NOTES ON NURSING:

WHAT IT IS, AND WHAT IT IS NOT. 

BYFLORENCE NIGHTINGALE. 

NEW YORK:D. APPLETON AND COMPANY72 FIFTH AVENUE1898. 

PREFACE. 

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

If, then, every woman must at some time or other of her life, become anurse, _i. E. _, have charge of somebody's health, how immense and howvaluable would be the produce of her united experience if every womanwould think how to nurse. 

I do not pretend to teach her how, I ask her to teach herself, and forthis purpose I venture to give her some hints. 

TABLE OF CONTENTS. 

VENTILATION AND WARMINGHEALTH OF HOUSESPETTY MANAGEMENTNOISEVARIETYTAKING FOODWHAT FOOD?BED AND BEDDINGLIGHTCLEANLINESS OF ROOMS AND WALLSPERSONAL CLEANLINESSCHATTERING HOPES AND ADVICESOBSERVATION OF THE SICKCONCLUSIONAPPENDIX

NOTES ON NURSING:

WHAT IT IS, AND WHAT IT IS NOT. 

* * * * *

[Sidenote: Disease a reparative process. ]

Shall we begin by taking it as a general principle--that all disease, atsome period or other of its course, is more or less a reparativeprocess, not necessarily accompanied with suffering: an effort ofnature to remedy a process of poisoning or of decay, which has takenplace weeks, months, sometimes years beforehand, unnoticed, thetermination of the disease being then, while the antecedent process wasgoing on, determined?

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

[Sidenote: Of the sufferings of disease, disease not always the cause. ]

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 beinevitable and incident to the disease are very often not symptoms ofthe disease at all, but of something quite different--of the want offresh air, or of light, or of warmth, or of quiet, or of cleanliness, orof punctuality and care in the administration of diet, of each or of allof these. And this quite as much in private as in hospital nursing. 

The reparative process which Nature has instituted and which we calldisease, has been hindered by some want of knowledge or attention, inone or in all of these things, and pain, suffering, or interruption ofthe 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 generallythe fault not of the disease, but of the nursing. 

[Sidenote: What nursing ought to do. ]

I use the word nursing for want of a better. It has been limited tosignify little more than the administration of medicines and theapplication of poultices. It ought to signify the proper use of freshair, light, warmth, cleanliness, quiet, and the proper selection andadministration of diet--all at the least expense of vital power to thepatient. 

[Sidenote: Nursing the sick little understood. ]

It has been said and written scores of times, that every woman makes agood nurse. I believe, on the contrary, that the very elements ofnursing are all but unknown. 

By this I do not mean that the nurse is always to blame. Bad sanitary, bad architectural, and bad administrative arrangements often make itimpossible to nurse. 

But the art of nursing ought to include such arrangements as alone makewhat I understand by nursing, possible. 

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

[Sidenote: Nursing ought to assist the reparative process. ]

To recur to the first objection. If we are asked, Is such or such adisease a reparative process? Can such an illness be unaccompanied withsuffering? Will any care prevent such a patient from suffering this orthat?--I humbly say, I do not know. But when you have done away with allthat pain and suffering, which in patients are the symptoms not of theirdisease, but of the absence of one or all of the above-mentionedessentials to the success of Nature's reparative processes, we shallthen know what are the symptoms of and the sufferings inseparable fromthe disease. 

Another and the commonest exclamation which will be instantly made is--Would you do nothing, then, in cholera, fever, &c. ?--so deep-rooted anduniversal is the conviction that to give medicine is to be doingsomething, or rather everything; to give air, warmth, cleanliness, &c. , is to do nothing. The reply is, that in these and many other similardiseases the exact value of particular remedies and modes of treatmentis by no means ascertained, while there is universal experience as tothe extreme importance of careful nursing in determining the issue ofthe disease. 

[Sidenote: Nursing the well. ]

II. The very elements of what constitutes good nursing are as littleunderstood for the well as for the sick. The same laws of health or ofnursing, for they are in reality the same, obtain among the well asamong the sick. The breaking of them produces only a less violentconsequence among the former than among the latter, --and this sometimes, not always. 

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

[Sidenote: Little understood. ]

Oh, mothers of families! You who say this, do you know that one in everyseven infants in this civilized land of England perishes before it isone year old? That, in London, two in every five die before they arefive years old? And, in the other great cities of England, nearly oneout of two?[1] "The life duration of tender babies" (as some Saturn, turned analytical chemist, says) "is the most delicate test" of sanitaryconditions. Is all this premature suffering and death necessary? Or didNature intend mothers to be always accompanied by doctors? Or is itbetter to learn the piano-forte than to learn the laws which subservethe preservation of offspring?

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

But how much more extraordinary is it that, whereas what we might callthe coxcombries of education--_e. G. _, the elements of astronomy--are nowtaught to every school-girl, neither mothers of families of any class, nor school-mistresses of any class, nor nurses of children, nor nursesof hospitals, are taught anything about those laws which God hasassigned to the relations of our bodies with the world in which He hasput them. In other words, the laws which make these bodies, into whichHe has put our minds, healthy or unhealthy organs of those minds, areall but unlearnt. Not but that these laws--the laws of life--are in acertain measure understood, but not even mothers think it worth theirwhile to study them--to study how to give their children healthyexistences. They call it medical or physiological knowledge, fit onlyfor doctors. 

Another objection. 

We are constantly told, --"But the circumstances which govern ourchildren's healths are beyond our control. What can we do with winds?There is the east wind. Most people can tell before they get up in themorning whether the wind is in the east. "

To this one can answer with more certainty than to the formerobjections. Who is it who knows when the wind is in the east? Not theHighland drover, certainly, exposed to the east wind, but the young ladywho is worn out with the want of exposure to fresh air, to sunlight, &c. Put the latter under as good sanitary circumstances as the former, andshe too will not know when the wind is in the east. 

FOOTNOTES:

[1][Sidenote: Curious deductions from an excessive death rate. ]

Upon this fact the most wonderful deductions have been strung. For along time an announcement something like the following has been goingthe round of the papers:--"More than 25, 000 children die every year inLondon under 10 years of age; therefore we want a Children's Hospital. "This spring there was a prospectus issued, and divers other means takento this effect:--"There is a great want of sanitary knowledge in women;therefore we want a Women's Hospital. " Now, both the above facts are toosadly true. But what is the deduction? The causes of the enormous childmortality are perfectly well known; they are chiefly want ofcleanliness, want of ventilation, want of whitewashing; in one word, defective _household_ hygiene. The remedies are just as well known; andamong 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 foradults. But the Registrar-General would certainly never think of givingus as a cause for the high rate of child mortality in (say) Liverpoolthat there was not sufficient hospital room for children; nor would heurge upon us, as a remedy, to found an hospital for them. 

Again, women, and the best women, are wofully deficient in sanitaryknowledge; although it is to women that we must look, first and last, for its application, as far as _household_ hygiene is concerned. But whowould ever think of citing the institution of a Women's Hospital as theway to cure this want? We have it, indeed, upon very high authoritythat there is some fear lest hospitals, as they have been _hitherto_, may not have generally increased, rather than diminished, the rate ofmortality--especially of child mortality. 

I. VENTILATION AND WARMING. 

[Sidenote: First rule of nursing, to keep the air within as pure as theair without. ]

The very first canon of nursing, the first and the last thing upon whicha nurse's attention must be fixed, the first essential to a patient, without which all the rest you can do for him is as nothing, with whichI had almost said you may leave all the rest alone, is this: TO KEEP THEAIR HE BREATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHILLING HIM. Yetwhat is so little attended, to? Even where it is thought of at all, themost extraordinary misconceptions reign about it. Even in admitting airinto the patient's room or ward, few people ever think, where that aircomes from. It may come from a corridor into which other wards areventilated, from a hall, always unaired, always full of the fumes ofgas, dinner, of various kinds of mustiness; from an underground kitchen, sink, washhouse, water-closet, or even, as I myself have had sorrowfulexperience, from open sewers loaded with filth; and with this thepatient's room or ward is aired, as it is called--poisoned, it shouldrather be said. Always, air from the air without, and that, too, throughthose windows, through which the air comes freshest. From a closedcourt, especially if the wind do not blow that way, air may come asstagnant as any from a hall or corridor. 

Again, a thing I have often seen both in private houses andinstitutions. A room remains uninhabited; the fireplace is carefullyfastened up with a board; the windows are never opened; probably theshutters are kept always shut; perhaps some kind of stores are kept inthe room; no breath of fresh air can by possibility enter into thatroom, nor any ray of sun. The air is as stagnant, musty, and corrupt asit can by possibility be made. It is quite ripe to breed small-pox, scarlet-fever, diphtheria, or anything else you please. [1]

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

A short time ago a man walked into a back-kitchen in Queen square, andcut the throat of a poor consumptive creature, sitting by the fire. Themurderer did not deny the act, but simply said, "It's all right. " Ofcourse he was mad. 

But in our case, the extraordinary thing is that the victim says, "It'sall right, " and that we are not mad. Yet, although we "nose" themurderers, in the musty unaired unsunned room, the scarlet fever whichis behind the door, or the fever and hospital gangrene which arestalking among the crowded beds of a hospital ward, we say, "It's allright. "

[Sidenote: Without chill. ]

With a proper supply of windows, and a proper supply of fuel in openfire places, fresh air is comparatively easy to secure when your patientor patients are in bed. Never be afraid of open windows then. Peopledon't catch cold in bed. This is a popular fallacy. With properbed-clothes and hot bottles, if necessary, you can always keep a patientwarm in bed, and well ventilate him at the same time. 

But a careless nurse, be her rank and education what it may, will stopup 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. Thetime 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 thetwo-fold exhaustion of dressing and of having had the skin relaxed bymany hours, perhaps days, in bed, and thereby rendered more incapable ofre-action. Then the same temperature which refreshes the patient in bedmay destroy the patient just risen. And common sense will point out, that, while purity of air is essential, a temperature must be securedwhich shall not chill the patient. Otherwise the best that can beexpected will be a feverish re-action. 

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

In the afternoon again, without care, the patient whose vital powershave then risen often finds the room as close and oppressive as he foundit cold in the morning. Yet the nurse will be terrified, if a window isopened. [2]

[Sidenote: Open windows. ]

I know an intelligent humane house surgeon who makes a practice ofkeeping the ward windows open. The physicians and surgeons invariablyclose them while going their rounds; and the house surgeon very properlyas invariably opens them whenever the doctors have turned their backs. 

In a little book on nursing, published a short time ago, we are told, that, "with proper care it is very seldom that the windows cannot beopened for a few minutes twice in the day to admit fresh air fromwithout. " I should think not; nor twice in the hour either. It onlyshows how little the subject has been considered. 

[Sidenote: What kind of warmth desirable. ]

Of all methods of keeping patients warm the very worst certainly is todepend for heat on the breath and bodies of the sick. I have known amedical officer keep his ward windows hermetically closed. Thus exposingthe sick to all the dangers of an infected atmosphere, because he wasafraid that, by admitting fresh air, the temperature of the ward wouldbe too much lowered. This is a destructive fallacy. 

To attempt to keep a ward warm at the expense of making the sickrepeatedly breathe their own hot, humid, putrescing atmosphere is acertain way to delay recovery or to destroy life. 

[Sidenote: Bedrooms almost universally foul. ]

Do you ever go into the bed-rooms of any persons of any class, whetherthey contain one, two, or twenty people, whether they hold sick or well, at night, or before the windows are opened in the morning, and ever findthe air anything but unwholesomely close and foul? And why should it beso? And of how much importance it is that it should not be so? Duringsleep, the human body, even when in health, is far more injured by theinfluence of foul air than when awake. Why can't you keep the air allnight, then, as pure as the air without in the rooms you sleep in? Butfor this, you must have sufficient outlet for the impure air you makeyourselves to go out; sufficient inlet for the pure air from without tocome in. You must have open chimneys, open windows, or ventilators; noclose curtains round your beds; no shutters or curtains to your windows, none of the contrivances by which you undermine your own health ordestroy the chances of recovery of your sick. [3]

[Sidenote: When warmth must be most carefully looked to. ]

A careful nurse will keep a constant watch over her sick, especiallyweak, protracted, and collapsed cases, to guard against the effects ofthe loss of vital heat by the patient himself. In certain diseasedstates much less heat is produced than in health; and there is aconstant tendency to the decline and ultimate extinction of the vitalpowers by the call made upon them to sustain the heat of the body. Caseswhere this occurs should be watched with the greatest care from hour tohour, I had almost said from minute to minute. The feet and legs shouldbe examined by the hand from time to time, and whenever a tendency tochilling is discovered, hot bottles, hot bricks, or warm flannels, withsome warm drink, should be made use of until the temperature isrestored. The fire should be, if necessary, replenished. Patients arefrequently lost in the latter stages of disease from want of attentionto such simple precautions. The nurse may be trusting to the patient'sdiet, or to his medicine, or to the occasional dose of stimulant whichshe is directed to give him, while the patient is all the while sinkingfrom want of a little external warmth. Such cases happen at all times, even during the height of summer. This fatal chill is most apt to occurtowards early morning at the period of the lowest temperature of thetwenty-four hours, and at the time when the effect of the precedingday's diets is exhausted. 

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

All these things require common sense and care. Yet perhaps in no onesingle thing is so little common sense shown, in all ranks, as innursing. [4]

[Sidenote: Cold air not ventilation, nor fresh air a method of chill. ]

The extraordinary confusion between cold and ventilation, even in theminds of well educated people, illustrates this. To make a room cold isby no means necessarily to ventilate it. Nor is it at all necessary, inorder to ventilate a room, to chill it. Yet, if a nurse finds a roomclose, she will let out the fire, thereby making it closer, or she willopen the door into a cold room, without a fire, or an open window in it, by way of improving the ventilation. The safest atmosphere of all for apatient is a good fire and an open window, excepting in extremes oftemperature. (Yet no nurse can ever be made to understand this. ) Toventilate a small room without draughts of course requires more carethan to ventilate a large one. 

[Sidenote: Night air. ]

Another extraordinary fallacy is the dread of night air. What air can webreathe at night but night air? The choice is between pure night airfrom without and foul night air from within. Most people prefer thelatter. An unaccountable choice. What will they say if it is proved tobe true that fully one-half of all the disease we suffer from isoccasioned by people sleeping with their windows shut? An open windowmost nights in the year can never hurt any one. This is not to say thatlight is not necessary for recovery. In great cities, night air is oftenthe best and purest air to be had in the twenty-four hours. I couldbetter understand in towns shutting the windows during the day thanduring the night, for the sake of the sick. The absence of smoke, thequiet, all tend to making night the best time for airing the patients. One of our highest medical authorities on Consumption and Climate hastold me that the air in London is never so good as after ten o'clock atnight. 

[Sidenote: Air from the outside. Open your windows, shut your doors. ]

Always air your room, then, from the outside air, if possible. Windowsare made to open; doors are made to shut--a truth which seems extremelydifficult of apprehension. I have seen a careful nurse airing herpatient's room through the door, near to which were two gaslights, (eachof which consumes as much air as eleven men, ) a kitchen, a corridor, thecomposition of the atmosphere in which consisted of gas, paint, foulair, never changed, full of effluvia, including a current of sewer airfrom an ill-placed sink, ascending in a continual stream by awell-staircase, and discharging themselves constantly into the patient'sroom. The window of the said room, if opened, was all that was desirableto air it. Every room must be aired from without--every passage fromwithout. But the fewer passages there are in a hospital the better. 

[Sidenote: Smoke. ]

If we are to preserve the air within as pure as the air without, it isneedless to say that the chimney must not smoke. Almost all smokychimneys can be cured--from the bottom, not from the top. Often it isonly necessary to have an inlet for air to supply the fire, which isfeeding itself, for want of this, from its own chimney. On the otherhand, almost all chimneys can be made to smoke by a careless nurse, wholets the fire get low and then overwhelms it with coal; not, as weverily believe, in order to spare herself trouble, (for very rare isunkindness to the sick), but from not thinking what she is about. 

[Sidenote: Airing damp things in a patient's room. ]

In laying down the principle that this first object of the nurse must beto keep the air breathed by her patient as pure as the air without, itmust not be forgotten that everything in the room which can give offeffluvia, besides the patient, evaporates itself into his air. And itfollows that there ought to be nothing in the room, excepting him, whichcan give off effluvia or moisture. Out of all damp towels, &c. , whichbecome dry in the room, the damp, of course, goes into the patient'sair. Yet this "of course" seems as little thought of, as if it were anobsolete fiction. How very seldom you see a nurse who acknowledges byher practice that nothing at all ought to be aired in the patient'sroom, 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 leaveshis bed, but not his room, open the sheets wide, and throw thebed-clothes back, in order to air his bed. And she will spread the wettowels or flannels carefully out upon a horse, in order to dry them. Noweither these bed-clothes and towels are not dried and aired, or they dryand air themselves into the patient's air. And whether the damp andeffluvia do him most harm in his air or in his bed, I leave to you todetermine, for I cannot. 

[Sidenote: Effluvia from excreta. ]

Even in health people cannot repeatedly breathe air in which they livewith impunity, on account of its becoming charged with unwholesomematter from the lungs and skin. In disease where everything given offfrom the body is highly noxious and dangerous, not only must there beplenty of ventilation to carry off the effluvia, but everything whichthe patient passes must be instantly removed away, as being more noxiousthan even the emanations from the sick. 

Of the fatal effects of the effluvia from the excreta it would seemunnecessary to speak, were they not so constantly neglected. Concealingthe utensils behind the vallance to the bed seems all the precautionwhich is thought necessary for safety in private nursing. Did you butthink for one moment of the atmosphere under that bed, the saturation ofthe under side of the mattress with the warm evaporations, you would bestartled and frightened too!

[Sidenote: Chamber utensils without lids. ]

The use of any chamber utensil _without a lid_[5] should be utterlyabolished, whether among sick or well. You can easily convince yourselfof the necessity of this absolute rule, by taking one with a lid, andexamining the under side of that lid. It will be found always covered, whenever the utensil is not empty, by condensed offensive moisture. Where does that go, when there is no lid?

Earthenware, or if there is any wood, highly polished and varnishedwood, are the only materials fit for patients' utensils. The very lid ofthe old abominable close-stool is enough to breed a pestilence. Itbecomes saturated with offensive matter, which scouring is only wantedto bring out. I prefer an earthenware lid as being always cleaner. Butthere are various good new-fashioned arrangements. 

[Sidenote: Abolish slop-pails. ]

A slop pail should never be brought into a sick room. It should be arule invariable, rather more important in the private house thanelsewhere, that the utensil should be carried directly to thewater-closet, emptied there, rinsed there, and brought back. Thereshould always be water and a cock in every water-closet for rinsing. Buteven if there is not, you must carry water there to rinse with. I haveactually seen, in the private sick room, the utensils emptied into thefoot-pan, and put back unrinsed under the bed. I can hardly say which ismost abominable, whether to do this or to rinse the utensil _in_ thesick room. In the best hospitals it is now a rule that no slop-pailshall ever be brought into the wards, but that the utensils, shall becarried direct to be emptied and rinsed at the proper place. I would itwere so in the private house. 

[Sidenote: Fumigations. ]

Let no one ever depend upon fumigations, "disinfectants, " and the like, for purifying the air. The offensive thing, not its smell, must beremoved. A celebrated medical lecturer began one day, "Fumigations, gentlemen, are of essential importance. They make such an abominablesmell that they compel you to open the window. " I wish all thedisinfecting fluids invented made such an "abominable smell" that theyforced you to admit fresh air. That would be a useful invention. 

FOOTNOTES:

[1][Sidenote: Why are uninhabited rooms shut up?]

The common idea as to uninhabited rooms is, that they may safely be leftwith doors, windows, shutters, and chimney-board, all closed--hermetically sealed if possible--to keep out the dust, it is said; andthat no harm will happen if the room is but opened a short hour beforethe inmates are put in. I have often been asked the question foruninhabited rooms. --But when ought the windows to be opened? The answeris--When ought they to be shut?

[2]It is very desirable that the windows in a sick room should be such thatthe patient shall, if he can move about, be able to open and shut themeasily himself. In fact, the sick room is very seldom kept aired if thisis not the case--so very few people have any perception of what is ahealthy atmosphere for the sick. The sick man often says, "This roomwhere I spend 22 hours out of the 24, is fresher than the other where Ionly spend 2. Because here I can manage the windows myself. " And it istrue. 

[3][Sidenote: An air-test of essential consequence. ]

Dr. Angus Smith's air test, if it could be made of simpler application, would be invaluable to use in every sleeping and sick room. Just aswithout the use of a thermometer no nurse should ever put a patient intoa bath, so should no nurse, or mother, or superintendent, be without theair test in any ward, nursery, or sleeping-room. If the main function ofa nurse is to maintain the air within the room as fresh as the airwithout, without lowering the temperature, then she should always beprovided with a thermometer which indicates the temperature, with an airtest which indicates the organic matter of the air. But to be used, thelatter must be made as simple a little instrument as the former, andboth should be self-registering. The senses of nurses and mothers becomeso dulled to foul air, that they are perfectly unconscious of what anatmosphere they have let their children, patients, or charges, sleep in. But if the tell-tale air test were to exhibit in the morning, both tonurses and patients, and to the superior officer going round, what theatmosphere has been during the night, I question if any greater securitycould be afforded against a recurrence of the misdemeanor. 

