl than usual, in. enjoyiiv^
the great exhibition, she was in the Kaiserwerth Institution, on tb.e
Rhine, going throiigh the training for nursing, and investigating the
methods of organization there and elsewhere.

The strongest sensation she perhaps evei- excited among her personal
acquaintance was when she ttndertook to set up the Sanitarium in
Harley Street, and left home to superintend the establishment. Her
first M'ork there was chiefly financial ; and the powers of administra-
tion she manifested were a complete justification of what she had done
in leaving her father's house to become what people called the matron
of a charity. At first common-minded people held up hands and eyes
as if she had done something almost scandalous. EetAveen that day
and this they must have discovered that she could exalt any function,
and that no function could lower her. She rectified the accounts, paid
the debts, and brought all round ; and she always had leisure to help
and comfort the sick ladies in the house. At one time, I remember,
there was not a case in the house which was not hopeless ; but there
was no sign of dismay in Florence Nightingale. She completed her
task, showing unconsciously by it how a woman as well as a man may
be born to administration and command.

By a sort of treachery only too common in the visitors of celebrated
people, Ave have all seen the letter of ilr. Sidney Herbert, in 1854,
entreating Miss Nightingale to go — accompanied by her friends the
Bracebridges, who are familiar Avith life in the East — to Turkey, to
minister among the sick and Avounded of our array. How soon she
was ready, and how she and her band of nurses went, and Avere just
in time to receive the Avounded from Inkermann, no Englishman for-
gets. No man of any nation concerned Avill ever forget her subsequent
serA'ices. She had against her not only a chaos of disorder in Avhich
to moA-e, and a hell of misery around her to relieve, but special diffi-
culties in the jealousy of the medical officers, the raAvness of the nurses
so hastily collected, and the incompatibilities of the volunteer ladies
who started on the enterprise Avith her or after her. On the state of
the hospitals it can, I hope, never be necessary to enlarge again. We
all knoAv hoAv, under her superintendence, places became clean and
airy, and persons cleanly, clothed, fed, and aff'orded some chance of
recovery from maladies or Avounds. "While history abides, the image
of Florence Nightingale, lamp in hand, going through miles of beds,
night by night, noting every patient as she Avent, and ministering
Avherever most Avanted, will always glow in men's hearts ; and the
sayings of the men about her Avill be traditions for future generations
to enjoy.

She Avas prostrated by the Crimean f?ver at Ealaklava, and carried
up to the hospital on the cliff's till she began to mend. Avhen she Avas
taken to sea. She Avould not come home, because her Avork at Scutari
Avas not finished. She remained there till the end of the Avar ; by
Avhieh time she and her military and medical coadjutors had shoAvn
Avhat hospitals may be, and how low the rate of mortality of an army
may be reduced, even in tiuie of Avar.

She has ncA'er recoA'ered from that feA'er ; find for '^ome years she has
been, confined by seA^ere and increasing illness. Not the less has she
worked, steadily and most efficiently. She caimot fulfil her aim —
of trainiiig nurses in an institution of her OAvn, and thus raising up a
body of successors. The grateful people of England supplied the

FLORENCE NIGHTLVGALE. 3

means, "without her knoAvledge or desire, which was the same thing as
imposing a ncAv service upon lier. She wished to decline it when she
found how little likely her health was to improve. Her letter to the
trustees of the fund mUst be fresh in all memories, and the reply of
the trustees, who satisfied her that the money was accumulating, and
the plan and Ihe public able and willing to wait. If she could not do
this particular work, she has done many others. Her written evidence
before the Sanitary Commission for the Army is a great work in itself.
So are various reforms urged on the military authorities by her and
her coadjutors, and now adopted by the war office. Reforms in the
Indian army are about to follow. The lives thus saved no one M'ill
attempt to number ; and the amount of misery and vice precluded by
her scientific humanity is past all estimate.

Her •• Notes on Nursing," prepared and issued in illness and pain,
are the crowning evidence of what she is, and can do. Hitherto we
have, I trust, appreciated and honored her acts ; now we are enabled
to perceive and appreciate her mind. It was as certain before as it
can ever be that she must have acquired no little science, in various
departments, to produce the effects she wrought ; but we see it all now.
We see also, much more clearly than ever, her nioral characteristics.
I will not describe them when they can be so much better seen in her
" Notes on Nursing." Any one who reads those Notes without being
moved in the depths of his heart M'ill not understand the writer of them
by any amount of description ; and those who have been so moved do
not need and will not tolerate it. The intense and exquisite humanity*
to the sick, underlying the glorious common sense about affairs, and .
the stern insight into the weaknesses and the perversions of the
healthy, troubled as they are by the sight of suffering, and sympa-
thizing with themselves instead of the patient, lay open a good deal
of the secret of this wonderful woman's life and power. We begin to
see how a woman, any thing but robust at any time, may have been
able, as well as willing, to undertake whatever was most repulsive and
most agonizing in the care of wounded soldiers and crowds of cholera
patients. We see how her minute economy and attention to the small-
est details are reconcilable with the magnitude of her administration,
and the comprehensiveness of her plans for hospital establishments,
and for the reduction of the national rate of mortality. As the livos
of the sick hang on small things, she is as earnest about the quality
of a cup of arrowroot, and the opening and shutting of doors, as about
the institution of a service between the commissariat and the regi-
mental, which shall insure an army against being starved when within
reach of food. In the mind of a true nurse nothing is too great or
too small to be attended to Avith all diligence ; and therefore we have
seen Florence Nightingale doing and insisting upon the right about
shirts and toAvels, spoon-mcate, and the boiling of rice, and largely
aiding in reducing the mortality of the army from nineteen in the
thousand to eight, in times of peace.

In the spirit and tone of this book we see, too, how it is that, with
all her fame, we have known so little of the woman herself. Where
it is of use to tell any piece of her own experience, she tills it ; and
these scraps of autobiography will be eagerly sei;^cd upon by all kinds
of readers ; but, except for the purpose of direct utility, she never
speaks of herself, more or less, or even discloses any of her opinions,
views, or feelings. This reserve is a great distinction in these days of
self-exposure, and descanting on personal experiences. It is th(; l)est
possible rebuke to the egotism, or the sentimentality, which has led

4 FLORENCE NIGHTINGALE.

several ladies to imagine thnt they could be nurses, without having
tried whether they could bear the discipline. Her pure, undisguised
common sense, and her keen perception of all deviations from common
sense, may have turned back more or fewer women from the nursing
vocation ; but this is probably an vuimixed good ; for those Avho could
be thus turned back were obviously unfit to proceed. She is the rep-
resentative of those only who are nurses ; that is, capable of the hardest
and highest duties and sacrifices which women can undertake from
love to their race.

In the end she will have won over far more than she can have (most
righteously and mercifully) discouraged. Generations of women for
centuries to come will be the better, the more helpful, and the more
devoted for Florence Nightingale having lived ; and no small number
of each generation will try their strength on that difficult path of
beneficence which she has opened, and on which her image will for-
ever stand to show the way. Ingleby Scott.

THE JEWEL PRESENTED TO MISS NIGHTINGALE,
BY QUEEN VltTORIA.

INDEX

PAGE

Disease a reparative process, . . 7
Of the sufferin<^8 of disease ; disease

not always the cause, 7

What mirsiiig ou^dit to do, .... 8
Nursiug^ the siek little understood, 8
Nurpinf,-- ouf,'-ht to assist the repara-
tive proccns, 8

Kursiuf^ the well little understood, 9
Curious deductions from an exces-
sive death rate, 9

First rule of nursing to keep the air

within as pure as the air without, 11
Why are uninhabited rooms shut

up? 11

Without chill, 12

Open windows, 13

What kind of warmth desirable, . . 13
Bedrooms almost universally foul, 13
An air-test of essential consequence, 14
When warmth must be most care-
fully looked to, 14

Cold air not ventilation, nor fresh

air a method of chill, 15

Kight air. Air from outside. Open

your windows, shut your doors, IG
Smoke. Airing damp things in a
patient's room. Effluvia from

excreta, 17

Chamber utensils without lids, . . 18
Don't make your sick room into a

sewer, 18

Abolish slop-pails. Fumigations.
Health of houses — five points es-
sential. Health of carriages, . . 19

Pure air. Pure water, 20

Drainage. Sinks, 21

Cleanliuess. Light, -22

Three common errors in managing

the health of houses, 22

Head in charge must see to house

hygiene, not do it herself, .... 23
Does God think of these things so

seriously ? 23

How does he carry out his laws ? . 24
How does he teach his laws .''... 24

Servants' rooms, 24

Physical degeneration in families ;
its causes. Don't make your sick
room into a ventilating shaft for
the whole house. lufuction. Dis-
eases are not individuals arranged
in classes, like cats and dogs, but
conditions growing out of one

another, 25

Why must children have measles,

&c. ? Petty management, .... 27
Hlustrations of the want of it, . . . 28
Strangers coming into sick room, . 28
Sick room airing the whole house, , 28
Uninhabited room fouling the
whole house. Lingering smell of

p;iiut a want of care, 28

Delivery and non-delivery of letters

and messages, 29

Partial measures such as " being al-

1*

Pl. .'V

ways in the way " yourself, in-
crease instead of savin"- the pa-
tient's anxiety, because tney must
be only partial. Why let your
patient ever be surprised.' . ... 29
AVhat is the cause of half the aeci-

dents which happen ? 30

Petty management better under-
stood in institutions than in pri-
vate houses. What institutions
are the exception ? Nursing in

regimental hospitals, 31

What it is to be " in charge," ... 32
Why hired nurses give so much
trouble. Unnecessary noise. Nev-
er let a patient be waked out of

his first sleep, 34

Noise which excites expectation, . 35
Whispered conversation in the

room, or just outside the door, 35, 36
Noise of female dress. Patient's
repulsion to nurses who rustle, . 36

Burning of the crinolines, 37

Indecency of the crinolines, .... 37
Hurry peculiarly hurtful to sick, . 37
How to visit the sick, and not hurt

them. These things not fancy, . 38
Interruption damaging to sick and

to well, 38, 39

Keeping a patient standing. Pa-
tients dread surprise. Never speak
to a patient in the act of moving, 39
Effects of over-exertion on sick, . . 40
Careless observation of the results

of careless visits, 40

Difference between real and fancy

patients, 41

Conciseness necessary*vith sick, . 41
Irresolution most painful to them, 43
What a patient must not have to 42

see to. Reading aloud, 42

Read aloud slowly, distinctly, and

steadily to the sick, 43

Never read aloud by fits and starts
to the sick. The sick would rather
be told a thing than have it read

to them, 43

People overhead. Music, 44

Variety a means of recovery, ... 44
Color and form means of recovery ;
this is no fancy. Flowers, ... 45

Effect of body on mind, 40

Sick suffer to excess from mental as
well as bodily pahi. Help the
sick to vary their thoughts, ... 40
Desperate desire in the sick to " see
out of window." Supply to the
sick the defect of manual lalwr, . 47
Physical effect of color. Want of at-
tention to hours of taking food, . 4fti
Life often hangs upon minutes in

taking food, 49

Patients often starved to death in
chronic cases. Food never to bo
left by the patient's side. Pa-
(5)

INDEX.

PAGE

ticnt had better not see more
loud tliaii his own, 50

You cauuot be too careful as to
quality in sick diet, 51

Nurse must have some rule of
thought about her patient's diet.
Nurse must have some ride of
time about the patient's (Uet, . . 52

Keep your patient's cup dry under-
neath. Common errors in diet.
Beef tea. Eggs. 3Ieat without
vegetables, 53

Arrowroot. Milk, butter, cream, &g.
Intelligt-nt cravings of particular
sick for particular articles of diet, 54

Sweet things. Jelly, 55

Beef tea. Observation, not chemis-
try, must decide sick diet, . . . . 5G

Home-made bread. Sound obser-
vation has scarcely yet been
brought to bear on sick diet, ... 57

Tea and coffee. Cocoa, 58, 59

Bulk. Feverishness a symptom of
bedding. Uncleanliness of ordi-
nary bedding. Nurses often do
not think the sick room any busi-
ness of theirs, but only the sick, 60

Air your dirty sheets, not only your
clean ones, • . . 61

Iron siJring bedsteads the best.
Comtort and cleanliness of two
beds. Bed not to be too wide, . . 62

Bed not to be too high, nor in a
dark place, nor a four-poster with
curtains. Scrofula often a result
of disposition of bed clothes.
Bed sores. Heavy and impervi-
ous bed clothes, 63

Light essential to both health and
recovery, 64

Aspect, view, ami sunlight, matters
of lirst importance to the sick, . . 65

Without sunlight, we degenerate
body and mind. Almost all pa-
tients lie with their faces to tlie
light. Cleanliness of carpets and
furniture, 66

Dust never removed now. How a
room is dunted, 67

Floors. Papered, plastered, oil-
painted walls. Atmosphere in
painted and papered rooms quite
distinguishable. Best kind of
wall for a sick room. How to
keep your wall clean at the ex-
pense of your clothes, 68

Dirty air from without. Best kind
of wall for a house. Dirty air
from within. Dirty air Irom the
carpet. Kemedies, 69

Poisoning by the skin, 70

Ventilation and skin-cleanlinesa
equally essential, 71

Steaming and rubbing the skin.
Advising the sick, 72

Chattering hopes the bane of the
sick, 73

Patient does not want to talk of
himself. Absurd statistical com-
parisons made in common, coa-

PAO>

versation by the most sensible
people for tlie benefit of the sick.
Absurd consolations put forth for
the benefit of the sick, 74

Wonderful presumption of the ad-
visers of tlie sick. Advisers the
same now as two hundred years
ago. Mockery of the advice given
to sick, 76

Means of giving pleasure to the
sick, 77

Two new classes of patients pe-
culiar to this generation. What
is tlie use of the question, Is he
better .' 79

Leading questions useless or mis-
leading, 81

Means of obtaining inaccurate in-
formation, 82

As to food patient takes or does
not take, 83

As to diari-hoea. More important to
spare the patient thouglit than
physical exertion. Means of cul-
tivating sound and ready obser-
vation, 83,84

Sound and ready observation essen-
tial in a nurse, 85

English women have great capacity
of, but little practice in, close ob-
servation, 86

Difference of excitable and accumu-
lative temperaments. Supersti-
tion the fVuit of bad observation.
Physiognomy of disease little
shown by the face, 87

Peculiarities of patients. Nurse
must observe for herself increase
of patient's weakness ; patient
will not tell her. Accidents aris-
ing from the nurse's want of ob-
servation, 89

Is tlie faculty of observing on the
decline i Observation of general
conditions. Approach of death ;
paleness by no means an invaria-
ble effect, as we find in novels,. . 90

" Average rate of mortality " tells
us only that so many per cent,
will die. Observation must tell
us ivhich in the hundred they will
be who will die, 93

What observation is for. What a
confidential nurse should be, . . 94

Observation is for practical pur-
poses. Sanitary nursing as es-
sential in surgical as in medical
cases, but not to supersede surgi-
cal nursing, 95

Children : their greater susceptibil-
ity to the same things, 90

Summary. Keckless amateur phys-
icking by women. Keal knowl-
edge of the laws of health alone
can check this. Danger of j^hys-
icldng by amateur females, ... 98

What pathology teaches. What ob-
servation alone teaches. What
medicine does. What nature alone
does, lOQ

^WES ON NURSING

WHAT IT IS AND ^VHAT IT IS NOT.

