 Preface and start of Notes on Nursing. The following notes are, by no means intended, as a rule of thought by which nurses can teach themselves to nurse, still less as a manual to teach nurses to nurse. They are meant simply to give hints for thought to women who have personal charge of the health of others. Every woman, or at least almost every woman in England, has, at one time or another of her life, charge of the personal health of somebody, whether child or invalid. In other words, every woman is a nurse. Every day, sanitary knowledge, or the knowledge of nursing, or in other words, how to put the Constitution in such a state as that it will have no disease, or that it can recover from disease, takes a higher place. It is recognised as the knowledge which every one ought to have, distinct from medical knowledge which only a profession can have. If, then, every woman must, at some time or other of her life, become a nurse, i.e., have charge of somebody's health, how immense and how valuable would be the produce of her united experience if every woman would think how to nurse. I do not pretend to teach her how. I ask her to teach herself, and for this purpose I venture to give her some hints. Notes on nursing, what it is, and what it is not. Shall we begin by taking it as a general principle that all disease, at some period or another of its course, is more or less a reparative process, not necessarily accompanied with suffering. An effort of nature to remedy a process of poisoning or of decay which has taken place weeks, months, sometimes years beforehand, unnoticed, the termination of the disease being, then, while the antecedent process was going on, determined. If we accept this as a general principle, we shall be immediately met with anecdotes and instances to prove the contrary. Just so, if we were to take, as a principle, all the climates of the earth are meant to be made habitable for man by the efforts of man. The objection would immediately be raised, will the top of Mount Blanc ever be made habitable? Our answer would be, it will be many thousands of years before we have reached the bottom of Mount Blanc, in making the earth healthy. Wait till we have reached the bottom, before we discuss the top. From watching diseases, both in private houses and in public hospitals, the thing which strikes the experienced observer most forcibly is this, that the symptoms, or the sufferings, generally considered to be inevitable and incident to the disease, are very often not symptoms of the disease at all, but of something quite different, of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each, or of all of these. And this quite as much in private as in hospital nursing. The reparative process which nature has instituted, and which we call disease, has been hindered by some want of knowledge or attention in one or in all of these things, and pain, suffering, or interruption of the whole process sets in. If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault not of the disease, but of the nursing. I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet, all at the least expense of vital power to the patient. It has been said, and written, scores of times, that every woman makes a good nurse. I believe, on the contrary, that the very elements of nursing are all but unknown. And by this I do not mean that the nurse is always to blame. Bad sanitary, bad architectural, and bad administrative arrangements often make it impossible to nurse. But the art of nursing ought to include such arrangements as alone make what I understand by nursing possible. The art of nursing, as now practised, seems to be expressly constituted to un-make what God had made disease to be, that is, a reparative process. To recur to the first objection, if we are asked, is such and such a disease a reparative process? Can such an illness be unaccompanied with suffering? Will any care prevent such a patient from suffering this or that? I humbly say, I do not know. But when you have done away with all that pain and suffering, which impatience of the symptoms not of their disease, but of the absence of one or all of the above mentioned essentials to the success of nature's reparative processes, we shall then know what are the symptoms of, and the sufferings inseparable from, the disease. Another, and the commonest exclamation which will instantly be made is, Would you do nothing then in cholera, fever, etc. So deep-rooted and universal is the conviction that to give medicine is to be doing something, or rather everything, to give air, warmth, cleanliness, etc., is to do nothing. The reply is that in these, and many other similar diseases, the exact value of particular remedies and modes of treatment is by no means ascertained, while there is universal experience as to the extreme importance of careful nursing in determining the issue of the disease. Two, the very elements of what constitutes good nursing are as little understood for the well as for the sick. The same laws of health or of nursing, for they are in reality the same, obtain among the well as among the sick. The breaking of them produces only a less violent consequence among the former than among the latter, and this sometimes not always. It is constantly objected, but how can I obtain this medical knowledge? I am not a doctor. I must leave this to doctors. O mothers of families, you who say this, do you know that one in every seven infants in this civilised land of England perishes before it is one year old, that in London two in every five die before they are five years old, and in the other great cities of England nearly one out of two. The life duration of tender babies, as some satan turned analytical chemist says, is the most delicate test of sanitary conditions. Is all this premature suffering and death necessary, or did nature intend mothers to be always accompanied by doctors? Or is it better to learn the piano forte than to learn the laws which observe the preservation of offspring? Macaulay somewhere says that it is extraordinary that, whereas the laws of the motions of the heavenly bodies, far removed as they are from us, are perfectly well understood, the laws of the human mind which are under our observation all day and every day, are no better understood than they were two thousand years ago. But how much more extraordinary is it that, whereas what we might call the coxedcomeres of education, e.g. the elements of astronomy, are now taught to every schoolgirl, neither mothers of families of any class, nor schoolmistresses of any class, nor nurses of children, nor nurses of hospital, are taught anything about those laws which God has assigned to the relations of our bodies with the world in which he has put them. In other words, the laws which make these bodies into which he has put our minds, healthy or unhealthy organs of those minds, are all but unlearned. Not but those laws, the laws of life, are in a certain measure understood, but not even mothers think it worth their while to study them, to study how to give their children healthy existences. They call it medical or physiological knowledge, fit only for doctors. Another objection. We are constantly told, but the circumstances which govern our children's healths are beyond our control. What can we do with winds? There is the east wind. Most people can tell before they get up in the morning whether the wind is in the east. To this one can answer with more certainty than to the former objections. Who is it who knows when the wind is in the east? Not the Highlands Drowver, certainly, exposed to the east wind, but the young lady who is worn out with the want of exposure to fresh air, to sunlight, etc. Put the latter under as good sanitary circumstances as the former, and she too will not know when the wind is in the east. End of Preface and Start. Section 1 of Notes on Nursing by Florence Nightingale. The very first canon of nursing, the first and the last thing upon which a nurse's attention must be fixed, the first essential to a servant, without which all the rest you can do for him is as nothing, with which I had almost said you may leave all the rest alone, is this, to keep the air he breathes as pure as the external air without chilling him. Yet what is so little attended to? Even where it is thought of at all, the most extraordinary misconceptions reign about it. Even in admitting air into the patient's room or ward, few people ever think where that air comes from. It may come from a corridor into which other wards are ventilated, from a hall always unaird, always full of the fumes of gas, dinner, of various kinds of mustiness. From an underground kitchen, sink, wash-house, water-closet, or even, as I myself have had sorrowful experience, from open sewers loaded with filth, and with this the patient's room or ward is aired, as it is called, poisoned it should rather be said. Always air from the air without, and that too, through those windows through which the air comes freshest. From a closed court, especially if the wind do not blow that way, air may come as stagnant as any from a hall or corridor. Again, a thing I have often seen both in private houses and institutions. A room remains uninhabited. The fireplace is carefully fastened up with a board. The windows are never opened. Probably the shutters are kept always shut. Perhaps some kind of stores are kept in the room. No breath of fresh air can by possibility enter into that room, nor any ray of sun. The air is as stagnant, musty and corrupt, as it can by possibility be made. It is quite ripe to breed smallpox, scarlet fever, diphtheria, or anything else you please. Yet the nursery, ward, or sick room adjoining, will be positively aired by having the door opened into that room, or children will be put into that room without previous preparation to sleep. A short time ago, a man walked into a back kitchen in Queen's Square and cut the throat of a poor consumptive creature sitting by the fire. The murderer did not deny the act, but simply said, It's all right. Of course, he was mad. But in our case the extraordinary thing is that the victim says, It's all right, and that we are not mad. Yet, though he knows the murderers, in the musty, unaired, unsunned room, the scarlet fever which is behind the door, or the fever and hospital gangrene which is stalking among the crowded beds of a hospital ward, we say, It's all right. With a proper supply of windows, and a proper supply of fuel in open fireplaces, fresh air is comparatively easy to secure when your patient or patients are in bed. Never be afraid of open windows, then. People don't catch cold in bed, this is a popular fallacy. With proper bed clothes and hot bottles, if necessary, you can always keep a patient warm in bed, and well ventilate him at the same time. But a carelessness, be her rank and education what it may, will stop up every cranny and keep a hot-house heat when her patient is in bed, and, if