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

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

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

But it is often observed that the nurses who make the greatest outcryagainst open windows, are those who take the least pains to preventdangerous draughts. The door of the patients' room or ward _must_sometimes stand open to allow of persons passing in and out, or heavythings being carried in and out. The careful nurse will keep the doorshut while she shuts the windows, and then, and not before, set the dooropen, so that a patient may not be left sitting up in bed, perhaps in aprofuse perspiration, directly in the draught between the open door andwindow. Neither, of course, should a patient, while being washed, or inany way exposed, remain in the draught of an open window or door. 

[5][Sidenote: Don't make your sick room into a sewer. ]

But never, never should the possession of this indispensable lid confirmyou in the abominable practice of letting the chamber utensil remain ina patient's room unemptied, except once in the 24 hours, i. E. , when thebed is made. Yes, impossible as it may appear, I have known the best andmost attentive nurses guilty of this; aye, and have known, too, apatient afflicted with severe diarrhoea for ten days, and the nurse (avery good one) not know of it, because the chamber utensil (one with alid) was emptied only once in 24 hours, and that by the housemaid whocame in and made the patient's bed every evening. As well might you havea sewer under the room, or think that in a water-closet the plug need bepulled up but once a day. Also take care that your _lid_, as well asyour utensil, be always thoroughly rinsed. 

If a nurse declines to do these kinds of things for her patient, "because it is not her business, " I should say that nursing was not hercalling. I have seen surgical "sisters, " women whose hands were worth tothem two or three guineas a-week, down upon their knees scouring a roomor hut, because they thought it otherwise not fit for their patients togo 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 oftheir sick first, and second only the consideration what it was their"place" to do--and that women who wait for the housemaid to do this, orfor the charwoman to do that, when their patients are suffering, havenot the _making_ of a nurse in them. 

II. HEALTH OF HOUSES. [1]

[Sidenote: Health of houses. Five points essential. ]

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

1. Pure air. 2. Pure water. 3. Efficient drainage. 4. Cleanliness. 5. Light. 

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

[Sidenote: Pure air. ]

1. To have pure air, your house be so constructed as that the outeratmosphere shall find its way with ease to every corner of it. Housearchitects hardly ever consider this. The object in building a house isto obtain the largest interest for the money, not to save doctors' billsto the tenants. But, if tenants should ever become so wise as to refuseto occupy unhealthy constructed houses, and if Insurance Companiesshould ever come to understand their interest so thoroughly as to pay aSanitary Surveyor to look after the houses where their clients live, speculative architects would speedily be brought to their senses. As itis, they build what pays best. And there are always people foolishenough to take the houses they build. And if in the course of time thefamilies die off, as is so often the case, nobody ever thinks of blamingany but Providence[2] for the result. Ill-informed medical men aid insustaining the delusion, by laying the blame on "current contagions. "Badly constructed houses do for the healthy what badly constructedhospitals do for the sick. Once insure that the air in a house isstagnant, and sickness is certain to follow. 

[Sidenote: Pure water. ]

2. Pure water is more generally introduced into houses than it used tobe, thanks to the exertions of the sanitary reformers. Within the lastfew years, a large part of London was in the daily habit of using waterpolluted by the drainage of its sewers and water closets. This hashappily been remedied. But, in many parts of the country, well water ofa very impure kind is used for domestic purposes. And when epidemicdisease shows itself, persons using such water are almost sure tosuffer. 

[Sidenote: Drainage. ]

3. It would be curious to ascertain by inspection, how many houses inLondon are really well drained. Many people would say, surely all ormost of them. But many people have no idea in what good drainageconsists. They think that a sewer in the street, and a pipe leading toit from the house is good drainage. All the while the sewer may benothing but a laboratory from which epidemic disease and ill health isbeing distilled into the house. No house with any untrapped drain pipecommunicating immediately with a sewer, whether it be from water closet, sink, or gully-grate, can ever be healthy. An untrapped sink may at anytime spread fever or pyaemia among the inmates of a palace. 

[Sidenote: Sinks. ]

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 knownwhole houses and hospitals smell of the sink. I have met just as stronga stream of sewer air coming up the back staircase of a grand Londonhouse from the sink, as I have ever met at Scutari; and I have seen therooms in that house all ventilated by the open doors, and the passagesall _un_ventilated by the closed windows, in order that as much of thesewer air as possible might be conducted into and retained in thebed-rooms. It is wonderful. 

Another great evil in house construction is carrying drains underneaththe house. Such drains are never safe. All house drains should begin andend outside the walls. Many people will readily admit, as a theory, theimportance of these things. But how few are there who can intelligentlytrace disease in their households to such causes! Is it not a fact, thatwhen scarlet fever, measles, or small-pox appear among the children, thevery first thought which occurs is, "where" the children can have"caught" the disease? And the parents immediately run over in theirminds all the families with whom they may have been. They never think oflooking at home for the source of the mischief. If a neighbour's childis seized with small-pox, the first question which occurs is whether ithad been vaccinated. No one would undervalue vaccination; but it becomesof doubtful benefit to society when it leads people to look abroad forthe source of evils which exist at home. 

[Sidenote: Cleanliness. ]

4. Without cleanliness, within and without your house, ventilation iscomparatively useless. In certain foul districts of London, poor peopleused to object to open their windows and doors because of the foulsmells that came in. Rich people like to have their stables and dunghillnear their houses. But does it ever occur to them that with manyarrangements of this kind it would be safer to keep the windows shutthan open? You cannot have the air of the house pure with dung-heapsunder the windows. These are common all over London. And yet people aresurprised that their children, brought up in large "well-aired"nurseries and bed-rooms suffer from children's epidemics. If theystudied Nature's laws in the matter of children's health, they would notbe so surprised. 

There are other ways of having filth inside a house besides having dirtin heaps. Old papered walls of years' standing, dirty carpets, uncleansed furniture, are just as ready sources of impurity to the airas if there were a dung-heap in the basement. People are so unaccustomedfrom education and habits to consider how to make a home healthy, thatthey either never think of it at all, and take every disease as a matterof course, to be "resigned to" when it comes "as from the hand ofProvidence;" or if they ever entertain the idea of preserving the healthof their household as a duty, they are very apt to commit all kinds of"negligences and ignorances" in performing it. 

[Sidenote: Light. ]

5. A dark house is always an unhealthy house, always an ill-aired house, always a dirty house. Want of light stops growth, and promotes scrofula, rickets, &c. , among the children. 

People lose their health in a dark house, and if they get ill theycannot get well again in it. More will be said about this farther on. 

[Sidenote: Three common errors in managing the health of houses. ]

Three out of many "negligences, and ignorances" in managing the healthof houses generally, I will here mention as specimens--1. That thefemale head in charge of any building does not think it necessary tovisit every hole and corner of it every day. How can she expect thosewho are under her to be more careful to maintain her house in a healthycondition than she who is in charge of it?--2. That it is not consideredessential to air, to sun, and to clean rooms while uninhabited; which issimply ignoring the first elementary notion of sanitary things, andlaying the ground ready for all kinds of diseases. --3. That the window, and one window, is considered enough to air a room. Have you neverobserved that any room without a fire-place is always close? And, if youhave 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 thechimney--to prevent the soot from coming down, you say? If your chimneyis foul, sweep it; but don't expect that you can ever air a room withonly one aperture; don't suppose that to shut up a room is the way tokeep it clean. It is the best way to foul the room and all that is init. Don't imagine that if you, who are in charge, don't look to allthese things yourself, those under you will be more careful than youare. It appears as if the part of a mistress now is to complain of herservants, and to accept their excuses--not to show them how there needbe neither complaints made nor excuses. 

[Sidenote: Head in charge must see to House Hygiene, not do it herself. ]

But again, to look to all these things yourself does not mean to do themyourself. "I always open the windows, " the head in charge often says. Ifyou do it, it is by so much the better, certainly, than if it were notdone at all. But can you not insure that it is done when not done byyourself? 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 itis, too. The former only implies that just what you can do with your ownhands is done. The latter that what ought to be done is always done. 

[Sidenote: Does God think of these things so seriously?]

And now, you think these things trifles, or at least exaggerated. Butwhat you "think" or what I "think" matters little. Let us see what Godthinks of them. God always justifies His ways. While we are thinking, Hehas been teaching. I have known cases of hospital pyaemia quite assevere in handsome private houses as in any of the worst hospitals, andfrom the same cause, viz. , foul air. Yet nobody learnt the lesson. Nobody learnt _anything_ at all from it. They went on _thinking_--thinking that the sufferer had scratched his thumb, or that it wassingular that "all the servants" had "whitlows, " or that something was"much about this year; there is always sickness in our house. " This is afavourite mode of thought--leading not to inquire what is the uniformcause of these general "whitlows, " but to stifle all inquiry. In whatsense is "sickness" being "always there, " a justification of its being"there" at all?

[Sidenote: How does He carry out His laws?]

[Sidenote: How does He teach His laws?]

I will tell you what was the cause of this hospital pyaemia being inthat large private house. It was that the sewer air from an ill-placedsink was carefully conducted into all the rooms by sedulously openingall the doors, and closing all the passage windows. It was that theslops were emptied into the foot pans!--it was that the utensils werenever properly rinsed;--it was that the chamber crockery was rinsed withdirty water;--it was that the beds were never properly shaken, aired, picked to pieces, or changed. It was that the carpets and curtains werealways musty;--it was that the furniture was always dusty;--it was thatthe papered walls were saturated with dirt;--it was that the floors werenever cleaned;--it was that the uninhabited rooms were never sunned, orcleaned, or aired;--it was that the cupboards were always reservoirs offoul air;--it was that the windows were always tight shut up at night;--it was that no window was ever systematically opened even in the day, orthat the right window was not opened. A person gasping for air mightopen a window for himself. But the servants were not taught to open thewindows, to shut the doors; or they opened the windows upon a dank wellbetween high walls, not upon the airier court; or they opened the roomdoors into the unaired halls and passages, by way of airing the rooms. Now all this is not fancy, but fact. In that handsome house I have knownin one summer three cases of hospital pyaemia, one of phlebitis, two ofconsumptive cough; all the _immediate_ products of foul air. When, intemperate climates, a house is more unhealthy in 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 notlearning. This poor body loses his finger, that one loses his life. Andall from the most easily preventible causes. [3]

[Sidenote: Physical degeneration in families. Its causes. ]

The houses of the grandmothers and great grandmothers of thisgeneration, at least the country houses, with front door and back dooralways standing open, winter and summer, and a thorough draught alwaysblowing through--with all the scrubbing, and cleaning, and polishing, and scouring which used to go on, the grandmothers, and still more thegreat grandmothers, always out of doors and never with a bonnet onexcept to go to church, these things entirely account for the fact sooften seen of a great grandmother, who was a tower of physical vigourdescending into a grandmother perhaps a little less vigorous but stillsound as a bell and healthy to the core, into a mother languid andconfined to her carriage and house, and lastly into a daughter sicklyand confined to her bed. For, remember, even with a general decrease ofmortality you may often find a race thus degenerating and still oftenera family. You may see poor little feeble washed-out rags, children of anoble stock, suffering morally and physically, throughout their useless, degenerate lives, and yet people who are going to marry and to bringmore such into the world, will consult nothing but their own convenienceas to where they are to live, or how they are to live. 

[Sidenote: Don't make your sickroom into a ventilating shaft for thewhole house. ]

With regard to the health of houses where there is a sick person, itoften happens that the sick room is made a ventilating shaft for therest of the house. For while the house is kept as close, unaired, anddirty as usual, the window of the sick room is kept a little openalways, and the door occasionally. Now, there are certain sacrificeswhich 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'tit keep itself thoroughly clean and unusually well aired, in deferenceto the sick person?

[Sidenote: Infection. ]

We must not forget what, in ordinary language, is called"Infection;"[4]--a thing of which people are generally so afraid thatthey frequently follow the very practice in regard to it which theyought to avoid. Nothing used to be considered so infectious orcontagious as small-pox; and people not very long ago used to cover uppatients with heavy bed clothes, while they kept up large fires and shutthe windows. Small-pox, of course, under this _regime_, is very"infectious. " People are somewhat wiser now in their management of thisdisease. They have ventured to cover the patients lightly and to keepthe windows open; and we hear much less of the "infection" of small-poxthan we used to do. But do people in our days act with more wisdom onthe subject of "infection" in fevers--scarlet fever, measles, &c. --thantheir forefathers did with small-pox? Does not the popular idea of"infection" involve that people should take greater care of themselvesthan of the patient? that, for instance, it is safer not to be too muchwith the patient, not to attend too much to his wants? Perhaps the bestillustration of the utter absurdity of this view of duty in attending on"infectious" diseases is afforded by what was very recently thepractice, if it is not so even now, in some of the European lazarets--inwhich the plague-patient used to be condemned to the horrors of filth, overcrowding, and want of ventilation, while the medical attendant wasordered to examine the patient's tongue through an opera-glass and totoss him a lancet to open his abscesses with?

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

Wise and humane management of the patient is the best safeguard againstinfection. 

[Sidenote: Why must children have measles, &c. , ]

There are not a few popular opinions, in regard to which it is useful attimes to ask a question or two. For example, it is commonly thought thatchildren must have what are commonly called "children's epidemics, ""current contagions, " &c. , in other words, that they are born to havemeasles, hooping-cough, perhaps even scarlet fever, just as they areborn to cut their teeth, if they live. 

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

Oh because, you say, we cannot keep it from infection--other childrenhave 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 mustyours have them too?

If you believed in and observed the laws for preserving the health ofhouses which inculcate cleanliness, ventilation, white-washing, andother means, and which, by the way, _are laws_, as implicitly as youbelieve in the popular opinion, for it is nothing more than an opinion, that your child must have children's epidemics, don't you think thatupon the whole your child would be more likely to escape altogether?

FOOTNOTES:

[1][Sidenote: Health of carriages. ]

The health of carriages, especially close carriages, is not ofsufficient universal importance to mention here, otherwise thancursorily. Children, who are always the most delicate test of sanitaryconditions, generally cannot enter a close carriage without being sick--and very lucky for them that it is so. A close carriage, with thehorse-hair cushions and linings always saturated with organic matter, ifto this be added the windows up, is one of the most unhealthy of humanreceptacles. The idea of taking an _airing_ in it is somethingpreposterous. Dr. Angus Smith has shown that a crowded railway carriage, which goes at the rate of 30 miles an hour, is as unwholesome as thestrong smell of a sewer, or as a back yard in one of the most unhealthycourts off one of the most unhealthy streets in Manchester. 

[2]God lays down certain physical laws. Upon His carrying out such lawsdepends our responsibility (that much abused word), for how could wehave any responsibility for actions, the results of which we could notforesee--which would be the case if the carrying out of His laws werenot certain. Yet we seem to be continually expecting that He will work amiracle--i. E. , break His own laws expressly to relieve us ofresponsibility. 

[3][Sidenote: Servants rooms. ]

I must say a word about servants' bed-rooms. From the way they arebuilt, but oftener from the way they are kept, and from no intelligentinspection whatever being exercised over them, they are almostinvariably dens of foul air, and the "servants' health" suffers in an"unaccountable" (?) way, even in the country. For I am by no meansspeaking only of London houses, where too often servants are put to liveunder the ground and over the roof. But in a country "_mansion_, " whichwas really a "mansion, " (not after the fashion of advertisements, ) Ihave known three maids who slept in the same room ill of scarlet fever. "How catching it is, " was of course the remark. One look at the room, one smell of the room, was quite enough. It was no longer"unaccountable. " The room was not a small one; it was up stairs, and ithad two large windows--but nearly every one of the neglects enumeratedabove was there. 

[4][Sidenote: Diseases are not individuals arranged in classes, like catsand dogs, but conditions growing out of one another. ]

Is it not living in a continual mistake to look upon diseases, as we donow, as separate entities, which _must_ exist, like cats and dogs?instead of looking upon them as conditions, like a dirty and a cleancondition, and just as much under our own control; or rather as thereactions of kindly nature, against the conditions in which we haveplaced ourselves. 

I was brought up, both by scientific men and ignorant women, distinctlyto believe that small-pox, for instance, was a thing of which there wasonce a first specimen in the world, which went on propagating itself, ina perpetual chain of descent, just as much as that there was a firstdog, (or a first pair of dogs, ) and that small-pox would not beginitself any more than a new dog would begin without there having been aparent dog. 

Since then I have seen with my eyes and smelt with my nose small-poxgrowing up in first specimens, either in close rooms, or in overcrowdedwards, where it could not by any possibility have been "caught, " butmust have begun. Nay, more, I have seen diseases begin, grow up, andpass into one another. Now, dogs do not pass into cats. 

I have seen, for instance, with a little overcrowding, continued fevergrow 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 upondisease in this light?

For diseases, as all experiences hows, [Transcriber's note: Possibly typofor "show"] are adjectives, not noun substantives. 

III. PETTY MANAGEMENT. 

[Sidenote: Petty management. ]

All the results of good nursing, as detailed in these notes, may bespoiled or utterly negatived by one defect, viz. : in petty management, or in other words, by not knowing how to manage that what you do whenyou are there, shall be done when you are not there. The most devotedfriend or nurse cannot be always _there_. Nor is it desirable that sheshould. And she may give up her health, all her other duties, and yet, for want of a little management, be not one-half so efficient as anotherwho is not one-half so devoted, but who has this art of multiplyingherself--that is to say, the patient of the first will not really be sowell cared for, as the patient of the second. 

It is as impossible in a book to teach a person in charge of sick how to_manage_, as it is to teach her how to nurse. Circumstances must varywith each different case. But it _is_ possible to press upon her tothink for herself: Now what does happen during my absence? I am obligedto be away on Tuesday. But fresh air, or punctuality is not lessimportant 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 himat 10 than it was at 5 minutes to 10. 

Curious as it may seem, this very obvious consideration occurscomparatively to few, or, if it does occur, it is only to cause thedevoted friend or nurse to be absent fewer hours or fewer minutes fromher patient--not to arrange so as that no minute and no hour shall befor her patient without the essentials of her nursing. 

[Sidenote: Illustrations of the want of it. ]

A very few instances will be sufficient, not as precepts, but asillustrations. 

[Sidenote: Strangers coming into the sick room. ]

A strange washerwoman, coming late at night for the "things, " will burstin by mistake to the patient's sickroom, after he has fallen into hisfirst doze, giving him a shock, the effects of which are irremediable, though he himself laughs at the cause, and probably never even mentionsit. The nurse who is, and is quite right to be, at her supper, has notprovided that the washerwoman shall not lose her way and go into thewrong room. 

[Sidenote: Sick room airing the whole house. ]

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

[Sidenote: Uninhabited room fouling the whole house. ]

An uninhabited room, a newly-painted room, [1] an uncleaned closet orcupboard, may often become the reservoir of foul air for the wholehouse, because the person in charge never thinks of arranging that theseplaces shall be always aired, always cleaned; she merely opens thewindow herself "when she goes in. "

[Sidenote: Delivery and non-delivery of letters and messages. ]

An agitating letter or message may be delivered, or an important letteror message _not_ delivered; a visitor whom it was of consequence to see, may be refused, or whom it was of still more consequence to _not_ seemay be admitted--because the person in charge has never asked herselfthis question, What is done when I am not there?[2]

At all events, one may safely say, a nurse cannot be with the patient, open the door, eat her meals, take a message, all at one and the sametime. Nevertheless the person in charge never seems to look theimpossibility in the face. 

Add to this that the _attempting_ this impossibility does more toincrease the poor patient's hurry and nervousness than anything else. 

[Sidenote: Partial measures such as "being always in the way" yourself, increase instead of saving the patient's anxiety. Because they must beonly partial. ]

It is never thought that the patient remembers these things if you donot. 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 whenit may arrive. So that your _partial_ measures for "being in the way"yourself, only increase the necessity for his thought. 

Whereas, if you could but arrange that the thing should always be donewhether you are there or not, he need never think at all about it. 

For the above reasons, whatever a patient _can_ do for himself, it isbetter, i. E. Less anxiety, for him to do for himself, unless the personin charge has the spirit of management. 

It is evidently much less exertion for a patient to answer a letter forhimself by return of post, than to have four conversations, wait fivedays, have six anxieties before it is off his mind, before the personwho has to answer it has done so. 

Apprehension, uncertainty, waiting, expectation, fear of surprise, do apatient more harm than any exertion. Remember, he is face to face withhis enemy all the time, internally wrestling with him, having longimaginary conversations with him. You are thinking of something else. "Rid him of his adversary quickly, " is a first rule with the sick. [3]

For the same reasons, always tell a patient and tell him beforehand whenyou are going out and when you will be back, whether it is for a day, anhour, or ten minutes. You fancy perhaps that it is better for him if hedoes not find out your going at all, better for him if you do not makeyourself "of too much importance" to him; or else you cannot bear togive him the pain or the anxiety of the temporary separation. 

No such thing. You _ought_ to go, we will suppose. Health or dutyrequires it. Then say so to the patient openly. If you go without hisknowing it, and he finds it out, he never will feel secure again thatthe things which depend upon you will be done when you are away, and innine cases out of ten he will be right. If you go out without tellinghim when you will be back, he can take no measures nor precautions as tothe things which concern you both, or which you do for him. 

[Sidenote: What is the cause of half the accidents which happen?]