3>«=;c

Shall we begin by taking it as a general principle — •
that all disease, at some period or other of its course, is
more or less a reparative process, not necessarily accom-
panied with suifering: an 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 bfeing then, while the an-
tecedent process was going on, determined ?

If we accept this as a general principle, we shall be im-
mediately 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 Avould be
immediately raised, — Will the top of Blount Blanc ever
be made habitable ? Our answer would be. It will be
many thousands of years before we have reached the bot-
tom of Mount Blanc in making the earth healthy. Wait
till we have reached the bottom before we discuss the top.

In watching diseases, both in private houses and in
public hospitals, the thing which strikes the experienced
observer most forcibly is this, that the symptoms or the
sufferings generally considered to be inevitable and inci-
dent to the disease are very often not symptoms of the
disease at all, but of sometliing quite different — of the
want of fresh air, or of hglit, or of warmth, or of quiet, or
of cleanliness, or of punctuality and care in the adminis-
tration of diet, of each or of all of these. And this quite
as much in private as in hospital nursing.

The reparative process Avhich Xature has instituted and

K7)

8 NOTES ON NURSING.

which we call disease, has been hindered by some want of
knowledge or attention, in one or in all of these things,
and pain, suffering, or interruption of the whole process
sets in.

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 httle more than the administration
of medicines and the application of poultices. It ought to
signify the proper use of fresh aii-, light, warmth, cleanli-
ness, 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 wi-itten scores of times, that every
woman makes a good nurse. I believe, on the contrary,
that the very 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
aiTangements often make it impossible to nurse. But the
art of nursing ought to include such an-angements as alone
make what I understand by nursing, possible.

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

To recur to the first objection. If we are asked, Is such
or such a disease a reparative process ? Can such an ill-
ness be unaccompanied 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 suc-
cess of ISTature'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 every thing ; to give air, warmth, cleanliness, &c.,
is to do nothing. The reply is, that in these and many

NOTES ON NURSING. '9

other similar diseases the exact vaUie of pai-ticular reme-
dies and modes of treatment is by no means ascertained,
while there is universal experience as to the extreme im-
portance of careful nursing in determining the issue of the
disease.

11. The very elements of what constitutes good nursing
are as httle 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 the well as among the sick. The
bi'eaking of them produces only a less violent consequence
among the former than among the latter, — and this some-
times, not always.

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

O, mothers of families ! You 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 England, nearly
one out of two ? * " The Ufe duration of tender babies "

* Upon, this fact the most wonderful deductions have been strung.
For a long time an announcement something like the following has
been going the round of the papers: "More than 25,000 children
die every year in London under 10 years of age ; therefore we want a
Children's Hospital." This spring there was a prospectus issued, and
divers other means taken to this effect: "There is a great want of
sanitary knoM'ledge in women ; therefore we want a Woman's Hospi-
tal." Now, both the above facts are too sadly true. But what is
the deduction r The causes of the enormous child-mortality are per-
fectly well known ; they are chiefly want of cleanliness, want of ven-
tilation, want of whitewashing ; m one word, defective household hy-
giene. 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 foi adults. But
the Registrar- General would certainly never think of giving us as a
cause for the high rate of child-mortality in (say) Liverpool that there
was 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 m sanitary
knowledge ; although it is to women that we must look, first and last,
for its application, as far as household hygiene is concerned. But who
would ever thmk of citing the institution of a Woman's Hospital aa
the way to cure this want ?

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

10 NOTES ON NURSING.

(as some Saturn, turned analytical chemist, says) "is the
most delicate test ^ of sanitary conditions. Is all this pre-
mature suffering and death necessary ? Or did Nature
intend mothers to be always accompanied by doctors?
Dr 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 extraordinaiy that,
whereas the laws of the motions of the heavenly liodies,
far removed as they are from us, are perfectly well under-
stood, the laws of the human mind, which are under our
observation all day and every day, are no better under-
stood 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 astronomy — are now taught to every
school-girl, neither mothers of fkmihes of any class, nor
school-mistresses of any class, nor nurses of children, nor
nurses of hospitals, are taught any thing about those laws
which God has assigned to the relations of our bodies with
the world in which He has put them. In other words, the
laws wliich make these bodies, into which He has put our
minds, healthy or unhealthy organs of those minds, are all
but unlearnt. Xot but that these laws — the laws of life
— are in a certain measure understood, but not even
mothei-s think it worth their while to study them — to
study how to give their children healthy 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 con-
trol. 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."

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, ex-
posed to the east wind, but the young lady who is worn
out with the want of exposure to the fresh air, to sunlight,
&c. Put the latter under as good sanitary circumstances
as the former, and she too will not know when the wind
is in the east.

VENTILATION AND "FARMING. 11

I. VEXTILATIOX AND WARMING.

The very first canon of nursing, the first and the last
thing upon which a nurse's attention must be fixed, the
first essential to a patient, without which all the rest you
can do fisr him is ao nothing, with which I had almost
said you may leave all the rest alone, is this : To keep

THE AIR HE BREATHES AS PURE AS THE EXTEEXAL AIR,

WITHOUT CHiLLixG HIM. Yct wliat is SO little attended
to ? Even where it is thought of at all. the most exti-aor-
dinary misconceptions reign about it. ±L'\'en 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 of 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 sewei-s 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 institutions. 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 stagnant, musty, and
corrupt as it can by possibility be made. It is quite ripe
to breed small-pox, scarlet-fever, diphtheria, or any thing-
else you please.*

Yet the nursery, ward, or sick room adjoining will posi

* The common idea as to uninhabited rooms is, that they may safely
be left Avith doors, -windows, shutters, and chimney-board, all closest
— hermetically sealed if possible — to keep out the dust, it is said
and that no harm will happen if the room is but opened a short hoiix
before the inmates are put in. I have often been asked the question
for uninhabited rooms, «' But when ought the windows to be opened ? "
The answer is, " When ought they to be shut ? "

12 NOTES ON NURSING.

tively 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 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 om' case, the extraordinary thing is that the vic-
tim 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 in open fire-places, fi-esh 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 comparatively 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, periiaps days, in bed, and
thereby rendered more incapable of reaction. Then the
same temperature 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 tempera-
ture must be secured which shall not chill the patient.
Otherwise the best that can be expected will be a feverish
reaction.

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
vitaJ Dowej's have then risen often finds the room as close

VENTILATION AND WARMING. 13

and oppressive as he found it cold in the morning. Yet
the niii-se will be terrified, if a window is opened.*

I know an intelligent humane house surgeon who makes
a practice of keeping the ward windows open. The phy-
sicians and surgeons invariably close them while going
their rounds ; and the house surgeon very properly as in-
variably 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 air from without." I should think
not ; nor twice in the hour either. It only shows how lit-
tle the subject has been considered.

Of ail methods of keeping patients warm the very worst
certainly is to depend for heat on the breath and bodies of
the sick. I have known a medical officer keep his ward
windows hermetically closed. Thus exposing the sick to
all the dangers of an infected atmosphere, because he v/as
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 atmosj^here is a certain way to delay recoveiy
or to destroy life.

Do you ever go into the bed-rooms of any persons of
any class, whether they contain one, two, or twenty peo-
ple, whether they hold sick or well, at night, or before the
windows are opened in the morning, and ever find the air
any thing but unwholesomely close and foul? And why
should it he so? And of hoAV much importance is it 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 keej) the air all

* It is very dosirable that the windows in a sick room should be
such 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 — so 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 tlie
windows myself," And it is true.
2

14 NOTES ON NURSING,

night, then, as pure as the air without in the rooma jon
sleep in? But for this, you must have sufficient outlet for
the impure air you make yourselves to go out ; sufficient
inlet for the pure air from without to come in. You must
have open chimneys, open windows, or ventilators ; no
close curtains round your beds ; no shutters or curtains to
your windows, none of the contnvanccs by v>'hich you un-
dermine your own health or destroy the chances of re-
covery of your sick.*

A careful nurse will keep a constant watch over her
sick, especially weak, protracted, and collapsed cases, to
guard against the effects of the loss of vital heat by the
patient himself. In certain diseased states much less heat
is produced than in health ; and there is a constant ten-
dency 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

* Dr. An^^s Smith's air-test, if it could be made of simpler appli-
cation, -would be invaluable to use in every sleeping and sick room.
Just as without the use of a thermometer no nurse should ever put a
patient into a bath, so should no nurse, or mother, or 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 instru-
ment as the former, and both should be self-registering. The senses
of nurses and mothers become so dulled to foul air, that they are per-
fectly unconscious of what an atmosphere they have let their children,
patients, or charges, sleep in. But if the tell-tale air-test were to ex-
hibit in the morning, both to nurses and patients, and to the superior
officer going round, what the atmosphere has been diiring the night, I
question if any greater security could be afforded against a recurrence
of the misdemeanor.

And O, 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 Avould 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 oxir own. The little air-test M'ould both
betray the cause of these " mysterious pestilences," and call upon us to
remedy it.

VENTILATION AND WARMING. 15

from minute to minute. The feet and legs should be ex-
amined by the hand from time to time, and whenever a
tendency to chilling is discovered, hot bottles, hot bricks,
or warm flannels, Avith some w^arm drink, sliould be made
use of until the temperature is restored. The fire should
be, if necessary, replenished. Patients are frequently lost
hi the latter stages of disease from w^ant of attention to
such simple precautions. The nurse may be trusting to
the patient's diet, or to his medicine, or to the occa-
sional dose of stimulant wdiich 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,
CA'on during the height of summer. This fatal cliill is most
apt to occur tow'ards early morning at the period of the
lowest temperature of the twenty-four hours, and at the
time when the effect of the preceding day's diets is ex-
hausted.

Generally speaking, you may expect that weak patients
w^ill sufier cold much more in the morning than in the
evening. The vital powers are much lower. If they are
feverisli at night, with buniing hands and feet, they are
almost sure to be chilly and shivering in the morning.
But nurses are very fond of heating the foot-wanner 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
shown, in all ranks, as in nursing.*

The extraordinary confusion between cold and ventila-
tion, even in the minds of Avell educated people, illustrates

AVith 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, Avhen still.

But it is often observed that the nurses Avho 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 waid
mu^it sometimes stand open to allow of persons passing in and out, or
heavy things being carried in and out. The carefiil nurse will keep
the door shut while she shuts the windows, and tlien, 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.

16 NOTES ON NURSING.

this. To make a room cold is by no means necessarily to
ventilate it. Nor is it at all necessary, in order to venti-
late a room, to chill it. Yet, if a nurse finds a room close,
she will let out the fire, thereby making it closer, or she
will open the door into a cold room, without a fire, or an
open window in it, by M'ay of improving the ventilation.
The safest atmosphere of all for a patient is a good fire
and an open window, excepting in extremes of tempera-
ture. (Yet no nurse can ever be made to understand
this.) To ventilate a small room without draughts of
course requires more care than to ventilate a large one.

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 pos-
sible. Windows are made to open ; doors are made to
shut — a truth which seems extremely difticult of appre-
hension. I have seen a careful nurse airing her patient's
room though 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 g&s, paint, foul air, never changed, full
of effluvia, including a current of sewer air from an ill-
placed sink, ascending in a continual stream by a well-
staircase, and discharging themselves constantly into the
])atient's room. The window of the said room, if opened,
was all that was desirable to air it. Every room must be

VENTILATION AND WARMING. 17

aired from without — every passage from without. But
the fewer passages there are in a hospital the better.

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 tire, 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 over-
whelms 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.

In laying down the principle that the first object of the
nurse must be to keep the air breathed by her patient as
pure as the air without, it must not be forgotten that
every thing in the room which can give off effluvia, be-
sides the patient, evaporates itself into his air. And it
follows that there ought to be nothing in the room, ex-
cepting him, which can give off effluvia or moisture. Out
of all damp towels, &c., which become dry in the room,
the damp, of course, goes into the patient's air. Yet this
" of course " seems as little thought of, as if it were an ob-
solete 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 and 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 effluvia 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 they live with impunity, on account of its becoming
charged with unwholesome matter from the lungs and
skin. In disease where every thing given off from the
body is highly noxious and dangerous, not only must there
be plenty of ventilation to carry ofl:* the effluvia, but every
2*

18 NOTES ON NURSING.

thing which the patient passes must be instantly removed
away, as being more noxious than even the emanations
from tlie sick.

Of the fatal effects of the effluvia from the excreta it
would seem unnecessary to speak, were they not so con-
stantly neglected. Concealing 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 atmosjihere under that
bed, the saturation of the under side of the mattress with
the warm evaporations, you would be startled and fright-
ened too !

The use of any chamber utensil vnthoiit a lid* should
be utterly abolished, whether among sick or well. You can
easily convince yourself of the necessity of this absolute
rule, by taking one with a lid, and examining the under
side of that lid. It will be found always covered, when-
ever the utensil is not empty, by condensed offensive mois-
ture. 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'

* But never, never should the possession of this indispensable lid
confirm you in the abominable practice of letting the chamber utensil
remain in a patient's room unemptied, except once in the 24 hours, i. e.,
when the bed is made. Yes, impossible as it may appear, I have
known the best and most attentive nurses guilty of this ; ay, and
have known, too, a patient afflicted with severe diarrhoea for ten days,
and the nurse (a very good one) not know of it, because the chamber
utensil (one with a lid) was emptied only once in 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 once a day. ALso
take care that your lid, as well as your utensil, be always thoroughly
rinsed.

K a nurse declines to do these kinds of things for her patient, " be-
cause 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 con-
sideration what it was their "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 nurse in
them.