he is able to get up, leave him comparatively unprotected. The time when people take cold, and there are many ways of taking cold, besides a cold in the nose, is when they first get up, after the twofold exhaustion of dressing, and of having had the skin relaxed by many hours, perhaps days in bed, and thereby rendered more incapable of reaction. Then the same temperature which refreshes the patient in bed may destroy the patient just risen. And common sense will point out, that while purity of air is essential, a temperature must be secured which shall not chill the patient. Otherwise the best that can be expected will be a feverish reaction. To have the air within as pure as the air without, it is not necessary, as often appears to be thought, to make it as cold. In the afternoon again, without care, the patient whose vital powers have then risen, often finds the room as close and oppressive as he found it cold in the morning. Yet the nurse will be terrified if a window is opened. I know an intelligent, humane house surgeon who makes practice of keeping the ward windows open. The physicians and surgeons invariably close them while going their rounds, and the house surgeon very properly, as invariably, opens them whenever the doctors have turned their backs. In a little book on nursing, published a short time ago, we are told that, with proper care, it is very seldom that the windows cannot be opened for a few minutes twice in the day to admit fresh air from without. I should think not, nor twice in the hour, either. It only shows how little the subject has been considered. Of all methods of keeping patients warm, the very worst, certainly, is to depend for heat on the breath and bodies of the sick. I have known a medical officer keep his ward windows hermetically closed, thus exposing the sick to all the dangers of an infected atmosphere, because he was afraid that, by admitting fresh air, the temperature of the ward would be too much lowered. This is a destructive fallacy. To attempt to keep a ward warm, at the expense of making the sick repeatedly breathe their own hot, humid, putressing atmosphere is a certain way to delay recovery or to destroy life. Do you ever go into the bedrooms of any persons of any class, whether they hold one, two, or twenty people, whether they hold sick or well, at night, or before the windows are opened in the morning, and ever find the air anything but unwholesomely close and foul? And why should it be so? And of how much importance is it that it should not be so? During sleep, the human body, even when in health, is far more injured by the influence of foul air than when awake. Why can't you keep the air all night, then, as pure as the air without, in the rooms you sleep in? But for this you must have sufficient outlet for the impure air you make yourselves to go out, sufficient inlet for the pure air from without to come in. You must have open chimneys, open windows, or ventilators, no close curtains round your beds, no shutters or curtains to your windows, none of the contrivances by which you undermine your own health or destroy the chances of recovery of your sick. A careful nurse will keep a constant watch over her sick, especially weak, protracted, and collapsed cases, to guard against the effects of the loss of vital heat by the patient himself. In certain diseased states much less heat is produced than in health, and there is constant tendency to the decline and ultimate extinction of the vital powers by the call made upon them to sustain the heat of the body. Cases where this occurs should be watched with the greatest care from hour to hour, I had almost said from minute to minute. The feet and legs should be examined by the hand from time to time, and whenever a tendency to chilling is discovered, hot bottles, hot bricks or warm flannels with some warm drink should be made use of until the temperature is restored. The fire should be, if necessary, replenished. Patients are frequently lost in the latter stages of disease from want of attention to such simple precautions. The nurse may be trusting to the patient's diet, or to his medicine, or to the occasional dose of stimulant which she is directed to give him, while the patient is all the while sinking from want of a little external warmth. Such cases happen at all times, even during the height of summer. This fatal chill is most apt to occur towards early morning at the period of the lowest temperature of the twenty-four hours, and at the time when the effect of the preceding day's diets is exhausted. Generally speaking, you may expect that weak patients will suffer cold much more in the morning than in the evening. The vital powers are much lower. If they are feverish at night, with burning hands and feet, they are almost sure to be chilly and shivering in the morning. But nurses are very fond of heating the foot warmer at night, and of neglecting it in the morning when they are busy. I should reverse the matter. All these things require common sense and care. Yet perhaps in no one single thing is so little common sense shown in all ranks as in nursing. The extraordinary confusion between cold and ventilation, even in the minds of well-educated people, illustrates this. To make a room cold is by no means necessary to ventilate it, nor is it at all necessary in order to ventilate a room to chill it. Yet, if a nurse finds a room close, she will let out the fire, thereby making it closer, or she will open the door into a cold room without a fire or an open window in it by way of improving the ventilation. The safest atmosphere of all for a patient is a good fire and an open window, accepting an extremes of temperature. Yet no nurse can ever be made to understand this. To ventilate a small room without drafts, of course, requires more care than to ventilate a large one. Another extraordinary fallacy is the dread of night air. What air can we breathe at night but night air? The choice is between pure night air from without and foul night air from within. Most people prefer the latter. An unaccountable choice. What will they say if it is proved to be true that fully one-half of all the disease we suffer from is occasioned by people sleeping with their windows shut? An open window, most nights in the year, can never hurt anyone. This is not to say that light is not necessary for recovery. In great cities night air is often the best and purest air to be had in the twenty-four hours. I could better understand in towns shutting the windows during the day than during the night for the sake of the sick. The absence of smoke, the quiet, all tend to making night the best time for airing the patients. One of our highest medical authorities on consumption and climate has told me that the air in London is never so good as after ten o'clock at night. Always air your room, then, from the outside air, if possible. Windows are made to open, doors are made to shut, a truth which seems extremely difficult of apprehension. I have seen a careful nurse airing her patient's room through the door, near to which were two gas lights, each of which consumes as much air as eleven men, a kitchen, a corridor, the composition of the atmosphere in which consisted of gas, paint, foul air, never changed, full of a fluvia, including a current of sewer air from an ill-placed sink ascending in a continual stream by a well staircase, and discharging themselves constantly into the patient's room. The window of the said room, if opened, was all that was desirable to air it. Every room must be aired from without, every passage from without, but the fewer passages there are in a hospital the better. If we are to preserve the air within as pure as the air without, it is needless to say that the chimney must not smoke. Almost all smoky chimneys can be cured from the bottom, not from the top. Often it is only necessary to have an inlet for air to supply the fire, which is feeding itself, for want of this from its own chimney. On the other hand, almost all chimneys can be made to smoke by a careless nurse who lets the fire get low and then overwhelms it with coal, not, as we verily believe, in order to spare herself trouble, for very rare is unkindness to the sick, but from not thinking what she is about. In laying down the principle that the first object of the nurse must be to keep the air breathed by her patient as pure as the air without. It must not be forgotten that everything in the room which can give off effluvia, besides the patient, evaporates itself into his air. And it follows that there ought to be nothing in the room excepting him which can give off effluvia or moisture. Out of all damp towels, etc., which become dry in the room, the damp, of course, goes into the patient's air. But this, of course, seems as little thought of as if it were an obsolete fiction. How very seldom you see a nurse who acknowledges by her practice that nothing at all ought to be aired in the patient's room, that nothing at all ought to be cooked at the patient's fire. Indeed, the arrangements often make this rule impossible to observe. If the nurse be a very careful one, she will, when the patient leaves his bed, but not his room, open the sheets wide and throw the bedclothes back in order to air his bed. And she will spread the wet towels or flannels carefully out upon a horse in order to dry them. Now, either these bedclothes and towels are not dried and aired, or the air and dry themselves into the patient's air. And whether the damp and effluvia do him most harm in his air or in his bed, I leave you to determine, for I cannot. Even in health, people cannot repeatedly breathe air in which they live with impunity, on account of it becoming charged with unwholesome matter from the lungs and skin. In disease, where everything given off from the body is highly noxious and dangerous, not only must there be plenty of ventilation to carry off the effluvia, but everything which the patient passes must be instantly removed away, as being more noxious than even the emanations from the sick. Of the fatal effects of the effluvia from the excretia, it would seem unnecessary to speak. Were they not so constantly neglected? Concealing the utensils behind the valance to the bed seems all the precaution which is thought necessary for safety in private nursing. Did you but think, for one moment of the atmosphere under that bed, the saturation of the underside of the mattress with the warm evaporations, you would be startled and frightened too. The use of any chamber utensil, without a lid, should be utterly abolished, whether among sick or well. You can easily convince yourself of the necessity of this absolute rule by taking one with a lid and examining the underside of that lid. It will be found always covered, whenever the utensil is not empty, by condensed offensive moisture. Where does that go when there is no lid? Earthenware, or if there is any wood, highly polished and varnished