If you look into the reports of trials or accidents, and especially ofsuicides, or into the medical history of fatal cases, it is almostincredible how often the whole thing turns upon something which hashappened because "he, " or still oftener "she, " "was not there. " But itis still more incredible how often, how almost always this is acceptedas a sufficient reason, a justification; why, the very fact of the thinghaving happened is the proof of its not being a justification. Theperson in charge was quite right not to be "_there_, " he was called awayfor quite sufficient reason, or he was away for a daily recurring andunavoidable cause; yet no provision was made to supply his absence. Thefault was not in his "being away, " but in there being no management tosupplement his "being away. " When the sun is under a total eclipse orduring his nightly absence, we light candles. But it would seem as if itdid not occur to us that we must also supplement the person in charge ofsick or of children, whether under an occasional eclipse or during aregular absence. 

In institutions where many lives would be lost and the effect of suchwant of management would be terrible and patent, there is less of itthan in the private house. [4]

But in both, let whoever is in charge keep this simple question in herhead (_not, _ how can I always do this right thing myself, but) how can Iprovide for this right thing to be always done?

Then, when anything wrong has actually happened in consequence of herabsence, which absence we will suppose to have been quite right, let herquestion still be (_not, _ how can I provide against any more of suchabsences? which is neither possible nor desirable, but) how can Iprovide against anything wrong arising out of my absence?

[Sidenote: What it is to be "in charge. "]

How few men, or even women, understand, either in great or in littlethings, what it is the being "in charge"--I mean, know how to carry outa "charge. " From the most colossal calamities, down to the most triflingaccidents, results are often traced (or rather _not_ traced) to suchwant of some one "in charge" or of his knowing how to be "in charge. " Ashort time ago the bursting of a funnel-casing on board the finest andstrongest ship that ever was built, on her trial trip, destroyed severallives and put several hundreds in jeopardy--not from any undetected flawin her new and untried works--but from a tap being closed which oughtnot to have been closed--from what every child knows would make itsmother's tea-kettle burst. And this simply because no one seemed to knowwhat it is to be "in charge, " or _who_ was in charge. Nay more, the juryat the inquest actually altogether ignored the same, and apparentlyconsidered the tap "in charge, " for they gave as a verdict "accidentaldeath. "

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

To be "in charge" is certainly not only to carry out the propermeasures yourself but to see that every one else does so too; to seethat no one either wilfully or ignorantly thwarts or prevents suchmeasures. It is neither to do everything yourself nor to appoint anumber of people to each duty, but to ensure that each does that duty towhich he is appointed. This is the meaning which must be attached to theword by (above all) those "in charge" of sick, whether of numbers or ofindividuals, (and indeed I think it is with individual sick that it isleast understood. One sick person is often waited on by four with lessprecision, and is really less cared for than ten who are waited on byone; or at least than 40 who are waited on by 4; and all for want ofthis one person "in charge. ")

It is often said that there are few good servants now; I say there arefew good mistresses now. As the jury seems to have thought the tap wasin charge of the ship's safety, so mistresses now seem to think thehouse is in charge of itself. They neither know how to give orders, norhow to teach their servants to obey orders--_i. E. _, to obeyintelligently, which is the real meaning of all discipline. 

Again, people who are in charge often seem to have a pride in feelingthat they will be "missed, " that no one can understand or carry on theirarrangements, their system, books, accounts, &c. , but themselves. Itseems to me that the pride is rather in carrying on a system, in keepingstores, closets, books, accounts, &c. , so that any body can understandand carry them on--so that, in case of absence or illness, one candeliver every thing up to others and know that all will go on as usual, and that one shall never be missed. 

[Sidenote: Why hired nurses give so much trouble. ]

NOTE. --It is often complained, that professional nurses, brought intoprivate families, in case of sickness, make themselves intolerable by"ordering about" the other servants, under plea of not neglecting thepatient. Both things are true; the patient is often neglected, and theservants are often unfairly "put upon. " But the fault is generally inthe want of management of the head in charge. It is surely for her toarrange both that the nurse's place is, when necessary, supplemented, and that the patient is never neglected--things with a littlemanagement quite compatible, and indeed only attainable together. It iscertainly not for the nurse to "order about" the servants. 

FOOTNOTES:

[1][Sidenote: Lingering smell of paint a want of care. ]

That excellent paper, the _Builder_, mentions the lingering of the smellof paint for a month about a house as a proof of want of ventilation. Certainly--and, where there are ample windows to open, and these arenever opened to get rid of the smell of paint, it is a proof of want ofmanagement in using the means of ventilation. Of course the smell willthen remain for months. Why should it go?

[2][Sidenote: Why let your patient ever be surprised?]

Why should you let your patient ever be surprised, except by thieves? Ido not know. In England, people do not come down the chimney, or throughthe window, unless they are thieves. They come in by the door, andsomebody must open the door to them. The "somebody" charged with openingthe door is one of two, three, or at most four persons. Why cannotthese, at most, four persons be put in charge as to what is to be donewhen there is a ring at the door-bell?

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

[3]There are many physical operations where _coeteris paribus_ the dangeris in a direct ratio to the time the operation lasts; and _coeterisparibus_ the operator's success will be in direct ratio to hisquickness. Now there are many mental operations where exactly the samerule holds good with the sick; _coeteris paribus_ their capability ofbearing such operations depends directly on the quickness, _withouthurry_, with which they can be got through. 

[4][Sidenote: Petty management better understood in institutions than inprivate houses. ]

So true is this that I could mention two cases of women of very highposition, both of whom died in the same way of the consequences of asurgical operation. And in both cases, I was told by the highestauthority that the fatal result would not have happened in a Londonhospital. 

[Sidenote: What institutions are the exception?]

But, as far as regards the art of petty management in hospitals, all themilitary hospitals I know must be excluded. Upon my own experience Istand, and I solemnly declare that I have seen or known of fatalaccidents, such as suicides in _delirium 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 havehappened in London civil hospitals nursed by women. The medical officersshould be absolved from all blame in these accidents. How can a medicalofficer mount guard all day and all night over a patient (say) in_delirium tremens?_ The fault lies in there being no organized systemof attendance. Were a trustworthy _man_ in charge of each ward, or setof wards, not as office clerk, but as head nurse, (and head nurse thebest hospital serjeant, or ward master, is not now and cannot be, fromdefault of the proper regulations, ) the thing would not, in allprobability, have happened. But were a trustworthy _woman_ in charge ofthe ward, or set of wards, the thing would not, in all certainty, havehappened. In other words, it does not happen where a trustworthy womanis really in charge. And, in these remarks, I by no means refer only toexceptional times of great emergency in war hospitals, but also, andquite as much, to the ordinary run of military hospitals at home, intime of peace; or to a time in war when our army was actually morehealthy than at home in peace, and the pressure on our hospitalsconsequently much less. 

[Sidenote: Nursing in Regimental Hospitals. ]

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

Now, have those who say this, considered that, in order to obey, youmust know _how_ to obey, and that these soldiers certainly do not knowhow to obey in nursing. I have seen these "kind" fellows (and how kindthey are no one knows so well as myself) move a comrade so that, in onecase at least, the man died in the act. I have seen the comrades'"kindness" produce abundance of spirits, to be drunk in secret. Let noone understand by this that female nurses ought to, or could beintroduced in regimental hospitals. It would be most undesirable, evenwere it not impossible. But the head nurseship of a hospital serjeant isthe more essential, the more important, the more inexperienced thenurses. Undoubtedly, a London hospital "sister" does sometimes setrelays of patients to watch a critical case; but, undoubtedly also, always under her own superintendence; and she is called to wheneverthere is something to be done, and she knows how to do it. The patientsare not left to do it of their own unassisted genius, however "kind" andwilling they may be. 

IV. NOISE. 

[Sidenote: Unnecessary noise. ]

Unnecessary noise, or noise that creates an expectation in the mind, isthat which hurts a patient. It is rarely the loudness of the noise, theeffect upon the organ of the ear itself, which appears to affect thesick. How well a patient will generally bear, _e. G. _, the putting up ofa scaffolding close to the house, when he cannot bear the talking, stillless the whispering, especially if it be of a familiar voice, outsidehis door. 

There are certain patients, no doubt, especially where there is slightconcussion or other disturbance of the brain, who are affected by merenoise. But intermittent noise, or sudden and sharp noise, in these as inall other cases, affects far more than continuous noise--noise with jarfar more than noise without. Of one thing you may be certain, thatanything which wakes a patient suddenly out of his sleep will invariablyput him into a state of greater excitement, do him more serious, aye, and lasting mischief, than any continuous noise, however loud. 

[Sidenote: Never let a patient be waked out of his first sleep. ]

Never to allow a patient to be waked, intentionally or accidentally, isa _sine qua non_ of all good nursing. If he is roused out of his firstsleep, he is almost certain to have no more sleep. It is a curious butquite 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 intensifiesitself. If you have gained a respite of either in sleep you have gainedmore than the mere respite. Both the probability of recurrence and ofthe same intensity will be diminished; whereas both will be terriblyincreased by want of sleep. This is the reason why sleep is soall-important. This is the reason why a patient waked in the early partof his sleep loses not only his sleep, but his power to sleep. A healthyperson who allows himself to sleep during the day will lose his sleep atnight. But it is exactly the reverse with the sick generally; the morethey sleep, the better will they be able to sleep. 

[Sidenote: Noise which excites expectation. ]

[Sidenote: Whispered conversation in the room. ]

I have often been surprised at the thoughtlessness, (resulting incruelty, quite unintentionally) of friends or of doctors who will hold along conversation just in the room or passage adjoining to the room ofthe patient, who is either every moment expecting them to come in, orwho has just seen them, and knows they are talking about him. If he isan amiable patient, he will try to occupy his attention elsewhere andnot to listen--and this makes matters worse--for the strain upon hisattention and the effort he makes are so great that it is well if he isnot worse for hours after. If it is a whispered conversation in the sameroom, then it is absolutely cruel; for it is impossible that thepatient's attention should not be involuntarily strained to hear. Walking on tip-toe, doing any thing in the room very slowly, areinjurious, for exactly the same reasons. A firm light quick step, asteady quick hand are the desiderata; not the slow, lingering, shufflingfoot, the timid, uncertain touch. Slowness is not gentleness, though itis often mistaken for such: quickness, lightness, and gentleness arequite compatible. Again, if friends and doctors did but watch, as nursescan and should watch, the features sharpening, the eyes growing almostwild, of fever patients who are listening for the entrance from thecorridor of the persons whose voices they are hearing there, these wouldnever run the risk again of creating such expectation, or irritation ofmind. --Such unnecessary noise has undoubtedly induced or aggravateddelirium in many cases. I have known such--in one case death ensued. Itis but fair to say that this death was attributed to fright. It was theresult of a long whispered conversation, within sight of the patient, about an impending operation; but any one who has known the more thanstoicism, the cheerful coolness, with which the certainty of anoperation will be accepted by any patient, capable of bearing anoperation at all, if it is properly communicated to him, will hesitateto believe that it was mere fear which produced, as was averred, thefatal result in this instance. It was rather the uncertainty, thestrained expectation as to what was to be decided upon. 

[Sidenote: Or just outside the door. ]

I need hardly say that the other common cause, namely, for a doctor orfriend to leave the patient and communicate his opinion on the result ofhis visit to the friends just outside the patient's door, or in theadjoining room, after the visit, but within hearing or knowledge of thepatient is, if possible, worst of all. 

[Sidenote: Noise of female dress. ]

It is, I think, alarming, peculiarly at this time, when the femaleink-bottles are perpetually impressing upon us "woman's" "particularworth and general missionariness, " to see that the dress of women isdaily more and more unfitting them for any "mission, " or usefulness atall. It is equally unfitted for all poetic and all domestic purposes. Aman is now a more handy and far less objectionable being in a sick roomthan a woman. Compelled by her dress, every woman now either shuffles orwaddles--only a man can cross the floor of a sick-room without shakingit! What is become of woman's light step?--the firm, light, quick stepwe have been asking for?

Unnecessary noise, then, is the most cruel absence of care which can beinflicted either on sick or well. For, in all these remarks, the sickare only mentioned as suffering in a greater proportion than the wellfrom precisely the same causes. 

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

[Sidenote: Patient's repulsion to nurses who rustle. ]

All doctrines about mysterious affinities and aversions will be found toresolve themselves very much, if not entirely, into presence or absenceof care in these things. 

A nurse who rustles (I am speaking of nurses professional andunprofessional) is the horror of a patient, though perhaps he does notknow why. 

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

The noiseless step of woman, the noiseless drapery of woman, are merefigures of speech in this day. Her skirts (and well if they do not throwdown some piece of furniture) will at least brush against every articlein the room as she moves. [1]

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

A good nurse will always make sure that no door or window in herpatient's room shall rattle or creak; that no blind or curtain shall, byany change of wind through the open window be made to flap--especiallywill she be careful of all this before she leaves her patients for thenight. If you wait till your patients tell you, or remind you of thesethings, where is the use of their having a nurse? There are more shythan exacting patients, in all classes; and many a patient passes a badnight, time after time, rather than remind his nurse every night of allthe things she has forgotten. 

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

[Sidenote: Hurry peculiarly hurtful to sick. ]

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

[Sidenote: How to visit the sick and not hurt them. ]

Always sit within the patient's view, so that when you speak to him hehas not painfully to turn his head round in order to look at you. Everybody involuntarily looks at the person speaking. If you make thisact 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 hiseyes to see you. Be as motionless as possible, and never gesticulate inspeaking to the sick. 

Never make a patient repeat a message or request, especially if it besome time after. Occupied patients are often accused of doing too muchof their own business. They are instinctively right. How often you hearthe person, charged with the request of giving the message or writingthe letter, say half an hour afterwards to the patient, "Did you appoint12 o'clock?" or, "What did you say was the address?" or ask perhaps somemuch more agitating question--thus causing the patient the effort ofmemory, or worse still, of decision, all over again. It is really lessexertion to him to write his letters himself. This is the almostuniversal experience of occupied invalids. 

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

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

[Sidenote: These things not fancy. ]

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

[Sidenote: Interruption damaging to sick. ]

If the invalid is forced, by his avocations, to continue occupationsrequiring much thinking, the injury is doubly great. In feeding apatient suffering under delirium or stupor you may suffocate him, bygiving him his food suddenly, but if you rub his lips gently with aspoon and thus attract his attention, he will swallow the foodunconsciously, but with perfect safety. Thus it is with the brain. Ifyou offer it a thought, especially one requiring a decision, abruptly, you do it a real not fanciful injury. Never speak to a sick personsuddenly; but, at the same time, do not keep his expectation on thetiptoe. 

[Sidenote: And to well. ]

This rule, indeed, applies to the well quite as much as to the sick. Ihave never known persons who exposed themselves for years to constantinterruption who did not muddle away their intellects by it at last. Theprocess with them may be accomplished without pain. With the sick, paingives warning of the injury. 

[Sidenote: Keeping a patient standing. ]

Do not meet or overtake a patient who is moving about in order to speakto him, or to give him any message or letter. You might just as wellgive him a box on the ear. I have seen a patient fall flat on the groundwho was standing when his nurse came into the room. This was an accidentwhich might have happened to the most careful nurse. But the other isdone with intention. A patient in such a state is not going to the EastIndies. If you would wait ten seconds, or walk ten yards further, anypromenade he could make would be over. You do not know the effort it isto a patient to remain standing for even a quarter of a minute to listento you. If I had not seen the thing done by the kindest nurses andfriends, I should have thought this caution quite superfluous. [2]

[Sidenote: Patients dread surprise. ]

Patients are often accused of being able to "do much more when nobody isby. " It is quite true that they can. Unless nurses can be brought toattend to considerations of the kind of which we have given here but afew specimens, a very weak patient finds it really much less exertion todo things for himself than to ask for them. And he will, in order to dothem, (very innocently and from instinct) calculate the time his nurseis likely to be absent, from a fear of her "coming in upon" him orspeaking to him, just at the moment when he finds it quite as much as hecan do to crawl from his bed to his chair, or from one room to another, or down stairs, or out of doors for a few minutes. Some extra call madeupon his attention at that moment will quite upset him. In these casesyou may be sure that a patient in the state we have described does notmake such exertions more than once or twice a day, and probably muchabout the same hour every day. And it is hard, indeed, if nurse andfriends cannot calculate so as to let him make them undisturbed. Remember, that many patients can walk who cannot stand or even sit up. Standing is, of all positions, the most trying to a weak patient. 

Everything you do in a patient's room, after he is "put up" for thenight, increases tenfold the risk of his having a bad night. But, if yourouse him up after he has fallen asleep, you do not risk, you secure hima bad night. 

One hint I would give to all who attend or visit the sick, to all whohave to pronounce an opinion upon sickness or its progress. Come backand look at your patient _after_ he has had an hour's animatedconversation with you. It is the best test of his real state we know. But never pronounce upon him from merely seeing what he does, or how helooks, during such a conversation. Learn also carefully and exactly, ifyou can, how he passed the night after it. 

[Sidenote: Effects of over-exertion on sick. ]

People rarely, if ever, faint while making an exertion. It is after itis over. Indeed, almost every effect of over-exertion appears after, notduring such exertion. It is the highest folly to judge of the sick, asis so often done, when you see them merely during a period ofexcitement. People have very often died of that which, it has beenproclaimed at the time, has "done them no harm. "[3]

Remember never to lean against, sit upon, or unnecessarily shake, oreven touch the bed in which a patient lies. This is invariably a painfulannoyance. If you shake the chair on which he sits, he has a point bywhich to steady himself, in his feet. But on a bed or sofa, he isentirely at your mercy, and he feels every jar you give him all throughhim. 

[Sidenote: Difference between real and fancy patients. ]

In all that we have said, both here and elsewhere, let it be distinctlyunderstood that we are not speaking of hypochondriacs. To distinguishbetween real and fancied disease forms an important branch of theeducation of a nurse. To manage fancy patients forms an important branchof her duties. But the nursing which real and that which fanciedpatients require is of different, or rather of opposite, character. Andthe latter will not be spoken of here. Indeed, many of the symptomswhich are here mentioned are those which distinguish real from fancieddisease. 

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

[Sidenote: Conciseness necessary with sick. ]

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

[Sidenote: Irresolution most painful to them. ]

Irresolution is what all patients most dread. Rather than meet this inothers, they will collect all their data, and make up their minds forthemselves. A change of mind in others, whether it is regarding anoperation, or re-writing a letter, always injures the patient more thanthe being called upon to make up his mind to the most dreaded ordifficult decision. Farther than this, in very many cases, theimagination in disease is far more active and vivid than it is inhealth. If you propose to the patient change of air to one place onehour, and to another the next, he has, in each case, immediatelyconstituted himself in imagination the tenant of the place, gone overthe whole premises in idea, and you have tired him as much by displacinghis imagination, as if you had actually carried him over both places. 

Above all, leave the sick room quickly and come into it quickly, notsuddenly, not with a rush. But don't let the patient be wearily waitingfor 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, arenecessary in the sick room, as necessary as absence of hurry and bustle. To possess yourself entirely will ensure you from either failing--eitherloitering or hurrying. 

[Sidenote: What a patient must not have to see to. ]

If a patient has to see, not only to his own but also to his nurse'spunctuality, or perseverance, or readiness, or calmness, to any or allof these things, he is far better without that nurse than with her--however valuable and handy her services may otherwise be to him, andhowever incapable he may be of rendering them to himself. 

[Sidenote: Reading aloud. ]

With regard to reading aloud in the sick room, my experience is, thatwhen the sick are too ill to read to themselves, they can seldom bear tobe read to. Children, eye-patients, and uneducated persons areexceptions, or where there is any mechanical difficulty in reading. People who like to be read to, have generally not much the matter withthem; while in fevers, or where there is much irritability of brain, theeffort of listening to reading aloud has often brought on delirium. Ispeak with great diffidence; because there is an almost universalimpression that it is _sparing_ the sick to read aloud to them. But twothings are certain:--

[Sidenote: Read aloud slowly, distinctly, and steadily to the sick. ]

(1. ) If there is some matter which _must_ be read to a sick person, doit slowly. People often think that the way to get it over with leastfatigue to him is to get it over in least time. They gabble; they plungeand gallop through the reading. There never was a greater mistake. Houdin, the conjuror, says that the way to make a story seem short is totell it slowly. So it is with reading to the sick. I have often heard apatient say to such a mistaken reader, "Don't read it to me; tell itme. "[4] Unconsciously he is aware that this will regulate the plunging, the reading with unequal paces, slurring over one part, instead ofleaving it out altogether, if it is unimportant, and mumbling another. If the reader lets his own attention wander, and then stops to read upto himself, or finds he has read the wrong bit, then it is all over withthe poor patient's chance of not suffering. Very few people know how toread to the sick; very few read aloud as pleasantly even as they speak. In reading they sing, they hesitate, they stammer, they hurry, theymumble; when in speaking they do none of these things. Reading aloud tothe sick ought always to be rather slow, and exceedingly distinct, butnot mouthing--rather monotonous, but not sing song--rather loud but notnoisy--and, above all, not too long. Be very sure of what your patientcan bear. 

[Sidenote: Never read aloud by fits and starts to the sick. ]

(2. ) The extraordinary habit of reading to oneself in a sick room, andreading aloud to the patient any bits which will amuse him or more oftenthe reader, is unaccountably thoughtless. What _do_ you think thepatient is thinking of during your gaps of non-reading? Do you thinkthat he amuses himself upon what you have read for precisely the time itpleases you to go on reading to yourself, and that his attention isready for something else at precisely the time it pleases you to beginreading again? Whether the person thus read to be sick or well, whetherhe 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 read_ee_ istoo amiable to say how much it hurts him. 