HEALTH OF HOUSES. 19

utensils. The very lid of the old abominable close-stool is
enough to breed a pestilence. It becomes saturated with
offensive matter, which scouring is only Avanted to bring
out. I prefer an earthenware lid as being always cleaner.
But there are various good new-fashioned arrangements.

A slop-pail should never be brouglit into a sick room. It
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 brouglit 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, wlietlier
to do this or to rinse the untensil i)i 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 car-
ried direct to be emptied and rinsed at the proper place.
I would it were so in the private house.

Let no one ever depend upon fumigations, "disinfect-
ants," and the like, for purifying the air. The offensive
thing, not" its smell, must be removed. A celebrated medi-
cal 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 " abomina-
ble smell " that they forced you to admit fresh air. That
would be a useful invention.

HEALTH OF HOUSES.*

There

are

five

essential points

in securing

the

health of

houses : -

1.

2.

Pure air.
Pure water.

s!

Eflicient drainage.

4.

Cleanliness.

5.

Lio-ht.

* The health of carriages, especially close carriages, is not of suffi-
cient universal importance to mention here, otherwise than cursorily.
Children, who are always the nioit delicate test of sanitary oouditiuns,

20 NOTES ON NURSING.

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 outer atmos]:>here 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 ten-
ants. But, if tenants should ever become so wise as to
refuse to occupy unhealthy constructed houses, 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 Provi-
dence * 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
wdiat 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 used to be, thanks to the exertions of the sanitary
reformers. Within the last few years, a large part of Lon-
don 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 j^arts of the country, well

generally cannot enter a close carriage without being sick — and very-
lucky for them that it is so. A close carriage, with the horse-hair
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 preposter-
ous. 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 un-
healthy courts off one of the most unhealthy streets in ^lanchester.

* 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 I'esponsibility 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.

HEALTH OP HOUSES. 21

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 houses in London are really well drained. JVIany
people Avould say, surely all or most of them. But many
people have no idea in what good drainage consists.
They think that a sewer in the street, and a pipe leading
to it from the house, is good drainage. All the while the
sewer may be nothing but a laboratory from which epi-
demic 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 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 staircase of a grand London
house from the sink, as I have ever met at Scutari; and I
have seen the rooms in that house all ventilated by the
open doors, and the passages all i^??ventilated 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 intelli-
gently trace disease in their households to such causes!
Is it not a fact, that Avlien 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 looking at home for the source
of the mischief If a neighbor's child is seized with small-
pox, the first question which occurs is whether it had been
vacchiated. No one would undervalue vaccination ; but
it becomes of doubtful benefit to societv when it leads

22 NOTES ON NURSING.

people to look abroad for the source of evils which exist at
home.

4. Without cleanliness, Avithin and without your house,
ventilation is comparatively useless. In certain foul dis-
tricts of London, poor people used to object to open their
windows and doors because of the foul smells that came in.
Rich people like to have their stables and dunghill near
their houses. But does it ever occur to them that with
many an-angements of this kind it would be safer to keep
tlie 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 epi-
demics. 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 unaccustomed 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.

5. A dark house is always an unhealthy house, always
an ill-aired house, always a dirty house. Waut of light
stops growth, and jDromotes 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 out of many "negligences and ignorances" in
managing the health of houses generally, I will here men-
tion as specimens — 1. That the female head in charge of
any building does not think it necessary to 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

HEALTH OP HOUSES. 23

clean rooms while uninhabited ; 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 tliat 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 do them yourself. " I always open the windows,"
the head in charge often says. If you do it, it is by so
much the better, certainly, than if it were not done at all.
But can you not insure that 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 exag-
gerated. But what you "think" or what I "think" mat-
ters little. Let us see what God thinks of them. God
always justifies His ways* While we are thinking, he has
been teaching. I have known cases of 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 any thing
at all from it. They went on thinJdng — thinking that the
sufferer 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 favorite mode of thought — leading not

24 NOTES ON NURSING.

to iuqnire 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 pyae-
mia being in that large private house. It was that the
sewer air from an ill-placed sink was carefully conducted
into all the rooms by sedulously 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 utensils
were never properly rinsed; — it was that the chamber
crockery was rinsed with 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 saturated 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 reser-
voirs of foul air; — it Avas 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. IS^ow all this is not fancy, but fact. In that hand-
some house I have known in one summer three cases of
hospital pyemia, one of phlebitis, two of consumptive
cough; all the imtnediate j^roducts of foul air. When, in
temperate climates, a house is more unhealthy ui summer
than 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 j^reventable causes.*

* I must say a -word about servants' bed-rooms. From the way
they are built, but oftener from the way they are kept, and from no
intelligent inspection whatever being exercised over them, they are al-
most invariably dens of foul air, and the «' servants' health" suffers in
an «' unaccountable " (?) way, even in the country. For I am by no

HEALTH OF HOUSES. 25

The houses of the grandmothers and great grandmoth-
ers of this generation, at least the country houses, with
front door and back door always standing open, winter
and summer, and a tliorou<>-h drauo-ht always • blowinor
through — with all the scrubbing, and cleaning, and pol-
ishing, and scouring which used to go on, the grandmoth-
ers, and still more the great 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 vigor,
descending into a grandmother perhaps a little less vigor-
rous 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 oft-
ener a family. You may see poor little feeble washed-out
rags, children of a noble stock, suffering morally and physi-
cally, throughout their useless, degenerate lives, and yet
people who are going to marry and to bring more such
into the world, will consult nothing but their own conven-
ience 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, it often happens that the sick room is made a
ventilating shaft for the rest of the house. For while the
house is kept as close, unaired, and dirty as usual, the win-
dow of the sick room is kept a little open always, and the
door occasionally. Now, there are certain sacrifices 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;"* — a thing of which peoj^le are generally so

means speaking only of London houses, where too often servants jjre
put to live under tlio ground and over the roof. But in a country
" mansion" which was really a "jnansion," (not after the fashion of
advertisements,) I have known three maids who slept in the same
room ill of scarlet fever. " Hoav 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 Avas not a
small one ; it was up stairs, and it had two large windows — but
nearlj'' every one of the neglects enumerated above was there.

* Is it not living in a continual mistake to look upon discuses, as wq

3

26 NOTES ON NURSING.

afraid that they frequently follow the very practice in re-
gard 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
management of this disease. They have ventured to cov-
er the 23atients 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 af-
forded by what was very recently the practice, if it is not
80 even now, in some of the European lazarets — in which
the plague-patient used to be condemned to the horrors of

do now, as separate entities, which jymst exist, like cats and dogs ?
instead of looking upon them as conditions, like a dirty and a clean con-
dition, and just as much under our own control ; or rather as the
reactions of kindly nature, against the conditions in which we have
placed ourselves.

I was brought up, both by scientific men and ignorant women, dis-
tinctly to believe that small-pox, for instance, was a thing of which
there was once a first specimen in the world, which went on propa-
gating itself, in a perpetual chain of 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 hav-
ing been a parent dog.

Since then I have seen with my eyes and smelt ■vv'ith my nose small-
pox growing up in first specimens, either in close rooms, or in over-
crowded wards, where it could 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
eubstantives.

PETTY MANAGEMENT. 27

filth, overcrowding, and want of ventilation, while the
medical attendant was ordered to examine the patient's
tongue through an opera-glass and to toss bini a lancet to
open his abscesses with!

True nursing ignores infection, except to prevent it.
Cleanliness and fresh air from open windows, with unre-
mitting 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
safeguard against infection.

There are not a few popular opinions, in regard to which
it is useful at times to ask a question or two. For exam-
ple, it is commonly thought that children must have what
are commonly called "children's epidemics," "current con-
tagions," &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 ?

O, 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 inculcate cleanliness, ventila-
tion, white-washing, and other means, and which, by the
way, are Iciims^ 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
aW'ogether?

m. 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 management, 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 manage-
ment, be not one-hah[' so efficient a^ another who is not

28 NOTES ON NURSING.

one-lialf so devoted, but "wlio 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 ini])ossible 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
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
w^as at 5 minutes to 10.

Curious as it may seem, this very obvious consideration
occurs comparatively to few, or, if it does occlir, 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 suflicient, not as precepts,
but as illustrations.

A strange washerwoman, coming late at night for the
" things," will burst in by mistake to the patient's sick-
room, after he has fallen into his first doze, giving him a
shocks the effects of which are irremediable, though he
himself laughs at the cause, and p>robably never even men-
tions 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 passage outside the patient's room, though pfb-
vided with several large 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 nui^e makes it her business to turn
the patient's room into a ventilating shaft for the foul air of
the whole house.

An uninhabited ix)om, a nevrly-painted room,* an un-

* That f'xoellent paper, the Builder, mentions the lingering of the
smell of paint for a month about a house as a proof of want of ventila-
tion. Certainly — and, where there are ample Avindows to open, and
these are never opened to get 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 remaiu for months. WTiy should it go ?

PETTY MANAGEMENT. 29

cleaned closet or cupboard, may often become the reser-
Toir of foul air for the whole house, because the person in
charge never thinks of arranging that these j^laces shall
be always aired, always cleaned; she merely oi^cns the
window herself " when she goes in."

An agitating letter or message may be delivered, or an
important letter or message not delivered ; a visitor whom
it was of consequence to see, may be refused, or one whom
it was of still more consequence to 7iot see may be admitted
— because the person in charge has never asked herseh
this question, What is done when I am not there ? *

At all events, one may safely say, a nurse cannot be
with the patient, open the door, eat her meals, take a mes-
sage, all at one and the same time. Nevertheless the per-
son in charge never seems to look the impossibility in the
face.

Add to this that the attempting this impossibihty does
more to increase the poor patient's hurry and nervousnesss
than anything else.

It is never thought that the 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 joiiY partial measures for "being in the way" your-
self, 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.

For the above reasons, whatever a patient ca7i do for

* Why should you let yovir patient ever be surprised, except by
thieves ? I do not know. In England, people do not come down the
chimney, or through the window, unless they are thieves. They come
in by the door, and somebody must open the door to them. The
" somebody " charged with opening the door is one of two, three, or
at most four persons. AVhy 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 ?

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 as 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 7iot "let in,"
and such a parcel had been wrongly delivered or lost because A and
not B had opened the door !

a*

80 NOTES OK NURSING.

tiraself, it is better, i. e., less anxiety, for him to do for him-
self, unless the person in charge has the spirit of manage-
ment.

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

Apprehension, uncertainty, waiting, expectation, fear of
surprise, do a patient more harm than any exertion. Re-
member, he is face to face with his enemy all the time,
internally wrestling with him, having long imaginary con-
versations with him. You are thinkmg of something else.
"Rid him of his adversary quickly," is a first rule with
the sick.*

For the same reasons, always tell a patient and tell him
beforehand when you are going out and when you will be
back, whether it is for a day, an hour, or ten minutes.
You 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 meas-
ures 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 fital
cases, it is ahnost incredible how often the whole thing
turns upon something which has happened because "he,"

* There are man)- physical operations where cfcteris paribus the dan-
ger is in a direct ratio to the time the operation lasts ; and ccefcris pari'
bics the operator's success will be in direct ratio to his quickness. Now
there are many mental operations where exactly the same rule holds
good with the sick ; c(vteris paribus their capability of bearing such
operations depends directly on the quickness, xcithou't hurry ^ with wliich
they can be got through.

PETTY MANAGEMENT. 31

or Still oftener "she," "was not tliere." But it is still more
incredible how often, how almost always tliis 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 "^Aere," he was 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." AYhen 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.*

* So true is this that I could meution two eases of women of very
high position, both of whom died in the same way of the consequences
of a surgiciil operation. And in both cases, I was told by the highest
authority that the fatal result would not have happened in a London
hospital.

But, as far as regards the art of petty management in hospitals, all
the military hospitals I know must l^e excluded. Upon my own expe-
rience I stand, and I solemnly declare that I have seen or known of
fatal accidents, such as suicides in ddiriiim tremens^ bleedings to death,
dying patients dragged out of bed by drunken Medical Staff Corps
men, and many other things less patent and striking, which would not
have happened in London civil hospitals nursed by women. The med-
ical officers shoiild 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 deHrium tremens f 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 ofiice clerk, but as head nurse,
(and head nurse the best hospital sergeant, or ward master, 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 %coman
in charge of the ward, or set of wards, the thing would not, in all cer-
tainty, have happened. In other words, it does not happen where a
trustworthy woman is really in charge. 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 home in peace, and the pressure on
our hospitals consequently much less.

It is often said that, in regimental hospitals, patients ought to

82 NOTES ON NUKSINOf,

But In both, let wlioerer is in charge keep this simple
question in her head (not, how can I always do this riglit
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 r>'e will sup-
pose to haye been quite right, let her question still be {7ioty
how can I provide against any more of such absences?
which is neither possible nor desirable, but) how can I
provide against anything wrong arising out of my ab-
sence?

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 caiTy out a "charge." From the most
colossal calamities, down to the most trifling accidents,
results are often traced (or rather 7iot 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 wliat every
child knows would make its mother's tea-kettle burst. And

♦•nurse each other," because the number of sick altogether beina:, say,
but thirty, and out of these one only perhaps being seriously ill, and
the other twenty-nine ha\-ing little the matter Avith 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 nm-sing. I have seen these "kind " fellows (and
how kind they are no one knows so Avell 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
cotdd be introduced in reghnental hospitals. It would be most unde-
sirable, even were it not impossible. But the head nurseship of a hos-
pital sergeant is the more essential, the m.ore 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 OAvn 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
tfcnius, however "kind" and willing they may be.

PETTY MANAGEMENT. S3

this simply because no one seemed to know vrhat it is to
be "in cliai-ge," or ichowas in clinrge. Xav more, the jury
at the inquest actually altogether ignored the same, and
apparently considered the taj) "in charge," for they gave
as a A^erdict " 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 burned herself slowly and intentionally
to death, while in her doctor's charge, and almost in her
nurse's presence. Yet neither was considered " at all 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 peiform it.

To be "in charge" is certainly not only to caiTy out the
proper measures yourself but to see that every one else
does so too ; to see that no one either wilfully or igno-
rantly 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 at-
tached 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 pre-
cision, and is really less cared for than ten who are waited
on by one ; or at least than forty who are waited on by
four ; and all for want of this one person " in charge.")

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 shiji'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., tb obey intelh-
gently, which is the real meaning of all discipline.