wood, are the only materials fit for patient's utensils. The very lid of the old abominable clothes-store is enough to breed a pestilence. It becomes saturated with offensive matter, which scouring is only wanted to bring out. I prefer an earthenware lid as being always cleaner, but there are various good new-fashioned arrangements. A slopped pail should never be bought into a sick room. It should be a rule invariable, rather more important in the private house than elsewhere, that the utensil should be carried directly to the water-closet, emptied there, rinsed there, and brought back. There should always be water and a cock in every water-closet for rinsing, but even if there is not, you must carry water there to rinse with. I have actually seen, in the private sick room, the utensils emptied into the foot-pan and put back un-rinsed under the bed. I can hardly say which is most abominable, whether to do this or to rinse the utensil in the sick room. In the best hospitals it is now a rule that no slopped pail shall ever be brought into the wards, but that the utensils should be carried direct to be emptied and rinsed at the proper place. I would it were so in the private house. Let no one ever depend on fumigations, disinfectants, and the like for purifying the air. The offensive thing, not its smell, must be removed. A celebrated medical lecturer began one day. Fumigations, gentlemen, are of essential importance. They make such an abominable smell that they compel you to open the window. I wish all the disinfecting fluids invented made such an abominable smell that they forced you to emit fresh air. That would be a useful invention. Section 2 of Notes on Nursing by Florence Nightingale. This LibriVox recording is in the public domain. Section 2. Health of Houses. 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 in proportion as they are deficient. 1. To have pure air, your house be so constructed as that the outer atmosphere shall find its way with ease to every corner of it. House architects hardly ever consider this. The object in building a house is to obtain the largest interest for the money, not to save doctor's bills to the tenants. But if tenants should ever become so wise as to refuse to occupy unhealthy constructed houses, and if insurance companies should ever come to understand their interests so thoroughly as to pay a sanitary surveyor to look after the houses where their clients live, speculative architects would speedily be brought to their senses. As it is, they build what pays best. And there are always people foolish enough to take the houses they build. And if, in the course of time the families die off, as is so often the case, nobody ever thinks of blaming any but providence for the result. Ill-informed medical men aid in sustaining the delusion by laying the blame on current contagions. Badly constructed houses do for the healthy what badly constructed hospitals do for the sick. Once insured that the air in a house is stagnant and sickness is certain to follow. Two. Pure water is more generally introduced into houses than it used to be, thanks to the exertions of the sanitary reformers. Within the last few years a large part of London was in the daily habit of using water polluted by the drainage of its sewers and water closets. This has happily been remedied. But in many parts of the country well water of a very impure kind is used for domestic purposes. And when epidemic disease shows itself, persons using such water are almost sure to suffer. Three. It would be curious to ascertain by inspection how many houses in London are really well drained. Many people would say, surely all or most of them. But many people have no idea in what good drainage consists. They think that a sewer in the street and a pipe leading to it from the house is good drainage. All the while the sewer may be nothing but a laboratory, from which epidemic disease and ill health is being distilled into the house. No house with any untapped drainpipe communicating immediately with a sewer, whether it be from water closet, sink, or gully grate, can ever be healthy. An untrapped sink may at times spread fever or pyemia among the inmates for palace. The ordinary oblong sink is an abomination. That great surface of stone, which is always left wet, is always exhaling into the air. I have known whole houses and hospitals smell of the sink. I have met just as strong a stream of sewer air coming up the back staircase of a grand London house from the sink as I have ever met at Scutari. And I have seen the rooms in that house all ventilated by the open doors and the passages all unventilated by the closed windows in order that as much of the sewer air as possible might be conducted into and retained in the bedrooms. It is wonderful. Another great evil in house construction is carrying drains underneath the house. Such drains are never safe. All house drains should begin and end outside the walls. Many people will readily admit as a theory the importance of these things. But how few are there who can intelligently trace disease in their households to such causes? Is it not a fact that when scarlet fever, measles, or small pox appear among the children, the very first thought which occurs is where the children can have caught the disease. And the parents immediately run over in their minds all the families with whom they may have been. They never think of looking at home for the source of the mischief. If a neighbour's child is seized with small pox, the first question which occurs is whether it had been vaccinated. No one would undervalue vaccination, but it becomes of doubtful benefit to society when it leads people to look broad for the source of evils which exist at home, for. Without cleanliness, within and without your house, ventilation is comparatively useless. In certain fowl districts of London, poor people used to object to open their windows and doors because of the foul smells that came in. Rich people like to have their stables and dung-hill near their houses. But does it ever occur to them that with many arrangements of this kind it would be safer to keep the windows shut than open? You cannot have the air of the house pure with dung-heaps under the windows. These are common all over London. And yet people are surprised that their children brought up in large, well-aired nurseries and bedrooms suffer from children's epidemics. If they studied nature's laws in the matter of children's health, they would not be so surprised. There are other ways of having filth inside a house besides having dirt in heaps. Old-papered walls of years standing, dirty carpets, uncleanced furniture are just as ready sources of impurity to the air as if they were a dung-heap in the basement. People are so unaccustomed from education and habits to consider how to make a home healthy that they either never think of it at all and take every disease as a matter of course to be resigned to when it comes as from the hand of Providence. Or if they ever entertain the idea of preserving the health of their household as a duty, they are very apt to commit all kinds of negligences and ignorances in performing it. Five. A dark house is always an unhealthy house, always an ill-aird house, always a dirty house. Wont of light stops growth and promotes scroffula, rickets, etc., among the children. People lose their health in a dark house, and if they get ill they cannot get well again in it. More will be said about this farther on. Three out of many negligences and ignorances in managing the health of houses generally I will here mention as specimens. One, that the female head in charge of any building does not think it necessary to visit every hole and corner of it every day. How can she expect those who are under her to be more careful to maintain her house in a healthy condition than she who is in charge of it? Two, that it is not considered essential to air, to sun, and to clean rooms while uninhabited, which is simply ignoring the first elementary notion of sanitary things and laying the ground ready for all kinds of diseases. Three, that the window, and one window, is considered enough to air a room. Have you never observed that any room without a fireplace is always close? And if you have a fireplace, would you cram it up, not only with a chimney board, but perhaps with a great wisp of brown paper in the throat of the chimney, to prevent the soot from coming down you say? If your chimney is foul, sweep it, but don't expect that you can ever air a room with only one aperture. Don't suppose that to shut up a room is the way to keep it clean. It is the best way to foul the room and all that is in it. Don't imagine that if you, who are in charge, don't look to all these things yourself, those under you will be more careful than you are. It appears as if the part of a mistress now is to complain of her servants, and to accept their excuses, not to show them how there need be neither complaints made nor excuses. But again, to look to all these things yourself does not mean to do them yourself. I always open the windows, the head in charge often says. If you do it, it is by so much the better, certainly, than if it were not done at all. But can you ensure that it is done when not done by yourself? Can you ensure that it is not undone when your back is turned? This is what being in charge means, and a very important meaning it is, too. The former only implies that just what you can do with your own hands is done. The latter, that what ought to be done, is always done. And now you think these things trifles are at least exaggerated. But what you think, or what I think, matters little. Let us see what God thinks of them. God always justifies his ways, while we are thinking he has been teaching. I have known cases of hospital paemia quite as severe in handsome private houses, as in any of the worst hospitals, and from the same cause, that is, 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 was singular that all the servants had Whitlows, or that something was much about this year there is always sickness in our house. This is a favourite mode of thought, leading not to inquire what is the uniform cause of these general Whitlows, but a stifle all-inquiry. In what sense is sickness being always there, a justification of its being there at all? I will tell you what was the cause of this hospital paemia being in that large private house. It was that the sewer air from an ill-placed sink was carefully conducted into all the rooms by sedulously opening all of the doors and closing all the passage windows. It was that the slops were emptied into the foot-pans. It was that the utensils were never properly rinsed. It was that the chamber-crockery was rinsed with dirty water. It was that the beds were never properly shaken, aired, picked to pieces, or changed. It was that the carpets and curtains were always musty. It was that the furniture was always dusty. It was