[Sidenote: People overhead. ]

One thing more:--From, the flimsy manner in which most modern houses arebuilt, where every step on the stairs, and along the floors, is felt allover the house; the higher the story, the greater the vibration. It isinconceivable how much the sick suffer by having anybody overhead. Inthe solidly built old houses, which, fortunately, most hospitals are, the noise and shaking is comparatively trifling. But it is a seriouscause of suffering, in lightly built houses, and with the irritabilitypeculiar to some diseases. Better far put such patients at the top ofthe house, even with the additional fatigue of stairs, if you cannotsecure the room above them being untenanted; you may otherwise bring ona state of restlessness which no opium will subdue. Do not neglect thewarning, when a patient tells you that he "Feels every step above him tocross his heart. " Remember that every noise a patient cannot _see_partakes of the character of suddenness to him; and I am persuaded thatpatients with these peculiarly irritable nerves, are positively lessinjured by having persons in the same room with them than overhead, orseparated by only a thin compartment. Any sacrifice to secure silencefor these cases is worth while, because no air, however good, noattendance, however careful, will do anything for such cases withoutquiet. 

[Sidenote: Music. ]

NOTE. --The effect of music upon the sick has been scarcely at allnoticed. In fact, its expensiveness, as it is now, makes any generalapplication of it quite out of the question. I will only remark here, that wind instruments, including the human voice, and stringedinstruments, capable of continuous sound, have generally a beneficenteffect--while the piano-forte, with such instruments as have _no_continuity of sound, has just the reverse. The finest piano-forteplaying will damage the sick, while an air, like "Home, sweet home, " or"Assisa a piè d'un salice, " on the most ordinary grinding organ, willsensibly soothe them--and this quite independent of association. 

FOOTNOTES:

[1][Sidenote: Burning of the crinolines. ]

Fortunate it is if her skirts do not catch fire--and if the nurse doesnot give herself up a sacrifice together with her patient, to be burntin her own petticoats. I wish the Registrar-General would tell us theexact number of deaths by burning occasioned by this absurd and hideouscustom. But if people will be stupid, let them take measures to protectthemselves from their own stupidity--measures which every chemistknows, such as putting alum into starch, which prevents starchedarticles of dress from blazing up. 

[Sidenote: Indecency of the crinolines. ]

I wish, too, that people who wear crinoline could see the indecency oftheir own dress as other people see it. A respectable elderly womanstooping forward, invested in crinoline, exposes quite as much of herown person to the patient lying in the room as any opera dancer does onthe stage. But no one will ever tell her this unpleasant truth. 

[2][Sidenote: Never speak to a patient in the act of moving. ]

It is absolutely essential that a nurse should lay this down as apositive rule to herself, never to speak to any patient who is standingor moving, as long as she exercises so little observation as not to knowwhen a patient cannot bear it. I am satisfied that many of the accidentswhich happen from feeble patients tumbling down stairs, fainting aftergetting up, &c. , happen solely from the nurse popping out of a door tospeak to the patient just at that moment; or from his fearing that shewill do so. And that if the patient were even left to himself, till hecan sit down, such accidents would much seldomer occur. If the nurseaccompanies the patient, let her not call upon him to speak. It isincredible that nurses cannot picture to themselves the strain upon theheart, the lungs, and the brain, which the act of moving is to anyfeeble patient. 

[3][Sidenote: Careless observation of the results of careless Visits. ]

As an old experienced nurse, I do most earnestly deprecate all suchcareless words. I have known patients delirious all night, after seeinga visitor who called them "better, " thought they "only wanted a littleamusement, " and who came again, saying, "I hope you were not the worsefor my visit, " neither waiting for an answer, nor even looking at thecase. No real patient will ever say, "Yes, but I was a great deal theworse. "

It is not, however, either death or delirium of which, in these cases, there is most danger to the patient. Unperceived consequences are farmore likely to ensue. _You_ will have impunity--the poor patient will_not_. That is, the patient will suffer, although neither he nor theinflictor of the injury will attribute it to its real cause. It will notbe directly traceable, except by a very careful observant nurse. Thepatient will often not even mention what has done him most harm. 

[4][Sidenote: The sick would rather be told a thing than have it read tothem. ]

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 tothem. 

V. VARIETY. 

[Sidenote: Variety a means of recovery. ]

To any but an old nurse, or an old patient, the degree would be quiteinconceivable to which the nerves of the sick suffer from seeing thesame walls, the same ceiling, the same surroundings during a longconfinement to one or two rooms. 

The superior cheerfulness of persons suffering severe paroxysms of painover that of persons suffering from nervous debility has often beenremarked upon, and attributed to the enjoyment of the former of theirintervals of respite. I incline to think that the majority of cheerfulcases is to be found among those patients who are not confined to oneroom, whatever their suffering, and that the majority of depressed caseswill be seen among those subjected to a long monotony of objects aboutthem. 

The nervous frame really suffers as much from this as the digestiveorgans from long monotony of diet, as e. G. The soldier from histwenty-one years' "boiled beef. "

[Sidenote: Colour and form means of recovery. ]

The effect in sickness of beautiful objects, of variety of objects, andespecially of brilliancy of colour is hardly at all appreciated. 

Such cravings are usually called the "fancies" of patients. And oftendoubtless patients have "fancies, " as e. G. When they desire twocontradictions. But much more often, their (so called) "fancies" are themost valuable indications of what is necessary for their recovery. Andit 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 beingable to see out of window, and the knots in the wood being the onlyview. I shall never forget the rapture of fever patients over a bunch ofbright-coloured flowers. I remember (in my own case) a nosegay of wildflowers being sent me, and from that moment recovery becoming morerapid. 

[Sidenote: This is no fancy. ]

People say the effect is only on the mind. It is no such thing. Theeffect is on the body, too. Little as we know about the way in which weare affected by form, by colour, and light, we do know this, that theyhave an actual physical effect. 

Variety of form and brilliancy of colour in the objects presented topatients are actual means of recovery. 

But it must be _slow_ variety, e. G. , if you shew a patient ten or twelveengravings successively, ten-to-one that he does not become cold andfaint, or feverish, or even sick; but hang one up opposite him, one oneach successive day, or week, or month, and he will revel in thevariety. 

[Sidenote: Flowers. ]

The folly and ignorance which reign too often supreme over thesick-room, cannot be better exemplified than by this. While the nursewill leave the patient stewing in a corrupting atmosphere, the bestingredient of which is carbonic acid; she will deny him, on the plea ofunhealthiness, a glass of cut-flowers, or a growing plant. Now, no oneever saw "overcrowding" by plants in a room or ward. And the carbonicacid they give off at nights would not poison a fly. Nay, in overcrowdedrooms, they actually absorb carbonic acid and give off oxygen. Cut-flowers also decompose water and produce oxygen gas. It is true thereare certain flowers, e. G. Lilies, the smell of which is said to depressthe nervous system. These are easily known by the smell, and can beavoided. 

[Sidenote: Effect of body on mind. ]

Volumes are now written and spoken upon the effect of the mind upon thebody. Much of it is true. But I wish a little more was thought of theeffect of the body on the mind. You who believe yourselves overwhelmedwith anxieties, but are able every day to walk up Regent-street, or outin the country, to take your meals with others in other rooms, &c. , &c. , you little know how much your anxieties are thereby lightened; youlittle know how intensified they become to those who can have nochange;[1] how the very walls of their sick rooms seem hung with theircares; how the ghosts of their troubles haunt their beds; how impossibleit is for them to escape from a pursuing thought without some help fromvariety. 

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

[Sidenote: Help the sick to vary their thoughts. ]

It is an ever recurring wonder to see educated people, who callthemselves nurses, acting thus. They vary their own objects, their ownemployments, many times a day; and while nursing (!) some bed-riddensufferer, they let him lie there staring at a dead wall, without anychange of object to enable him to vary his thoughts; and it never evenoccurs to them, at least to move his bed so that he can look out ofwindow. No, the bed is to be always left in the darkest, dullest, remotest, part of the room. [2]

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

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

[Sidenote: Supply to the sick the defect of manual labour. ]

We will suppose the diet of the sick to be cared for. Then, this stateof nerves is most frequently to be relieved by care in affording them apleasant view, a judicious variety as to flowers, [3] and pretty things. Light by itself will often relieve it. The craving for "the return ofday, " which the sick so constantly evince, is generally nothing but thedesire for light, the remembrance of the relief which a variety ofobjects before the eye affords to the harassed sick mind. 

Again, every man and every woman has some amount of manual employment, excepting a few fine ladies, who do not even dress themselves, and whoare virtually in the same category, as to nerves, as the sick. Now, youcan have no idea of the relief which manual labour is to you--of thedegree to which the deprivation of manual employment increases thepeculiar irritability from which many sick suffer. 

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

I need hardly say that I am well aware that excess in needle-work, inwriting, in any other continuous employment, will produce the sameirritability that defect in manual employment (as one cause) produces inthe sick. 

FOOTNOTES:

[1][Sidenote: Sick suffer to excess from mental as well as bodily pain. ]

It is a matter of painful wonder to the sick themselves, how muchpainful ideas predominate over pleasurable ones in their impressions;they reason with themselves; they think themselves ungrateful; it is allof no use. The fact is, that these painful impressions are far betterdismissed by a real laugh, if you can excite one by books orconversation, than by any direct reasoning; or if the patient is tooweak to laugh, some impression from nature is what he wants. I havementioned the cruelty of letting him stare at a dead wall. In manydiseases, especially in convalescence from fever, that wall will appearto make all sorts of faces at him; now flowers never do this. Form, colour, will free your patient from his painful ideas better than anyargument. 

[2][Sidenote: Desperate desire in the sick to "see out of window. "]

I remember a case in point. A man received an injury to the spine, froman accident, which after a long confinement ended in death. He was aworkman--had not in his composition a single grain of what is called"enthusiasm for nature"--but he was desperate to "see once more out ofwindow. " His nurse actually got him on her back, and managed to perchhim up at the window for an instant, "to see out. " The consequence tothe poor nurse was a serious illness, which nearly proved fatal. The mannever knew it; but a great many other people did. Yet the consequence innone of their minds, so far as I know, was the conviction that thecraving for variety in the starving eye, is just as desperate as that offood in the starving stomach, and tempts the famishing creature ineither case to steal for its satisfaction. No other word will express itbut "desperation. " And it sets the seal of ignorance and stupidity justas much on the governors and attendants of the sick if they do notprovide the sick-bed with a "view" of some kind, as if they did notprovide the hospital with a kitchen. 

[3][Sidenote: Physical effect of colour. ]

No one who has watched the sick can doubt the fact, that some feelstimulus from looking at scarlet flowers, exhaustion from looking atdeep blue, &c. 

VI. TAKING FOOD. 

[Sidenote: Want of attention to hours of taking food. ]

Every careful observer of the sick will agree in this that thousands ofpatients are annually starved in the midst of plenty, from want ofattention to the ways which alone make it possible for them to takefood. This want of attention is as remarkable in those who urge upon thesick to do what is quite impossible to them, as in the sick themselveswho will not make the effort to do what is perfectly possible to them. 

For instance, to the large majority of very weak patients it is quiteimpossible to take any solid food before 11 A. M. , nor then, if theirstrength is still further exhausted by fasting till that hour. For weakpatients have generally feverish nights and, in the morning, dry mouths;and, if they could eat with those dry mouths, it would be the worse forthem. A spoonful of beef-tea, of arrowroot and wine, of egg flip, everyhour, will give them the requisite nourishment, and prevent them frombeing too much exhausted to take at a later hour the solid food, whichis necessary for their recovery. And every patient who can swallow atall can swallow these liquid things, if he chooses. But how often do wehear a mutton-chop, an egg, a bit of bacon, ordered to a patient forbreakfast, to whom (as a moment's consideration would show us) it mustbe quite impossible to masticate such things at that hour. 

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

I am bound to say, that I think more patients are lost by want of careand ingenuity in these momentous minutiae in private nursing than inpublic hospitals. And I think there is more of the _entente cordiale_ toassist one another's hands between the doctor and his head nurse in thelatter institutions, than between the doctor and the patient's friendsin the private house. 

[Sidenote: Life often hangs upon minutes in taking food. ]

If we did but know the consequences which may ensue, in very weakpatients, from ten minutes' fasting or repletion (I call it repletionwhen they are obliged to let too small an interval elapse between takingfood and some other exertion, owing to the nurse's unpunctuality), weshould be more careful never to let this occur. In very weak patientsthere is often a nervous difficulty of swallowing, which is so muchincreased by any other call upon their strength that, unless they havetheir food punctually at the minute, which minute again must be arrangedso as to fall in with no other minute's occupation, they can takenothing till the next respite occurs--so that an unpunctuality or delayof ten minutes may very well turn out to be one of two or three hours. And why is it not as easy to be punctual to a minute? Life oftenliterally 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 orNurse, or both, in ordering and giving nourishment with minute selectionand punctuality. 

[Sidenote: Patients often starved to death in chronic cases. ]

But in chronic cases, lasting over months and years, where the fatalissue is often determined at last by mere protracted starvation, I hadrather not enumerate the instances which I have known where a littleingenuity, and a great deal of perseverance, might, in all probability, have averted the result. The consulting the hours when the patient cantake food, the observation of the times, often varying, when he is mostfaint, the altering seasons of taking food, in order to anticipate andprevent such times--all this, which requires observation, ingenuity, andperseverance (and these really constitute the good Nurse), might savemore lives than we wot of. 

[Sidenote: Food never to be left by the patient's side. ]

To leave the patient's untasted food by his side, from meal to meal, inhopes that he will eat it in the interval is simply to prevent him fromtaking any food at all. I have known patients literally incapacitatedfrom taking one article of food after another, by this piece ofignorance. Let the food come at the right time, and be taken away, eatenor uneaten, at the right time; but never let a patient have "somethingalways standing" by him, if you don't wish to disgust him of everything. 

On the other hand, I have known a patient's life saved (he was sinkingfor want of food) by the simple question, put to him by the doctor, "Butis there no hour when you feel you could eat?" "Oh, yes, " he said, "Icould always take something at ---- o'clock and ---- o'clock. " Thething was tried and succeeded. Patients very seldom, however, can tellthis; it is for you to watch and find it out. 

[Sidenote: Patient had better not see more food than his own. ]

A patient should, if possible, not see or smell either the food ofothers, or a greater amount of food than he himself can consume at onetime, or even hear food talked about or see it in the raw state. I knowof no exception to the above rule. The breaking of it always induces agreater or less incapacity of taking food. 

In hospital wards it is of course impossible to observe all this; and insingle wards, where a patient must be continuously and closely watched, it is frequently impossible to relieve the attendant, so that his or herown meals can be taken out of the ward. But it is not the less truethat, in such cases, even where the patient is not himself aware of it, his possibility of taking food is limited by seeing the attendant eatingmeals under his observation. In some cases the sick are aware of it, andcomplain. A case where the patient was supposed to be insensible, butcomplained as soon as able to speak, is now present to my recollection. 

Remember, however, that the extreme punctuality in well-orderedhospitals, the rule that nothing shall be done in the ward while thepatients are having their meals, go far to counterbalance whatunavoidable evil there is in having patients together. I have often seenthe private nurse go on dusting or fidgeting about in a sick room allthe while the patient is eating, or trying to eat. 

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

When a person is compelled, by the pressure of occupation, to continuehis business while sick, it ought to be a rule WITHOUT ANY EXCEPTIONWHATEVER, that no one shall bring business to him or talk to him whilehe is taking food, nor go on talking to him on interesting subjects upto the last moment before his meals, nor make an engagement with himimmediately after, so that there be any hurry of mind while taking them. 

Upon the observance of these rules, especially the first, often dependsthe patient's capability of taking food at all, or, if he is amiable andforces himself to take food, of deriving any nourishment from it. 

[Sidenote: You cannot be too careful as to quality in sick diet. ]

A nurse should never put before a patient milk that is sour, meat orsoup that is turned, an egg that is bad, or vegetables underdone. Yetoften I have seen these things brought in to the sick in a stateperfectly perceptible to every nose or eye except the nurse's. It ishere that the clever nurse appears; she will not bring in the peccantarticle, but, not to disappoint the patient, she will whip up somethingelse in a few minutes. Remember that sick cookery should half do thework of your poor patient's weak digestion. But if you further impair itwith your bad articles, I know not what is to become of him or of it. 

If the nurse is an intelligent being, and not a mere carrier of diets toand 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, becauseone meal was left untasted (at that time he was incapable of eating), atanother the milk was sour, the third was spoiled by some other accident. And it never occurred to the nurse to extemporize some expedient, --itnever occurred to her that as he had had no solid food that day he mighteat a bit of toast (say) with his tea in the evening, or he might havesome 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 somehownurses never "think of these things. " One would imagine they did notconsider themselves bound to exercise their judgment; they leave it tothe patient. Now I am quite sure that it is better for a patient ratherto suffer these neglects than to try to teach his nurse to nurse him, ifshe does not know how. It ruffles him, and if he is ill he is in nocondition to teach, especially upon himself. The above remarks applymuch more to private nursing than to hospitals. 

[Sidenote: Nurse must have some rule of thought about her patient'sdiet. ]

I would say to the nurse, have a rule of thought about your patient'sdiet; consider, remember how much he has had, and how much he ought tohave to-day. Generally, the only rule of the private patient's diet iswhat the nurse has to give. It is true she cannot give him what she hasnot got; but his stomach does not wait for her convenience, or even hernecessity. [1] If it is used to having its stimulus at one hour to-day, and to-morrow it does not have it, because she has failed in getting it, he will suffer. She must be always exercising her ingenuity to supplydefects, and to remedy accidents which will happen among the bestcontrivers, but from which the patient does not suffer the less, because"they cannot be helped. "

[Sidenote: Keep your patient's cup dry underneath. ]

One very minute caution, --take care not to spill into your patient'ssaucer, in other words, take care that the outside bottom rim of his cupshall be quite dry and clean; if, every time he lifts his cup to hislips, he has to carry the saucer with it, or else to drop the liquidupon, and to soil his sheet, or his bed-gown, or pillow, or if he issitting up, his dress, you have no idea what a difference this minutewant of care on your part makes to his comfort and even to hiswillingness for food. 

FOOTNOTE:[1][Sidenote: Nurse must have some rule of time about the patient's diet. ]

Why, because the nurse has not got some food to-day which the patienttakes, can the patient wait four hours for food to-day, who could notwait two hours yesterday? Yet this is the only logic one generallyhears. On the other hand, the other logic, viz. , of the nurse giving apatient a thing because she _has_ got it, is equally fatal. If shehappens to have fresh jelly, or fresh fruit, she will frequently give itto the patient half an hour after his dinner, or at his dinner, when hecannot possibly eat that and the broth too--or worse still, leave it byhis bed-side till he is so sickened with the sight of it, that he cannoteat it at all. 

VII. WHAT FOOD?

[Sidenote: Common errors in diet. ]

[Sidenote: Beef tea. ]

[Sidenote: Eggs. ]

[Sidenote: Meat without vegetables. ]

[Sidenote: Arrowroot. ]

I will mention one or two of the most common errors among women incharge of sick respecting sick diet. One is the belief that beef tea isthe most nutritive of all articles. Now, just try and boil down a lb. Ofbeef into beef tea, evaporate your beef tea, and see what is left ofyour beef. You will find that there is barely a teaspoonful of solidnourishment to half a pint of water in beef tea;--nevertheless there isa certain reparative quality in it, we do not know what, as there is intea;--but it may safely be given in almost any inflammatory disease, andis as little to be depended upon with the healthy or convalescent wheremuch nourishment is required. Again, it is an ever ready saw that an eggis equivalent to a lb. Of meat, --whereas it is not at all so. Also, itis seldom noticed with how many patients, particularly of nervous orbilious temperament, eggs disagree. All puddings made with eggs, aredistasteful to them in consequence. An egg, whipped up with wine, isoften the only form in which they can take this kind of nourishment. Again, if the patient has attained to eating meat, it is supposed thatto give him meat is the only thing needful for his recovery; whereasscorbutic sores have been actually known to appear among sick personsliving in the midst of plenty in England, which could be traced to noother source than this, viz. : that the nurse, depending on meat alone, had allowed the patient to be without vegetables for a considerabletime, these latter being so badly cooked that he always left themuntouched. Arrowroot is another grand dependence of the nurse. As avehicle for wine, and as a restorative quickly prepared, it is all verywell. But it is nothing but starch and water. Flour is both morenutritive, and less liable to ferment, and is preferable wherever it canbe used. 

[Sidenote: Milk, butter, cream, &c. ]

Again, milk and the preparations from milk, are a most important articleof food for the sick. Butter is the lightest kind of animal fat, andthough it wants the sugar and some of the other elements which there arein milk, yet it is most valuable both in itself and in enabling thepatient to eat more bread. Flour, oats, groats, barley, and their kind, are, as we have already said, preferable in all their preparations toall the preparations of arrowroot, sago, tapioca, and their kind. Cream, in many long chronic diseases, is quite irreplaceable by any otherarticle whatever. It seems to act in the same manner as beef tea, and tomost it is much easier of digestion than milk. In fact, it seldomdisagrees. Cheese is not usually digestible by the sick, but it is purenourishment for repairing waste; and I have seen sick, and not a feweither, whose craving for cheese shewed how much it was needed bythem. [1]

But, if fresh milk is so valuable a food for the sick, the least changeor sourness in it, makes it of all articles, perhaps, the mostinjurious; diarrhoea is a common result of fresh milk allowed to becomeat all sour. The nurse therefore ought to exercise her utmost care inthis. In large institutions for the sick, even the poorest, the utmostcare is exercised. Wenham Lake ice is used for this express purposeevery summer, while the private patient, perhaps, never tastes a drop ofmilk that is not sour, all through the hot weather, so little does theprivate nurse understand the necessity of such care. Yet, if youconsider that the only drop of real nourishment in your patient's tea isthe drop of milk, and how much almost all English patients depend upontheir tea, you will see the great importance of not depriving yourpatient of this drop of milk. Buttermilk, a totally different thing, isoften very useful, especially in fevers. 