Again, people who are in charge often seem to have a
pride in feeling that they will be "missed," that no one
can understand or carry on their arrangements, their system,
books, accounts, &c., but themselves. It seems to me that
the pride is rather in carrying on a sj'stem, in keeping
stores, closets, books, accounts, &c., so that any body can
Tuidcrstand and carry them on — so that, in case of absence
or illness, one can deliver everything up to others and

84 NOTES ON NURSING.

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 families, in case of sickness, make themselves intolerable
by "ordering about" the other servants, under pka of not neglecting
the patient. Both things are true ; the patient is often neglected, and
the servants are often unfairly "put upon." But the fault is gen-
erally 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 necessary, sup-
plemented, and that the patient is never neglected — things with a little
management quite compatible, and indeed only attainable together. It
is certainly not for the nurse to "order about" the servants.

IV. NOISE.

Unnecessary noise, or noise that creates an expectation
in the mind, is that which hurts a patient. It is rarely the
J.oudness of the noise, the effect upon the organ of the ear
Itself, which appears to affect the sick. How well a patient
w^ill 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
accidentally, is a siiie qua non of all good nursing. If he
is roused out of his first sleep, he is almost certain to have
no more sleep. It is a curious but quite intelligible fact
that, if a patient is waked after a few hours' instead of a
few minutes' sleep,, he is much more likely to sleep again.
Because pain, like irritability of brain, perpetuates and in-
tensifies itself If you have gained a respite of either in
sleep you have gained more than the mere respite. Both
the probability of recurrence and of the same intensity

NOISE. 35

Will be dimmishecl ; whereas both will be tembly 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.

I have often been surprised at the thoughtlessness, (re-
sulting in cruelty, quite unintentionally) of friends or of
doctors who will 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 atten-
tion elsewhere and not to listen — and this makes matters
worse — for the strain upon his attention and the eifort he
makes are so great that it is well if he is not worse for
hours after. If it is a whispered conversation in the same
room, then it is absolutely cruel ; for it is impossible that
the patient's attention should not be involuntarily strained
to hear. Walking on tip-toe, doing anything in the room
very slowly, are injurious, for exactly the same reasons.
A firm, light, quick step, a steady quick hand, are the de-
siderata ; not the slow, lingering, shuffling foot, the timid,
uncertain touch. Slowness is not gentleness, though it is
often mistaken for such : quickness, lightness, and gentle-
ness 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 undoubt-
edly 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 attributed 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 cool-
ness, with which the certainty of an operation will be ac-
cepted by any patient, capable of bearing an operation at
all, if it is properly communicated to him, will hesitate to

86 NOTES On K1JR3ING.

believe that it was mere fear which produced, as was
averred, the fiital result in this instance. It was rather the
uncertainty, the strained expectation as to what was to be
decided upon.

I need hardly say that the other common cause, namely,
for a doctor or friend to leave the patient and communi-
cate 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 knowledge of the jDatient
is, if possible, worst of all.

It is, I think, alarming, peculiarly at this time, wiien
the female ink-bottles are perpetually impressing upon us
"woman's" "particular worth and general missionariness,"
to see that the dress of women is daily more and more un-
fitting 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 be-
ing 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 per-
son much more than necessary noise (of a much greater
amount.)

All doctrines about mysterious affinities and aversions
will be found to resolve themselves very much, if not en-
tirely, into presence or absence of care in these things.

A nurse w^ho rustles (I am speaking of nurses jirofes-
sional 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 medicines 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 furni-

NOISE. 87

ture) 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 Avindow 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 a patient passes a bad night, time after
time, rather than remmd 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
httle 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 consid-

* Fortunate it is if her skirts do not catch fire — and if the nurse
docs not give herself v\p a sacrifice together with her patient, to bo
burnt in her own petticoats. I wish tlie llegistrar-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 own dress as other people see it. A respectable elderly woman
stooping forward, 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 luipleasant tiuth.

4

38 NOTES ON NURSING.

eration if your advice is wanted, and go away tlie 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. Every body invcluntarily 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 per-
son charged with the request of giving the message or
writing the letter, say half an hour afterwards to the pa-
tient, "Did you appoint 12 o'clock?" or, "What did you
say was the address ? " or ask perhaps some much more agi-
tating 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.
Tliis 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 dis-
tance 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 nerv-
ous 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 abrupt-
ly 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 fimcies, we shall remember that we are
doing positive injury by interrupting, by "startling a fanci-
ful " person, as it is called. Alas ! it is no fancy.

If the invalid is forced, by his avocations, to continue
occupations requiring much thinking, the injury is doubly
great. In feeding a patient sufl'ering under delirium or
stui^or you may suffocate him, by giving him his food sud»

NOISE. 39

'denly, but if you rub Lis lips gently with a spoon and thus
attract his attention, he will swallow the food unconscious-
ly, but with perfect safety. Thus it is with the brain. If
you ofler it a thought, especially one requiring a decision,
abruptly, you do it a real not fanciful injury. Xever speak
to a sick person suddenly; but, at the same time, do not
keep his expectation on the tip-toe.

This rule, indeed, applies to the well quite as much as to
the sick. I have never known persons who exposed them-
selves for years to constant interruption who did not mud-
dle 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 to speak to him, or to give him any message or let-
ter. You might just as well give him a box on the ear.
I have seen a patient fall flat on the ground "s\'ho was stand-
ing when his nurse came into the room. This was an acci-
dent 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 eflbrt 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 nobody is by." It is quite true that they can.
Unless nurses can be brought to attend to considerations of
the kind of which we have given here but a few specimens,

* It is absolutely essential that a nurse should lay this down as a
positive rule to herself, never to speak to any patient who is standing
or moving, as long as she exercises so little observation as not to know
when a patient cannot bear it. I am satisfied that many of the acci-
dents which happen from feeble patients tumbling down stairs, fainting
after getting up, &c., happen solely from the nurse popping out of a
door to speak to the patient just at that moment ; or from his fearing
that she will do so ; and that i£ 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 cannot picture to themselves the strain
upon the heart, the lungs, and the brain, Avhich the act of moving is to
any feeble patient.

40 'NOTES ON NURSING.

a very weak patient finds it really much less exertion to do
tliino-s for himself than to ask for tliem. And he will, in or-
der 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 mo-
ment 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 ex-
tra 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 exer-
tions more than once or twice a day, and probably 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 jDatient'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 progress. 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 pro-
nounce upon him from merely seeing what he does, or how
he looks, during such a conversation. Learn also careful-
ly and exactly, if you can, how he passed the night after it.

People rarely, if ever, feint 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. Peo-
ple have very often died of that which, it has been pro-
claimed at the time, has " done them no harm." *

* As an old experienced nurse, I do most earnestly deprecate all
such careless words. I have known patients delirious all night, after
seeing a visitor who called thern "better," thought they " only wanted
a little amusement," and who came again, saying,- "I hope you were
not the worse for my ^dsit," neither waiting 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,

NOISE. 41

Remember never to lean against, sit upon, or nnneces-
sarily shake, or even touch the bed in which a patient lies.
This is invariably 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 hypo-
chondriacs. To distinguish between real and fancied dis-
ease forms an important branch of the education of a
nurse. To manage flmcy patients forms an important
branch of her duties. But the nursing which real and that
which fancied patients require is of different, 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.

It is true that hj^iochondriacs very often do that behind
a nurse's back which they would not do before her flice.
Many such I have had as patients who scarcely ate any-
thing 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 difiei-ent 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, neces-
sary with the sick. Let your thought expressed to them
be concisely and decidedly expressed. What doubt and
hesitation there may be in your own mind must never be
communicated to theirs, not even (I would rather say es-
pecially not) in little things. Let your doubt be to your-
self, 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

there is most danger to the patient. ITnperceived consequences are
far more likely to ensue. You 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 pa-
tient will often not even mention what has done him most harm.
4*

42 NOTES ON NURSING.

that led them toward^ this conchision and away from that,
ouoht never to be with the siek.

Irresohition is what all patients most dread. Rather
than meet this in others, they will collect all their data,
and make up their minds for themselves. A change of
mind in others, whether it is regarding 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 difficult 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 pa-
tient 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
eitlier failing — either loitering or hurrying.

If a patient has to see, not only to his own but also to
his nurse's punctuality, or perseverance, or readiness, or
calmness, to any or all of these things, he is far better
without that nurse than with her — 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 is, that when the sick are too ill to read to
themselves, they can seldom bear to be read to. Children,
eye-patients, and uneducated persons are exceptions, or
where there is any mechanical difficulty in reading. People
who like to be read to, have generally not much the mat-
ter with them ; while in fevers, or where there is much
irritability of brain, the effort of listening to reading aloud
has often brought on delirium. I speak with great diffi-
dence ; because there is an almost universal impression
that it is sparing the sick to read aloud to them. But
two thin«'s are certain: —

NOISE. 43

(1.) If tliere is some matter wliich must be read to a
sick person, do it slowly. People often think that the way
to get it over with least fati.Gjue 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. Hou-
din, 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
aware that this will regulate the plunging, the reading
with unequal paces, slurring over one part, instead of leav-
ing it out altogether, if it is unimportant, and mumbling
an'other. 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 j^atient'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 mouth-
ing — rather monotonous, but not sing song — 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 pf 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 observation of the
person who does it, is equally difficult to understand — ■
although very often the readet^ is too amiable to say how
much it hurts him.

* 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
read to them.

44 NOTES ON NURSING.

One thing more: — From the flimsy manner in which
most modern houses are built, where 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 incon-
ceivable how much the sick suflTer by having anybody
overhead. In the solidly built old houses, which fortu-
nately, most hospitals are, the noise and shaking is com-
paratively trifling. But it is a serious cause of suftering,
in lightly built houses, and with the irritability pecuhar to
some diseases. Better for 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 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." Remember 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 per-
sons in the same room with them than overhead, or sep-
arated 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. 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 instrimaents, including the human voice, and stringed instru-
ments capable of continuous sound, have generally a beneficent effect ;
Avhile the piano-forte, with such instruments as have no continuity of
sound, has just the reverse. The finest piano-forte playing will dam-
age the sick, while an air, like "Home, sweet home," or " Assisa a
pie d'un salice," on the most ordinary grindmg organ, will sensibly
soothe them — and this quite independent of association.

Y. VARIETY.

To any but an old nurse, or an old patient, the degree
would be quite inconceivable to which the nerves of the
sick suffer from seeing the same walls, the same ceiling,
the same surroundings during a long confinement to cne
or two rooms.

VARIETY. 45

The superior cheerfulness of persons suffering severe
paroxysms of pain over that of persons suffering from ner-
vous debiUty has often been remarked upon, and attrib-
uted to the enjoyment of the former of their intervals of
resj^ite. 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 tlie
majority of depressed cases will be seen among those sub-
jected to a long monotony of objects about them.

The nervous frame really suffers as much from this as
the digestive organs from long monotony of diet, as, e, g.^
the soldier from his twenty-one years' " boiled beef."

The effect in sickness of beautiful objects, of variety of
objects, and especially of brilliancy of color, is hardly at
all appreciated.

Such cravings are usually called the "fancies" of pa-
tients. And 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 being the only view. I shall
never forget the rapture of fever patients over a bunch of
bright-colored flowers. I remember (in my own case)
a nosegay of wild flowers being sent me, and from that
moment recovery becoming more rapid.

People say the effect is only on the mind. It is no such
thing. The effect is on the body, too. Little as we know
about the way in which we are affected by form, by color,
and light, we do know this, that they have an actual
})hysical effect.

Variety of form and brilliancy of color in the objects
presented to patients are actual means of recovery.

But it must be sloio variety, e. g.^ if you show 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 one up opposite to him, on each successive day,
or week, or month, and he will revel in the variety.

The folly and ignorance which reign too often supreme

46 NOTES ON NURSING.

over the sick-room, cannot be better exemplified than by
uhis. While the nurse will leave the patient stewing in a
corrupting atmosphere, the. best ingredient of which is car-
bonic acid, she will deny him, on the plea of unhealthiness,
a glass of cut-flowers, or a gi'owing 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 certam flowei-s, e. g.^ the lilies, the smell of which
is said to depress the nervous system. These are easily
known by the smell, and can be avoided.

Volumes are now written and spoken upon the effect of
the mind upon the body. Much of it is true. But I wish
a httle more was thought of the effect of the body on the
mind. You who believe yourselves overwhelmed with
anxieties, but are able every day to walk up Regent Street,
or out in the country, to take your meals with others in
other rooms, &c., &c., you little know how much your anx-
ieties are thereby lightened ; you little know how inten-
sified 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 pur-
suing thought without some help from variety.

A patient can just as much move liis leg when it is frac-
tured as change his thoughts when no external help from
variety is given him. This is, indeed, one of the main suf-
ferings of Sickness; just as the fixed posture is one of the
main sufferings of the broken limb.

It is an ever recurring wonder to see educated people,

* It is a matter of painful wonder to the sick themselves, how much
painful ideas predominate over pleasurable ones in their impressions.
They reason with themselves ; they think themselves ungrateful. It
is all of no use. The fact is, that these painful impressions are for
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 dis-
eases, especially in convalescence from fever, that wall will appear to
make all sorts of faces at him ; now flowers never 'do this. Form,
color, wQl free your patient from his painful ideas better than any
argument.

VARIETY. 47

who call themselves nurses, acting thus. They vary their
own objects, their own employments, many times a day;
and while nursing (!) some bed-ridden sufferer, they let him
lie there staring at a dead wall, without any change of ob-
ject 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 they choose, " dismiss painful thoughts " which " aggra-
vate their disease," &c. Believe me, almost any sick per-
son, who behaves decently Avell, 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 J^im : and if he can speak without being
savage, and look without being unpleasant, he is exercising
self-controh

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 Avill suppose the diet of the sick to be cared for.
Then, this state of nerves is most frequently to be relieved
by care in affording them a pleasant view, a judicious va-

* I remember a case in point. A man received an injury to the
spine, from an accident, which, after a long confinement, ended in
death. He was a workman — had not in his composition a single
grain of what is called "enthusiasm for nature" — but he was des-
perate to •' see once more ovit of window." His nurse actually got
him on her back, and managed to perch him up at the window for an
instant, " to see out." The consequence to the poor nurse was a seri-
ous 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 of food in the
starving stomach, and tempts the famishing creature in either case to
steal for its satisfaction. No other Avord will express it but " despera-
tion." 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 \A\X\ a " view" of some kind, as if they did not provide the
hospital with a Idtchcn.

48 NOTES ON NURSING.

riety as to flowers,* and pretty things. Light by itself
will often relieve it. The craving for " the return of day,"
which tlie 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 emplopnent, excepting a few fine ladies, who
do not even dress themselves, 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 labor is to you —
of the degree to which the deprivation of manual employ-
ment increases the peculiar irritabiUty 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 r^ief 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 hardly say that I am well aware that excess in
needle-work, in writing, in any other continuous employ-
ment, will produce the same irritability that defect in man-
ual emj^loyment (as one cause) produces in the sick.