that the papered walls were saturated with dirt. It was that the floors were never cleaned. It was that the uninhabited rooms were never sunned, or cleaned, or aired. It was that the cupboards were always reservoirs of foul air. It was that the windows were always tight shut up at night. It was that no window was ever systematically opened even in the day, or that the right window was not opened. A person gasping for air might open a window for himself, but the servants were not taught to open the windows to shut the doors, or they opened the windows upon a dank well between high walls, not upon the area court, or they opened the room doors into the unaired halls and passages by way of airing the rooms. Now all of this is not fancy, but fact. In that handsome house I've known in one summer, three cases of hospital paemia, one of phlebitis, two of consumptive cough, all the immediate products of foul air. When in temperate climates a house is more unhealthy in summer than in winter it is a certain sign of something wrong. Yet nobody learns the lesson. Yes, God always justifies His ways. He is teaching while you are not learning. This poor body loses his finger, that one loses his life, and all from the most easily preventable causes. The houses of the grandmothers and great-grandmothers of this generation, at least the country houses, with front door and back door always standing open, winter and summer, and a thorough draft always blowing through, with all the scrubbing and cleaning and polishing and scouring which used to go on. The grandmothers, and still more the great-grandmothers, always out of doors and never with a bonnet on except to go to church. These things entirely account for the fact so often seen of a great-grandmother, who was a tower of physical vigor, descending into a grandmother, perhaps a little less vigorous, but still sound as a bell and healthy to the core, into a mother languid and confined to her carriage and house, and lastly into a daughter, sickly and confined to her bed. For remember, even with a general decrease of mortality, you may often find a race thus degenerating and still oftener a family. You may see poor little feeble washed out rags, children of a noble stock, suffering morally and physically, throughout their useless degenerate lives, and yet people who are going to marry and bring more such into the world will consult nothing but their own convenience as to where they are to live or how they are to live. With regard to the health of houses where there is a sick person, it often happens that the sick room is made a ventilating shaft for the rest of the house. For while the house is kept as close, unerred and dirty as usual, the window of the sick room is kept a little open always and the door occasionally. Now there are certainly sacrifices which a house with one sick person in its does make to that sick person, it ties up its knocker, it lays straw before it in the street. Why can't it keep itself thoroughly clean and unusually well-air in deference to the sick person? We must not forget what, in ordinary language, is called infection, a thing of which people are generally so afraid that they frequently follow the very practice in regard to it which they ought to avoid. Nothing used to be considered so infectious or contagious as smallpox, and people not very long ago used to cover up patients with heavy bed-clothes while they kept up large fires and shut the windows. Smallpox, of course, under this regime, is very infectious. People are somewhat wiser now in their management of this disease. They have ventured to cover the patients lightly and to keep the windows open, and we hear much less of the infection of smallpox than we used to do. But do people in our days act with more wisdom on the subject of infection in fevers, scarlet fever, measles, etc., than their forefathers did with smallpox? Does not the popular idea of infection involve that people should take greater care of themselves than of the patient? That, for instance, it is safer not to be too much with the patient, not to attend too much to his wants. Perhaps the best illustration of the utter absurdity of this view of duty in attending on infectious diseases is afforded by what was very recently the practice, if it is not so even now, in some of the European lazarets in which the plague patient used to be condemned to the horrors of filth overcrowding and want of ventilation, while the medical attendant was ordered to examine the patient's tongue through an opera-glass and to toss him a lancet to open his abscesses with. True nursing ignores infection, except to prevent it. Cleanliness and fresh air from open windows, with unremitting attention to the patient, are the only defence a true nurse either asks or needs. Wise and humane management of the patient is the best safeguard against infection. There are not a few popular opinions in regards to which it is useful at times to ask a question or two. For example, it is commonly thought that children must have what are commonly called children's epidemics, current contagions, etc. In other words that they are born to have measles, whooping cough, perhaps even scarlet fever, just as they are born to cut their teeth if they live. Now, do tell us, why must a child have measles? Oh, because, you say, we cannot keep it from infection, other children have measles, and it must take them, and it is safer that it should. But why must other children have measles? And if they have, why must yours have them, too? If you believed in and observed the laws for preserving the health of houses, which inculcate cleanliness, ventilation, whitewashing and other means, and which, by the way, are laws, as implicitly as you believe in the popular opinion, for it is nothing more than an opinion that your child must have children's epidemics, don't you think that upon the whole your child would be more likely to escape altogether? Section 3 of Notes on Nursing by Florence Nightingale Section 3. Petty Management All the results of good nursing, as detailed in these notes, may be spoiled or utterly negative by one defect, that is, in petty management. Or in other words, by not knowing how to manage that what you do when you are there shall be done when you are not there. The most devoted friend or nurse cannot always be there, nor is it desirable that she should, and she may give up her health, all her other duties, and yet, for want of a little management, be not one half so efficient as another who is not one half so devoted, but who has this art of multiplying herself, that is to say, the patient of the first will not be really so well cared for as the patient of the second. It is as impossible in a book the teacher person in charge of sick how to manage as it is to teach her how to nurse. Circumstances must vary with each different case, but it is possible to press upon her to think for herself, now what does happen during my absence? I am obliged to be away on Tuesday, but fresh air or punctuality is not less important to my patient on Tuesday than it was on Monday. Or at ten p.m. I am never with my patient, but quiet is of no less consequence to him at ten than it was at five minutes to ten. Curious as it may seem, this very obvious consideration occurs comparatively to few, or if it does occur, it is only to cause the devoted friend or nurse to be absent fewer hours or fewer minutes from her patient. Not to arrange, so is that no minute and no hour shall be for her patient without the essentials of her nursing. A very few instances will be sufficient, not as precepts, but as illustrations. A strange washerwoman coming late at night for the things will burst in by mistake to the patient's sick room after he has fallen into his first dose, giving him a shock, the effects of which are irremediable, though he himself laughs at the cause and probably never even mentions it. The nurse, who is, and is quite right to be, at her supper, has not provided that the washerwoman shall not lose her way and go into the wrong room. The patient's room may always have the window open, but the passage outside the patient's room, though provided with several large windows, may never have one open, because it is not understood that the charge of the sick room extends to the charge of the passage, and thus, as often happens, the nurse makes it her business to turn the patient's room into a ventilating shaft for the foul air of the whole house. An uninhabited room, a newly painted room, an uncleaned closet or cupboard, may often become a reservoir of foul air for the whole house, because the person in charge never thinks of arranging that these places shall always be aired, always cleaned. She merely opens the window herself when she goes in. An agitating letter or message may be delivered, or an important letter or message not delivered, a visitor whom it was of consequence to see may be refused, or one whom it was of still more consequence not to see may be admitted, because the person in charge has never asked herself this question, what is done when I am not there? At all events, one may safely say, a nurse cannot be with a patient, open the door, eat her meals, take a message, all at one and at the same time. For the less the person in charge never seems to look the impossibility in the face. Add to this that the attempting this impossibility does more to increase the poor patient's hurry and nervousness than anything else. It is never thought that the patient remembers these things if you do not. He has not only to think whether the visit or letter may arrive, but whether you will be in the way at the particular day and hour when it may arrive, so that your partial measures for being in the way yourself only increase the necessity for his thought. Whereas if you could but arrange that the thing should always be done whether you were there or not, you need never think at all about it. For the above reasons, whatever a patient can do for himself, it is better, that is less anxiety, for him to do for himself, unless the person in charge has the spirit of management. It is evidently much less exertion for a patient to answer a letter for himself by return of post than to have four conversations, wait five days, have six anxieties before it is off his mind, before the person who is to answer it has done so. Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion. Remember, he is face to face with his enemy all the time, internally wrestling with him, having long imaginary conversations with him. You are thinking of something else. Rid him of his adversary quickly is a first rule with the sick. For the same reasons, always tell a patient and tell him beforehand when you are going out and when you will be back, whether it is for a day, an hour, or ten minutes. You fancy, perhaps, that it is better for him if he does not find out you're going at all, better for him if you do not make yourself of too much importance to him, or else you cannot bear to give him the pain or the anxiety of the temporary separation. No such thing. You ought to go, we will suppose, health or duty requires it. And say so to the patient openly. If you go without his knowing it, and he finds it out, he will never feel secure again that the things which depend upon you will be done when you are away, and in nine times out of ten he will be right. If you go out without telling him when you will be back, he can take no measures nor precautions as to the things which concern you both, or which you do for him. If you look into the reports of trials or accidents, and especially of suicides, or into the medical history of fatal cases, it is almost incredible how often the whole thing turns upon something which has happened because he, or still often a she, was not there. But it is still more incredible how often, how almost always, this is accepted as a sufficient reason, a justification. Why the very fact of the thing having happened is the proof of its not being a justification. The person in charge was quite right not to be there, he was called away for quite sufficient reason, or he was away for a daily recurring and unavoidable cause, yet no provision was made to supply his absence. The fault was not in his being away, but in their being no management to supplement his being away. When the sun is under a total eclipse, or during his nightly absence, we light candles. But it would seem as if it did not occur to us that we must also supplement the person in charge of sick, or of children, whether under an occasional eclipse, or during a regular absence. In institutions where many lives would be lost, and the effect of such want of management would be terrible and patent, there is less of it than in the private house. But in both, let whoever is in charge keep this simple question in her head. Not, how can I always do this right thing myself, but, how can I provide for this right thing to be always done? Then, when anything wrong has actually happened in consequence of her absence, which absence we will suppose to have been quite right, let her question still be, not, how can I provide against any more of such absences, which is neither possible nor desirable, but, how can I provide against any thing wrong arising out of my absence? How few men, or even women, understand, either in great or in little things, what it is, the being in charge, I mean, know how to carry out a charge. From the most colossal calamities, down to the most trifling accidents, results are often traced, or rather not traced, to such want of someone being in charge, or of his knowing how to be in charge. A short time ago, the bursting of a funnel casing on board the finest and strongest ship that was ever built on her trial trip, destroyed several lives, and put several hundreds in jeopardy, not from any undetected flaw in her new and untried works, but from a tap being closed, which ought to not to have been closed, from what every child knows would make its mother's teakettle burst. And this, simply because no one seemed to know what it is to be in charge, or who was in charge. Nay more, the jury at the inquest actually altogether ignored the same, and apparently considered the tap in charge, for they gave as a verdict accidental death. This is the meaning of the word on a large scale. On a much smaller scale, it happened a short time ago that an insane person burnt herself slowly and intentionally to death, while in her doctor's charge, and almost in his nurse's presence. Yet neither was considered at all to blame. The very fact of the accident happening proves its own case, there is nothing more to be said. Either they did not know their business, or they did not know how to perform it. To be in charge is certainly not only to carry out the proper measures yourself, but to see that everyone else does so too, to see that no one either willfully or ignorantly thwarts or prevents such measures. It is neither to do everything yourself, nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed. This is the meaning which must be attached to the word, by, above all, those in charge of sick, whether of numbers or of individuals, and indeed I think it is with individual sick that it is least understood. One sick person is often waited on by four with less precision and is less really well cared for than ten who are waited on by one, or at least than forty who are waited on by four, and all for one to this one person in charge. It is often said that there are few good servants now. I say there are few good mistresses now. As the jury seems to have thought the tap was in charge of the ship's safety, so mistresses now seem to think the house is in charge of itself. They neither know how to give orders, nor how to teach their servants to obey orders, that is, to obey intelligently, which is the real meaning of all discipline. Again, people who are in charge often seem to have a pride in feeling that they will be missed, that no one can understand or carry on their arrangements, their system, books, accounts, etcetera, but themselves. It seems to me that the pride is rather in carrying on a system, in keeping stores, closets, books, accounts, etcetera, so that anybody can understand and carry them on, so that, in case of absence or illness, one can deliver everything up to others and know that all will go on as usual and that one shall never be missed. End of Section 3 Section 4 NOISE Unnecessary noise, or noise that creates an expectation in the mind, is that which hurts a patient. It is rarely the loudness of the noise, the effect upon the organ of the ear itself, which appears to affect the sick. How well a patient will generally bear, for example, the putting up of a scaffolding close to the house, when he cannot bear the talking, still less the whispering, especially if it be of a familiar voice outside his door. There are certain patients, no doubt, especially where there is slight concussion or other disturbance of the brain, who are affected by mere noise. But intermittent noise, or sudden and sharp noise, in these as in all other cases, affects far more than continuous noise, noise with jar far more than noise without. Of one thing you may be certain, that anything which wakes a patient suddenly out of his sleep will invariably put him into a state of greater excitement, do him more serious, eye and lasting mischief, than any continuous noise, however loud. Never to allow a patient to be waked intentionally or accidentally is a sine qua non of all good nursing. If he is roused out of his first sleep, he is almost certain to have no more sleep. It is a curious, but quite intelligible fact that if a patient is waked after a few hours instead of a few minutes' sleep, he is much more likely to sleep again. Because pain, like irritability of brain, perpetuates and intensifies itself. If you have gained a respite of either in sleep, you have gained more than the mere respite. Both the probability of recurrence and of the same intensity will be diminished, whereas both will be terribly increased by want of sleep. This is the reason why sleep is so all-important. This is the reason why a patient waked in the early part of his sleep loses not only his sleep, but his power to sleep. A healthy person who allows himself to sleep during the day will lose his sleep at night, but it is exactly the reverse with the sick generally. The more they sleep, the better will they be able to sleep. I have often been surprised at the thoughtlessness, resulting in cruelty, quite unintentionally, of friends or of doctors who will hold a long conversation just in a room or passage adjoining to the room of the patient, who is either every moment expecting them to come in or who has just seen them and knows they are talking about him. If he is an amiable patient, he will try to occupy his attention elsewhere and not to listen, and this makes matters worse, for the strain upon his attention and the effort he makes are so great that it is well if he is not worse for hours after. If it is a whispered conversation in the same room, then it is absolutely cruel, for it is impossible that the patient's attention should not be involuntarily strained to hear. Walking on tiptoe, doing anything in the room very slowly, are injurious for exactly the same reasons. A firm, light, quick step, a steady, quick hand at the deciderata, not the slow, lingering, shuffling foot, the timid, uncertain touch. Slowness is not gentleness, though it is often mistaken for such. Quickness, lightness, and gentleness are quite compatible. Again if friends and doctors did but watch, as nurses can and should watch, the features sharpening, the eyes growing almost wild, a fever-patience, who are listening for the entrance from the corridor of the persons whose voices they are hearing there. These would never run the risk again of creating such unnecessary noise as undoubtedly induced or aggravated delirium in many cases. I have known such in one case death-insued. It is but fair to say that this death was attributed to fright. It was the result of a long, whispered conversation, within sight of the patient, about an impending operation. But anyone who has known the more than stoicism, the cheerful coolness with which the certainty of an operation will be accepted by any patient capable of bearing an operation at all if it is properly communicated to him, will hesitate to believe that it was mere fear which produced, as was avert, the fatal result in this instance. It was rather the uncertainty, the strained expectation as to what was to be decided upon. I need hardly say that the other common cause, namely for a doctor or friend to leave the patient and communicate his opinion on the result of his visit to the friends just outside the patient's door or in the adjoining room after the visit, but within hearing or knowledge of the patient is, if possible, worst of all. It is, I think, alarming, peculiarly at this time, when the female ink-bottles are perpetually impressing upon us, women's particular worth and general missionariness, to see that the dress of women is daily more and more unfitting than them for any mission or usefulness at all. It is equally unfitted for all poetic and all domestic purposes. A man is now a more handy and far less objectionable being in a sick-room than a woman. Compelled by her dress every woman now either shuffles or waddles, only a man can cross the floor of a sick-room without shaking it. What is become of women's light step, the firm light quick step we have been asking for? Unnecessary noise, then, is the most cruel absence of care which can be inflicted either on sick or well. For, in all these remarks, the sick are only mentioned as suffering in a greater proportion than the well from precisely the same causes. Unnecessary, although slight noise, injures a sick person much more than necessary noise of a much