[Sidenote: Sweet things. ]

In laying down rules of diet, by the amounts of "solid nutriment" indifferent kinds of food, it is constantly lost sight of what the patientrequires to repair his waste, what he can take and what he can't. Youcannot diet a patient from a book, you cannot make up the human body asyou would make up a prescription, --so many parts "carboniferous, " somany parts "nitrogenous" will constitute a perfect diet for the patient. The nurse's observation here will materially assist the doctor--thepatient'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 ofall patients in England, young and old, male and female, rich and poor, hospital and private, dislike sweet things, --and while I have neverknown a person take to sweets when he was ill who disliked them when hewas well, I have known many fond of them when in health, who in sicknesswould leave off anything sweet, even to sugar in tea, --sweet puddings, sweet drinks, are their aversion; the furred tongue almost always likeswhat is sharp or pungent. Scorbutic patients are an exception, theyoften crave for sweetmeats and jams. 

[Sidenote: Jelly. ]

Jelly is another article of diet in great favour with nurses and friendsof the sick; even if it could be eaten solid, it would not nourish, butit is simply the height of folly to take 1/8 oz. Of gelatine and make itinto a certain bulk by dissolving it in water and then to give it to thesick, as if the mere bulk represented nourishment. It is now known thatjelly does not nourish, that it has a tendency to produce diarrhoea, --and to trust to it to repair the waste of a diseased constitution issimply to starve the sick under the guise of feeding them. If 100spoonfuls of jelly were given in the course of the day, you would havegiven one spoonful of gelatine, which spoonful has no nutritive powerwhatever. 

And, nevertheless, gelatine contains a large quantity of nitrogen, whichis one of the most powerful elements in nutrition; on the other hand, beef tea may be chosen as an illustration of great nutrient power insickness, co-existing with a very small amount of solid nitrogenousmatter. 

[Sidenote: Beef tea]

Dr. Christison says that "every one will be struck with the readinesswith which" certain classes of "patients will often take diluted meatjuice 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 teacontains scarcely 1/4 oz. Of anything but water, "--the result is sostriking that he asks what is its mode of action? "Not simply nutrient--1/4 oz. Of the most nutritive material cannot nearly replace the dailywear and tear of the tissues in any circumstances. Possibly, " he says, "it belongs to a new denomination of remedies. "

It has been observed that a small quantity of beef tea added to otherarticles of nutrition augments their power out of all proportion to theadditional amount of solid matter. 

The reason why jelly should be innutritious and beef tea nutritious tothe sick, is a secret yet undiscovered, but it clearly shows thatcareful observation of the sick is the only clue to the best dietary. 

[Sidenote: Observation, not chemistry, must decide sick diet. ]

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 discoverable in different dietetic articles. Ithas given us lists of dietetic substances, arranged in the order oftheir richness in one or other of these principles; but that is all. Inthe great majority of cases, the stomach of the patient is guided byother principles of selection than merely the amount of carbon ornitrogen in the diet. No doubt, in this as in other things, nature hasvery definite rules for her guidance, but these rules can only beascertained by the most careful observation at the bedside. She thereteaches us that living chemistry, the chemistry of reparation, issomething different from the chemistry of the laboratory. Organicchemistry is useful, as all knowledge is, when we come face to face withnature; but it by no means follows that we should learn in thelaboratory any one of the reparative processes going on in disease. 

Again, the nutritive power of milk and of the preparations from milk, isvery much undervalued; there is nearly as much nourishment in half apint of milk as there is in a quarter of a lb. Of meat. But this is notthe whole question or nearly the whole. The main question is what thepatient's stomach can assimilate or derive nourishment from, and of thisthe patient's stomach is the sole judge. Chemistry cannot tell this. Thepatient's stomach must be its own chemist. The diet which will keep thehealthy man healthy, will kill the sick one. The same beef which is themost nutritive of all meat and which nourishes the healthy man, is theleast nourishing of all food to the sick man, whose half-dead stomachcan _assimilate_ no part of it, that is, make no food out of it. On adiet of beef tea healthy men on the other hand speedily lose theirstrength. 

[Sidenote: Home-made bread. ]

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

[Sidenote: Sound observation has scarcely yet been brought to bear onsick diet. ]

To watch for the opinions, then, which the patient's stomach gives, rather than to read "analyses of foods, " is the business of all thosewho have to settle what the patient is to eat--perhaps the mostimportant thing to be provided for him after the air he is to breathe. 

Now the medical man who sees the patient only once a day or even onlyonce or twice a week, cannot possibly tell this without the assistanceof the patient himself, or of those who are in constant observation onthe patient. The utmost the medical man can tell is whether the patientis weaker or stronger at this visit than he was at the last visit. Ishould therefore say that incomparably the most important office of thenurse, after she has taken care of the patient's air, is to take care toobserve 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 ofnursing, or the help it would give to the medical man. 

[Sidenote: Tea and coffee. ]

A great deal too much against tea[2] is said by wise people, and a greatdeal too much of tea is given to the sick by foolish people. When yousee the natural and almost universal craving in English sick for their"tea, " you cannot but feel that nature knows what she is about. But alittle tea or coffee restores them quite as much as a great deal, and agreat deal of tea and especially of coffee impairs the little power ofdigestion they have. Yet a nurse, because she sees how one or two cupsof tea or coffee restores her patient, thinks that three or four cupswill do twice as much. This is not the case at all; it is howevercertain that there is nothing yet discovered which is a substitute tothe English patient for his cup of tea; he can take it when he can takenothing else, and he often can't take anything else if he has it not. Ishould be very glad if any of the abusers of tea would point out what togive to an English patient after a sleepless night, instead of tea. Ifyou give it at 5 or 6 o'clock in the morning, he may even sometimes fallasleep after it, and get perhaps his only two or three hours' sleepduring the twenty-four. At the same time you never should give tea orcoffee to the sick, as a rule, after 5 o'clock in the afternoon. Sleeplessness in the early night is from excitement generally and isincreased by tea or coffee; sleeplessness which continues to the earlymorning is from exhaustion often, and is relieved by tea. The onlyEnglish patients I have ever known refuse tea, have been typhus cases, and the first sign of their getting better was their craving again fortea. In general, the dry and dirty tongue always prefers tea to coffee, and will quite decline milk, unless with tea. Coffee is a betterrestorative than tea, but a greater impairer of the digestion. Let thepatient's taste decide. You will say that, in cases of great thirst, thepatient's craving decides that it will drink _a great deal_ of tea, andthat you cannot help it. But in these cases be sure that the patientrequires diluents for quite other purposes than quenching the thirst; hewants a great deal of some drink, not only of tea, and the doctor willorder what he is to have, barley water or lemonade, or soda water andmilk, 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, " [Transcriber's note: Quotes as inthe original] and Dr. Christison adds that tea has the same property. Now this is actual experiment. Lehman weighs the man and finds the factfrom his weight. It is not deduced from any "analysis" of food. Allexperience among the sick shows the same thing. [3]

[Sidenote: Cocoa. ]

Cocoa is often recommended to the sick in lieu of tea or coffee. Butindependently of the fact that English sick very generally dislikecocoa, it has quite a different effect from tea or coffee. It is an oilystarchy nut having no restorative power at all, but simply increasingfat. It is pure mockery of the sick, therefore, to call it a substitutefor tea. For any renovating stimulus it has, you might just as welloffer them chestnuts instead of tea. 

[Sidenote: Bulk. ]

An almost universal error among nurses is in the bulk of the food andespecially the drinks they offer to their patients. Suppose a patientordered 4 oz. Brandy during the day, how is he to take this if you makeit into four pints with diluting it? The same with tea and beef tea, with arrowroot, milk, &c. You have not increased the nourishment, youhave not increased the renovating power of these articles, by increasingtheir bulk, --you have very likely diminished both by giving thepatient's digestion more to do, and most likely of all, the patient willleave half of what he has been ordered to take, because he cannotswallow the bulk with which you have been pleased to invest it. Itrequires very nice observation and care (and meets with hardly any) todetermine 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. 

FOOTNOTES:

[1][Sidenote: Intelligent cravings of particular sick for particulararticles of diet. ]

In the diseases produced by bad food, such as scorbutic dysentery anddiarrhoea, the patient's stomach often craves for and digests things, some of which certainly would be laid down in no dietary that ever wasinvented for sick, and especially not for such sick. These are fruit, pickles, jams, gingerbread, fat of ham or bacon, suet, cheese, butter, 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 was wrong. The articlescraved for, in these cases, might have been principally arranged underthe two heads of fat and vegetable acids. 

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

[2]It is made a frequent recommendation to persons about to incur greatexhaustion, either from the nature of the service, or from their beingnot in a state fit for it, to eat a piece of bread before they go. Iwish the recommenders would themselves try the experiment ofsubstituting a piece of bread for a cup of tea or coffee, or beef-tea, as a refresher. They would find it a very poor comfort. When soldiershave to set out fasting on fatiguing duty, when nurses have to gofasting in to their patients, it is a hot restorative they want, andought to have, before they go, not a cold bit of bread. And dreadfulhave been the consequences of neglecting this. If they can take a bit ofbread _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 almostanything else, has probably induced the mistake. That it is a fatalmistake, there is no doubt. It seems, though very little is known on thesubject, that what "assimilates" itself directly, and with the leasttrouble of digestion with the human body, is the best for the abovecircumstances. 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 haveundergone great fatigue, such as riding long journeys without stopping, or sitting up for several nights in succession, is that they could do itbest upon an occasional cup of tea--and nothing else. 

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

[3]In making coffee, it is absolutely necessary to buy it in the berry andgrind it at home. Otherwise you may reckon upon its containing a certainamount of chicory, _at least_. This is not a question of the taste, orof the wholesomeness of chicory. It is that chicory has nothing at allof the properties for which you give coffee. And therefore you may aswell not give it. 

Again, all laundresses, mistresses of dairy-farms, head nurses, (I speakof the good old sort only--women who unite a good deal of hard manuallabour with the head-work necessary for arranging the day's business, sothat none of it shall tread upon the heels of something else, ) set greatvalue, I have observed, upon having a high-priced tea. This is calledextravagant. But these women are "extravagant" in nothing else. And theyare right in this. Real tea-leaf tea alone contains the restorative theywant; which is not to be found in sloe-leaf tea. 

The mistresses of houses, who cannot even go over their own house once aday, are incapable of judging for these women. For they are incapablethemselves, to all appearance, of the spirit of arrangement (no smalltask) necessary for managing a large ward or dairy. 

VIII. BED AND BEDDING. 

[Sidenote: Feverishness a symptom of bedding. ]

A few words upon bedsteads and bedding; and principally as regardspatients who are entirely, or almost entirely, confined to bed. 

Feverishness is generally supposed to be a symptom of fever--in ninecases out of ten it is a symptom of bedding. [1] The patient has hadre-introduced into the body the emanations from himself which day afterday and week after week saturate his unaired bedding. How can it beotherwise? Look at the ordinary bed in which a patient lies. 

[Sidenote: Uncleanliness of ordinary bedding. ]

If I were looking out for an example in order to show what _not_ to do, I should take the specimen of an ordinary bed in a private house: awooden bedstead, two or even three mattresses piled up to above theheight of a table; a vallance attached to the frame--nothing but amiracle could ever thoroughly dry or air such a bed and bedding. Thepatient must inevitably alternate between cold damp after his bed ismade, and warm damp before, both saturated with organic matter[2], andthis from the time the mattresses are put under him till the time theyare picked to pieces, if this is ever done. 

[Sidenote: Air your dirty sheets, not only your clean ones. ]

If you consider that an adult in health exhales by the lungs and skin inthe twenty-four hours three pints at least of moisture, loaded withorganic matter ready to enter into putrefaction; that in sickness thequantity is often greatly increased, the quality is always more noxious--just ask yourself next where does all this moisture go to? Chieflyinto the bedding, because it cannot go anywhere else. And it staysthere; because, except perhaps a weekly change of sheets, scarcely anyother airing is attempted. A nurse will be careful to fidgetiness aboutairing the clean sheets from clean damp, but airing the dirty sheetsfrom noxious damp will never even occur to her. Besides this, the mostdangerous effluvia we know of are from the excreta of the sick--theseare placed, at least temporarily, where they must throw their effluviainto the under side of the bed, and the space under the bed is neveraired; it cannot be, with our arrangements. Must not such a bed bealways saturated, and be always the means of re-introducing into thesystem of the unfortunate patient who lies in it, that excrementitiousmatter to eliminate which from the body nature had expressly appointedthe disease?

My heart always sinks within me when I hear the good house-wife, ofevery class, say, "I assure you the bed has been well slept in, " and Ican only hope it is not true. What? is the bed already saturated withsomebody else's damp before my patient comes to exhale in it his owndamp? Has it not had a single chance to be aired? No, not one. "It hasbeen slept in every night. "

[Sidenote: Iron spring bedsteads the best. ]

[Sidenote: Comfort and cleanliness of _two_ beds. ]

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 tothe very mattress (no vallance, of course), the mattress to be a thinhair one; the bed to be not above 3-1/2 feet wide. If the patient beentirely confined to his bed, there should be _two_ such bedsteads; eachbed to be "made" with mattress, sheets, blankets, &c. , complete--thepatient to pass twelve hours in each bed; on no account to carry hissheets with him. The whole of the bedding to be hung up to air for eachintermediate twelve hours. Of course there are many cases where thiscannot be done at all--many more where only an approach to it can bemade. I am indicating the ideal of nursing, and what I have actually haddone. But about the kind of bedstead there can be no doubt, whetherthere be one or two provided. 

[Sidenote: Bed not to be too wide. ]

There is a prejudice in favour of a wide bed--I believe it to be aprejudice. All the refreshment of moving a patient from one side to theother of his bed is far more effectually secured by putting him into afresh bed; and a patient who is really very ill does not stray far inbed. 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 canturn on his side, he will eat more comfortably from a bed-side table;and on no account whatever should a bed ever be higher than a sofa. Otherwise the patient feels himself "out of humanity's reach;" he canget at nothing for himself: he can move nothing for himself. If thepatient cannot turn, a table over the bed is a better thing. I needhardly say that a patient's bed should never have its side against thewall. The nurse must be able to get easily to both sides of the bed, andto reach easily every part of the patient without stretching--a thingimpossible if the bed be either too wide or too high. 

[Sidenote: Bed not to be too high. ]

When I see a patient in a room nine or ten feet high upon a bed betweenfour 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 thisexpressly planned to produce that peculiarly distressing feeling commonto the sick, viz. , as if the walls and ceiling were closing in uponthem, and they becoming sandwiches between floor and ceiling, whichimagination is not, indeed, here so far from the truth? If, over andabove this, the window stops short of the ceiling, then the patient'shead may literally be raised above the stratum of fresh air, even whenthe window is open. Can human perversity any farther go, in unmaking theprocess of restoration which God has made? The fact is, that the headsof sleepers or of sick should never be higher than the throat of thechimney, which ensures their being in the current of best air. And wewill not suppose it possible that you have closed your chimney with achimney-board. 

If a bed is higher than a sofa, the difference of the fatigue of gettingin and out of bed will just make the difference, very often, to thepatient (who can get in and out of bed at all) of being able to take afew minutes' exercise, either in the open air or in another room. It isso very odd that people never think of this, or of how many more times apatient who is in bed for the twenty-four hours is obliged to get in andout of bed than they are, who only, it is to be hoped, get into bed onceand out of bed once during the twenty-four hours. 

[Sidenote: Nor in a dark place. ]

A patient's bed should always be in the lightest spot in the room; andhe should be able to see out of window. 

[Sidenote: Nor a four poster with curtains. ]

I need scarcely say that the old four-post bed with curtains is utterlyinadmissible, whether for sick or well. Hospital bedsteads are in manyrespects very much less objectionable than private ones. 

[Sidenote: Scrofula often a result of disposition of bed clothes. ]

There is reason to believe that not a few of the apparentlyunaccountable cases of scrofula among children proceed from the habit ofsleeping with the head under the bed clothes, and so inhaling airalready breathed, which is farther contaminated by exhalations from theskin. Patients are sometimes given to a similar habit, and it oftenhappens that the bed clothes are so disposed that the patient mustnecessarily breathe air more or less contaminated by exhalations fromhis skin. A good nurse will be careful to attend to this. It is animportant part, so to speak, of ventilation. 

[Sidenote: Bed sores. ]

It may be worth while to remark, that where there is any danger ofbed-sores a blanket should never be placed _under_ the patient. Itretains damp and acts like a poultice. 

[Sidenote: Heavy and impervious bed clothes. ]

Never use anything but light Whitney blankets as bed covering for thesick. The heavy cotton impervious counterpane is bad, for the veryreason that it keeps in the emanations from the sick person, while theblanket allows them to pass through. Weak patients are invariablydistressed by a great weight of bed clothes, which often prevents theirgetting any sound sleep whatever. 

NOTE. --One word about pillows. Every weak patient, be his illness whatit may, suffers more or less from difficulty in breathing. To take theweight of the body off the poor chest, which is hardly up to its work asit is, ought therefore to be the object of the nurse in arranging hispillows. Now what does she do and what are the consequences? She pilesthe pillows one a-top of the other like a wall of bricks. The head isthrown upon the chest. And the shoulders are pushed forward, so as notto allow the lungs room to expand. The pillows, in fact, lean upon thepatient, not the patient upon the pillows. It is impossible to give arule for this, because it must vary with the figure of the patient. Andtall patients suffer much more than short ones, because of the _drag_ ofthe long limbs upon the waist. But the object is to support, with thepillows, the back _below_ the breathing apparatus, to allow theshoulders room to fall back, and to support the head, without throwingit forward. The suffering of dying patients is immensely increased byneglect of these points. And many an invalid, too weak to drag about hispillows himself, slips his book or anything at hand behind the lowerpart of his back to support it. 

FOOTNOTES:

[1][Sidenote: Nurses often do not think the sick room any business oftheirs, but only, the sick. ]

I once told a "very good nurse" that the way in which her patient's roomwas kept was quite enough to account for his sleeplessness; and sheanswered quite good-humouredly she was not at all surprised at it--as ifthe state of the room were, like the state of the weather, entirely outof her power. Now in what sense was this woman to be called a "nurse?"

[2]For the same reason if, after washing a patient, you must put the samenight-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 hasnow got cold from having been off him for a few minutes. The fire willdry and at the same time air it. This is much more important than withclean things. 

IX. LIGHT. 

[Sidenote: Light essential to both health and recovery. ]

It is the unqualified result of all my experience with the sick, thatsecond only to their need of fresh air is their need of light; that, after a close room, what hurts them most is a dark room. And that it isnot only light but direct sun-light they want. I had rather have thepower of carrying my patient about after the sun, according to theaspect of the rooms, if circumstances permit, than let him linger in aroom when the sun is off. People think the effect is upon the spiritsonly. This is by no means the case. The sun is not only a painter but asculptor. You admit that he does the photograph. Without going into anyscientific exposition we must admit that light has quite as real andtangible effects upon the human body. But this is not all. Who has notobserved the purifying effect of light, and especially of directsunlight, upon the air of a room? Here is an observation withineverybody's experience. Go into a room where the shutters are alwaysshut (in a sick room or a bedroom there should never be shutters shut), and though the room be uninhabited, though the air has never beenpolluted by the breathing of human beings, you will observe a close, musty smell of corrupt air, of air _i. E. _ unpurified by the effect ofthe sun's rays. The mustiness of dark rooms and corners, indeed, isproverbial. The cheerfulness of a room, the usefulness of light intreating disease is all-important. 

[Sidenote: Aspect, view, and sunlight matters of first importance to thesick. ]

A very high authority in hospital construction has said that people donot enough consider the difference between wards and dormitories inplanning their buildings. But I go farther, and say, that healthy peoplenever remember the difference between _bed_-rooms and _sick_-rooms inmaking arrangements for the sick. To a sleeper in health it does notsignify what the view is from his bed. He ought never to be in itexcepting when asleep, and at night. Aspect does not very much signifyeither (provided the sun reach his bed-room some time in every day, topurify the air), because he ought never to be in his bed-room exceptduring the hours when there is no sun. But the case is exactly reversedwith the sick, even should they be as many hours out of their beds asyou are in yours, which probably they are not. Therefore, that theyshould be able, without raising themselves or turning in bed, to see outof window from their beds, to see sky and sun-light at least, if you canshow them nothing else, I assert to be, if not of the very firstimportance for recovery, at least something very near it. 

And you should therefore look to the position of the beds of your sickone of the very first things. If they can see out of two windows insteadof 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 moreimportance 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 bythe window, where they can see the sun. But the best rule is, ifpossible, to give them direct sunlight from the moment he rises till themoment he sets. 

Another great difference between the _bed_-room and the _sick_-room is, that the _sleeper_ has a very large balance of fresh air to begin with, when he begins the night, if his room has been open all day as it oughtto be; the _sick_ man has not, because all day he has been breathing theair in the same room, and dirtying it by the emanations from himself. Far more care is therefore necessary to keep up a constant change of airin the sick room. 