A^. TAKING FOOD.

Every careful observer of the sick will agree in this that
thousands of patients are annually starved in the midst of
jDlenty, from want of attention to the ways which alone
make it possible for them to take food. This want of at-
tention is as remarkable in those who urge ujDon the sick
to do what is quite impossible to them, as in the sick
themselves who will not rnako the effort to do what is per-
fectly possible to them.

For instance, to the large majority of very weak patients

* Xo one Avho has watched the sick can doubt the fact, that some
feel stimulus from looking at scarlet flowers, exhaustion from looking
at deep blue, &c.

TAKING FOOD. 49

it is quite impossible to take any solid food before 11 a.m.,
nor then, if their strength is still further exhausted by fast-
ing till that hour. For weak patients have generally fe-
verish nights and, in the morning, dry mouths; and, if
they could eat with those dry mouths, it would be the
worse for them. A spoonful of beef-tea, of arrowroot and
wine, of egg flip, every hour, will give them the requisite
nourishment, and j^revent them from being too much ex-
hausted 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
egg, 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 mi-
nutiae in private nursing than in public hospitals. And 1
think there is more of the entente cordiale to assist one
another's hands between the doctor and his head nurse in
the latter institutions, than between the doctor and the jDa-
tient'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 reple-
tion (I call it repletion when they are obliged to let too
small an interval elapse betAveen taking food and some
other exertion, owing to the nurse's unpunctuality), we
should be more careful never to let this occur. In very
weak patients there is often a nervous difficulty of swal-
lowing, which is so much increased by any other call upon
their strength that, unless they have their food punctually
at the minute, which minute again must be arranged so as
to fall in with no other minute's occupation, they can take
nothing till the next respite occurs — so that an unpunctu-
ality 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

60 NOTES ON NURSING.

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 se-
lection and punctuaUty.

But in chronic cases, lasting over months and years,
where the fatal issue is often determined at last by mere
protracted starvation, I had rather not enumerate the in-
stances which I have known where a little ingenuity, and
a great deal of perseverance, might, in all probability, have
averted the result. The consulting the hours when the
l^atient 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 observation, ingenuity, and per-
severance (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 meal, in hopes that he will eat it in the interval is
simply to prevent him from taking any food at all. I have
known patients literally 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 away,
eaten or uneaten, at the right time ; but never let a patient
have " something always standing " by him, if you don't
wish to disgust him of every thing.

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 ? " " O, 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 others, or a greater amount of food than he him-
self can consume at 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.

TAKING FOOD. 51

In hospital wards it is of course impossible to observe
all this ; and in single wards, where a patient must be con-
tinuously and closely watched, it is frequently impossible
to relieve the attendant, so that his 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 com-
plained 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
f:ir to counterbalance what unavoidable 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 occupa-
tion, to continue his business while sick, it ought to be a
rule WITHOUT axy exceptiox whateveb, that no one
shall bring business to him or talk to him while he is
taking food, nor go on talking to him on interesting sub-
jects up to the last moment before his meals, nor make an
engagement with him in\mediately 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 de-
riving any nourishment from it.

A nurse should never put before a patient milk that is
sour, meat or soup that is turned, an egg that is bad, or
vegetables underdone. 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
somcthincj else in a few minutes. Remember that sick

52 NOTES ON NURSING.

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 car-
rier 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 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 suffer 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 condi-
tion 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 patient's diet; consider, remember how much he has
had, and how much he ought to have to-day. Generally,
the only rule of the private patient's diet is what the nurse
has to give. It is true she cannot give him what she has
not got ; but his stomach does not wait for her conven-
ience, 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 filled in getting it, he will suffer.

* 'Why, because the nurse has not got some food to-day which the pa-
tient takes, can the patient wait four hours for food to-day, who could
not wait t\A-o hours yesterday ? Yet this is the only logic one generally
hears. On the other hand, the other logic, viz., of the nurse giving a
patient a thing because she /las got it, is equally ftital. K she happens
to have fresh jelly or fresh fruit, she will frequently give it to the
patient half an 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.

WHAT POOD? 68

She must be always exercising her ingenuity to supj^ly de-
fects, 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 patient's saucer, in other words, take care that the
outside bottom rim of his cup shall be quite dry and clean;
if, every time he lifts his cup to his lips, he has to carry
the saucer with it, or else -to drop the liquid upon, and to
soil his sheet, or his bed-gown, or pillow, or if he is sitting
up, his dress, you have no idea what a difference this
minute want of care on your part makes to his comfort
and even to his willincrness for food.

Vn. WHAT FOOD?

I will mention one or two of the most common errors
among women in charge of sick respecting sick diet. One
is the belief that beef tea is the most nutritive of all arti-
cles. Now, just try and boil dov^n a lb. of beef into beef
tea, evaporate your beef tea, and see what is left of your
beef You will find that there is barely a teaspoonful of
sohd nourishment to half a pint of water in beef tea ; —
nevertheless 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 patients, particularly of nervous or bilious tem-
perament, eggs disagree. All puddings made with eggs,
are distasteftil to them in consequence. An egg whipped
up with wine, is often the only form in which they can
take this kind of nourishment. Again, if the patient has
attained to eating meat, it is sup])osed that to give liim
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,
5*

54 NOTKS ON NURSING.

these Ipittcr being so badly cooked that he always left
them untouched. Arrovrroot is another grand depend-
ence of the nurse. As a vehicle for wine^ and as a restor-
ative quickly prepared, it is all very well. But it is noth-
ing but starch and water. Flour is both more nutritive,
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 theisick. Butter is the liglit-
est kind of animal fat, and though it wants the sugar and
some of the other elements which 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 arrowroot, sago,
tapioca, and their kind. Cream, in many long chronic
diseases, is quite irreplaceable by any other article what-
ever. It seems to act in the same manner as beef tea, and
to most it is much easier of digestion than milk. In fact, it
seldom 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, if fresh milk is so valuable a food for the sick, the
least change or sourness in it, makes it of all articles, per-
haps, the most injurious ; diarrhcsa is a common result of
fresh milk allowed to become at all sour. The nurse there-
fore ought to exercise her utmost care in this. In larsje
institutions for the sick, 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 weather, so little does the private nurse understand

* In the diseases produced by bad food, such as scorbutic dysentery
and diarrhoea, the patient's stomach often craves for and digests things,
some of which certainly would be laid down in no dietary that ever
was invented for sick, and especially not for such sick. The-e are
fruit, pickles, jams, gingerbread, fat of ham or bacon, suet, cheese, but-
ter, milk. These cases I have seen not by ones, nor by tens, but by
hundreds. And the patient's stomach was right and the book v/as
wrong. The articles craved for, in these cases, might have l:)een princi-
pally arranged under the two heads of fat and vegetable acids.

There is often a marked difference between men and women in thia
matter of sick feeding. Women' .s digestion is generally slower.

WHAT FOOD ? 65

the necessity of such care. Yet, if you consider that the
only drop of real nourishment in your ]xatient's tea is the
drop of milk, and how much almost all English patients
depend upon their tea, you will see the great importance
of not depriving your patient of this drop of milk. But-
termilk, a totally different thing, is often very useful,
especially in fevers.

In laying down rules of diet, by the amounts of " solid
nutriment" in different kinds of food, it is constantly lost
sight of what the patient requires to repair his v/aste, what
he can take and what he can't. You cannot diet a patient
from a book, you cannot make up the human body as you
would make up a prescription, — so many parts " carbonif-
erous," so many parts " nitrogenous " will constitute a per-
fect diet for the patient. The nui-se's observation here
will materially assist the doctor — the patient's "fancies"
will materially assist the nurse. For instance, sugar is one
of the most nutritive of all articles, being pure carbon,
and is particularly recommended in some books. But the
vast majority of all patients in England, young^ and old,
male and female, rich and poor, hospital and private, dis-
like sweet things, — and while I have never known a per-
son 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 any thing 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 favor with nurses
and 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 I 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 pro-
duce 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 Avould have given one
spoonful of gelatine, which spoonful has no nutritive power
whatever.

And, nevertheless, gelatine contains a large quantity of

66 NOTES ON NtTRglNG,

nitrogen, which is one of the most poweiful elements in
nutrition ; on the other hand, beef tea may be chosen as
an ilhistration of great nutrient power in sickness, co-
existing with a very small amount of solid nitrogenous
matter.

Dr. Christison says that "erery one will be struck with
the readiness with which " certain classes of " patients will
often take diluted meat juice or beef tea repeatedly, when
they refuse all 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. Pos-
sibly," he saySj "it belongs to a new denomination of
remedies."

It has been obseiwed that a small quantity of beef tea
added to 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
nutritious 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.

Chemistry has as yet afforded little insight into the
dieting of sick. All that chemistry can tell us is the
amount of " carboniferous " or " nitrogenous " elements dis-
coverable in different dietetic articles. It hns 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. Xo doubt, in
this as in other things, nature has very definite niles for
her guidance, but these rules can onl}'^ be ascertained by
the most careful observation at the bed-side. She there
teaches us that living chemistry, the chemistry of repara-
tion, is something different from tlie chemistry of the labo-
ratory. Organic cliemistry is useful, as all knowledge is,
when we come face to face with nature ; but it by no

WHAT FOOD ? 57

means follows that we shoiild learn in the laboratory any
one of the reparative processes going on in disease.

Again, the nutritive power of milk and of the prepara-
tions from milk, is very much undervalued ; there is nearly
as much nourishment in half a pint of milk as there is in a
quarter of a lb. of meat. But this is not the whole ques-
tion 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.
Chemistry cannot tell this. The patient's stomach must
be its own chemist. The diet which will keep the healthy
man healthy, will kill the sick one. The same beef which
is the most nutritive of all meat which nourishes the
healthy man, is the least nouiishing 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 important thing to be 2)ro-
vided for him after the air he is to breathe.

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 obser\"ation 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 impor-
tant office of the nurse, after she has taken care of the
patient's 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 of nursing, or the help it would give to
tlie medical man.

68 NOTES ON NURSING.

A great deal too much against tea* is said by wise peo-
ple, and a 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 coifee restores them 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
she sees how one or two cups of tea or coffee restoresLher
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 five or six 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 five o'clock in the afternoon. Sleeplessness
in the early night is from excitement generally and is

* It is made a frequent recommendation to persons about to incur
great exhaustion, either from the nature of the service, or from their
being not in a state fit for it, to eat a piece of bread before they go. I
wish the recommenders would themselves try the experiment of substi-
tuting a piece of bread for a cup of tea or coffee, or beef tea, as a
refresher. They M^ould find it a very poor comfort. When soldiers
have to set out fasting on fatiguing duty, when nurses have to go fast-
ing 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
with 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 circiimstances.
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
undergone 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 uj^on all other things.

WHAT FOOD? 69

increased by tea or coffee ; sleeplessness which continues
to the early morning is from exhaustion often, and is re-
lieved 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 cof-
fee, and will quite decline milk, unless with tea. Coffee is
a better restorative than tea, but a greater impairer of the
digestion. Let the patient's taste decide. You will say
that, in cases of great thirst, the patient's craving decides
that it will drink 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, bar-
ley water or lemonade, or soda water and milk, as the case
may be.

Lehman, 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. Lehman 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 is often recommended to the sick in lieu of tea or
coffee. But independently of the fact that English sick

* In making coffee, it is absolutely necessary to buy it in the berry
and grind it at home. Otherwise you may reckon upon its contahiing
a certain amount of chiccory, at least. This is not a question of the
taste or the wholcsomeness of chiccory. It is that chiccory 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 \mite a good deal of hard
manual labor with the head-work necessary for arranging the day's
business, so that none of it shall tread upon the heeU 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 con-
tains the restorative they want ; which is not to be fovmd in sloe-leaf tea.

The mivStresses of houses, who cannot even go over their own house
once a day, are iAcapable of judging for these women. For they are
incapable themselves, to all appearance, of the spirit of arrangement
(no small task) necessary for managing a large ward or dairy.

6.0 NOTES ON NURSING.

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 chestnuts 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 the 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 can-
not 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, while giving him no
more than the bulk which he is able to swallow.

Vm. BED AXD BEDDING.

A few words upon bedsteads and bedding ; and princi-
pally as regards patients who are entirely, or almost
entirely, confined to bed.

Feverishness is generally supposed to be a sjnnptom of
fever — in nine cases out often it is a symptom of bedding.*
The patient has had re-introduced into the body the ema-
nations from himself which day after day and week after
week saturate his unaired bedding. How can it be other-
wise ? Look at the ordinary bed in which a patient lies.

If I were looking out for an example in order to show
what 7iot to do, I should take the specimen of an ordinary

* I once told a "very good niirse " that the way in which her
patient's room was kept was quite enough to account for her sleepless-
ness ; and she answered quite good-humoredly she was not at all sur-
prised at it — as if the state of the room were, like the state of the
weather, entirely out of her power. Now in what sense was this
woman to be culled a •' nurse ? "

BED AND BEDDING. 61

bed in a private house : a wooden bedstead, two or even
three mattresses piled up to above the height of a table ; a
vallance attached to the frame — nothing but a miracle
could ever thoroughly 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 satu-
rated with organic matter,* 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 skin in the twenty-four hours three pints at least
of moisture, loaded with organic matter ready to enter into
putrefaction ; that in sickness the quantity is often greatly
increased, the quahty is always more noxious — just ask
yourself next 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 airing the dirty sheets from
noxious damp will never even occur to her. Besides this,
the most dangerous eflluvia we know of are from the
excreta of the sick — these are placed, at least temporarily,
where they must throw their eflluvia into the under side
of the bed, and the space under the bed is never aired ; it
cannot be, with our arrangements. Must not such a bed
be always saturated, and be always the means of re-intro-
ducing 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 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 in it his own
damp? Has it not had a single chance to be aired? No,
not one. " It has been slept in every night."

* For the same reason if, after -washing a patient, yoxi must put the
same 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 off him for a few min-
utes. The fire will dry and at tlie same time air it. This is much more
important than with clean things.

6

62 NOTES ON NURSING.

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 ti/)o such bedsteads; each bed to be
" made " with mattress, sheets, blankets, <fcc., complete —
the patient to pass twelve hours in each l)ed ; on no account
to carry his sheets with him. The whole of the bedding
to be hung uj) 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 favor 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 w^ho 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. Other-
w^ise the patient feels himself " out of humanity's reach ; "
he can get at nothing for himself: he can move nothing
for himself. If the j^atient 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 of the bed, and to
reach easily every part of the patient without stretching —
a thing impossible if the bed be either too wide or too high.