greater amount. All doctrines about mysterious affinities and aversions will be found to resolve themselves very much, if not entirely, into presence or absence of care in these things. A nurse who rustles—I'm speaking of nurse's professional and unprofessional—is the horror of a patient, though perhaps he does not know why. The fidget of silk and of crinoline, the rattling of keys, the creaking of stays and of shoes, will do a patient more harm than all the medicines in the world will do him good. The noiseless step of women, the noiseless drapery of women, are mere figures of speech in this day. Her skirts, and well if they do not throw down some piece of furniture, will at least brush against every article in the room as she moves. Again one nurse cannot open the door without making everything rattle, or she opens the door unnecessarily often for want of remembering all the articles that might be brought in at once. A good nurse will always make sure that no door or window in her patient's room shall rattle or creak, that no blind or curtain shall, by any change of wind through the open window, be made to flap, especially will she be careful of all this before she leaves her patients for the night. If you wait till your patients tell you, or remind you of these things, where is the use of their having a nurse? There are more shy than exacting patients in all classes, and many a patient passes a bad night, time after time, rather than remind his nurse every night of all the things she has forgotten. If there are blinds to your windows, always take care to have them well up when they are not being used. A little piece slipping down and flapping with every draft will distract a patient. All hurry or bustle is peculiarly painful to the sick. And when a patient has compulsory occupations to engage him, instead of having simply to amuse himself, it becomes doubly injurious. The friend who remains standing and fidgeting about while a patient is talking business to him, or the friend who sits and prozes, the one from an idea of not letting the patient talk, the other from an idea of amusing him, each is equally inconsiderate. Always sit down when a sick person is talking business to you, show no signs of hurry, give complete attention and full consideration if your advice is wanted, and go away the moment the subject is ended. Always sit within the patient's view, so that when you speak to him he has not painfully to turn his head round in order to look at you. Everybody involuntarily looks at the person speaking. If you make this act a wearisome one on the part of the patient, you are doing him harm. So also if by continuing to stand, you make him continuously raise his eyes to see you. Be as motionless as possible, and never gesticulate in speaking to the sick. Never make a patient repeat a message or a request, especially if it be some time after. Occupied patients are often accused of doing too much of their own business. They are instinctively right. How often you hear the person, charged with the request of giving the message or writing the letter, say half an hour afterwards to the patient, did you appoint twelve o'clock, or what did you say was the address, or ask perhaps some much more agitating question, thus causing the patient the effort of memory, or worse still of decision, all over again. It is really less exertion to him to write his letters himself. This is the almost universal experience of occupied invalids. This brings us to another caution. Never speak to an invalid from behind, nor from the door, nor from any distance from him, nor when he is doing anything. The official politeness of servants in these things is so grateful to invalids that many prefer, without knowing why, having none but servants about them. These things are not fancy. If we consider that, with sick as with well, every thought decomposes some nervous matter, that decomposition as well as recomposition of nervous matter is always going on, and more quickly with the sick than with the well, that, to obtrude abruptly another thought upon the brain, while it is in the act of destroying nervous matter by thinking, is calling upon it to make a new exertion. If we consider these things, which are facts, not fancies, we shall remember that we are doing positive injury by interrupting, by startling a fanciful person, as it is called. Alas, it is no fancy. If the invalid is forced, by his avocations, to continue occupations requiring much thinking, the injury is doubly great. In feeding a patient, suffering under delirium or stupor, you may suffocate him by giving him his food suddenly, but if you rub his lips gently with a spoon and thus attract his attention, he will swallow the food unconsciously, but with perfect safety. Thus it is with the brain. If you offer it a thought, especially one requiring a decision abruptly, you do it a real, not fanciful injury. Never speak to a sick person suddenly, but at the same time do not keep his expectation on the tiptoe. This rule, indeed, applies to the well quite as much as to the sick. I have never known persons who exposed themselves for years to constant interruption, who did not muddle away their intellects by it at last. The process with them may be accomplished without pain. With the sick, pain gives warning of the injury. Do not meet or overtake a patient who is moving about in order to speak to him or to give him any message or letter. You might just as well give him a box on the ear. I have seen a patient fall flat on the ground who was standing when his nurse came into the room. This was an accident which might have happened to the most careful nurse, but the other is done with intention. A patient in such a state is not going to the East Indies. If you would wait ten seconds or walk ten yards further, any promenade he could make would be over. You do not know the effort it is to a patient to remain standing for even a quarter of a minute to listen to you. If I had not seen a thing done by the kindest nurses and friends, I should have thought this caution quite superfluous. Patients are often accused of being able to do much more when nobody is by. It is quite true that they can. And less nurses can be brought to attend to considerations of the kind of which we have given here but a few specimens. A very weak patient finds it really much less exertion to do things for himself than to ask for them. And he will, in order to do them, very innocently and from instinct, calculate the time his nurse is likely to be absent from a fear of her coming in upon him or speaking to him just at the moment when he finds it quite as much as he can do to crawl from his bed to his chair or from one room to another or downstairs or out of doors for a few minutes. Some extra call made upon his attention at that moment will quite upset him. In these cases you may be sure that a patient in the state we have described does not make such exertions more than once or twice a day and probably much about the same hour every day. And it is hard indeed if nurse and friends cannot calculate so as to let him make them undisturbed. Remember that many patients can walk who cannot stand or even sit up. Everything is of all positions the most trying to a weak patient. Everything you do in a patient's room, after he has put up for the night, increases tenfold the risk of his having a bad night. But if you rouse him up after he has fallen asleep, you do not risk you secure him a bad night. One hint I would give to all who attend or visit the sick to all who have to pronounce an opinion upon sickness or its progress. Come back and look at your patient after he has had an hour's animated conversation with you. It is the best test of his real state we know. But never pronounce upon him for merely seeing what he does or how he looks during such a conversation. Learn also carefully and exactly, if you can, how he passed the night after it. People rarely, if ever, faint while making an exertion. It is after it is over. Indeed, almost every effect of overexertion appears after, not during, such exertion. It is the highest folly to judge of the sick, as is so often done when you see them merely during a period of excitement. People have very often died of that which, it has been proclaimed at the time, has done them no harm. Never, never to lean against, sit upon, or unnecessarily shake, or even touch the bed in which a patient lies. This is invariably a painful annoyance. If you shake the chair on which he sits, he has a point by which to steady himself in his feet. But on a bed or sofa he is entirely at your mercy, and he feels every jar you give him all through him. In all that we have said, both here and elsewhere, let it be distinctly understood that we are not speaking of hypochondriacs. To distinguish between real and fancied disease forms an important branch of the education of a nurse. To manage fancy patients forms an important branch of her duties. But the nursing which real and that which fancied patients require is of different or rather of opposite character. And the latter will not be spoken of here. Many of the symptoms which are here mentioned are those which distinguish real from fancied disease. It is true that hypochondriacs very often do that behind a nurse's back which they would not do before her face. Many such I have had as patients who scarcely ate anything at their regular meals, but if you concealed food for them in a draw they would take it at night or in secret. But this is from quite a different motive. They do it from the wish to conceal, whereas the real patient will often boast to his nurse or doctor if these do not shake their heads at him of how much he has done or eaten or walked. To return to real disease. Conciseness and decision are above all things necessary with the sick. Let your thought express to them be concisely and decidedly expressed. What doubt and hesitation there may be in your own mind must never be communicated to theirs, not even, I would rather say especially not, in little things. Let your doubt be to yourself, your decision to them. People who think outside their heads, the whole process of whose thought appears, like homers, in the act of secretion, who tell everything that led them towards this conclusion and away from that, ought never to be with the sick. The resolution is what all patients most dread. Rather than meet this in others, they will collect all their data and make up their minds for themselves. A change of mind in others, whether it is regarding an operation or rewriting a letter, always injures the patient more than the being called upon to make up his mind to the most dreaded or difficult decision. Farther than this, in very many cases, the imagination in disease is far more active and vivid than it is in health. If you propose to the patient change of air to one place one hour and to another the next, he has, in each case, immediately constituted himself in