It is hardly necessary to add that there are acute cases (particularly afew ophthalmic cases, and diseases where the eye is morbidly sensitive), where a subdued light is necessary. But a dark north room isinadmissible even for these. You can always moderate the light by blindsand curtains. 

Heavy, thick, dark window or bed curtains should, however, hardly everbe used for any kind of sick in this country. A light white curtain atthe head of the bed is, in general, all that is necessary, and a greenblind to the window, to be drawn down only when necessary. 

[Sidenote: Without sunlight, we degenerate body and mind. ]

One of the greatest observers of human things (not physiological), says, in another language, "Where there is sun there is thought. " Allphysiology goes to confirm this. Where is the shady side of deepvallies, there is cretinism. Where are cellars and the unsunned sides ofnarrow streets, there is the degeneracy and weakliness of the humanrace--mind and body equally degenerating. Put the pale withering plantand human being into the sun, and, if not too far gone, each willrecover health and spirit. 

[Sidenote: Almost all patients lie with their faces to the light. ]

It is a curious thing to observe how almost all patients lie with theirfaces turned to the light, exactly as plants always make their waytowards 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 notknow, --but we do. It is because it is the side towards the window. Afashionable physician has recently published in a government report thathe always turns his patient's faces from the light. Yes, but nature isstronger than fashionable physicians, and depend upon it she turns thefaces back and _towards_ such light as she can get. Walk through thewards of a hospital, remember the bed sides of private patients you haveseen, and count how many sick you ever saw lying with their facestowards the wall. 

X. CLEANLINESS OF ROOMS AND WALLS. 

[Sidenote: Cleanliness of carpets and furniture. ]

It cannot be necessary to tell a nurse that she should be clean, or thatshe should keep her patient clean, --seeing that the greater part ofnursing consists in preserving cleanliness. No ventilation can freshen aroom or ward where the most scrupulous cleanliness is not observed. Unless the wind be blowing through the windows at the rate of twentymiles an hour, dusty carpets, dirty wainscots, musty curtains andfurniture, will infallibly produce a close smell. I have lived in alarge and expensively furnished London house, where the only constantinmate in two very lofty rooms, with opposite windows, was myself, andyet, owing to the above-mentioned dirty circumstances, no opening ofwindows could ever keep those rooms free from closeness; but the carpetand curtains having been turned out of the rooms altogether, they becameinstantly as fresh as could be wished. It is pure nonsense to say thatin London a room cannot be kept clean. Many of our hospitals show theexact reverse. 

[Sidenote: Dust never removed now. ]

But no particle of dust is ever or can ever be removed or really got ridof by the present system of dusting. Dusting in these days means nothingbut flapping the dust from one part of a room on to another with doorsand windows closed. What you do it for I cannot think. You had muchbetter leave the dust alone, if you are not going to take it awayaltogether. For from the time a room begins to be a room up to the timewhen it ceases to be one, no one atom of dust ever actually leaves itsprecincts. Tidying a room means nothing now but removing a thing fromone place, which it has kept clean for itself, on to another and adirtier one. [1] Flapping by way of cleaning is only admissible in thecase of pictures, or anything made of paper. The only way I know to_remove_ dust, the plague of all lovers of fresh air, is to wipeeverything with a damp cloth. And all furniture ought to be so made asthat it may be wiped with a damp cloth without injury to itself, and sopolished as that it may be damped without injury to others. To dust, asit is now practised, truly means to distribute dust more equally over aroom. 

[Sidenote: Floors. ]

As to floors, the only really clean floor I know is the Berlin_lackered_ floor, which is wet rubbed and dry rubbed every morning toremove the dust. The French _parquet_ is always more or less dusty, although infinitely superior in point of cleanliness and healthiness toour absorbent floor. 

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

[Sidenote: Papered, plastered, oil-painted walls. ]

As for walls, the worst is the papered wall; the next worst is plaster. But the plaster can be redeemed by frequent lime-washing; the paperrequires frequent renewing. A glazed paper gets rid of a good deal ofthe danger. But the ordinary bed-room paper is all that it ought _not_to be. [2]

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

The best wall now extant is oil paint. From this you can wash the animalexuviæ. [3]

These are what make a room musty. 

[Sidenote: Best kind of wall for a sick-room. ]

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

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

Want of cleanliness, then, in rooms _and_ wards, which you have to guardagainst, may arise in three ways. 

[Sidenote: Dirty air from without. ]

1. Dirty air coming in from without, soiled by sewer emanations, theevaporation from dirty streets, smoke, bits of unburnt fuel, bits ofstraw, bits of horse dung. 

[Sidenote: Best kind of wall for a house. ]

If people would but cover the outside walls of their houses with plainor encaustic tiles, what an incalculable improvement would there be inlight, cleanliness, dryness, warmth, and consequently economy. The playof a fire-engine would then effectually wash the outside of a house. This kind of _walling_ would stand next to paving in improving thehealth of towns. 

[Sidenote: Dirty air from within. ]

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 nopretence have any ledge whatever out-of sight. Dust accumulates there, and will never be wiped off. This is a certain way to soil the air. Besides this, the animal exhalations from your inmates saturate yourfurniture. And if you never clean your furniture properly, how can yourrooms or wards be anything but musty? Ventilate as you please, the roomswill never be sweet. Besides this, there is a constant _degradation_, asit is called, taking place from everything except polished or glazedarticles--_E. G. _ in colouring certain green papers arsenic is used. Nowin the very dust even, which is lying about in rooms hung with this kindof green paper, arsenic has been distinctly detected. You see your dustis anything but harmless; yet you will let such dust lie about yourledges for months, your rooms for ever. 

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

[Sidenote: Dirty air from the carpet. ]

3. Dirty air coming from the carpet. Above all, take care of thecarpets, that the animal dirt left there by the feet of visitors doesnot stay there. Floors, unless the grain is filled up and polished, arejust as bad. The smell from the floor of a school-room or ward, when anymoisture brings out the organic matter by which it is saturated, mightalone be enough to warn us of the mischief that is going on. 

[Sidenote: Remedies. ]

The outer air, then, can only be kept clean by sanitary improvements, and by consuming smoke. The expense in soap, which this singleimprovement would save, is quite incalculable. 

The inside air can only be kept clean by excessive care in the waysmentioned above--to rid the walls, carpets, furniture, ledges, &c. , ofthe organic matter and dust--dust consisting greatly of this organicmatter--with which they become saturated, and which is what really makesthe 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 theexquisite cleanliness required in the sick-room. For much of what I havesaid applies less to the hospital than to the private sick-room. Thesmoky chimney, the dusty furniture, the utensils emptied but once a day, often keep the air of the sick constantly dirty in the best privatehouses. 

The well have a curious habit of forgetting that what is to them but atrifling inconvenience, to be patiently "put up" with, is to the sick asource of suffering, delaying recovery, if not actually hastening death. The well are scarcely ever more than eight hours, at most, in the sameroom. Some change they can always make, if only for a few minutes. Evenduring the supposed eight hours, they can change their posture or theirposition in the room. But the sick man who never leaves his bed, whocannot change by any movement of his own his air, or his light, or hiswarmth; 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 themerest trifle. 

"What can't be cured must be endured, " is the very worst and mostdangerous maxim for a nurse which ever was made. Patience andresignation in her are but other words for carelessness or indifference--contemptible, if in regard to herself; culpable, if in regard to hersick. 

FOOTNOTES:

[1][Sidenote: How a room is _dusted_. ]

If you like to clean your furniture by laying out your clean clothesupon your dirty chairs or sofa, this is one way certainly of doing it. Having witnessed the morning process called "tidying the room, " for manyyears, and with ever-increasing astonishment, I can describe what it is. From the chairs, tables, or sofa, upon which the "things" have lainduring the night, and which are therefore comparatively clean from dustor blacks, the poor "_things_" having "caught" it, they are removed toother chairs, tables, sofas, upon which you could write your name withyour finger in the dust or blacks. The _other_ side of the "things" istherefore now evenly dirtied or dusted. The housemaid then flapseverything, or some things, not out of her reach, with a thing called aduster--the dust flies up, then re-settles more equally than it laybefore the operation. The room has now been "put to rights. "

[2][Sidenote: Atmosphere in painted and papered rooms quitedistinguishable. ]

I am sure that a person who has accustomed her senses to compareatmospheres proper and improper, for the sick and for children, couldtell, blindfold, the difference of the air in old painted and in oldpapered rooms, _coeteris paribus. _ The latter will always be dusty, evenwith all the windows open. 

[3][Sidenote: How to keep your wall clean at the expense of your clothes. ]

If 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 oneway certainly, and the most usual way, and generally the only way ofcleaning either door or wall in a bed room!

XI. PERSONAL CLEANLINESS. 

[Sidenote: Poisoning by the skin. ]

In almost all diseases, the function of the skin is, more or less, disordered; and in many most important diseases nature relieves herselfalmost entirely by the skin. This is particularly the case withchildren. But the excretion, which comes from the skin, is left there, unless removed by washing or by the clothes. Every nurse should keepthis fact constantly in mind, --for, if she allow her sick to remainunwashed, or their clothing to remain on them after being saturated withperspiration or other excretion, she is interfering injuriously with thenatural processes of health just as effectually as if she were to givethe patient a dose of slow poison by the mouth. Poisoning by the skin isno less certain than poisoning by the mouth--only it is slower in itsoperation. 

[Sidenote: Ventilation and skin-cleanliness equally essential. ]

The amount of relief and comfort experienced by sick after the skin hasbeen carefully washed and dried, is one of the commonest observationsmade at a sick bed. But it must not be forgotten that the comfort andrelief so obtained are not all. They are, in fact, nothing more than asign that the vital powers have been relieved by removing something thatwas oppressing them. The nurse, therefore, must never put off attendingto the personal cleanliness of her patient under the plea that all thatis to be gained is a little relief, which can be quite as well givenlater. 

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

Just as it is necessary to renew the air round a sick person frequently, to carry off morbid effluvia from the lungs and skin, by maintainingfree ventilation, so is it necessary to keep the pores of the skin freefrom all obstructing excretions. The object, both of ventilation and ofskin-cleanliness, is pretty much the same, --to wit, removing noxiousmatter from the system as rapidly as possible. 

Care should be taken in all these operations of sponging, washing, andcleansing the skin, not to expose too great a surface at once, so as tocheck the perspiration, which would renew the evil in another form. 

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

In several forms of diarrhoea, dysentery, &c. , where the skin is hardand harsh, the relief afforded by washing with a great deal of soft soapis incalculable. In other cases, sponging with tepid soap and water, then with tepid water and drying with a hot towel will be ordered. 

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

One word as to cleanliness merely as cleanliness. 

[Sidenote: Steaming and rubbing the skin. ]

Compare the dirtiness of the water in which you have washed when it iscold without soap, cold with soap, hot with soap. You will find thefirst has hardly removed any dirt at all, the second a little more, thethird a great deal more. But hold your hand over a cup of hot water fora minute or two, and then, by merely rubbing with the finger, you willbring off flakes of dirt or dirty skin. After a vapour bath you may peelyour whole self clean in this way. What I mean is, that by simplywashing or sponging with water you do not really clean your skin. Take arough towel, dip one corner in very hot water, --if a little spirit beadded to it it will be more effectual, --and then rub as if you wererubbing the towel into your skin with your fingers. The black flakeswhich will come off will convince you that you were not clean before, however much soap and water you have used. These flakes are what requireremoving. And you can really keep yourself cleaner with a tumbler of hotwater and a rough towel and rubbing, than with a whole apparatus of bathand soap and sponge, without rubbing. It is quite nonsense to say thatanybody need be dirty. Patients have been kept as clean by these meanson a long voyage, when a basin full of water could not be afforded, andwhen they could not be moved out of their berths, as if all theappurtenances of home had been at hand. 

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

XII. CHATTERING HOPES AND ADVICES. 

[Sidenote: Advising the sick. ]

The sick man to his advisers. "My advisers! Their name is legion. * * *Somehow or other, it seems a provision of the universal destinies, thatevery man, woman, and child should consider him, her, or itselfprivileged especially to advise me. Why? That is precisely what I wantto know. " And this is what I have to say to them. I have been advised togo to every place extant in and out of England--to take every kind ofexercise by every kind of cart, carriage---yes, and even swing (!) anddumb-bell (!) in existence; to imbibe every different kind of stimulusthat ever has been invented; And this when those _best_ fitted to know, viz. , medical men, after long and close attendance, had declared anyjourney out of the question, had prohibited any kind of motion whatever, had closely laid down the diet and drink. What would my advisers say, were they the medical attendants, and I the patient left their advice, and took the casual adviser's? But the singularity in Legion's mind isthis: it never occurs to him that everybody else is doing the samething, and that I the patient _must_ perforce say, in sheerself-defence, like Rosalind, "I could not do with all. "

[Sidenote: Chattering hopes the bane of the sick. ]

"Chattering Hopes" may seem an odd heading. But I really believe thereis scarcely a greater worry which invalids have to endure than theincurable hopes of their friends. There is no one practice against whichI can speak more strongly from actual personal experience, wide andlong, of its effects during sickness observed both upon others and uponmyself. I would appeal most seriously to all friends, visitors, andattendants of the sick to leave off this practice of attempting to"cheer" the sick by making light of their danger and by exaggeratingtheir probabilities of recovery. 

Far more now than formerly does the medical attendant tell the truth tothe 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 acursory observation, will weigh with the patient, against the opinion ofthe medical attendant, given, perhaps, after years of observation, afterusing every help to diagnosis afforded by the stethoscope, theexamination of pulse, tongue, &c. ; and certainly after much moreobservation than the friend can possibly have had. 

Supposing the patient to be possessed of common sense, --how can the"favourable" opinion, if it is to be called an opinion at all, of thecasual visitor "cheer" him, --when different from that of the experiencedattendant? Unquestionably the latter may, and often does, turn out to bewrong. But which is most likely to be wrong?

[Sidenote: Patient does not want to talk of himself. ]

The fact is, that the patient[1] is not "cheered" at all by thesewell-meaning, most tiresome friends. On the contrary, he is depressedand wearied. If, on the one hand, he exerts himself to tell eachsuccessive member of this too numerous conspiracy, whose name is legion, why he does not think as they do, --in what respect he is worse, --whatsymptoms exist that they know nothing of, --he is fatigued instead of"cheered, " and his attention is fixed upon himself. In general, patientswho are really ill, do not want to talk about themselves. Hypochondriacsdo, but again I say we are not on the subject of hypochondriacs. 

[Sidenote: Absurd consolations put forth for the benefit of the sick. ]

If, on the other hand, and which is much more frequently the case, thepatient says nothing but the Shakespearian "Oh!" "Ah!" "Go to!" and "Ingood sooth!" in order to escape from the conversation about himself thesooner, he is depressed by want of sympathy. He feels isolated in themidst of friends. He feels what a convenience it would be, if there wereany single person to whom he could speak simply and openly, withoutpulling the string upon himself of this shower-bath of silly hopes andencouragements; to whom he could express his wishes and directionswithout that person persisting in saying, "I hope that it will pleaseGod yet to give you twenty years, " or, "You have a long life of activitybefore you. " How often we see at the end of biographies or of casesrecorded in medical papers, "after a long illness A. Died rathersuddenly, " or, "unexpectedly both to himself and to others. ""Unexpectedly" to others, perhaps, who did not see, because they did notlook; but by no means "unexpectedly to himself, " as I feel entitled tobelieve, both from the internal evidence in such stories, and fromwatching similar cases; there was every reason to expect that A. Woulddie, and he knew it; but he found it useless to insist upon his ownknowledge to his friends. 

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

By the first much interest in, their own danger is very rarely felt. Inwritings of fiction, whether novels or biographies, these death-beds aregenerally depicted as almost seraphic in lucidity of intelligence. Sadlylarge has been my experience in death-beds, and I can only say that Ihave seldom or never seen such. Indifference, excepting with regard tobodily suffering, or to some duty the dying man desires to perform, isthe far more usual state. 

The "nervous case, " on the other hand, delights in figuring to himselfand others a fictitious danger. 

But the long chronic case, who knows too well himself, and who has beentold by his physician that he will never enter active life again, whofeels that every month he has to give up something he could do the monthbefore--oh! spare such sufferers your chattering hopes. You do not knowhow you worry and weary them. Such real sufferers cannot bear to talk ofthemselves, still less to hope for what they cannot at all expect. 

So also as to all the advice showered so profusely upon such sick, toleave 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 sickman not to believe his own doctor's prognostics, because "doctors arealways mistaken, " but to believe some other doctor, because "this doctoris always right. " Sure also are these advisers to be the persons tobring the sick man fresh occupation, while exhorting him to leave hisown. 

[Sidenote: Wonderful presumption of the advisers of the sick. ]

Wonderful is the face with which friends, lay and medical, will come inand worry the patient with recommendations to do something or other, having just as little knowledge as to its being feasible, or even safefor him, as if they were to recommend a man to take exercise, notknowing he had broken his leg. What would the friend say, if _he_ werethe medical attendant, and if the patient, because some _other_ friendhad come in, because somebody, anybody, nobody, had recommendedsomething, anything, nothing, were to disregard _his_ orders, and takethat other body's recommendation? But people never think of this. 

[Sidenote: Advisers the same now as two hundred years ago. ]

A celebrated historical personage has related the commonplaces which, when on the eve of executing a remarkable resolution, were showered innearly the same words by every one around successively for a period ofsix months. To these the personage states that it was found leasttrouble always to reply the same thing, viz. , that it could not besupposed that such a resolution had been taken without sufficientprevious consideration. To patients enduring every day for years fromevery friend or acquaintance, either by letter or _viva voce_, sometorment of this kind, I would suggest the same answer. It would indeedbe spared, if such friends and acquaintances would but consider for onemoment, that it is probable the patient has heard such advice at leastfifty times before, and that, had it been practicable, it would havebeen practised long ago. But of such consideration there appears to beno chance. Strange, though true, that people should be just the same inthese 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 thedecline of such sufferers, recall the slimy trail left by the snail onthe sunny southern garden-wall loaded with fruit. 

[Sidenote: Mockery of the advice given to sick. ]

No mockery in the world is so hollow as the advice showered upon thesick. It is of no use for the sick to say anything, for what the adviserwants is, _not_ to know the truth about the state of the patient, but toturn whatever the sick may say to the support of his own argument, setforth, it must be repeated, without any inquiry whatever into thepatient's real condition. "But it would be impertinent or indecent in meto make such an inquiry, " says the adviser. True; and how much moreimpertinent is it to give your advice when you can know nothing aboutthe truth, and admit you could not inquire into it. 

To nurses I say--these are the visitors who do your patient harm. Whenyou hear him told:--1. That he has nothing the matter with him, and thathe wants cheering. 2. That he is committing suicide, and that he wantspreventing. 3. That he is the tool of somebody who makes use of him fora purpose. 4. That he will listen to nobody, but is obstinately bentupon his own way; and 5. That, he ought to be called to a sense of duty, and is flying in the face of Providence;--then know that your patient isreceiving all the injury that he can receive from a visitor. 

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

[Sidenote: Means of giving pleasure to the sick. ]

Do, you who are about the sick or who visit the sick, try and give thempleasure, remember to tell them what will do so. How often in suchvisits the sick person has to do the whole conversation, exerting hisown imagination and memory, while you would take the visitor, absorbedin his own anxieties, making no effort of memory or imagination, for thesick person. "Oh! my dear, I have so much to think of, I really quiteforgot to tell him that; besides, I thought he would know it, " says thevisitor to another friend. How could "he know it?" Depend upon it, thepeople who say this are really those who have little "to think of. "There are many burthened with business who always manage to keep apigeon-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 forhim and good for you too; but if you tell him what is anxious, surelyyou can remember to tell him what is pleasant too. 

A sick person does so enjoy hearing good news:--for instance, of a loveand courtship, while in progress to a good ending. If you tell him onlywhen the marriage takes place, he loses half the pleasure, which Godknows he has little enough of; and ten to one but you have told him ofsome love-making with a bad ending. 

A sick person also intensely enjoys hearing of any _material_ good, anypositive or practical success of the right. He has so much of books andfiction, of principles, and precepts, and theories; do, instead ofadvising him with advice he has heard at least fifty times before, tellhim of one benevolent act which has really succeeded practically, --it islike a day's health to him. [2]

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

Do observe these things with the sick. Do remember how their life is tothem disappointed and incomplete. You see them lying there withmiserable disappointments, from which they can have no escape but death, and you can't remember to tell them of what would give them so muchpleasure, or at least an hour's variety. 

They don't want you to be lachrymose and whining with them, they likeyou to be fresh and active and interested, but they cannot bear absenceof mind, and they are so tired of the advice and preaching they receivefrom everybody, no matter whom it is, they see. 

There is no better society than babies and sick people for one another. Of course you must manage this so that neither shall suffer from it, which is perfectly possible. If you think the "air of the sick room" badfor the baby, why it is bad for the invalid too, and, therefore, youwill of course correct it for both. It freshens up a sick person's wholemental atmosphere to see "the baby. " And a very young child, ifunspoiled, will generally adapt itself wonderfully to the ways of a sickperson, if the time they spend together is not too long. 

If you knew how unreasonably sick people suffer from reasonable causesof distress, you would take more pains about all these things. An infantlaid upon the sick bed will do the sick person, thus suffering, moregood than all your logic. A piece of good news will do the same. Perhapsyou are afraid of "disturbing" him. You say there is no comfort for hispresent cause of affliction. It is perfectly reasonable. The distinctionis this, if he is obliged to act, do not "disturb" him with anothersubject of thought just yet; help him to do what he wants to do; but, ifhe _has_ done this, or if nothing _can_ be done, then "disturb" him byall means. You will relieve, more effectually, unreasonable sufferingfrom reasonable causes by telling him "the news, " showing him "thebaby, " or giving him something new to think of or to look at than by allthe logic in the world. 