When I see a patient in a room 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 feeUng 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

BED AND BEDDING. 63

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 perversity any farther go,
in unmaking the process of restoration which God has
made ? The flict 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 diiference of the
fatigue of getting in and out of bed will just make the
difference, very often, to the patient (who can get in and
out of bed at all) of being able to take a few minutes' exer-
cise, 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, Avho
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 ; and he should be able to see out of window.

I need scarcely say that the old four-post bed with cur-
tains is utterly inadmissible, whether for sick or well. Hos-
pital bedsteads are in many respects very much less objec-
tionable than private ones.

There is reason to believe that not a few of the appar-
ently unaccountable cases of scrofula among children pro-
ceed from the habit of sleeping with the head under the
bed clothes, and so inhaling air already breathed, which is
farther contaminated by exhalations from the skin. Pa-
tients are sometimes given to a similar habit, and it often
happens that the bed clothes are so disposed that the
patient must necessarily breathe air more or less contami-
nated by exhalations from his skin. A good nurse will be
careful to attend to this. It is an important part, so to
sj^eak, of ventilation.

It may be worth while to remark, that where there is
any danger of bed-sores a blanket should never be placed
under the patient. It retains dam^) and acts like a poul-
tice.

ISTever use anything but light Whitney blankets as bed
covei-ing for the sick. The heavy cotton impervious coun-
terpane is bad, for the very reason that it keeps in the

64 NOTES ON NURSING.

emanations from the sick person, while the blanket allows
them to pass through. AVeak patients are invaiiably dis-
tressed by a great weight of bed clothes, which often pre-
vents their getting any sound sleep whatever.

Note. — One word about pillows. Every weak patient, be his ill-
ness 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 arrang-
ing his pillows. Now what does she do and Avhat are the conse-
quences ? 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 ap-
paratus, to allow the shoulders room to fall back, and to support the
head, without throwing it forward. The suffering of dying patients is
immensely 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, that second only to their need of fi-esh air is their
need of light ; that, after a close room, what hurts them
most is a dark room. And that it is not only light but
sunlight they want. I had rather have the power of car-
rying 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 tlie
effect is upon the spirits only. This is by no means the
case. The sun is not only a j^ainter but a sculptor. You
admit that he does the photograph. Without going into
any scientific exposition we must admit that hght has quite
as real and tangible effects upon the hitman body. But
this is not all. Who has not observed the j^urifying effect
of light, and especially of direct sunlight, upon the air of
a room ? Here is an observation within everybody's ex-
perience. Go into a room where the shutters are always
shut (in a sick room or a bed-room there never should be
shutters shut,) and though the room be uninhabited, though

LIGHT. 65

the air has never been polluted by the breathing of human
beings, you will observe a close, musty smell of corrupt air,
i. e. of air 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 treat-
ing disease is all-important. >

A very high authority in hospital construction has said
that people do not enough consider the difference between
wards and dormitories in planning their buildings. But I
go farther, and say, that healthy people never remember
the difference between ^ec?-rooms and sicA-rooms, in mak-
ing 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. As-
pect does not very much signify either (provided the sun
reach his bed-room some time in every day, to purify the
air), because he 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 sunlight at
least, if you can show them nothing else, I assert to be, if
not of the very first importance for recovery, at least some-
thing very near it. And you should therefore 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 sunlight from the moment he rises till the
moment he sets.

Another great difference between the hed-YOom. and the
sick-Yooxn. is, that the sleeper has a very large balance of
fresh air to begin with, when he be*gins 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 breathing the air in
the same room, and dirtying it by the emanations from
6*

66 NOTES ON NURSING.

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
(particularly 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, how-
ever, hardly ever be used for any kind of sick in this coun-
try. A light white curtain at the head of the bed is, in
general, all that is necessary, and a green blind to the
window, to be drawn down only when necessary.

One of the greatest observers of human things (not phys-
iological), says, in another language, "Where there is sun
there is thought." All physiology goes to confirm this.
Where is the shady side of deep vallies, there is cretinism.
Where are cellai's and the unsunned sides of narrow streets,
there is the degeneracy and w^eakliness of the human race

— mind and body equally degenerating. Put the pale
withering plant and human being into the sun, and, if not
too fir gone, each will recover health and spirit.

It is a curious thing to observe how almost all patients
lie with their faces turned to the light, exactly as plants
always make their way towards the light; a patient will
even complain that it gives 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 fash-
ionable physicians, and depend upon it she turns the faces
back and toicards 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 l^ing with their faces towards the wall.

X. CLEANLINESS OF ROOMS AND WALLS.

It cannot be necessary to tell a nurse that she should be
clean, or that she should keep her patient clean, — seeing
that the greater part of nursing consists in preserving

CLEANLINESS OF ROOMS AND WALLS. 67

cleanliness. No ventilation 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 infalhbly 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 above-mentioned dirty circumstances, no open-
ing of windows could ever keep those rooms free from close-
ness ; 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 Lon-
don a room cannot be kept clean. Many of our hosj^itals
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 to another with doors and win-
dows 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 be-
gins 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 an-
other and a dirtier one.* Flapping by way of cleaning is
only admissible in the case of pictures, or anything made
o£ 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 ouo-ht to be so made as that it

* If you like to clean your furniture by laying out your clean clothes
upon yoiir 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 chairs, tables, or sofa, upon which the '* things"
have lain during the night, and which are therefore comparatively clean
from dust or blacks, the poor ^^ things" having "caught" it, they are
removed to other chairs, tables, solas, upon which you could write
your name with your finger in the dust or blacks. The other side of the
"things" is therefore now evenly dirtied or dusted. The housemaid
then tlaps everything, or some things, not out of her reach, with a thing
called a duster — the dust flies up, then re-settles more equally than it
lay before the operation. The room has now been " put to rights."

68 NOTES ON NURSING.

may be wiped with a damp cloth without injury to itself
and so polislied as 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 YY(i,wQ\\ parquet
is always more or less dusty, although infinitely superior
in point of cleanliness and healthiness to our absorbent
floor.

For a sick room, a carpet is jierhaps 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 liter-
ally 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 fre-
quent lime-washing; the paper requires frequent renewing.
A glazed paper gets rid of a good deal of the danger.
But the ordinary bed-room paper is all that it ought not
to be.*

The close connection between ventilation and cleanli-
ness 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 exuvi£e. t •

These are what make a room musty.

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

Air can be soiled just like water. If 3'ou blow into wa-
ter you will soil it with the animal matter from your breath.

* I am sure that a person who has accustomed her senses to compare
atmospheres proper and improper, for the sick and for children, could
tell, blindfold, the difference of the air in old painted and in old papered
rooms, ccetcris paribus. The latter "will always be musty, even with all
the windows open.

t K you like to wipe your dirty door, or some portion of your dirty
wall, by hanging up your clean gown or shawl against it on a peg, this
is one way certainly, and the most usual way, and generally the only
way of cleaning either door or wall in a bed-room !

CLEANLLNESS OF ROOMS AND WALLS. 69

So it is with air. Air is always soiled in 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, the evaporation from dirty streets, smoke, bits
of unburnt fuel, bits of straw, bits of horse dung.

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

2. Dirty air coming from within, from dust, which you
often displace, but never remove. And this recalls what
ought to be a 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 oif. This is a certain way to soil
the air. Besides this, the animal exhalations from your
inmates saturate 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. ^., in coloring cer-
tain 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 forever.

Again, the fire fills the room with coal dust.

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. Floors, 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 mois-
ture brings out the organic matter by which it is satui-ated,
might alone be enougli to warn us of the mischief that is
going on.

The outer air, then, can oidy be kept clean by sanitary
improvements, and by consuming smoke. The expense in

70 NOTES ON NURSING.

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 gTcatly 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 chim-
ney, 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, Avho 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. PERSONAL CLEANLINESS.

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

PERSONAL CLEANLINESS. ll

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 should keep this
fact constantly in mind, — for, if she allow her sick to re-
main unwashed, or their clotliing to remain on them after
being saturated with perspiration or other excretion, she is
interfering injuriously with the natural processes of health
just as eftectually 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 skin has been carefully washed and dried, is one
of the commonest observations made at a sick bed. But
it must not be forgotten that the comfort and relief so ob-
tained are not all. They are, in fact, nothing more than a
sign that the vital powers have been relieved by removing
something that was oppressing them. The nurse, therefore,
must never put off attending to the personal cleanliness
of her patient under the plea that all that is to be gained
is a little relief, which can be quite as well given later.

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

Just as it is necessary to renew the air round a sick per-
son frequently, to carry off morbid effluvia from the lungs
and skin, by maintaining free ventilation, so it is 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.

Cai-e should be taken in all tliese o]>erations of sponging,
washing, and cleansing the skin, not to expose too great
a surface at once, so as to check the perspiration, wliich
would renew tlie evil in another form.

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

In several forms of diar]-ha?a, dysentery, &c., where the
skin is hard and harsh, the relief afforded by washing with
a great deal of soft soap is incalcuhible. In otlier cases,
sponging with tepid soap and water, then with tepid water
and drying Avith a hot towel will be ordered.

72 NOTES ON NURSING.

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

One word as to cleanUness merely as cleanliness.

Compare the dirtiness of the water in which you have
washed when it is cold without soap, cold with soap, hot
with soap. You will find the first has hardly removed any
dirt at all, the second a 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 fin-
ger, you will bring of flakes off dirt or dirty skin. After
a vapor bath you may peel your whole self clean in this
way. What I mean is, that by simply washing or spong-
ing 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
jour fingers. The black iiakes which will come off will
eonvince 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 your-
self 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 aflbrded, and when they could
not be moved out of their berths, as if all the appurte-
nances of home had been at hand.

Washing, however, with a large quantity of water lias
quite other eftects than those of mere cleanliness. The
skin absorbs the water and becomes softer and more per-
spirable. To wash with soap and soft water is, therefore,
desirable from other points of view than that of cleanli-
ness.

Xn. CHATTERING HOPES AND ADVICES.

The sick man to his advisers.

" ]My advisers ! Their name is legion. * * *
Somehow or other, it seems a provision of the universal
destinies, that every man, woman, and child should con-
sider him, her, or itself privileged especially to advise me.

CHATTERING HOPES AND ADVICES. 73

"Wliy ? 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, car-
riage — yes, and even swing (I) and dnmb-bell (!) in exist-
ence ; to imbibe every different kind of stimulus that ever
has been invented. And this when those best fitted to
know, viz., medical men, after long und close attendance,
}iad declared any journey out of the question, had prohib-
ited 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 liim that
everybody else is doing the same tiling, and that I the pa-
tient must perforce say, in sheer self-defence, like Rosalind,
" I could not do with all."

" Chattering Hopes " may seem an odd heading. But I
really believe there is scarcely a gi'eater worry which in-
valids have to endure than the incurable hopes of their
friends. There is no one practice against which I can
speak more strongly from actual personal experience, 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 probabili-
ties 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 state.

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, against the opinion of the medical attendant,
given, perhaps, after years of observation, after using every
help to diagnosis afforded by the stethosco]>e, the exami-
nation of pulse, tongue, &c. ; and certainly after much more
observation than the friend can possibly liave had.

Supposing the ])atient to be possessed of common sense

— how can the "favourable" opinion, if it is to be called

an opinion at all, of the casual visitor "cheer" him, —

when different from that of the experienced attendant?

7

74 NOTES ON NURSING.

Unquestionably the latter may, and often does, turn out
to be ^Vrong. But which is most likely to be wrong?

The fact is, that the patient * is not " cheered " at all by
these well-meaning, most tiresome friends. On the con-
trary, he is depressed and wearied. If, on the one hand,
he exerts himself to tell each successive member of this
too numerous conspiracy, w^hose 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, — lie
is fatigued instead of " cheered," and his attention is fixed
uj^on himself. In general, patients who are really ill, do
not want to talk about themselves. Hypochondriacs do,
but again I say we are not on the subject of hypochon-
driacs.

If, on the other hand, and w^hich is much more fi-e-
quently the case, the patient says nothing, but the Shake-
spearian «0h!" "Ah!" "Go to!" and '^n good sooth!"
in order to escape from the conversation about himself the
sooner, he is depressed by want of sympathy. He feels
isolated in the midst of friends. He feels what a conven-
ience it would be, if there were any single person to whom

* There are, of course, cases, as in first confinements, when an
assurance from the doctor or experienced nurse •to the frightened suf-
fering woman that there is nothing unusual in her case, that she has
nothing to fear but a few hours' pain, may cheer her most effectually.
This is ad\'ice of quite another order. It is the advice of experience to
utter inexperience. But the advice we have been referring to is the
advice of inexperience to bitter experience ; and, in general, amounts to
nothing more than this, that you think I shall recover from consump-
tion because somebody knows somebody somewhere who has recovered
from fever.

I have heard a doctor condemned whose patient did not, alas !
recover, because another doctor's patient of a different sex, of a different
age, recovered from a different disease, in a different 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 Avith v/hich
such comparisons require to be made, (and are made,) in order to be
of any value Avhatever, 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 no compari-
son between old men with dropsies and young women with consump-
tions. Yet the cleverest men and the cleverest women are often lieard
making such comparisons, ignoring entirely sex, age, disease, place —
in fact, all the conditions essential to the question. It is the merest
gossip.

CHATTERING HOPES AND ADVICES. 75

he could speak simply and openly, without pulling the string
upon himself of this shower-bath of silly hopes and en-
couragements; to whom he could express liis wishes and
directions without that pei-son persisting in saying " I ho])e
that it will please God yet to give you twenty years," or,
" You 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 sud-
denly," or, " unexpectedly both to himself and to others."
"Unexpectedly" to others, perhaps, who did not see, be-
cause they did not look; but by no means "unexpectedly
to himself," as I feel entitled to believe, both from the in-
ternal 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 biog-
raphies, these death-beds are generally depicted as almost
seraphic in lucidity of intelhgence. 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 fig-
uring 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 wdll 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. You do not
know how you worry and weary them. Such real suffer-
ers 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 inconsistency — for these advisers are
sure to be the same persons who exhorted the sick man
not to beUeve his own doctor's prognostics, because " doc-
tors are always mistaken," but to believe some other

76 NOTES ON NURSING.

doctor, because " this doctor is always right." Sure also
are these advisers to be the persons to bring the sick man
fresh occupation, while exhorting him to leave his own.