imagination, the tenant of the place, gone over the whole premises in idea, and you have tired him as much by displacing his imagination, as if you had actually carried him over both places. Of all, leave the sick room quickly and come into it quickly. Not suddenly, not with a rush, but don't let the patient be weirdly waiting for when you will be out of the room or when you will be in it. Conciseness and decision in your movements, as well as your words, are necessary in the sick room, as necessary as absence of hurry and bustle. To possess yourself entirely will ensure you from either failing, either loitering or hurrying. If a patient has to see, not only to his own, but also to his nurse's punctuality, or perseverance, or readiness, or calmness, to any or all of these things, he is far better without that nurse than with her, however valuable and handy her services may otherwise be to him, and however incapable he may be of rendering them to himself. With regard to reading aloud in the sick room, my experience is that when the sick are too ill to read to themselves, they can seldom bear to be read to. Children, eye-patients, and uneducated persons, are exceptions, or when there is any mechanical difficulty in reading. People who like to be read to have generally not much to matter with them, while in fevers, or where there is much irritability of brain, the effort of listening to reading aloud has often brought on delirium. I speak with great diffidence, because there is an almost universal impression that it is sparing the sick to read aloud to them. But two things are certain. One, if there is some matter which must be read to a sick person, do it slowly. People often think that the way to get it over with least fatigue to him is to get it over in least time. They gabble, they plunge and gallop through the reading. There never was a greater mistake. Houdin, the conjurer, says that the way to make a story seem short is to tell it slowly, so it is with reading to the sick. I have often heard a patient say to such a mistaken reader, don't read it to me, tell it to me. Unconsciously he is aware that this will regulate the plunging, the reading with unequal paces, slurring over one part instead of leaving it out altogether if it is unimportant, and mumbling another. If the reader lets his own attention wander, and then stops to read up to himself, or finds he has read the wrong bit, then it is all over with the poor patient's chance of not suffering. Very few people know how to read to the sick. Very few people read aloud as pleasantly even as they speak. In reading they sing, they hesitate, they stammer, they hurry, they mumble, when in speaking they do none of these things. Reading aloud to the sick ought always to be rather slow and exceedingly distinct, but not mouthing, rather monotonous, but not sing-song, rather loud, but not noisy, and above all, not too long. Be very sure of what your patient can bear. Two. The extraordinary habit of reading to oneself in a sick room, and reading aloud to the patient any bits which will amuse him, or more often the reader, is unaccountably thoughtless. What do you think the patient is thinking of during your gaps of non-reading? Do you think that he amuses himself upon what you have read, for precisely the time it pleases you to go on reading to yourself, and that his attention is ready for something else, and precisely the time it pleases you to begin reading again? Whether the person thus read to be sick or well, whether he be doing nothing or doing something else while thus being read to, the self-absorption and want of observation of the person who does it is equally difficult to understand, although very often the readee is too amiable to say how much it hurts him. One thing more, from the flimsy manner in which most modern houses are built, where every step on the stairs and along the floors is felt all over the house, the higher the story, the greater the vibration. It is inconceivable how much the sick suffer by having anybody overhead. In the solidly built old houses, which fortunately most hospitals are, the noise and shaking is comparatively trifling. But it is a serious cause of suffering in lightly built houses, and with the irritability peculiar to some diseases. Better far put, such patients at the top of the house, even with the additional fatigue of stairs, if you cannot secure the room above them being untenanted. You may otherwise bring on a state of restlessness, which no opium will subdue. Do not neglect the warning when a patient tells you that he feels every step above him to cross his heart. Remember that every noise a patient cannot see partakes of the character of suddenness to him. And I am persuaded that patients with these peculiarly irritable nerves are positively less injured by having persons in the same room with them than overhead or separated by only a thin compartment. Any sacrifice to secure silence for these cases is worth while, because no air, however good, no attendance, however careful, will do anything for such cases without quiet. To any but an old nurse, or an old patient, the degree would be quite inconceivable to which the nerves of the sick suffer from seeing the same walls, the same ceiling, the same surroundings during a long confinement to one or two rooms. The superior cheerfulness of persons suffering severe paroxysms of pain over that of persons suffering from nervous stability has often been remarked upon and attributed to the enjoyment of the former of their intervals of respite. I inclined to think that the majority of cheerful cases is to be found among those patients who are not confined to one room whatever they are suffering, and that the majority of depressed cases will be seen among those subjected to a long monotony of objects about them. The nervous frame really suffers as much from this as the digestive organs from long monotony of diet, as, for example, the soldier from his twenty-one years boiled beef. The effect in sickness of beautiful objects, a variety of objects, and especially of brilliancy of colour, is hardly at all appreciated. Such cravings are usually called the fancies of patients. And often, doubtless, patients have fancies, as, for example, when they desire two contradictions. But much more often their so-called fancies are the most valuable indications of what is necessary for their recovery, and it would be well if nurses would watch these, so-called fancies, closely. I have seen in fevers, and felt when I was a fever-patient myself, the most acute suffering produced from the patient, in a hut, not being able to see out of window, and the knots in the wood being the only view. I shall never forget the rapture of fever-patients over a bunch of bright-coloured flowers. I remember in my own case, a nose-gay of wildflowers being sent me, and from that moment recovery becoming more rapid. People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Little as we know about the way in which we are affected by form, by colour, and light, we do know this, that they have an actual physical effect. The degree of form and brilliancy of colour in the objects presented to patients are actual means of recovery. But it must be slow variety. That is, if you show a patient ten or twelve engravings successively, ten to one that he does not become cold and faint, or feverish, or even sick, but hang one up opposite him, one on each successive day, or week, or month, and he will revel in the variety. The folly and ignorance which reign too often supreme over the sick room cannot be better exemplified than by this. While the nurse will leave the patient stewing in a corrupting atmosphere, the best ingredient of which is carbonic acid, she will deny him, on the plea of unhealthiness, a glass of cut flowers, or a growing plant. Now no one ever saw overcrowding by plants in a room or ward, and the carbonic acid they give off at nights would not poison a fly. Nay, in overcrowded rooms, they actually absorb carbonic acid and give off oxygen. Cut flowers also decompose water and produce oxygen gas. It is true there are certain flowers, for example lilies, the smell of which is said to depress the nervous system. These are easily known by the smell and can be avoided. Volumes are now written and spoken upon the effect of the mind upon the body. Much of it is true. But I wish a little more was thought of the effect of the body on the mind. You who believe yourselves overwhelmed with anxieties, but are every day able to walk up Regent Street, or out in the country, to take your meals with others in other rooms, etc., etc. You little know how much your anxieties are thereby lightened. You little know how intensified they become to those who can have no change. How the very walls of their sick rooms seem hung with their cares. How the ghosts of their troubles haunt their beds. How impossible it is for them to escape from a pursuing thought without some help from variety. A patient can just as much move his leg when it is fractured as changes thoughts when no external help from variety is given him. This is indeed one of the main sufferings of sickness, just as the fixed posture is one of the main sufferings of the broken limb. It is an ever-recurring wonder to see educated people who call themselves nurses, acting thus. They vary their own objects, their own employments, many times a day, and while nursing some bed-ridden sufferer, they let him lie there, staring at a dead wall, without any change of object to enable him to vary his thoughts, and it never even occurs to them, at least to move his bed so that he can look out of window. No, the bed is always to be left in the darkest, dullest, remotest part of the room. I think it is a very common error among the well to think that with a little more self-control, the sick might, if they choose, dismiss painful thoughts which aggravate their disease, etc. Believe me, almost any sick person who behaves decently well exercises more self-control every moment of his day than you will ever know till you are sick yourself. Almost every step that crosses his room is painful to him. Almost every thought that crosses his brain is painful to him. And if he can speak without being savage, and look without being unpleasant, he is exercising self-control. Suppose you have been up all night, and instead of being allowed to have your cup of tea, you were to be told that you ought to exercise self-control. What should you say? Now the nerves of the sick are always in the state that yours are in, after you have been up all night. We will suppose the diet of the sick to be cared for. Then this state of nerves is most frequently to be relieved by care in affording them a pleasant view, a judicious variety as to flowers and pretty things. Light by itself will often relieve it. The craving for the return of day which the sick so constantly evinces is generally nothing but the desire for light. The