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

[Sidenote: Two new classes of patients peculiar to this generation. ]

NOTE. --There are two classes of patients which are unfortunatelybecoming more common every day, especially among women of the richerorders, to whom all these remarks are pre-eminently inapplicable. 1. Those who make health an excuse for doing nothing, and at the same timeallege that the being able to do nothing is their only grief. 2. Thosewho have brought upon themselves ill-health by over pursuit ofamusement, which they and their friends have most unhappily calledintellectual activity. I scarcely know a greater injury that can beinflicted than the advice too often given to the first class to"vegetate"--or than the admiration too often bestowed on the latterclass for "pluck. "

FOOTNOTES:

[1][Sidenote: Absurd statistical comparisons made in common conversation bythe most sensible people for the benefit of the sick. ]

There are, of course, cases, as in first confinements, when an assurancefrom the doctor or experienced nurse to the frightened suffering womanthat there is nothing unusual in her case, that she has nothing to fearbut a few hours' pain, may cheer her most effectually. This is advice ofquite another order. It is the advice of experience to utterinexperience. But the advice we have been referring to is the advice ofinexperience to bitter experience; and, in general, amounts to nothingmore than this, that _you_ think _I_ shall recover from consumptionbecause 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 with whichsuch comparisons require to be made, (and are made, ) in order to be ofany value whatever, they would spare their tongues. In comparing thedeaths of one hospital with those of another, any statistics are justlyconsidered absolutely valueless which do not give the ages, the sexes, and the diseases of all the cases. It does not seem necessary to mentionthis. It does not seem necessary to say that there can be no comparisonbetween old men with dropsies and young women with consumptions. Yet thecleverest men and the cleverest women are often heard making suchcomparisons, ignoring entirely sex, age, disease, place--in fact, _all_the conditions essential to the question. It is the merest _gossip_. 

[2]A small pet animal is often an excellent companion for the sick, forlong chronic cases especially. A pet bird in a cage is sometimes theonly pleasure of an invalid confined for years to the same room. If hecan feed and clean the animal himself, he ought always to be encouragedto do so. 

XIII. OBSERVATION OF THE SICK. 

[Sidenote: What is the use of the question, Is he better?]

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 ofwhom else, if you wish for a real answer to your question, would youask? Certainly not of the casual visitor; certainly not of the nurse, while the nurse's observation is so little exercised as it is now. Whatyou want are facts, not opinions--for who can have any opinion of anyvalue as to whether the patient is better or worse, excepting theconstant medical attendant, or the really observing nurse?

The most important practical lesson that can be given to nurses is toteach them what to observe--how to observe--what symptoms indicateimprovement--what the reverse--which are of importance--which are ofnone--which are the evidence of neglect--and of what kind of neglect. 

All this is what ought to make part, and an essential part, of thetraining of every nurse. At present how few there are, eitherprofessional or unprofessional, who really know at all whether any sickperson they may be with is better or worse. 

The vagueness and looseness of the information one receives in answer tothat much abused question, "Is he better?" would be ludicrous, if itwere not painful. The only sensible answer (in the present state ofknowledge about sickness) would be "How can I know? I cannot tell how hewas when I was not with him. "

I can record but a very few specimens of the answers[1] which I haveheard made by friends and nurses, and accepted by physicians andsurgeons at the very bed-side of the patient, who could havecontradicted every word, but did not--sometimes from amiability, oftenfrom shyness, oftenest from languor!

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

"Do you think the patient is much weaker than he was six weeks ago?" "Ohno, sir; you know it is very long since he has been up and dressed, andhe can get across the room now. " This means that the nurse has notobserved that whereas six weeks ago he sat up and occupied himself inbed, he now lies still doing nothing; that, although he can "get acrossthe room, " he cannot stand for five seconds. 

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

[Sidenote: Leading questions useless or misleading. ]

Questions, too, as asked now (but too generally) of or about patients, would obtain no information at all about them, even if the person askedof had every information to give. The question is generally a leadingquestion; and it is singular that people never think what must be theanswer to this question before they ask it: for instance, "Has he had agood night?" Now, one patient will think he has a bad night if he hasnot slept ten hours without waking. Another does not think he has a badnight if he has had intervals of dosing occasionally. The same answerhas, actually been given as regarded two patients--one who had beenentirely sleepless for five times twenty-four hours, and died of it, andanother 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?[2] "I have never closed my eyes allnight, " an answer as frequently made when the speaker has had severalhours' sleep as when he has had none, would then be less often said. Lies, intentional and unintentional, are much seldomer told in answer toprecise than to leading questions. Another frequent error is to inquirewhether one cause remains, and not whether the effect which may beproduced by a great many different causes, _not_ inquired after, remains. As when it is asked, whether there was noise in the street lastnight; and if there were not, the patient is reported, without more ado, to have had a good night. Patients are completely taken aback by thesekinds of leading questions, and give only the exact amount ofinformation asked for, even when they know it to be completelymisleading. The shyness of patients is seldom allowed for. 

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

[Sidenote: Means of obtaining inaccurate information. ]

I knew a very clever physician, of large dispensary and hospitalpractice, who invariably began his examination of each patient with "Putyour finger where you be bad. " That man would never waste his time withcollecting inaccurate information from nurse or patient. Leadingquestions always collect inaccurate information. 

At a recent celebrated trial, the following leading question was putsuccessively to nine distinguished medical men. "Can you attribute thesesymptoms to anything else but poison?" And out of the nine, eightanswered "No!" without any qualification whatever. It appeared, uponcross-examination:--1. That none of them had ever seen a case of thekind of poisoning supposed. 2. That none of them had ever seen a case ofthe kind of disease to which the death, if not to poison, wasattributable. 3. That none of them were even aware of the main fact ofthe disease and condition to which the death was attributable. 

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

I had rather not say how many instances I have known, where, owing tothis system of leading questions, the patient has died, and theattendants have been actually unaware of the principal feature of thecase. 

[Sidenote: As to food patient takes or does not take. ]

It is useless to go through all the particulars, besides sleep, in whichpeople have a peculiar talent for gleaning inaccurate information. As tofood, for instance, I often think that most common question, How is yourappetite? can only be put because the questioner believes the questionedhas really nothing the matter with him, which is very often the case. But where there is, the remark holds good which has been made aboutsleep. The _same_ answer will often be made as regards a patient whocannot take two ounces of solid food per diem, and a patient who doesnot enjoy five meals a day as much as usual. 

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

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

1. Defect in cooking;

2. Defect in choice of diet;

3. Defect in choice of hours for taking diet;

4. Defect of appetite in patient. 

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

Surely many lives might be saved by drawing a closer distinction; forthe remedies are as diverse as the causes. The remedy for the first isto cook better; for the second, to choose other articles of diet; forthe 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 unexpectedly. But no one of these remedies will do for any other of the defects notcorresponding with it. 

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

Again, I say, what _is_ the nurse or friend there for except to takenote of these things, instead of the patient doing so?[3]

[Sidenote: As to diarrhoea]

Again, the question is sometimes put, Is there diarrhoea? And the answerwill be the same, whether it is just merging into cholera, whether it isa trifling degree brought on by some trifling indiscretion, which willcease the moment the cause is removed, or whether there is no diarrhoeaat all, but simply relaxed bowels. 

It is useless to multiply instances of this kind. As long as observationis so little cultivated as it is now, I do believe that it is better forthe physician _not_ to see the friends of the patient at all. They willoftener mislead him than not. And as often by making the patient outworse as better than he really is. 

In the case of infants, _everything_ must depend upon the accurateobservation of the nurse or mother who has to report. And how seldom isthis condition of accuracy fulfilled. 

[Sidenote: Means of cultivating sound and ready observation. ]

A celebrated man, though celebrated only for foolish things, has told usthat one of his main objects in the education of his son, was to givehim a ready habit of accurate observation, a certainty of perception, and that for this purpose one of his means was a month's course asfollows:--he took the boy rapidly past a toy-shop; the father and sonthen described to each other as many of the objects as they could, whichthey had seen in passing the windows, noting them down with pencil andpaper, and returning afterwards to verify their own accuracy. The boyalways succeeded best, e. G. , if the father described 30 objects, the boydid 40, and scarcely ever made a mistake. 

I have often thought how wise a piece of education this would be formuch higher objects; and in our calling of nurses the thing itself isessential. For it may safely be said, not that the habit of ready andcorrect observation will by itself make us useful nurses, but thatwithout it we shall be useless with all our devotion. 

I have known a nurse in charge of a set of wards, who not only carriedin her head all the little varieties in the diets which each patient wasallowed to fix for himself, but also exactly what each patient had takenduring each day. I have known another nurse in charge of one singlepatient, who took away his meals day after day all but untouched, andnever knew it. 

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

Surely you can learn at least to judge with the eye how much an oz. Ofsolid food is, how much an oz. Of liquid. You will find this helps yourobservation 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 hoursabout 1/4 pint of beef tea;" instead of saying "B. Has taken nothing allday, " or "I gave A. His dinner as usual. "

[Sidenote: Sound and ready observation essential in a nurse. ]

I have known several of our real old-fashioned hospital "sisters, " whocould, as accurately as a measuring glass, measure out all theirpatients' wine and medicine by the eye, and never be wrong. I do notrecommend this, one must be very sure of one's self to do it. I onlymention it, because if a nurse can by practice measure medicine by theeye, surely she is no nurse who cannot measure by the eye about how muchfood (in oz. ) her patient has taken. [4] In hospitals those who cut upthe diets give with sufficient accuracy, to each patient, his 12 oz. Orhis 6 oz. Of meat without weighing. Yet a nurse will often have patientsloathing all food and incapable of any will to get well, who just tumbleover the contents of the plate or dip the spoon in the cup to deceivethe nurse, and she will take it away without ever seeing that there isjust the same quantity of food as when she brought it, and she will tellthe doctor, too, that the patient has eaten all his diets as usual, whenall she ought to have meant is that she has taken away his diets asusual. 

Now what kind of a nurse is this?

[Sidenote: Difference of excitable and _accumulative_ temperaments. ]

I would call attention to something else, in which nurses frequentlyfail in observation. There is a well-marked distinction between theexcitable and what I will call the _accumulative_ temperament inpatients. One will blaze up at once, under any shock or anxiety, andsleep very comfortably after it; another will seem quite calm and eventorpid, under the same shock, and people say, "He hardly felt it atall, " yet you will find him some time after slowly sinking. The sameremark applies to the action of narcotics, of aperients, which, in theone, take effect directly, in the other not perhaps for twenty-fourhours. A journey, a visit, an unwonted exertion, will affect the oneimmediately, but he recovers after it; the other bears it very well atthe time, apparently, and dies or is prostrated for life by it. Peopleoften say how difficult the excitable temperament is to manage. I sayhow difficult is the _accumulative_ temperament. With the first you havean out-break which you could anticipate, and it is all over. With thesecond you never know where you are--you never know when theconsequences are over. And it requires your closest observation to knowwhat _are_ the consequences of what--for the consequent by no meansfollows immediately upon the antecedent--and coarse observation isutterly at fault. 

[Sidenote: Superstition the fruit of bad observation. ]

Almost all superstitions are owing to bad observation, to the _post hoc, ergo propter hoc_; and bad observers are almost all superstitious. Farmers used to attribute disease among cattle to witchcraft; weddingshave been attributed to seeing one magpie, deaths to seeing three; and Ihave heard the most highly educated now-a-days draw consequences for thesick closely resembling these. 

[Sidenote: Physiognomy of disease little shewn by the face. ]

Another remark: although there is unquestionably a physiognomy ofdisease as well as of health; of all parts of the body, the face isperhaps the one which tells the least to the common observer or thecasual visitor. Because, of all parts of the body, it is the one mostexposed to other influences, besides health. And people never, orscarcely ever, observe enough to know how to distinguish between theeffect of exposure, of robust health, of a tender skin, of a tendency tocongestion, of suffusion, flushing, or many other things. Again, theface is often the last to shew emaciation. I should say that the handwas a much surer test than the face, both as to flesh, colour, circulation, &c. , &c. It is true that there are _some_ diseases whichare only betrayed at all by something in the face, _e. G. _, the eye orthe tongue, as great irritability of brain by the appearance of thepupil of the eye. But we are talking of casual, not minute, observation. And few minute observers will hesitate to say that far more untruth thantruth is conveyed by the oft repeated words, He _looks_ well, or ill, orbetter or worse. 

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

I have known patients dying of sheer pain, exhaustion, and want ofsleep, from one of the most lingering and painful diseases known, preserve, till within a few days of death, not only the healthy colourof the cheek, but the mottled appearance of a robust child. And scoresof times have I heard these unfortunate creatures assailed with, "I amglad to see you looking so well. " "I see no reason why you should notlive till ninety years of age. " "Why don't you take a little moreexercise and amusement, " with all the other commonplaces with which weare so familiar. 

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

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

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

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

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

[Sidenote: Peculiarities of patients. ]

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

[Sidenote: Nurse must observe for herself increase of patient'sweakness, patient will not tell her. ]

Again, I think that few things press so heavily on one suffering fromlong and incurable illness, as the necessity of recording in words fromtime to time, for the information of the nurse, who will not otherwisesee, that he cannot do this or that, which he could do a month or a yearago. What is a nurse there for if she cannot observe these things forherself? Yet I have known--and known too among those--and _chiefly_among those--whom money and position put in possession of everythingwhich money and position could give--I have known, I say, more accidents(fatal, slowly or rapidly) arising from this want of observation amongnurses than from almost anything else. Because a patient could get outof a warm-bath alone a month ago--because a patient could walk as far ashis bell a week ago, the nurse concludes that he can do so now. She hasnever observed the change; and the patient is lost from being left in ahelpless state of exhaustion, till some one accidentally comes in. Andthis not from any unexpected apoplectic, paralytic, or fainting fit(though even these could be expected far more, at least, than they arenow, if we did but _observe_). No, from the unexpected, or to beexpected, inevitable, visible, calculable, uninterrupted increase ofweakness, which none need fail to observe. 

[Sidenote: Accidents arising from the nurse's want of observation. ]

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

[Sidenote: Is the faculty of observing on the decline?]

Yet it appears that scarcely any improvement in the faculty of observingis being made. Vast has been the increase of knowledge in pathology--that science which teaches us the final change produced by disease onthe human frame--scarce any in the art of observing the signs of thechange while in progress. Or, rather, is it not to be feared thatobservation, as an essential part of medicine, has been declining?

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

Let people who have to observe sickness and death look back and try toregister in their observation the appearances which have precededrelapse, attack, or death, and not assert that there were none, or thatthere were not the _right_ ones. [5]

[Sidenote: Observation of general conditions. ]

A want of the habit of observing conditions and an inveterate habit oftaking averages are each of them often equally misleading. 

Men whose profession like that of medical men leads them to observeonly, or chiefly, palpable and permanent organic changes are often justas wrong in their opinion of the result as those who do not observe atall. For instance, there is a broken leg; the surgeon has only to lookat it once to know; it will not be different if he sees it in themorning to what it would have been had he seen it in the evening. And inwhatever conditions the patient is, or is likely to be, there will stillbe 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 knowsthat there is aneurism which will kill some time or other. 

But with the great majority of cases, there is nothing of the kind; andthe power of forming any correct opinion as to the result must entirelydepend upon an enquiry into all the conditions in which the patientlives. In a complicated state of society in large towns, death, as everyone of great experience knows, is far less often produced by any oneorganic disease than by some illness, after many other diseases, producing just the sum of exhaustion necessary for death. There isnothing so absurd, nothing so misleading as the verdict one so oftenhears: So-and-so has no organic disease, --there is no reason why heshould not live to extreme old age; sometimes the clause is added, sometimes not: Provided he has quiet, good food, good air, &c. , &c. , &c. : the verdict is repeated by ignorant people _without_ the latterclause; or there is no possibility of the conditions of the latterclause 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 nowprescribed a course, every detail of which the patient had followed foryears. And because he had forbidden a course which the patient could notby any possibility alter. [6]

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

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

[Sidenote: "Average rate of mortality" tells us only that so many percent. Will die. Observation must tell us _which_ in the hundred theywill be who will die. ]

Averages again seduce us away from minute observation. "Averagemortalities" merely tell that so many per cent. Die in this town and somany 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 24per 1, 000 will die in London next year. But minute enquiries intoconditions enable us to know that in such a district, nay, in such astreet, --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 ofmortality, that is, the person will die who ought not to have diedbefore old age. 

Now, would it not very materially alter the opinion of whoever wereendeavouring to form one, if he knew that from that floor, of thathouse, of that street the man came. 

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

It is well known that the same names may be seen constantly recurring onworkhouse books for generations. That is, the persons were born andbrought up, and will be born and brought up, generation aftergeneration, in the conditions which make paupers. Death and disease arelike the workhouse, they take from the same family, the same house, orin other words, the same conditions. Why will we not observe what theyare?

The close observer may safely predict that such a family, whether itsmembers marry or not, will become extinct; that such another willdegenerate morally and physically. But who learns the lesson? On thecontrary, it may be well known that the children die in such a house atthe 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, thefamily goes on living there till it dies out, and then some other familytakes it. Neither would they listen "if one rose from the dead. "

[Sidenote: What observation is for. ]

In dwelling upon the vital importance of _sound_ observation, it mustnever be lost sight of what observation is for. It is not for the sakeof piling up miscellaneous information or curious facts, but for thesake of saving life and increasing health and comfort. The caution mayseem useless, but it is quite surprising how many men (some women do ittoo), practically behave as if the scientific end were the only one inview, or as if the sick body were but a reservoir for stowing medicinesinto, and the surgical disease only a curious case the sufferer has madefor the attendant's special information. This is really no exaggeration. You think, if you suspected your patient was being poisoned, say, by acopper kettle, you would instantly, as you ought, cut off all possibleconnection between him and the suspected source of injury, withoutregard 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 aquestion of medical ethics, what should the medical man do if hesuspected poisoning? The answer seems a very simple one, --insist on aconfidential nurse being placed with the patient, or give up the case. 

[Sidenote: What a confidential nurse should be. ]

And remember every nurse should be one who is to be depended upon, inother words, capable of being, a "confidential" nurse. She does not knowhow soon she may find herself placed in such a situation; she must be nogossip, no vain talker; she should never answer questions about her sickexcept to those who have a right to ask them; she must, I need not say, be strictly sober and honest; but more than this, she must be areligious and devoted woman; she must have a respect for her owncalling, because God's precious gift of life is often literally placedin her hands; she must be a sound, and close, and quick observer; andshe must be a woman of delicate and decent feeling. 

[Sidenote: Observation is for practical purposes. ]

To return to the question of what observation is for:--It would reallyseem as if some had considered it as its own end, as if detection, notcure, was their business; nay more, in a recent celebrated trial, threemedical men, according to their own account, suspected poison, prescribed for dysentery, and left the patient to the poisoner. This isan extreme case. But in a small way, the same manner of acting fallsunder the cognizance of us all. How often the attendants of a case havestated that they knew perfectly well that the patient could not get wellin such an air, in such a room, or under such circumstances, yet havegone on dosing him with medicine, and making no effort to remove thepoison from him, or him from the poison which they knew was killing him;nay, more, have sometimes not so much as mentioned their conviction inthe right quarter--that is, to the only person who could act in thematter. 

FOOTNOTES:[1]It is a much more difficult thing to speak the truth than peoplecommonly imagine. There is the want of observation _simple_, and thewant of observation _compound_, compounded, that is, with theimaginative faculty. Both may equally intend to speak the truth. Theinformation of the first is simply defective. That of the second is muchmore dangerous. The first gives, in answer to a question asked about athing that has been before his eyes perhaps for years, informationexceedingly 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 immediatelysteps in, and he describes the whole thing from imagination merely, being perfectly convinced all the while that he has seen or heard it; orhe will repeat a whole conversation, as if it were information which hadbeen addressed to him; whereas it is merely what he has himself said tosomebody else. This is the commonest of all. These people do not evenobserve that they have _not_ observed, nor remember that they haveforgotten. 

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 manyfaculties 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 havefibbed until they tells me so, " was a remark actually made. It is alsoone of much more extended application than most people have the leastidea of. 

Concurrence of testimony, which is so often adduced as final proof, mayprove nothing more, as is well known to those accustomed to deal withthe unobservant imaginative, than that one person has told his story agreat many times. 

I have heard thirteen persons "concur" in declaring that fourteenth, whohad never left his bed, went to a distant chapel every morning at seveno'clock. 

I have heard persons in perfect good faith declare, that a man came todine every day at the house where they lived, who had never dined thereonce; that a person had never taken the sacrament, by whose side theyhad twice at least knelt at Communion; that but one meal a day came outof a hospital kitchen, which for six weeks they had seen provide fromthree to five and six meals a day. Such instances might be multiplied_ad infinitum_ if necessary. 

[2]This is important, because on this depends what the remedy will be. If apatient sleeps two or three hours early in the night, and then does notsleep again at all, ten to one it is not a narcotic he wants, but foodor stimulus, or perhaps only warmth. If, on the other hand, he isrestless and awake all night, and is drowsy in the morning, he probablywants sedatives, either quiet, coolness, or medicine, a lighter diet, orall four. Now the doctor should be told this, or how can he judge whatto give?