Wonderful is the foce with which friends, lay and medi-
cal, will come in and wony the patient with recommenda-
tions to do something or other, having just as little knowl-
edge as to its being 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 Mend had come in, because somebody,
anybody, nobody, had recommended something, anything,
nothing, were to disregard his orders, and take that other
body's recommendation ? But people never think of this.

A celebrated historical personage has related the com-
monplaces which, when on the eve of executing a remark-
able resolution, were showered in nearly the same words
by every one around successively for a period of six
nionths. To these the personage states that it was found
least trouble always to reply the same thing, viz., that it
could not be supj^osed that such a resolution had been
taken without sufficient previous consideration. To pa-
tients enduring every day for years from every friend or
acquaintance, either by letter or m^ya 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 pa-
tient has heard sueh advice at least fifty times before, and
that, had it been practicable, it would have been practised
long ago. But of such consideration there appear 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 the decline of such sufferers, re-
call the slimy tmil 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 upon the sick. It is of no use for the sick to
say anything, for what the adviser wants is, not to know
the truth about the state of the patient, but to turn what-
ever the sick may say to the support of his own argument,

CHATTERING HOPES AND ADVICES. 77

get forth, it must be repeated, without any inquiry what-
ever into the jD^tient's real condition. " But it would be
impertinent 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 Avho do your
patient harm. When you hear him told: — 1. That he
has nothing the matter with him, and that he wants cheer-
ing. 2. That he is committing suicide, and that he wants
preventing. 3. That he is the tool of somebody who
makes use of him for a purpose. 4. That he will listen to
nobody, but is obstinately bent upon his own way ; and 5.
That he ought to be called to a sense of duty, and is fly-
ing in the face of Providence ; — then know that your pa-
tient 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 Aerself into the life of a sick person.

Do, you who are about the sick or who visit the sick, try
and give them pleasure, remember to tell them what will
do so. How often in such visits the sick person has to do
the whole conversation, exerting his own imagination and
memory, while you would take the visitor, absorbed in-his
own anxieties, making no effort of memory or imagination,
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 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
think of" There are many burthened with business who
always 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

7*

78 KOTES ON NUriSIKG.

he lias little cnoiigli of; and ten to one but you have told
him of some love-making with a had ending.

A sick person also intensely enjoys hearing of any m«-
terial good, any positive or practical success of the light.
He has so much of books and fiction, of principles, and
precepts, and theories ; do, instead 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 w^ith undi-
minished power of thinking, but little power of doing, is
to hear of good j^ractical 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.
You 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 w%ant 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 preaching they receive from every-
body, no matter whom it is, they see.

TKere is no better society than babies and sick pe(tj)le
for one another. Of course you must manage this so that
neither shall suffer from it, which is perfectly possible. If
you think the " air of the sick room " bad for the baby, wliy
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, w^ill 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 suifer from
reasonable causes of distress, you would take more pains
about all these things. An infant laid upon the sick bed
will do the sick person, thus suffering, more good than all

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

OBSERVATION OP THE SICK. 79

your logic. A piece of good news will do the same. Per-
haj^s you are afraid of "disturbing" him. You say there
is no comfort for his present cause of affliction. It is per-
fectly reasonable. The distinction 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. You will relieve, more effect-
ually, unreasonable suffering from reasonable causes by
telling him " the news," showing him " the baby," or giv-
ing him 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 chil-
dren in this, that there is no proportion in events to them.
Now it is your business a^ their visitor to restore this right
proportion for them — to show them what the rest of the
world is doing. How can they find it out otherwise ?
You will find them fir more open to conviction than chil-
dren in this. And you will find that their unreasonable
intensity of suffering from unkindness, from want of sym-
pathy, &c., will disappear Avith their freshened interest in
the big workfs 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 more common every day, e.^pecially among women of the
richer orders, to whom all these remarks are preeminently inapplicable.

1. Those who make health an excuse for doing nothing, and at the
same time allege that the being able to do nothing is their only grief.

2. Those who have brought upon themselves ill-health by over pursuit
of amusement, which they and their friends have most unhappily 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."

Xni. OBSERVATION OF THE SICK.

There is no more silly or universal question scarcely
asked than this, " Is he better ? " Ask it of the medical
attendant, if you please. But of whom else, if you wish
for a real answer to your question, would you ask it? Cer-
tainly not of the casual visitor; certainly not of the nurse,
while the nurse's obseiwation is so little exercised as it is

so NOTES ON t^vmtm.

now* What you want are fact;?, not opinions ; for who can
have any opinion of any vahxe a» to whether the patient is
better or wor&e, excepting the constant medical attendant,
or the really observing nurse ?

The most important practical lesson that can be given
to nur»es is to teach them what to obsen^e — how to ob-
geiwe — 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 pait, and an essential
part, of the training of every nurse. At present, how few
there are, either professional 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 infoiination one re-
ceives in answer to that much abused question, "Is he
better ? " would be ludicrous, if it were not painful. The
only sensible answer (in the present state of knowledge
about sickness) Tvould be " How can I know ? I cannot tell
how he was when I was not with him."

I can record but a very few ^^pecimens of the answers *

* It is a much more difficult thing to speak the truth than people
commonly imagine. There is the want of observation simple, and the
ivant of observation compoimd, compounded, that is, with the imagina-
tive 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 imagination 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 7iot observed, nor remember that they have
forgotten.

Courts of justice seem to think that anybody 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.

OBSERVATION OF THE SICK. 81

which I have heard made by friends and nurses, and ac-
cepted 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.

"I)o 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 ob-
seiwed that whereas six weeks ago he sat up and occupied
himself in bed, he now lies still doing nothing ; that al-
though 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 Avalk or stand, is
represented to the doctor as making no progress at all.

Questions, too, as asked now (but too generally) of or
about patients, would obtain no information at all about
them, even if the 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 good night ? " Now, one patient will think
he has had a bad night if he has not slept ten hours with-
out waking. Another does not think he has had a bad
night if he has had intervals of dozing occasionally. The
same answer has actually been given as regarded two pa-

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 four-
teenth, who had never left his bed, went to a distant chapel every morn-
ing 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 saci-ament, by whose side
they liad 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 pro-
vide from three to five and six meals a day. Such instances might be
multiplied ad infiuUuin if necessary.

82 NOTES ON NURSING.

tients — one who had been entirely sleepless for five thnea
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 ray eyes all night," an answer as fre-
quently 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 sel-
domer 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 j)ro-
duced by a great many different causes, 7iot inquired after,
remains. As 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 questions, and give only the exact amount of in-
formation asked for, even when they know it to be com-
pletely misleading. The shyness of patients is seldom al-
lowed 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 ivhere the patient is.

I knew a very clever physician, of large dispensary and
hospital practice, who invariably began his examination of
each patient with "Put your linger where you be Ijad."
That man would never- waste his time with collecting in-
accurate information from nurse or patient. Leading ques-
tions always collect inaccurate information.

At a recent celebrated trial, the following leading ques-
tion was put successively to nine distinguished medical
men. " Can you attribute these symptoms to anything
else but poison ? " And out of the nine, eight answered
" No ! " without any qualification whatever. It appeared,

* This is important, because on this depends Avhat the remedy will
be. If a patient sleeps two 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 proba-
bly 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 r

OBSERVATION OP THE SICK. 83

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 dis-
ease to which the death, if not to poison, was attributa-
ble. 3. That none of them were even aware 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,
w^here, owing to this system of leading questions, the pa-
tient has died, and the attendants have been actually un-
aware of the principal feature of the case.

It is useless to go through all the particulars, besides
sleep, in which people have a peculiar talent for gleaning
inaccurate information. As to food, for instance, I often
think that most common question, How^ is your appetite ? can
only be put because the questioner believes the questioned
has really nothing the matter with him, which is very oft-
en the case. But where there is, the remark holds 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 hav-
ing got him the thing he fancies. But many another pa-
tient does not care between grapes and turnips — every
thing is equally distasteful to him. He would try to eat
anything which would do him good ; but everything
"makes him worse." The fault here generally lies in the
cooking. It is not his " appetite " which requires " tempt-
ing," 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 starv-
ing 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 ;

84 NOTES ON NURSING.

4. Defect of appetite in patient.
Yet all these are generally comprehended in the one sweep-
ing assertion that the patient has " no appetite."

Surely many lives might be saved by drawing closer dis-
tinction ; 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 sometimes unex-
pectedly. 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.

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

Again, the question is sometimes put. Is there diarrhcea ?
And the answer will be the same, whether it is just mer-
ging into cholera, whether it is a trifling degree brought on
by some trifling indiscretion, 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 multiply instances of this kind. As long
as observation is so little cultivated as it is now, I do be-
lieve that it is better for the physician 7iot to see the friends
of the patient at all. 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 fooUsh

* It is commonly supposed that the nurse is there to spare the patient
from making physical exertion for himself — I would rather say that she
ought to be there to spare him from taking thought for himself. And
I am quite sure, that if the patient were spared all thought for himself,
and 7iot spared all physical exertion, he would be intinitely the gamer.
The reverse is generally the case in the private house. In the hospital
it is the relief from all anxiety, afforded by the rules of a well-regulated
institution, which has often such a beneticial etiect upon the patient.

OBSERVATION OF THE SICK. 85

things, has told us that one of his main objects in the edu-
cation of his son, was to give hiin a ready habit of accurate
observation, a certainty of perception, and that for this pur-
pose one of his means was a month's 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 that the habit of ready and correct observa-
tion 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.
J have known another nurse in charge of one single pa-
tient, who took away his meals day after day all but un-
touched, 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 calhng, however kind and anxious you may be.

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.
You 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."

I have known several of our real old-fashioned hospital
"sisters," who could, as accurately as a measuring glass,
measure out all their patients' wine and medicine by the
eye, and never be wrong. I do not recommend this ; one
must be very sure of one's self to do it. I only mention it,
because if a nurse can by practice measure medicine by the

86 NOTES ON NURSING.

eye, surely she is no nurse who cannot measure by the eye
about liow much food (in oz.) her patient has taken* In hos-
pitals 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. Yet 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 Avill take it away
without ever seeing that there is just the same quantity of

* It may be too broad an assertion, and it certainly sounds like a para-
dox. But I think that in no country are women to be found so deficient
in ready and sound observation as in England, -while peculiarly capable
of being trained to it. The French or Irish woman is too quick of per-
ception to be so sound an observer — the Teuton is too slow to be so
ready an observer as the English woman might be. Yet English
women lay themselves open to the charge so often made against them
by men, viz., that they are not to be trusted in handicrafts to which
their strength is quite equal, for want of a practised and steady obser-
vation. In countries where women (with average intelligence certainly
not superior to that of English women) are employed, e. g., in dispen-
sing, 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 English women 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 sarne places ; you don't know how suddenly you may be
called on some day to find something, and may not be able to remem-
ber in your haste where you yourself had put it, if your memory is not
there always,

OBSERVATION OF THE SICK. 87

food as when she brought it, and she will tell the doctor,
too, that the patient 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
frequently fail in observation. There is a well-marked dis-
tinction between the excitable and what I will call the
accumulative temperament in jDatients. One will blaze up
at once, under any shock or anxiety, and sleep very com-
fortably 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 will find him some time after slowly
sinking. The same remark applies to the action of nar-
cotics, of aperients, which, in the one, take eftect directly,
in the other not perhaps for twenty-four hours. A journey,
a visit, an unwonted exertion, will aflTect the one immedi-
ately, but he recovers after it ; the other bears it very well
at the time, apparently, and dies or is prostrated for life by
it. People often say how difficult the excitable tempera-
ment is to manage. I say how difficult is tlie 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 Avhere you are — you never know when
the consequences are over. And it requires your closest
observation to know what «re 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 ^9<9s^ Aoc, ergo propter hoc; and bad observers are
almost all superstitious. Farmers used to attribute disease
among cattle to witchcraft ; weddings have been attrib-
uted 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 : although there is unquestionably a phys-
iognomy of disease as well as of health; of all parts of the
body, the face is perhaps the one which tells the least to the
common observer 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 e^ er, ob-
serve enough to know how to distinguish between the ef-
fect of exposure, of robust health, of a tender skin of a

88 NOTES ON NURSING.

tendency to congestion, of suffusion, flushing, or many
other things. Again, the face is often the hist to sliow
emaciation. I should say that the hand was a much surer
test than the face, both as to flesh, color, 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 con-
veyed by the oft repeated words, He looks 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 saic^ which the world's experience, if it had
any, would have pronounced utterly false long ago

I have 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 color 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
you should not live till ninety years of age." " AVhy don't
y(fti take a little more exercise and amusement ? " with all
the other commonplaces 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 pat chin ess of the
color about the face, when the re-action of depression has
set in ; that very color which the inexperienced will point
to as a proof of health.

There is, again, a faintness which does not betray itself
by the color 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 scru-
ple, unless he is pale and unless, luckily for him, the mus-
cles of the throat are aflected and he loses his voice.

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

OBSERVATION OF THE SICK. 89

Again, the nurse must distinguish between the idiosyn-
crasies of patients. One Hkes to suffer out all his suffer-
ing 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 attend-
ance is forced upon the first patient, who wishes for noth-
ing 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 Avords from time to time, for the informa-
tion of the. nurse, who Avill not otherwise see, that he can-
not do this or that, which he could do a month or a year
ago. AYliat is a nurse there for if she cannot observe these
things for herself? Yet 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 acci-
dents, (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 un-
expected apoplectic, paralytic, or fainting fit (though even
these could be expected far more, at least, than they are
now, if we did but observe). No, from the expected, or to
be expected, inevitable, visible, calculable, uninterrupted
increase of weakness, which none need fail to observe.

Again, a patient not usually confined to bed, is compelled
by an attack of diarrhoea, vomiting, or other accident, to
keep his bed for a few days ; he gets up for the first time,
and the nurse lets him go into another room, without com-
ing in, a few minutes afterwards, to 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 ;
8*

90 NOTES ON NURSING.

and if lie 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 faint, or cold, or hungry, after
getting up for the first time.

Yet it appears that scarcely any improvement in the
faculty of observing is being made. Vast has been the
increase of knowledge in pathology — that science which
teaches us the final change produced by disease on the hu-
man 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 would think it the
more natural thing, " There must have been some appear-
ance, 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 appear-
ances 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 in-

* It falls to few ever to have had the opportunity of observing the
different aspects which the human face puts on at the sudden approach
of certain forms of death by violence ; and as it is a knowledge of little
use, I only mention it here as being the most startling exam.ple of what
I mean. In the nervous temperament the face becomes pale (this is the
only recognized effect) ; in the sanguine temperament purple ; in the
bilious yellow, or every manner of color in patches. Now, it is gen-
erally 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.