remembrance of the relief which a variety of objects before the eye affords to the harassed sick mind. Again, every man and every woman has some amount of manual employment, excepting a few fine ladies who do not even dress themselves, and who are virtually in the same category as to nerves as the sick. Now you can have no idea of the relief which manual labour is to you. Of the degree to which the deprivation of manual employment increases the peculiar irritability from which many sick suffer. A little needlework, a little writing, a little cleaning would be the greatest relief the sick could have if they could do it. These are the greatest relief to you, though you do not know it. Reading, although it is often the only thing the sick can do, is not this relief. Bearing this in mind, bearing in mind that you have all these varieties of employment which the sick cannot have, bear also in mind to obtain for them all the varieties which they can enjoy. I need hardly say that I am well aware that excess in needlework, in writing, in any other continuous employment, will produce the same irritability that defect in manual employment, as one cause, produces in the sick. End of Section 5. Section 6 of Notes on Nursing by Florence Nightingale. Every careful observer of the sick will agree in this, that thousands of patients are annually starved in the midst of plenty, from want of attention to the ways which alone make it possible for them to take food. This want of attention is as remarkable in those who urge upon the sick to do what is quite impossible to them, as in the sick themselves, who will not make the effort to do what is perfectly possible to them. For instance, to the large majority of very weak patients, it is quite impossible to take any solid food before eleven a.m., nor then if their strength is still further exhausted by fasting till that hour. For weak patients have generally feverish nights, and in the morning dry mouths, and if they could eat with those dry mouths, it would be the worse for them. A spoonful of beef tea, of arrowroot and wine, of egg flip, every hour will give them the requisite nourishment, and prevent them being too much exhausted to take at a later hour the solid food which is necessary for their recovery. And every patient who can swallow at all can swallow these liquid things if he chooses. But how often do we hear a mutton chop, an egg, a bit of bacon, ordered to a patient for breakfast, to whom, as a moment's consideration would show us, it must be quite impossible to domesticate such things at that hour. Again, a nurse is ordered to give a patient a teacup full of some article of food every three hours. The patient's stomach rejects it. If so, try a tablespoonful every hour. If this will not do, a teaspoonful every quarter of an hour. I am bound to say that I think more patients are lost by want of care and ingenuity in these momentous minutiae in private nursing than in public hospitals. And I think there is more of the entente cordial to assist one another's hands between the doctor and his head nurse in the latter institutions than between the doctor and the patient's friends in the private house. If we did but know the consequences which may ensue in very weak patients from ten minutes fasting or repletion, I call it when they are obliged to let too small an interval elapse between taking food and some other exertion owing to the nurse's unpunctuality. We should be more careful never to let this occur. In very weak patients there is often a nervous difficulty of swallowing, which is so much increased by any other call upon their strength that, unless they have their food punctually at the minute, which minute again must be arranged so as to fall in with no other minute's occupation, they can take nothing until the next respite occurs, so that an unpunctuality or delay of ten minutes may very well turn out to be one of two or three hours. And why is it not as easy to be punctual to a minute? Life often literally hangs upon these minutes. In acute cases, where life or death is to be determined in a few hours, these matters are very generally attended to, especially in hospitals. And the number of cases is large where the patient is, as it were, brought back to life by exceeding care on the part of the doctor or nurse, or both, in ordering and giving nourishment, with minute selection and punctuality. But in chronic cases, lasting over months and years, where the fatal issue is often determined at last by mere protracted starvation, I had rather not enumerate the instances which I have known where a little ingenuity and a great deal of perseverance might, in all probability, have averted the result. The consulting the hours when the patient can take food, the observation of the times often varying when he is most faint, the altering seasons of taking food in order to anticipate and prevent such times. All this, which requires observation, ingenuity and perseverance, and these really constitute the good nurse, might save more lives than we want of. To leave the patient's untasted food by his side, from meal to meal, in hopes that he will eat it in the interval, is simply to prevent him from taking any food at all. I have known patients literally incapacitated from taking one article of food after another by this piece of ignorance. Let the food come at the right time and be taken away, eaten or uneaten, at the right time, but never let a patient have something always standing by him if you don't wish to discuss him of everything. On the other hand, I have known a patient's life saved, he was sinking for want of food, by the simple question put to him by the doctor. It is then no hour when you feel you could eat. Oh, yes, he said, I could always take something at a clock and a clock. The thing was tried and succeeded. Patients very seldom, however, can tell you this, it is for you to watch and find it out. A patient should, if possible, not see or smell either the food of others, or a greater amount of food than he himself can consume at one time, or even hear food talked about or see it in the raw state. I know of no exception to the above rule. The breaking of it always induces a greater or less incapacity of taking food. In hospital wards it is, of course, impossible to observe all this, and in single wards, where a patient must be continuously and closely watched, it is frequently impossible to relieve the attendant, so that his or her own meals can be taken out of the ward. But it is not the less true that, in such cases, even where the patient is not himself aware of it, his possibility of taking food is limited by seeing the attendant eating meals under his observation. In some cases the sick are aware of it, and complain. A case where the patient was supposed to be insensible, but complained as soon as able to speak, is now present to my recollection. And remember, however, that the extreme punctuality in well-ordered hospitals, the rule that nothing shall be done in the ward while the patients are having their meals, go far to counterbalance what unavoidable evil there is in having patients together. I have often seen the private nurse go on dusting or fidgeting about in a sick room all the while the patient is eating or trying to eat. That the more alone an invalid can be when taking food the better is unquestionable, and even if he must be fed the nurse should not allow him to talk or to talk to him especially about food while eating. When a person is compelled by the pressure of occupation to continue his business while sick it ought to be a rule without any exception whatever that no one shall bring business to him or talk to him while he is taking food nor go on talking to him on interesting subjects up to the last moment before his meals nor make an engagement with him immediately after so that there can be any hurry of mind while taking them. Upon the observance of these rules especially the first often depends the patient's capability of taking food at all or if he is amiable and forces himself to take food of deriving any nourishment from it. A nurse should never put before a patient milk that is sour, meat or soup that is turned, an egg that is bad, or vegetables underdone, yet often I have seen these things brought into the sick in a state perfectly perceptible to every nose or eye except the nurses. It is here that the clever nurse appears. She will not bring in the peckant article, but not to disappoint the patient she will whip up something else in a few minutes. Remember that sick cookery should half do the work of your poor patient's weak digestion, but if you further impair it with your bad articles I know not what is to become of him or of it. If the nurse is an intelligent being and not a mere carrier of diets to and from the patient let her exercise her intelligence in these things. How often we have known a patient eat nothing at all in a day because one meal was left untasted—at that time he was incapable of eating—at another the milk was sour, the third was spoiled by some other accident, and it never occurred to the nurse to extemporize some expedient. It never occurred to her that as he had had no solid food that day he might eat a bit of toast, say, with his tea in the evening, or he might have some meal an hour earlier. A patient who cannot touch his dinner at two will often accept it gladly if brought to him at seven, but somehow nurses never think of these things. One would imagine they did not consider themselves bound to exercise their judgment, they leave it to the patient. Now, I'm quite sure that it is better for a patient rather to suffer these neglects than to try to teach his nurse to nurse him if she does not know how. It ruffles him, and if he is ill he is in no condition to teach, especially upon himself. The above remarks apply much more to private nursing than to hospitals. I would say to the nurse, have a rule of thought about your patient's diet. Consider, remember how much she has had and how much he ought to have to-day. Generally the only rule of the private patient's diet is what the nurse has to give. It is true she cannot give him what she has not got, but his stomach does not wait for her convenience or even her necessity. If it is used to having it stimulus at one hour today and tomorrow it does not have it, because she has failed in getting it, he will suffer. She must be always exercising her ingenuity to supply defects and to remedy accidents which will happen among the best contrivers, but from which the patient does not suffer the less because they cannot be helped. One very minute caution. Take care not to spill into your patient's saucer. In other words, take care that the outside bottom rim of his cup should be quite dry and clean. If, every time he lifts his cup to his lips, he has to carry the saucer with it, or else to drop the liquid upon and to soil his sheet or his bed-gown or pillow, or if he is sitting up-