[3][Sidenote: More important to spare the patient thought than physicalexertion. ]

It is commonly supposed that the nurse is there to spare thepatient from making physical exertion for himself--I would rathersay that she ought to be there to spare him from taking thoughtfor himself. And I am quite sure, that if the patient were sparedall thought for himself, and _not_ spared all physical exertion, hewould be infinitely the gainer. The reverse is generally the casein the private house. In the hospital it is the relief from allanxiety, afforded by the rules of a well-regulated institution, which has often such a beneficial effect upon the patient. 

[4][Sidenote: English women have great capacity of, but little practice inclose observation. ]

It may be too broad an assertion, and it certainly sounds like aparadox. But I think that in no country are women to be found sodeficient in ready and sound observation as in England, while peculiarlycapable of being trained to it. The French or Irish woman is too quickof perception to be so sound an observer--the Teuton is too slow to beso ready an observer as the English woman might be. Yet English womenlay themselves open to the charge so often made against them by men, viz. , that they are not to be trusted in handicrafts to which theirstrength is quite equal, for want of a practised and steady observation. In countries where women (with average intelligence certainly notsuperior to that of English women) are employed, e. G. , in dispensing, men responsible for what these women do (not theorizing about man's andwoman's "missions, ") have stated that they preferred the service ofwomen to that of men, as being more exact, more careful, and incurringfewer 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 bysome one who sent two girls to fetch a "bottle of salvolatile from herroom;" "Mary could not stir, " she said, "Fanny ran and fetched a bottlethat was not salvolatile, and that was not in my room. "

Now this sort of thing pursues every one through life. A woman is askedto 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 bythe fire. And this, though she has "put that room to rights" every dayfor a month perhaps, and must have observed the books every day, lyingin 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'sroom, " every day she was there, she would more probably have found itwhen it was suddenly wanted. 

There are two causes for these mistakes of inadvertence. 1. A want ofready attention; only a part of the request is heard at all. 2. A wantof the habit of observation. 

To a nurse I would add, take care that you always put the same things inthe same places; you don't know how suddenly you may be called on someday to find something, and may not be able to remember in your hastewhere you yourself had put it, if your memory is not in the habit ofseeing the thing there always. 

[5][Sidenote: Approach of death, paleness by no means an invariableeffect, as we find in novels. ]

It falls to few ever to have had the opportunity of observing thedifferent aspects which the human face puts on at the sudden approach ofcertain forms of death by violence; and as it is a knowledge of littleuse, I only mention it here as being the most startling example of whatI mean. In the nervous temperament the face becomes pale (this is theonly _recognised_ effect); in the sanguine temperament purple; in thebilious yellow, or every manner of colour in patches. Now, it isgenerally supposed that paleness is the one indication of almost anyviolent change in the human being, whether from terror, disease, oranything else. There can be no more false observation. Granted, it isthe one recognised livery, as I have said--_de rigueur_ in novels, butnowhere else. 

[6]I have known two cases, the one of a man who intentionally andrepeatedly displaced a dislocation, and was kept and petted by all thesurgeons; the other of one who was pronounced to have nothing the matterwith him, there being no organic change perceptible, but who died withinthe week. In both these cases, it was the nurse who, by accuratelypointing out what she had accurately observed, to the doctors, saved theone case from persevering in a fraud, the other from being dischargedwhen actually in a dying state. 

I will even go further and say, that in diseases which have their originin the feeble or irregular action of some function, and not in organicchange, it is quite an accident if the doctor who sees the case onlyonce a day, and generally at the same time, can form any but a negativeidea of its real condition. In the middle of the day, when such apatient 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 cleanlinen, you can scarcely believe that he is the same person as lay with arapid fluttering pulse, with puffed eye-lids, with short breath, coldlimbs, and unsteady hands, this morning. Now what is a nurse to do insuch a case? Not cry, "Lord, bless you, sir, why you'd have thought hewere a dying all night. " This may be true, but it is not the way toimpress with the truth a doctor, more capable of forming a judgment fromthe facts, if he did but know them, than you are. What he wants is notyour opinion, however respectfully given, but your facts. In alldiseases it is important, but in diseases which do not run a distinctand fixed course, it is not only important, it is essential that thefacts the nurse alone can observe, should be accurately observed, andaccurately reported to the doctor. 

I must direct the nurse's attention to the extreme variation there isnot unfrequently in the pulse of such patients during the day. A verycommon case is this: Between 3 and 4 A. M. , the pulse become quick, perhaps 130, and so thready it is not like a pulse at all, but like astring vibrating just underneath the skin. After this the patient getsno more sleep. About mid-day the pulse has come down to 80; and thoughfeeble and compressible, is a very respectable pulse. At night, if thepatient has had a day of excitement, it is almost imperceptible. But, ifthe patient has had a good day, it is stronger and steadier, and notquicker than at mid-day. This is a common history of a common pulse; andothers, equally varying during the day, might be given. Now, ininflammation, which may almost always be detected by the pulse, intyphoid fever, which is accompanied by the low pulse that nothing willraise, there is no such great variation. And doctors and nurses becomeaccustomed not to look for it. The doctor indeed cannot. But thevariation 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 ofexhaustion necessary to produce death. And everybody cries, Who wouldhave thought it? except the observing nurse, if there is one, who hadalways expected the exhaustion to come, from which there would be norally, because she knew the patient had no capital in strength on whichto draw, if he failed for a few days to make his barely daily income insleep and nutrition. 

I have often seen really good nurses distressed, because they could notimpress the doctor with the real danger of their patient; and quiteprovoked because the patient "would look" either "so much better" or "somuch worse" than he really is "when the doctor was there. " The distressis very legitimate, but it generally arises from the nurse not havingthe power of laying clearly and shortly before the doctor the facts fromwhich she derives her opinion, or from the doctor being hasty andinexperienced, and not capable of eliciting them. A man who really caresfor his patients, will soon learn to ask for and appreciate theinformation of a nurse, who is at once a careful observer and a clearreporter. 

CONCLUSION. 

[Sidenote: Sanitary nursing as essential in surgical as in medicalcases, but not to supersede surgical nursing. ]

The whole of the preceding remarks apply even more to children and topuerperal woman than to patients in general. They also apply to thenursing of surgical, quite as much as to that of medical cases. Indeed, if it be possible, cases of external injury require such care even morethan sick. In surgical wards, one duty of every nurse certainly is_prevention_. Fever, or hospital gangrene, or pyaemia, or purulentdischarge of some kind may else supervene. Has she a case of compoundfracture, of amputation, or of erysipelas, it may depend very much onhow she looks upon the things enumerated in these notes, whether one orother of these hospital diseases attacks her patient or not. If sheallows her ward to become filled with the peculiar close foetid smell, so apt to be produced among surgical cases, especially where there isgreat suppuration and discharge, she may see a vigorous patient in theprime of life gradually sink and die where, according to all humanprobability, he ought to have recovered. The surgical nurse must be everon the watch, ever on her guard, against want of cleanliness, foul air, want of light, and of warmth. 

Nevertheless let no one think that because _sanitary_ nursing is thesubject of these notes, therefore, what may be called the handicraft ofnursing is to be undervalued. A patient may be left to bleed to death ina 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 hehas every requisite of air, light, and quiet. But nursing, as ahandicraft, has not been treated of here for three reasons: 1. Thatthese notes do not pretend to be a manual for nursing, any more than forcooking for the sick; 2. That the writer, who has herself seen more ofwhat may be called surgical nursing, i. E. Practical manual nursing, than, perhaps, any one in Europe, honestly believes that it isimpossible to learn it from any book, and that it can only be thoroughlylearnt in the wards of a hospital; and she also honestly believes thatthe perfection of surgical nursing may be seen practised by theold-fashioned "Sister" of a London hospital, as it can be seen nowhereelse in Europe. 3. While thousands die of foul air, &c. , who have thissurgical nursing to perfection, the converse is comparatively rare. 

[Sidenote: Children: their greater susceptibility to the same things. ]

To revert to children. They are much more susceptible than grown peopleto all noxious influences. They are affected by the same things, butmuch more quickly and seriously, viz. , by want of fresh air, of properwarmth, want of cleanliness in house, clothes, bedding, or body, bystartling noises, improper food, or want of punctuality, by dulness andby want of light, by too much or too little covering in bed, or when up, by want of the spirit of management generally in those in charge ofthem. One can, therefore, only press the importance, as being yetgreater in the case of children, greatest in the case of sick children, of attending to these things. 

That which, however, above all, is known to injure children seriously isfoul air, and most seriously at night. Keeping the rooms where theysleep tight shut up, is destruction to them. And, if the child'sbreathing be disordered by disease, a few hours only of such foul airmay endanger its life, even where no inconvenience is felt by grown-uppersons in the same room. 

The following passages, taken out of an excellent "Lecture on SuddenDeath in Infancy and Childhood, " just published, show the vitalimportance of careful nursing of children. "In the great majority ofinstances, when death suddenly befalls the infant or young child, it isan _accident_; it is not a necessary result of any disease from which itis suffering. "

It may be here added, that it would be very desirable to know how oftendeath is, with adults, "not a necessary, inevitable result of anydisease. " Omit the word "sudden;" (for _sudden_ death is comparativelyrare in middle age;) and the sentence is almost equally true for allages. 

The following causes of "accidental" death in sick children areenumerated:--"Sudden noises, which startle--a rapid change oftemperature, which chills the surface, though only for a moment--a rudeawakening from sleep--or even an over-hasty, or an overfull meal"--"anysudden impression on the nervous system--any hasty alteration ofposture--in short, any cause whatever by which the respiratory processmay be disturbed. "

It may again be added, that, with very weak adult patients, these causesare also (not often "suddenly fatal, " it is true, but) very much oftenerthan is at all generally known, irreparable in their consequences. 

Both for children and for adults, both for sick and for well (althoughmore certainly in the case of sick children than in any others), I wouldhere again repeat, the most frequent and most fatal cause of all issleeping, for even a few hours, much more for weeks and months, in foulair, a condition which, more than any other condition, disturbs therespiratory process, and tends to produce "accidental" death in disease. 

I need hardly here repeat the warning against any confusion of ideasbetween cold and fresh air. You may chill a patient fatally withoutgiving 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 goodnurse. 

In cases of long recurring faintnesses from disease, for instance, especially disease which affects the organs of breathing, fresh air tothe lungs, warmth to the surface, and often (as soon as the patient canswallow) hot drink, these are the right remedies and the only ones. 

Yet, oftener than not, you see the nurse or mother just reversing this;shutting up every cranny through which fresh air can enter, and leavingthe body cold, or perhaps throwing a greater weight of clothes upon it, when already it is generating too little heat. 

"Breathing carefully, anxiously, as though respiration were a functionwhich required all the attention for its performance, " is cited as a notunusual state in children, and as one calling for care in all the thingsenumerated above. That breathing becomes an almost voluntary act, evenin grown up patients who are very weak, must often have been remarked. 

"Disease having interfered with the perfect accomplishment of therespiratory function, some sudden demand for its complete exercise, issues in the sudden standstill of the whole machinery, " is given as oneprocess:--"life goes out for want of nervous power to keep the vitalfunctions in activity, " is given as another, by which "accidental" deathis 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. 

[Sidenote: Summary. ]

To sum up:--the answer to two of the commonest objections urged, one bywomen themselves, the other by men, against the desirableness ofsanitary knowledge for women, _plus_ a caution, comprises the wholeargument for the art of nursing. 

[Sidenote: Reckless amateur physicking by women. Real knowledge of thelaws of health alone can check this. ]

(1. ) It is often said by men, that it is unwise to teach women anythingabout these laws of health, because they will take to physicking, --thatthere is a great deal too much of amateur physicking as it is, which isindeed true. One eminent physician told me that he had known morecalomel given, both at a pinch and for a continuance, by mothers, governesses, and nurses, to children than he had ever heard of aphysician prescribing in all his experience. Another says, that women'sonly idea in medicine is calomel and aperients. This is undeniably toooften the case. There is nothing ever seen in any professional practicelike the reckless physicking by amateur females. [1] But this is justwhat the really experienced and observing nurse does _not_ do; sheneither physics herself nor others. And to cultivate in thingspertaining to health observation and experience in women who aremothers, governesses or nurses, is just the way to do away with amateurphysicking, and if the doctors did but know it, to make the nursesobedient to them, --helps to them instead of hindrances. Such educationin women would indeed diminish the doctor's work--but no one reallybelieves that doctors wish that there should be more illness, in orderto have more work. 

[Sidenote: What pathology teaches. What observation alone teaches. Whatmedicine does. What nature alone does. ]

(2. ) It is often said by women, that they cannot know anything of thelaws of health, or what to do to preserve their children's health, because they can know nothing of "Pathology, " or cannot "dissect, "--aconfusion of ideas which it is hard to attempt to disentangle. 

Pathology teaches the harm that disease has done. But it teaches nothingmore. We know nothing of the principle of health, the positive of whichpathology is the negative, except from observation and experience. Andnothing but observation and experience will teach us the ways tomaintain or to bring back the state of health. It is often thought thatmedicine is the curative process. It is no such thing; medicine is thesurgery of functions, as surgery proper is that of limbs and organs. Neither can do anything but remove obstructions; neither can cure;nature alone cures. Surgery removes the bullet out of the limb, which isan obstruction to cure, but nature heals the wound. So it is withmedicine; the function of an organ becomes obstructed; medicine, so faras we know, assists nature to remove the obstruction, but does nothingmore. And what nursing has to do in either case, is to put the patientin the best condition for nature to act upon him. Generally, just thecontrary is done. You think fresh air, and quiet and cleanlinessextravagant, perhaps dangerous, luxuries, which should be given to thepatient only when quite convenient, and medicine the _sine qua non_, thepanacea. 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 willhave been answered. 

Now for the caution:--

(3. ) It seems a commonly received idea among men and even among womenthemselves that it requires nothing but a disappointment in love, thewant of an object, a general disgust, or incapacity for other things, toturn a woman into a good nurse. 

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

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

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

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

The everyday management of a large ward, let alone of a hospital--theknowing what are the laws of life and death for men, and what the lawsof health for wards--(and wards are healthy or unhealthy, mainlyaccording to the knowledge or ignorance of the nurse)--are not thesematters of sufficient importance and difficulty to require learning byexperience and careful inquiry, just as much as any other art? They donot come by inspiration to the lady disappointed in love, nor to thepoor workhouse drudge hard up for a livelihood. 

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

In this respect (and why is it so?), in Roman Catholic countries, bothwriters and workers are, in theory at least, far before ours. They wouldnever think of such a beginning for a good working Superior or Sister ofCharity. And many a Superior has refused to admit a _Postulant_ whoappeared to have no better "vocation" or reasons for offering herselfthan these. 

It is true _we_ make "no vows. " But is a "vow" necessary to convince usthat the true spirit for learning any art, most especially an art ofcharity, aright, is not a disgust to everything or something else? Do wereally place the love of our kind (and of nursing, as one branch of it)so low as this? What would the Mère Angélique of Port Royal, what wouldour own Mrs. Fry have said to this?

NOTE. --I would earnestly ask my sisters to keep clear of both thejargons now current every where (for they _are_ equally jargons); of thejargon, namely, about the "rights" of women, which urges women to do allthat men do, including the medical and other professions, merely becausemen do it, and without regard to whether this _is_ the best that women, can do; and of the jargon which urges women to do nothing that men do, merely because they are women, and should be "recalled to a sense oftheir duty as women, " and because "this is women's work, " and "that ismen's, " and "these are things which women should not do, " which is allassertion, and nothing more. Surely woman should bring the best she has, _whatever_ that is, to the work of God's world, without attending toeither 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, " toopinion, to the "voices from without?" And as a wise man has said, noone has ever done anything great or useful by listening to the voicesfrom without. 

You do not want the effect of your good things to be, "How wonderful fora _woman_!" nor would you be deterred from good things by hearing itsaid, "Yes, but she ought not to have done this, because it is notsuitable 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 shouldhave been able to do it. Neither does it make a thing bad, which wouldhave 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, insimplicity and singleness of heart. 

FOOTNOTES:

[1][Sidenote: Danger of physicking by amateur females. ]

I have known many ladies who, having once obtained a "blue pill"prescription from a physician, gave and took it as a common aperient twoor three times a week--with what effect may be supposed. In one case Ihappened to be the person to inform the physician of it, who substitutedfor the prescription a comparatively harmless aperient pill. The ladycame 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 tookphysic, who would not take the pains to learn the names of the commonestmedicines, and confounded, _e. G. _, colocynth with colchicum. This _is_playing with sharp-edged tools "with a vengeance. "

There are excellent women who will write to London to their physicianthat there is much sickness in their neighbourhood in the country, andask for some prescription from him, which they used to like themselves, and then give it to all their friends and to all their poorer neighbourswho will take it. Now, instead of giving medicine, of which you cannotpossibly know the exact and proper application, nor all itsconsequences, would it not be better if you were to persuade and helpyour poorer neighbours to remove the dung-hill from before the door, toput in a window which opens, or an Arnott's ventilator, or to cleanseand lime-wash the cottages? Of these things the benefits are sure. Thebenefits of the inexperienced administration of medicines are by nomeans so sure. 

Homoeopathy has introduced one essential amelioration in the practice ofphysic by amateur females; for its rules are excellent, its physickingcomparatively harmless--the "globule" is the one grain of folly whichappears to be necessary to make any good thing acceptable. Let thenwomen, if they will give medicine, give homoeopathic medicine. It won'tdo 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 mustfly immediately to aperients. The reverse is the conclusion ofexperience. 

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

It is very seldom indeed, that by choosing your diet, you cannotregulate your own bowels; and every woman may watch herself to know whatkind of diet will do this; I have known deficiency of meat produceconstipation, quite as often as deficiency of vegetables; baker's breadmuch oftener than either. Home made brown bread will oftener cure itthan anything else. 

APPENDIX. 

[Transcriber's note: These tables have been transposed to fit the pagewidth. 

The figures in the left hand column, Table B: Nurse (not DomesticServant) do not add up. There is probably a typographical error in thiscolumn since it cannot be accounted for by errors in transcription. ]

TABLE A. 

GREAT BRITAIN. 

AGES. 

NURSES. Nurse (not Domestic Nurse (Domestic Servant) Servant)All Ages. 25, 466 39, 139Under 5 years . .. . .. 5- . .. 50810- . .. 7, 25915- . .. 10, 35520- 624 6, 53725- 817 4, 17430- 1, 118 2, 49535- 1, 359 1, 68140- 2, 223 1, 46845- 2, 748 1, 20650- 3, 982 1, 19655- 3, 456 83360- 3, 825 71265- 2, 542 36970- 1, 568 20475- 746 10180- 311 2585 and upwards 147 16

TABLE B. 

AGED 20 YEARS, AND UPWARDS. 

NURSES. Nurse (not Domestic Nurse (Domestic Servant) Servant)Great Britain and 25, 466 21, 017Islands in theBritish Seas. England and Wales. 23, 751 18, 945Scotland. 1, 543 1, 922Islands in theBritish Seas. 172 1501st Division. London. 7, 807 5, 0612nd Division. South Eastern. 2, 878 2, 5143rd Division. South Midland. 2, 286 1, 2524th Division. Eastern Counties. 2, 408 9595th Division. South WesternCounties. 3, 055 1, 7376th Division. West MidlandCounties. 1, 225 2, 2837th Division. North MidlandCounties. 1, 003 9578th Division. North WesternCounties. 970 2, 1359th Division. Yorkshire. 1, 074 1, 02310th Division. NorthernCounties. 462 41011th Division. Monmouthand Wales. 343 614

NOTE AS TO THE NUMBER OF WOMEN EMPLOYED AS NURSES IN GREAT BRITAIN. 

25, 466 were returned, at the census of 1851, as nurses by profession, 39, 139 nurses in domestic service, [1] and 2, 822 midwives. The numbers ofdifferent ages are shown in table A, and in table B their distributionover Great Britain. 

To increase the efficiency of this class, and to make as many of them aspossible the disciples of the true doctrines of health, would be a greatnational work. 

For there the material exists, and will be used for nursing, whether thereal "conclusion of the matter" be to nurse or to poison the sick. Aman, who stands perhaps at the head of our medical profession, once saidto me, I send a nurse into a private family to nurse the sick, but Iknow that it is only to do them harm. 

Now a nurse means any person in charge of the personal health ofanother. And, in the preceding notes, the term _nurse_ is usedindiscriminately for amateur and professional nurses. For, besidesnurses of the sick and nurses of children, the numbers of whom are heregiven, there are friends or relations who take temporary charge of asick person, there are mothers of families. It appears as if theseunprofessional nurses were just as much in want of knowledge of the lawsof health as professional ones. 

Then there are the schoolmistresses of all national and other schoolsthroughout the kingdom. How many of children's epidemics originate inthese! Then the proportion of girls in these schools, who becomemothers or members among the 64, 600 nurses recorded above, orschoolmistresses in their turn. If the laws of health, as far as regardsfresh air, cleanliness, light, &c. , were taught to these, would this notprevent some children being killed, some evil being perpetuated? Onwomen we must depend, first and last, for personal and householdhygiene--for preventing the race from degenerating in as far as thesethings are concerned. Would not the true way of infusing the art ofpreserving its own health into the human race be to teach the femalepart of it in schools and hospitals, both by practical teaching and bysimple experiments, in as far as these illustrate what may be called thetheory of it?

[1] A curious fact will be shown by Table A, viz. , that 18, 122 out of39, 139, or nearly one-half of all the nurses, in domestic service, arebetween 5 and 20 years of age.