OBSERVATION OF THE SICK. 91

veterate habit of taking averages are each of tliem often
equally misleading.

Men 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 diiferent if he sees 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 inquiry 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 produced by any one
organic disease than by some illness, after many other dis-
eases, 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 why he should not live to
extreme old age; sometimes the clause is added, some-
times 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 only 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 pa-
tient had followed for years. And because he had forbid-
den a course which the patient could not by any possibil-
ity alter.*

* I have known two cases, the one of a man who intentionally and
repeatedly displaced a di.slocation, 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 doc-

92 NOTES ON NURSING.

Undoubtedly a person of no scientific knowledge what-
ever but of observation and experience in these kinds of
conditions, will be able to arrive at a much truer guess as

tors, saved the one case from persevering in a fraud, the other from
being discharged when actually in a djHng state.

I will even go further and say, that in diseases which have their ori-
gin 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 daj^ 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 forming 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 dis-
eases it is important, but in diseases which do not run a distinct and
fixed 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.

I must direct the nurse's attention to the extreme variation there is
not unfrequently 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 \ibrating 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 imperceptible.
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 inflammation, 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 can-
not. 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, which just makes up the sum
of exhaustion necessary to produce death. And everybody cries, "Who
would have thought it r 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 in-
come 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" cither " so much better"

OBSERVATION OF THE SICK. 93

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 haye their pulse
felt ; no inquiry being made into their conditions.

In Life Insurance and such like societies, Avere they in-
stead of haying the person examined by a medical man,
to haye the houses, conditions, ways of life, of these per-
sons examined, at how much truer results would they ar-
rive ! W. Smith appears a fine hale man, but it might be
known that the next cholera epidemic he runs a bad
cliance. Mr. and Mrs. J. are a strong healthy couple, but
it might be known that they liye in such a house, in such
part of London, so near the riyer that they will kill four-
fifths of their children ; which of the children will be the
ones to suryiye might also be known.

Averages again seduce us away from minute observa-
tion. " Average mortalities " merely tell that so many per
cent, die in this town and so many in that, per annum.
But whether A or B will be among these, the " average
rate " of course does not tell. We know, say, that from
22 to 24 per 1,000 will die in London next year. But mi-
nute inquiries into conditions enable us to know that in
such a district, nay, in such a street, — or even on one side
of that street, in such a particular house, or even on one
floor of that particular house, will be the excess of mortal-
ity, that is, the person will die wlio ought not to have died
before old age.

Xow, would it not very materially alter the opinion of
whoever were endeavoring 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 con-
stantly recurring on workhouse books for generations. That
is, the persons were born and brought uj), and will be born
and brought up, generation after generation, in the condi-

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 from which she derives her opinion, or from the doctor being
hasty and inexperienced, and not capable of eliciting tliem. 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.

94 NOTES ON NURSING.

lions 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 Avhat they are?

The close observer may safely predict that such a fam-
ily, whether its members marry or not, Avill become extinct ;
til at 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."

In dwelling upon the vital importance of sound obser-
vation, it must never be lost sight of what observation is
for. It is not for the sake of piling up miscellaneous in-
formation 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 scien-
tific 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 ex-
aggeration. You think, if you suspected your patient was
being poisoned, say, by a copper kettle, you would in-
stantly, as you ought, cut off* all possible connection be-
tween him and the suspected source of injury, Avithout
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 confi-
dential nurse being placed with the patient, or give up the
case.

And remember every nurse should be one who is to be
depended upon, in other words, capable of being a " con-
fidential " 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 hon-

CONCLUSION. 95

est; but more than this, she must be a rehgious and de-
voted woman ; she must have a respect for her own calUng,
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 de-
cent feeling.

To return to the question of what observation is for: —
It would really seem as if some had considered it as its
own end, as if detection, not cure, was their business; nay
more, in a recent celebrated trial, three medical men, ac-
cording 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 fills under the cognizance of us all. How often
the attendants of a case have stated that they knew per-
fectly 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 only person who could act
in the matter.

CONCLUSION.

The whole of the preceding remarks apply even more to
children and to puerperal women than to patients in gen-
eral. They also apply to the nursing of surgical, quite as
much as to that of medical cases. Indeed, if it be possi-
ble, cases of external injury require such care even more
than sick. In surgical wards, one duty of every nurse
certainly is prevention. Fever, or hospital gangrene, or
pyccmia, or purulent discharge of some kind may else su-
pervene. Has she a case of compound fracture, of am})u-
tation, or of erysipelas, it may depend very much on how
she looks upon the things enumerated in these notes,
Avhether one or other of these hospital diseases attacks her
patient or not. If she allows her ward to become filled
with the peculiar close foetid smell, so apt to be produced
among surgical cases, especially where there is great sup-
puration and discharge, she may see a vigorous patient in
the prime of life gradually sink and die where, according

96 NOTES ON NURSING.

to all human probability, he ought to have recoTered. 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.

Xevertheless 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,
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 hospital ; 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., w^ho have this surgical nursing to per-
fection, 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 things, but much more quickly and
seriously, viz., by want of fresh 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 w4ien up, by want of the spirit of man-
agement generally in those in charge of them. One can,
therefore, only press the importance, as being yet greater
in the case of children, greatest in the case of sick chil-
dren, of attending to these things.

That which, however, above all, is known to injure chil-
dren seriously is foul air, and most seriously at night.
Keeping the rooms where they sleep tight shut up, is de-
struction to them. And, if the child's breathing be dis-
ordered 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.

CONCLUSION. 97

The folloT^ing passages, taken out of an excellent "Lec-
ture 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 acci-
dent ; it is not a necessary, inevitable result of any disease
from which it is suifering."

It may be here added, that it would be very desirable to
know how often death is, with adults, " not a necessary,
inevitable result of any disease." Omit the word " sud-
den ; " (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 chil-
dren are enumerated: — "Sudden noises, which startle — •
a rapid change of temperature, which chills the surface,
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 al-
teration 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 pa-
tients, these cases are also (not often "suddenly fatal," it
is true, but) very much often er than is at all generally
known, irreparable in their consequences.

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 fre-
quent 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 other condition, disturbs
the respiratory process, and tends to produce "accidental"
death in disease.

I need hardly here repeat the warning agahist any con-
fusion of ideas between cold and fresh air. You may chill
a patient fitally without giving him fresh air at all. And
you can quite well, nay, much better, give him fresh air
without chilling him. This is the test of a good nurse.

In cases of long recurring laintnesses from disease, for
instance, especially disease which aftects the organs of
breathing, fresh air to the lungs, warmth to the surf ice,
and often (as soon as the patient can swallow) hot drink,
these are the right remedies and the only ones. Yet,
oftener than not, you see the nurse or mother just reversing

98 NOTES ON NURSING.

tiiis; shuttii\2^ ^ip ovcry cranny throngli wlilch fresh ah
can enter, and leaving the body cold, or j^erhaps throwing
a greater weiglit of clothes npon it, when already it is gen-
erating too little heat.

"Breathing carefully, anxionsly, as thongh respiration
were a function Avhich 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 accomplish-
ment of the respiratory function, some sudden demand for
its complete exercise, issues in the sudden stand-still of the
whole machinery," is given as one process : — " life goes
out for want of nervous power to keep the vital functions
in acti^4ty," is given as another, by which " accidental"
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 I
have seen, even in middle age, the '•'-sudden stand-still"
here mentioned, and from the same causes.

To sum up : — the answer to two of the commonest ob-
jections urged, one by women themselves, the other by
men, against the desirableness of sanitary knowledge for
women, plus a caution, comprises the whole argument for
the art of nursing.

(1.) It is often said by men, that it is unwise to teach
women anything about these laws of health, because they
Vv^ill take to physicking, — that there is a great deal too
much of amateur physicking as it is, which is indeed true.
One eminent physician told me that he had known more
calomel given, both at a pinch and for a continuance, by
mothers, governesses, and nurses, to children than he had
ever heard of a physician prescribing in all his experience.
Another says, that women's only idea in medicine is calo-
mel and aperients. This is undeniably too often the case.
There is nothing ever seen in any professional practice like
the reckless j^hysicking by amateur females.* But this is

* I have known many ladies who, having once obtained a "blue
pill" prescription from a physician, gave and took it as a common
aperient two or three times a week ■ — witli >^•hat effect may be supposed.

CONCLUSION. 99

just ^vllat the really experienced and deserving nurse does
not do ; she neither physics herself nor others. And to
cultivate in things pertaining to health, observation and
experience in women who are mothers, governesses or
nurses, is 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 doc-
tor's work — but no one really believes that doctors wish

In one case I happened to be the person to inform the physician of it,
who substituted for the prescription a comparatively 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, who would not take the pains to learn the names of
the commonest medicines, and confounded, e. </., colocynth with colchi-
cum. This is playing with sharp-edged tools " with a vengeance."

There are excellent women who will write to London to their physi-
cian that there is much sickness in their neighborhood in the country,
and ask for some prescription from him which they used to like them-
selves, and then give it to all their friends and to all their poorer
neighbors who will take it. Now, instead of giving medicine, of which
you cannot possibly know the exact and proper application, nor all its
consequences, would it not be better if you were to persuade and help
your poorer neighbors to remove the dung-hill from before the door,
to put in a window which opens, or an Arnott's ventilator, or to cleanse
and limewash the cottages ? Of these things the benefits are sure.
The benefits of the inexperienced administration of medicines are by no
means so sure.

Homoeopathy has introduced one essential amelioration in the prac-
tice of physic by amateur females ; for its rules are excellent, its
physicking comparatively harmless — the "globule" is the one grain
of folly which appears to be necessary to make any good thing accepta-
ble. Let then women, if they will give medicine, 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 immediately to aperients. The reverse is the con-
clusion of experience.

This is a doctor's subject, and I will not enter more uito 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 verj' 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 anything else.

100 NOTES ON NURSING.

that there should be more ilhiess, in order to have more
work.

(2.) It is often said by women, that they cannot know
anything of the Laws of health, or what to do to preserve
their children's health, because they can know nothing of
" Pathology," or cannot " dissect," — a confusion of ideas
which it is hard to attempt to disentangle. Pathology
teaches the harm that disease has done. But it teaches
nothing more. We know nothing of the principle of
health, the 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 bring back the state of health. It is often
thought that medicine is the curative process. It is no
suchthing ; medicine is the surgery of functions, as sur-
gery proper is that of limbs and organs. Neither can do
anything but remove obstructions; neither can cure; na-
ture alone cures. Surgery removes the bullet out of the
limb, which is 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. You 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 oion^ the pan-
acea. 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 receiA^ed idea among men and
even among women themselves that it requires nothing
but a disappointment in love, the want of an object, a gen-
eral disgust, or incapacity for other things, to turn a wo-
man 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.

CONCLUSION.

101

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

^^' Whft cruel mistakes are sometimes made by bcneyo-
lentmen and women in matters of business about >yhich
they can know nothing and think they know a gicat

^iie everyday management of a large ward, let alone of
ahospital-the knowing what are the laws of h.e and
death for men, and what the laws of health for wards -
rand wards are healthy or unhealthy, mainly according to
the knowledge or io-norance of the nurse) -are not these
rnatte^-s of sufficieirt importance and difficulty to require
learning by experience and careful inqmry, just as much
as any'other art? They do not come by mspiration to
the ladv disappointed in love, nor to the poor workhouse
drudo-e hard up for a livelihood.

And terribli is the injury which has followed to the sick

from such wild notions ! ox • t» no^L.Jw.

In this respect (and why is it so?), in Roman Catholic
countries, both writers and workers are, in theoiy at least,
far before ours. They would never think of such a begm-
nino- for a good working Superior or bister of Chanty
And manv a Superior has refused to admit ^Postulant
who appeared to have no better "vocation" or reasons for
offering herself than these. ^

ll is'true ,o« make " no vows." But is a " vow neees-
sai-v to convince ns that the true spirit for learning any art,
moit especially an art of charity, aright, is not a disgust to
everything or something else? Do we '-^^'"y P^^e the
love of our kind (and of nursing, as one branch of it) so
low as this? What would the Mere Angeliqne of 1 ort
Royal, what would our own Mra. try have said to this .■■

Note. -I would earnestly aA my risters to keep eleav of both the
,„^,„„.„o..eu.enteve;,«.e.

rSX meJ; c*rcludh.«"ae medical and ot.er V^^^fT^^
because men do it, and without regard to whether this ,» the be»t that
9*

102 NOTES ON NURSING.

■women can do ; and of the jargon Avhicli urges -women to do nothing
that men do, merely because they are -women, and should be " recalled
to a sense of their duty as Avomcn," and because "this is -women's
•work," and " that is men's," and " these are things ^vhich -women
should not do," -which is all assertion, and nothing more. Surely
woman should bring the best she has, ichatever that is, to the work of
God's world, Avithout 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 r "
And as a wise man has said, no one has ever done anything great or
useful by listening to the voices from without.

You do not want the effect of your good things to be, ** How won-
derful for a rrotnan ! " 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 is
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.

NOTE AS TO THE NUMBER OF AVOMEN EMPLOYED AS
NURSES IN GREAT BRITAN,

25,466 were returned, at the census of 1851, as nurses by profession,
39,139 nurses in domestic service,* and 2,822 midwives. The num-
bers of diiferent ages are shown in table A, and in table B their distri-
bution 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 health, 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 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 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 indiscrim-
inately for amateur and professional nurses. For, besides nurses of
the sick and nurses of children, the numbers of whom are hei'e given,
there are friends or relations who take temporary charge of a sick per-
son, there are mothers of families. It appears as if these unprofes-
sional nurses were just as much in want of knowledge of the laws of
health as professional ones.

Then there are the schoolmistresses of all national and other schools
throughout the kingdom. IIo w many of children's epidemics originate in
these ! Then the proportion of girls in these schools who become mothers
or members among the 64,000 nurses recorded above, or schoolmistresses
in their turn. If the laws of health, as far as regards fresh air, clean-
liness, 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 pre-
venting the race from degenerating in as far as these things are con-
cerned. 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 exper-
iments, in as far as these illustrate what may be called the theory of it.

* A curious fact will be shown by Tablo A ; viz., that 18,1C*2 out of :}0,-.3!», or
nearly one half of all thu uurucs ia (loniestic service, arc l)ct\v«en 5 and 'iO years
ofa'^e. (IO.J)

lOi

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